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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 127-133

Ayurveda management of COVID-19 on the principles of psychoneuroimmunology


1 Department of Swasthavritta and Yoga, Faculty of Ayurveda, IMS BHU, Varanasi, Uttar Pradesh, India
2 Department of Swasthavritta and Yoga, SAS Ayurvedic College, Varanasi, Uttar Pradesh, India
3 Department of Vikriti Vigyan, Faculty of Ayurveda, IMS BHU, Varanasi, Uttar Pradesh, India
4 Department of Swasthavritta and Yoga, National Institute of Ayurveda, Jaipur, Rajasthan, India

Date of Submission15-Aug-2020
Date of Decision26-Sep-2020
Date of Acceptance06-Nov-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Mamta Tiwari
Department of Swasthavritta and Yoga, Faculty of Ayurveda, IMS BHU, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joa.joa_62_20

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  Abstract 


Introduction: Coronavirus Disease COVID-19 is caused by SARS-CoV2 that can spread between animals and humans. Ayurveda and yoga, popular traditional and complementary medicine systems, have prophylactic and therapeutic potential that may be the answer to the global search of a comprehensive preventive strategy against COVID 19.The objective of study is to explore and provide an integrated understanding of basic preventive principles of Ayurveda in light psychoneuroimmunology. Methods: The present review study was carried out by collecting the literature and research finding from various classical and modern texts books, online reports and online research articles in Google Scholar and PubMed Database. Results: In this review it was revealed that the practices of Dinacharya (daily regimen), Ritucharya (seasonal regimen), Ayurveda dietetics, yoga, Achara Rasayana (rejuvenation through right code of conduct), and Rasayana (rejuvenation) drugs may have a comprehensive area of influence on the nervous, endocrine, and digestive systems and immune functions of the body. Conclusion: The attempts have been made to deliver an integrated understanding of the above principles in light of psychoneuroimmunology. Adopting these principles may have the restorative role of health and immunity by reducing the susceptibility for COVID infection.

Keywords: Ayurveda, COVID-19, immunity, prevention, psychoneuroimmunology, Yoga


How to cite this article:
Tiwari M, Singh V, Pandey A, Agrawal SK. Ayurveda management of COVID-19 on the principles of psychoneuroimmunology. J Ayurveda 2020;14:127-33

How to cite this URL:
Tiwari M, Singh V, Pandey A, Agrawal SK. Ayurveda management of COVID-19 on the principles of psychoneuroimmunology. J Ayurveda [serial online] 2020 [cited 2021 Jan 23];14:127-33. Available from: http://www.journayu.in/text.asp?2020/14/4/127/304916




  Introduction Top


Mind–body therapies in the form of Ayurveda and yoga are our ancient health systems having preventive, promotive, curative, and rehabilitative schemes. Ayurveda focuses on the relationships between the brain, mind, body, and behavior and their effect on health and disease. The three basic pillars to sustain life are mind, soul, and body and two basic modalities to maintain the state of equilibrium in tripods are Ahara (diet) and Vihara (behavior). The key premise of mind–body relation is that a person's mental state influences his/her physical health though the exact mechanisms underlying the health effects are unknown. In recent years, there is growing scientific evidence supporting the brain and central nervous system's influence on immune function and thus potentially on immune outcomes. Psychoneuroimmunology (PNI) is a new branch to understand the interactions between behavioral functions, neuro-endocrinal functions, and immune processes. These systems have shown to respond to the information supplied by other and work in the integrated biological framework in an organism. The considerations of diet, thoughts, perceptions, emotions, and environmental factors are important implications capable of altering the immune function. The present pandemic poses a challenge to fully decipher the preventive principles and strategies of Ayurveda with the help of the links revealed by various scientific findings in light of PNI. The paper attempts to explore the understanding of basic preventive principles of Ayurveda in light of scientific shreds of evidence for better understanding of mechanisms that link gut health, central nervous system, and immune functions. The literary search of classical treatises of Ayurveda and yoga was done. The contemporary search of related pieces of evidence in online research publications was done for the present review. The finding of the work may help to synthesize a more complete understanding of the various holistic principles of Ayurveda which can be eventually used for better management of COVID crisis in integration with the treatment of modern medicine.


