3.1. Seasonal and Daily Cycles with Subjective Pain Perception
In the first theme, the emphasis on seasonal cycles (e.g., summer and winter) and quotidian cycles (e.g., of day and night) were identified in the Ayurvedic physician’s tailored chronic pain management protocol (refer to Figure 1
). The seasonal and daily cycles are connected with the individual anatomical and physiological composition through the three regulatory control factors for the fundamental physiological processes that maintain their integrity through the biological history [16
], called doshas
), that comprise each and whose balance and aggravation shapes the individual pain perception. The seasons and daily cycles are connected with the food and lifestyle, each of which is governed by the tri-doshas
In patient consultation, the Ayurvedic physician considered the relationship of seasons with each individual patient’s unique lifestyle and situates this to understand the effect of daily rhythms on their pathophysiology. Physician A said that in devising a treatment plan for chronic pain, he will look at the “dinacharya, along with that diet … exercise … yogasana … pranayama, which is directly related with that joint pain, or … chronic pain.” Dinacharya, or the daily routine, alongside diet, exercise, as the yogic asanas, and pranayama, or the exercises pertaining to the breath, were emphasized in A’s response in designing an individualized protocol. Participant C emphasized these relationships: “apart from just giving medications or giving therapies, we, on the first day of consultation itself … It’s an intense consultation where we try to understand the lifestyle of the person, the kind of food the person is eating and even the kind of job, the kind of relation they have in the family and if that... What are the factors which may aggravate vata, which may aggravate stress and ultimately create more vata.”
The Ayurveda physician conceptualized individual agency as the mind, through the breath, and the regulatory principles, through the tri-doshas of the vata, pitta, and kapha, as key to their particular manifestation and operation in the individual body. Participant B described the role of dinacharya or daily rhythm with the doshas (regulatory principles) in diagnosis and treatment of chronic pain: “At the beginning of the day, kapha is dominant, in the middle of the day … pitta is dominant, and at that end vata is dominant … If the pain is aggravating in the middle of the day, say, abdominal pain is aggravating in the middle of the day” understood in relationship with location and nature (e.g., sharp, dull, burning) of the pain: “some patients have … burning sensation, and they wake up because of that pain and burning sensation in their abdomen” (Participant B). Participant I explained how the Ayurvedic approach is based “on the sun, like praat kaal … or the sunrise time medicine, that is the rasayan kaal” tailoring treatment with the circadian rhythm: “Medicines given in that period … We have just had the bowel movements … so these medicines work, or the herbs work more efficiently.” Explaining how the day is divided into different sections, each governed by a particular dosha, Participant I said: “this is the morning, kapha kaal. Then comes the pitta kaal, that is 10:00 a.m. to 2:00 p.m. Then again, comes the vata kaal. So, it depends on the kaal also, that is the vata, pitta, kapha also, and the sun also.” Diagnosis and prognosis take the doshas into account with the solar movement in the sky: “Suppose you give medicine at 10:00 a.m. … so 10:00 a.m. the pitta kaal starts. If you give the medicines [then], it will work on the pitta or the rakta. If a person is suffering from acidity, or if he has some blood related problems, if you give medicines at 10:00 a.m., they will surely work very well.” However, the same medicine can have a different effect based on the circadian cycle and the individual patient: “Suppose on mann (mind) … then we give it mostly on the udaan kaal. It works on the prayatna (individual effort), oorja (mental strength), and during swapna kaal (time of sleep/dreams) that is just before bed” (Participant I).
Likewise, Participant B said: “we ask many other things, like, in which season this pain is aggravating, in which part of the day or night it is aggravating. Accordingly, we can come to some conclusion.” The same diagnosis will differ in its prognosis based on “for example, if this pain is aggravating in, say, rainy season when clouds come, so it is said that sometimes ama plus vata, vata, which is having some ama in it, that is undigested vata, that is aggravating in this rainy season when clouds come.” Accordingly, the Ayurvedic physician will attend to the balancing of vata and pitta through an examination of their relationship with the patient’s own doshic composition. The physician will also take into account the influence of the season on the natural elements, such as on the quality of natural water (heavy during the monsoons).
For the Ayurvedic physician, the seasonal routines (ritucharya), are in an intimate relationship with the individual human physiology and the doshas. Participant B described the role of seasonal and daily cycles in diagnosis and management of chronic pain thus: “if this pain is increasing only in cold seasons, then this pain is increasing because of vata, but that may not be [in] summer, and I will treat accordingly.” In other words, “When, in which season, in which part of the day or night this pain is increasing, we are to understand that, then diagnose and treat accordingly” (Participant B). The day is divided into eight sections, each governed by one of the tridoshas (vata, pitta, kapha). These practices illustrate the relationship between the environmental rhythms and individual pathophysiology in pain perception and management.