  Ayurvedic Practices to Prevent Infectious Diseases – COVID-19 Top


The various practices that can be incorporated in routine life for maintaining a healthy life as a preventive measure of COVID are summarized below with the scientific rationale.

Dinacharya

The treatise of Ayurveda upholds the importance of rituals that should be followed every day, which helps to regulate a person's biological clock and synchronize it to nature's circadian rhythms. The self-care practices enumerated in Dinacharya lessen the harmful impact of these changes on the human body. Increasing research evidences have shown that circadian rhythms play a dire role in the regulation of the immune system. The procedures involved in Dinacharya are cleansing and evacuating procedures such as Brahmamuhurta Jagarana[1] (early awakening before sunrise), Ushapana[2] (drinking water in the morning), Mala-MutraVisarjana[3] (defecation), Dantadhavana[4] (brushing), Kavala-Gandusha[5] (gargling), Nasya[6] (oily nasal drops), Abhyanga[7] (body massage with oil), Sharira-Parimarjana[8] (body cleansing), and Snana[9] (bathing). Brahmamuhurta Jagarana (early awakening before sunrise) is the rejuvenating time to wake up. Disturbance in circadian rhythm and sleep is frequently seen in psychiatric patients and those with neurodegenerative disease.[10] Several biologists and physiologists have studied and found that this period is associated with hormonal changes, resulting in blossoming of mind.[11] Ushapana is drinking water stored in copper or silver pot in the morning. Drinking warm water in the early morning is associated with healthy gut microbiota by improving intestinal health.[12] Defecation is an important aspect of healthy gastrointestinal functioning. Irregularities in the habits of defecation are important etiology of various diseases. It has been seen that oxidative stress is found in patients with constipation, colorectal cancer, cardiovascular disease, and other chronic illnesses related to constipation.[13] Ayurvedic classic recommends Dinacharya procedures such as brushing (Dantadhavana) and gargling (Kavala and Gandusha) to retain the healthiness of the oral cavity for prevention and management of ailments of the oral cavity.[14] Gargling with sesame oil and coconut oil acts as antimicrobial and anti-plaque activities, thus promoting oral hygiene.[15] Nasya karma is one of the five purificatory procedures of Panchkarma. Application of coconut oil, sesame oil, or Ghee in nostrils helps in the formation of biofilm which can act as a barrier to prevent the entry of virus particles.[16] Similarly, in Yogic sciences, Jalaneti (cleansing of the nasal passage with salt water) is recommended.[17] If the above-mentioned daily regimens are not followed properly, wastes are accumulated inside the body and they start to vitiate their accumulating anatomical structures and disturb the overall physiology associated with a particular system, especially the digestive system.[18] Hence, the regular observance of Dinacharya is associated with the harmonization of the human body with an environment which helps in achieving an improved feeling of wellness by uplifting immunity.

Ritucharya

Season is a major instrumental factor for the various changes in nature as well as in a human body. Climate change along with human-made stressors threatens health and well-being. Simultaneous exposure to climate change and human made stressors has a compounding impact on health. The negative impact in the form of adverse health outcomes depends on the individual vulnerability factors encompassing three basic elements namely exposure, sensitivity, and capacity to adopt.[19] This indicates that the ancient concept of Kala in the form of Ritu (season) and Ritucharya (seasonal regimen) should be followed religiously. Ayurveda mentioned that these changes are responsible for the changes in the characters of Prakriti (genetic constitution) normally as well as responsible to create imbalance or abnormal changes in Dosha, resulting in the disease. Ritucharya[20] enumerates the changes in diet and practices opposite in characters and qualities of the original Deha Prakriti (body constitution) and Dosha in response to variation in climatic attributes such as heat, cold, and rain to acclimatize seasonal enforcement easily without altering body homeostasis. This warrants the true and deep understanding of this concept of Ritucharya (seasonal regimen) to know the effects of Ritu (season) on Prakriti (genetic constitution), and to adjust the day-to-day behavior according to the changes in Ritu (seasons) to keep Doshas in an equilibrium state and the body healthy.[21] The idea is consistent with a recent research that says seasonal changes in immune function are mediated by the pineal hormone, melatonin. Melatonin affects the immune function both indirectly, acting through other hormones, and directly by acting on the components of the immune system.[22] This indicates that the ancient concept of Kala in the form of Ritu (season) and Ritucharya (seasonal regimen) should be followed religiously.

Role of diet

A balanced diet is one of the key Ayurvedic tools for promoting good health. Having proper food at the right time is said to be best to maintain health.[23] Food plays an important role in the development of the body, continues the process of growth, and gives protection to the body from decay and diseases. The diets for people are individualized, based on numerous factors, such as their age, gender, constitution, bodily strength, and digestive fire. The considerations mentioned under the Ashta vidha ahara visheshayatana (eight specific factors for diet)[24] and Dwadasha Ashana Pravichara[25] (the 12 kinds of food administration) take account of the individual variations along with nature, the quantity of food to be consumed which is important for digestion and metabolism. Adequate nutrition in terms of macro- and micronutrients is important for proper functioning of the immune system. The balanced diet concept of Ayurveda is mentioned under Nitya Sevniya Ahara (wholesome daily food);[26] it is the list of foods which are advised to be consumed daily, namely, Shashtika shali (a kind of rice maturing in 60 days), Godhuma (wheat), Yava (Hordeum vulgare Linn), Mudga (Phaseolus mungo Linn), Saindhava (rock salt), Amalaki (Emblica officinalis), Antariksha jala (rain water), Ghrita (ghee), Go dugdha (cow milk), Madhu (honey), and Jangala Mamsa (meat of animals) dwelling in the arid climate. The appropriate nutrition derived from natural sources such as fruits, vegetables, and grains are rich in fibers and antioxidants. They may have anti-inflammatory property by downregulation of nuclear factor-kappa B (NF-κB) pathway which has been recognized to play a critical role in regulating energy balance and providing a link between diet and inflammation.[27] Acharya Charaka says that the Bala (strength) depends on the Agni of an individual. Proper maintenance of Jatharagni (enzymes located in the gastrointestinal tract) helps a person to live healthy and long life while its impairment gives rise to various diseases. The complex communities of microbes that include bacteria, fungi, viruses, and other microbial and eukaryotic species provide a tremendous enzymatic capability and play a fundamental role in controlling most of the aspects of host physiology.[28] It also provides essential health benefits to its host, particularly by regulating immune homeostasis.[29] These micro-florae themselves are sources of Agni which reside in Mahasrotasa (gastrointestinal tract) and are responsible for the metabolism of drug and food items.[30] The intestinal epithelium, consisting of a single layer of intestinal epithelial cells, provides the primary physical barrier and though typically not classified as immune cells, has several immune-regulatory roles such as secretion of antimicrobial peptides, cytokines, and chemokine.[31]

Sleep

Sleep is a physiological state of relaxation for the body, mind, sensory, and internal organs. Nidra (sleep), if properly taken in terms of quality and duration, is the reason for Sukha (happiness), Pushti (nourishment), Bala (strength), Gyana (knowledge), and Jivitam (life).[32] Several laboratory-based studies have concluded that a week of sleep deprivation can result in a significant alteration in metabolic, endocrine,[33] and immune functions.[34] Sleep influences the two primary effector systems, the hypothalamic–pituitary–adrenal (HPA) axis and the sympathetic nervous system (SNS), which in turn regulate adaptive and innate immune responses. Evidence indicates that sleep disturbance induces downregulation of adaptive immunity, as indexed by an impaired response to the infectious challenge, along with an upregulation of innate immune responses, as indexed by increases in cellular and genomic markers of inflammation.[35] Some scholars project that sympathetic stimulation occurs with sleep deprivation and might contribute in the metabolic deregulation,[36] and it also “steers” immune responses between antiviral and pro-inflammatory immune responses by upregulating the transcription of pro-inflammatory immune response genes such as interleukin (IL)-1β, tumor necrosis factor, and IL-6, leading to increases in systemic inflammatory activity.[37] The importance of proper quality and quantity of sleep is highlighted in classical Ayurvedic literature for better health and well-being. In the present pandemic, the various psychological, as well as biological, stress factors have raised the concerns of fear, anxiety, and depression, which are important concerns that need to be addressed in the population in general and specifically to the confirmed cases of COVID-19. These factors may cause disturbed or reduced sleep patterns. Scientific community that explores the link between sleep, nervous system, and immunity presents a view that the endocrine and autonomous nervous systems regulate immune functions not only directly via hormones and neural innervation but also indirectly via influences on blood flow; blood pressure; lymph flow; and the supply of substrates such as glucose, fatty acids, and oxygen and on nonimmune cells in the vicinity of lymphatic tissues such as adipocytes surrounding the spleen and lymph nodes.[38] The extremes of habitual sleep duration, both reduced (<5 h) and prolonged (>9 h), are related to the increased risk of infectious diseases such as pneumonia.[39] The evident effect of nocturnal sleep on health warrants proper time, duration, and norms of sleep that are well elaborated in Ayurveda.