In determining the influence of the season or the day on the individual patient’s physiological perception of pain, the Ayurvedic physician considers diet as an important in the diagnosis and prognosis protocol. As Participant A describes, food is intimately connected with the mind and the body “because our ahara (food) creates our body. Whatever our body, it’s created by our ahara, whatever we are taking, it converts it into our body. Our food (ahara) nourishes our mind.” Thus, food comprises the body in a manner that the individual’s body, psycho-cognitive qualities (e.g., sattvic, rajasic, or tamasic) is made up of their daily diet, or ahara. As Participant A elaborated, “sattvic ahara” is food that nourishes the higher, reflective, contemplative, and thoughtful qualities of the mind. Likewise, rajasic and tamasic ahara nourish the active (outward agency) and the lower or less contemplative qualities of the mind.” By determining the dietary choices, the physician seeks to gain an understanding of the subjective experience of pain perception by the patient.
In Participant C’s approach to treating patients with chronic pain, lifestyle is part of the intake interview: “if there are certain things which are vata increasing, for example, too much exercise. Too much physical exercise the body can’t handle.” In this case, by looking at age, “for example in 65 age, doing excessive exercise where the body’s kapha is not handling, plus he is skipping the meals, not having breakfast for example.” The diet is tailored to the patients: “If he likes to have drinks or beverages, then I can suggest some khajur manthan, dates smoothie.” As Participant C notes, “half of our time goes more into this. And it happens every follow-up. Because once you suggest, we have to see whether the person is following.” Monitoring and encouraging self-management is a key part of the Ayurvedic approach. For instance, if their patients are “not following, what are the challenges. I even go to the extent of understanding, if they are working in some pantry, what are the food available there, what can be the better choices … So, it goes to such a minute level of holding hands with the patient.” This attention to detail references the patient-centered and individualized approach of Ayurvedic medicine to the lifestyle-based management of chronic pain.
In the first theme, seasonal and daily cycles with subjective pain perception
, the Ayurvedic physicians connecting the cycles with the breath as the state of mind, and mind-body exercise (e.g., yoga), in designing the chronic pain management protocol for the individual patient. In tailoring the protocol, the physicians described the relationship of the balance or aggravation of the vata, pitta
, and kapha
during the seasons, particular time of day, and the food with the patients’ own unique physiological composition of the tri-doshas
3.2. Biogeographical and Ecological Regions with Subjective Pain Perception
In the second theme, the emphasis on biogeographical and ecosystemic regions was identified in the Ayurvedic physician's tailored chronic pain management protocol. Both biogeographical and ecological regions reference the processes that determine spatial and temporal patterns in nature, however biogeographical studies reference planetary evolutionary patterns while ecological studies reference adaptive evolutionary patterns in local areas [58
]. The ecosystemic view accounts for flow and cycling in ecological systems without looking at population dynamics or organism activities [59
]. Biogeography describes the evolutionary, climatic, and geological processes that explain the distribution of diversity on the planet. Analytical approaches related to mapping (e.g., geographical information systems), spatial relationships, and large-scale patterns in macroecology have allowed for greater inferential understandings. Ecology focuses on adaptive evolution, population processes, and abiotic and species interactions underlying distributions of species in local areas (i.e., within restricted spatial and temporal scales) and relies upon experimentation and statistical models for its inferential power [58
]. As an ethnomedical approach, Ayurveda considers food, climate, and stress as potential disruptors of the normal regulatory principles governing the body beyond the cutaneous level [16
]. The Ayurvedic physician’s description connects the biogeographical and the ecoregional with human health (refer to Figure 2
In examining a patient, the Ayurvedic physician considers diet based on the ecoregion, for instance, in their description of the “desh ahara
, which means, [giving an example of the city the provider lives in] is the sadharan
(ordinary, not extremely hot or cold) desh
” (Participant A; see also primary Ayurvedic text, Charaka Samhita
). As A describes, “when you are going to the coastal region ... in that region, salt is much more present in the environment also, in the water also, in the food also. In that case, we are giving them mainly the alkaline nature of the food.” Biogeographical examinations seek to understand how and to what effect the ecosystems and species distributed in a geographic space and geological time influence each other [60
]. The physicians’ description illustrates how they take into account ecosystemic elements such as biota (e.g., invertebrates for lakes, wetlands, and rivers), geological formations (e.g., sedimentary, metamorphic, or volcanic rock), soil (e.g., calcareous sands, clay-rich soil, leached soil, or brown forest soil), and categories (e.g., salt marshes, desert, coral reef) in assessing the individual patient’s physiology in chronic pain management.