Rasayana

Rasayana promotes nutrition by direct enrichment of the nutritional quality of Rasa (nutritional blood), by promoting nutrition through improving Agni (metabolic fire) and by promoting the competence of Srotas (microcirculatory channels in the body).[40] It has been reported that Rasayana drugs are rejuvenators, nutritional supplements and possess strong antioxidant activities. Among Rasayana drugs such as Aswagandha (Withania somnifera), Shilajatu (Asphaltum punjabianum), Amalaki (Emblica officinalis), Tulsi (Ocimum sanctum), Guduchi (Tinospora cordifolia), Pippali (Piper longum), and Punarnava (Boerhaavia diffusa), Guduchi and Tulsi have been extensively studied to exhibit an immunomodulatory effect. Guduchi could regulate animals' immune system by stimulating the secretion or proliferation of macrophages, T/B lymphocytes, and natural killer cells, modulating the release of cytokines, promoting the production of antibodies, and activating the complement system.[41] It demonstrates macrophage-activating abilities through TLR6 signaling and NF-κB activation mechanism.[42] Aswagandha Rasayana has been found to enhance antibody dependent cytotoxicity and activate macrophages.[43] The immunomodulation activity of Rasayana drugs occurs via stimulation of phagocytosis, activation of macrophages, immuno-stimulatory effect on peritoneal macrophages, increased production of antigen specific immunoglobin and by increase in the number of circulating total white blood cells.[44] It is pertinent to highlight here that the role of emotional and psychological influences over the effective functioning of the immune system has been very clearly appreciated by seers of Ayurveda, which is now being gradually documented by the modern science based on the evidence of various experimental and clinical studies. The concept of Achara Rasayan is the moral conduct and social behavior which has a rejuvenating effect on a person who follows it regularly and religiously. The similar concept of Sadvritta (good conducts) is discussed by Acharya Charak which deals with the rules and regulations for attaining a happy long life. The thoughts, feelings, behavior, and social elements often interact and affect the individual appraisal of stress. Stress can effectively modulate the secretion of pro-inflammatory cytokines both directly and indirectly and that eventually leads to systemic inflammation that may cause deregulation of the immune system and increase the risk for chronic diseases. The various cognitive, behavioral, and interpersonal skills discussed in Achara Rasayan can be used as a multimodal technique to counter the effect of stress (endogenous as well as exogenous). It can be understood that following practices such as being truthful, not indulging in violence, avoiding alcohol as well as sex indulgence, free from barbarous acts, and having a proper understanding of place and situation helps in the improvement of personality. It helps to avoid the stress and psychological burden arising out of these negative personality traits. This also holds a similarity with cognitive restructuring for changing negative thoughts that can have a poor impact on mental health.Being peaceful and maintaining a pleasant speech; practicing cleanliness, with a stable mind; doing charity work; being free from ego; and having good conduct are proactive coping skills. These qualities would help to gain aids and abilities to assess the changing circumstances and prepare a person who could face those stressors that are likely to arise in the normal course of life. The conducts of being compassionate, empathetic, peaceful, and pleasing in speech and respecting teachers, parents, and old-age persons are the behavioral modifications that would improve social support and help in restricting negative emotions. The Framingham Heart Study attempted to correlate social integration with serum markers of inflammation (C-reactive protein and IL-6). Controlling for age and potential confounders, only IL-6 was found to be inversely associated with social integration in men.[45] Anyone who wishes to practice Achara Rasayana should steer clear of the Rajas and Tamas food items and stick on to a Satwika-dominant diet, which is said to augment the coordination of the mental functions. The study area similar to this is PNI, which draws the connection between the immune system and the nervous system concerning mental health.[46] The sympathetic nerves innervate both the primary lymphatic organs (thymus and bone marrow) and secondary lymphatic organs (spleen and lymph nodes), and the cells in the lymph organs have receptor sites for many hormones and neurotransmitters secreted by the pituitary gland. The pituitary gland is regulated by the hypothalamus and it sends messages to the pituitary gland to either release or restrict hormones depending on the information received from the autonomic nervous system. Hence, a web of communication keeps happening between the immune system and the neuroendocrine system. Thus, Achara Rasayana can be translated into mean restorative behavioral practices that cleanse the subtle body and refine the physical body by giving favorable impressions to the sensory organs.[47] This is an exceptional idea that our thoughts, words, and actions have a dominant impact on the restoration of health and well-being. The full benefit of herbal therapies and dietary changes depends on the implementation of restorative behavioral practices in the form of improving physical, social, mental, and spiritual conduct.

Yoga therapy

Yoga is an integrated mind–body practice, which aims at inducing relaxation and reducing stress and is supposed to modulate the central stress response and regulate autonomic balance. Yoga encompasses a range of techniques of Asana (postures), Pranayama (breathing techniques), and Dhyana (meditation), which have reported to exhibit anti inflammatory effect in a randomized controlled trial of 12 week yoga training conducted on industrial workers prone to airway inflammation; the techniques could reduce pro inflammatory cytokines such as IL 1β and increase anti inflammatory IL 10 levels.[48] A study conducted to assess the effects of a yoga program on patients with breast cancer after surgery has acknowledged the positive impact of yoga on immunity. The results of a trial showed a significantly lower decrease in T lymphocyte subsets such as CD4+, CD8+, and CD56+ and lower levels of serum IgA in the yoga group as compared to the control group.[49] Yoga therapy is effective in regulating the autonomic nervous system as affirmed by different studies. The secretion of sympathetic hormones such as cortisol and catecholamine is optimized by yoga therapy that leads to improved parasympathetic activity by which metabolic rate is scaled down.[50] The stress response of the body is mediated by intricate stress system which mainly includes hypothalamic –pitutary-adrenal (HPA) axis. The stress-related upregulation of HPA axis leads to deregulation of normal body system leading to noncommunicable diseases such as diabetes, depression, obesity, cardiovascular diseases, and dysfunction of the immune system. Yoga as a holistic therapy addresses the whole continuum of body–mind–consciousness of an individual. Awareness and deep relaxation are important to downregulate the HPA axis and balance the autonomic nervous system. Yoga practice can reduce SNS signaling through β-adrenergic receptors which normally activate NF-κB and upregulate the transcription of pro-inflammatory cytokine genes.[51] Besides reducing inflammation, yoga may exert beneficial effects on other parameters of the innate and adaptive immune systems, including cell-mediated and mucosal immunity. A study indicated that yoga practice can, in healthy individuals, increase the levels of interferon-gamma, which is a central regulator of cell-mediated immunity, having antiviral, immune-regulatory, and anti-tumor properties.[52] The yoga practice including Pranayama may improve pulmonary functions along with enhancing cell-mediated and mucosal immunity. These clues can be employed as a complementary intervention for people at risk or those suffering from COVID-19 infection. In essence, yoga is designed to optimize an individual's PNI functioning by addressing the roots of negative, unconscious conditioning and by recommending a multidimensional practice for positive alteration. The Acharya Patanjali delineates in Ashtânga Yoga that for repelling of the unwholesome behaviour, a person should pursue the cultivation of opposite thought or behaviour. He instructs us to cultivate “wholesome” alternative attitudes and behaviors to resolve our suffering. This approach is essential for making fundamental modifications to our limbic “wiring” because the limbic system does not diagnose or self-correct; it only depends on feelings. The alteration in the limbic system has a positive feedback on hypothalamus and autonomic nervous, endocrine, and immune systems.


  Discussion Top


The perfect balance of mind, body, and soul is considered complete health in Ayurveda. The concepts of prevention are not only ameliorates the body or physical symptoms but also improves spiritual, mental and social health as well. The optimum functioning of PNI can be linked to the balanced qualities (sattva) of the body/mind, and diseased PNI functioning can be linked to the disturbing qualities (rajas or tamas) of mind. The concepts of Ahara, Vihara, and Vichara have been the mainstay of the principles of Dincharya, Ritucharya, Nidra, Achara Rasayan, and yoga. The effect of ignoring these notions may be additive, and findings have shown faulty dietary practices and negative emotions to modulate the key pathways of inflammation including transcription factor kappa NF-κB activation, sympathetic activity, and pro-inflammatory cytokine production. Proper adherence to dietetics mentioned in Ayurveda may help in optimizing the gut–brain connection, which is evident from recent research findings. Proper food choices are important for maintaining optimum metabolism and host–microbe interplay, and both these are pertinent in health and disease pathogenesis. High fruit and vegetable intake is associated with lower oxidative stress and inflammation. NF-κB appears to be a key regulator in energy balance and inflammation.[53] Improper dietary practices are associated with obesity and metabolic syndrome. The underlying pathogenesis in these diseases is inflammatory response which in turn leads to activation of NF-κB signaling pathway in liver, adipocytes, macrophages resulting in chronic low grade inflammation, which in turn is linked to decreased immunity.[54] Physical stressors such as microbial pathogens and psychological stress activate the HPA and increase the production of corticotropin-releasing factor (CRF) through different mechanisms. Under the influence of the CRF, the anterior pituitary gland releases the stress hormone adrenocorticotropic hormone (ACTH), which in turn stimulates the release of cortisol from the adrenal gland. Cortisol, through a feedback loop, regulates the levels of CRF and ACTH. These substances bind to specific receptors on white blood cells and have diverse regulatory effects on their distribution and function.[55] Hence, it can be easily understood that under normal conditions, the neuroendocrine and immune systems coordinate in maintaining homeostasis. Thus, behavior represents a potentially important pathway linking stress with the immune system. The Sadvritta and Achara Rasayana concepts are behavioral modifications with positive emotions. They help individuals in developing a better stress-coping capability. The hypothalamus receives several neuronal inputs including that from the limbic system, which is affected by our feeling, thoughts, and behavior. These afferents can impact the hypothalamic neurons by forming synapses in the neuronal cell body and nerve terminals. Norepinephrine, GABA, dopamine, and serotonin are involved in altering immune functions via the neurotransmitter receptors present in the immune cells.[56] Yoga has been defined as the process of gaining mastery over fluctuations in the mental state. The practices of yoga including Ashtanga Yoga increase the activation of the parasympathetic nervous system (the calming side) without decreasing the influence of the sympathetic nervous system (the arousing side). Physical postures and breathing exercises improve muscle strength, flexibility, blood circulation, and oxygen uptake as well as hormonal functions. The yoga philosophy and practices help the practitioners to become more resilient to stressful conditions and thus can avoid important risk factors of various diseases. In yoga, the relaxation induced by meditation helps to stabilize the autonomic nervous system with a tendency toward parasympathetic dominance. The resulting physiological benefits of yoga practices help practitioners become more resilient to stressful conditions and reduce a variety of important risk factors for various diseases.


  Conclusion Top


The holistic principles of Ayurveda can be explored with broader and deeper insights. The doctrines of Dincharya, Ritucharya, Nidra, Sadvritta, and yoga represent a full array of recommendations for a long healthy life in terms of diet and behavior. These concepts have a comprehensive area of influence on the nervous, endocrine, and digestive systems and immune functions of the body. This understanding is closely related to the new field of PNI. These recommendations of Ayurveda science can be interpreted as a multimodal stress-reducing strategy that can bring about a major change in the immunological status of individuals in the present pandemic crisis.

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