Through examining the interplay of the operational principles of the human body and the ecoregions (e.g., doshas, gunas, agni), the theme of biogeographical regions suggests how these are understood as mutually influencing each other in the diagnosis and prognosis process for chronic pain management. In Participant A’s description, water chemistry (e.g., alkaline or acidic) and temperature is taken into account as the seeks to “balance the pH, means [when] the environment is acidic in nature, and we are giving the alkaline food. It balances the pH of the body, and it give nourishment to the body.” Balancing soil characteristics and food with the geographical region, A explains: “if you are in north part of the India …where too much cold is present in the environment, ice is present all over the environment.” These are associated with the biodiversity distribution and vegetation qualities that correspond with the regulatory principles. In his example above, A describes how, “in that condition, we are using the sarson … [or] methi (mustard). It is hot in potency.” Here hot refers not to the objective temperature but to the abstract mechanism through which mustard operates in the human body and is inferred through the foundational texts that recognize the properties of biotic and abiotic elements will evolve over the succeeding centuries.
In other words, the ecoregions are associated with the tridoshic energy dimensions that interact in particular ways with the individual’s own composition of the energy dimensions. As B describes: “The places where vata is more, like arid lands, the dry desert lands. In such places, the same patient, if he’s staying in, say, more medium … atmosphere and if that patient goes to this such place, his pain may aggravate. Desh [ecoregion] also plays important role in pain.” In other words, “In the jangal land or arid land, the dryness is more, more many times” (Participant B). Because dryness is one characteristic of vata, its ecoregional aggravation will act in particular ways with the patient’s own physiological pain perception (the perception of pain is governed by the vata principle) and its distribution that can then be shaped by the diet, soil characteristics, water, and other ecological elements of the region that reflect the particular energy composition of that ecosystem and geological typology.
The climate regions (comprising factors such as latitude, solar radiation, air mass, pressure zones, oceanic heat exchange, mountains, winds, and altitude) shape the pain experience in the patient. As Participant B explained, “it may be winter; it may be hot season. Every time the dryness is more … the nourishment and dryness is lost from the place [in the body], the joint, so this condition will worsen in such situations if he moves to that place, or otherwise he moves to cold places, the vata has cold quality.” Such reasoning underlies the Ayurvedic physicians’ recommendation to support the alignment of particular ecoregions in different chronic pain diagnoses and individual energy dimensions. As illustrated in B’s assessment of chronic pain management: “vata, it aggravates in cold places, so this person if moves to cold areas also, then also the pain is going to aggravate, so you have to take care of such things.”
In the case of chronic knee pain, with the complex array of factors including the cartilage, ligaments, tendons, and menisci, associated with degenerative tissue disorders (e.g., osteoarthritis), auto-inflammatory diseases (e.g., rheumatoid arthritis) the underlying premise, as B explained, was: “if the environment is dry…the dryness will increase in your body also, in the person’s body also. That is affecting the knee also.” For Participant C, “in diagnosis we take into [account] … ten factors and that includes desh … If a person is living in Bay area with so much vata aggravation. Every hour there is a change in … climate itself [which] defines more vata. So, there the protocol will be [s]trict, more important for vata disease for example.” By examining the variation in the biogeographical factors with the individual’s anatomical and physiological factors and regulatory principles, this illuminates how the ecoregions are intimately connected with chronic pain diagnosis and treatment in the domain of chronic knee pain.
An example of how an Ayurvedic practitioner connects the factors in their treatment management approach of osteoarthritis by examining the functioning of the digestive system is illustrated by Participant C: “If the cause of pain in the joints, be it osteoarthritis, if the main cause is more gases in the colons. Now Ayurveda connects that the vata aggravation is primarily at the level of colons.” In Ayurveda, each organ has its own role in balancing the doshas. Thus, as C explains: “I have to first clean the colon. I have to give some panchakarma to cleanse it, detox it. Then I have to lubricate the colons, so that there are no more vata generation there.” Once the vata generation has been balanced in the colon, C “will suggest food which will not create more vata because of the food as the source of more gas or vata aggravation. I will suggest food which will create more lubrication, more kapha enhancement to pacify vata.” Thus, for C, the osteoarthritis pain management protocol will involve, “a good cleanse and strengthening of colons. Second thing, diet. Third thing, [the] connection between the mind and intestine.” C addressees the mind and the intestine with the osteoarthritis pain management protocol by applying the Ayurvedic principle which “says these are the two places of vata, mind and colons … So, if the person is in too much chintan (rumination) and chinta (worry). I have to deal there also … And fourth, then I will give some herbs.” In sum, C will “find the exact cause where the vata is aggravating. Is it only at the mind, is it only at the colons or is it at the extremities level, where more physical work and [is] it more related to indriya (sense organs)?”
Biogeographical regions represent discrete homogenous areas wherein natural communities and species interact with the physical elements of the environment and are employed to model patterns in biodiversity. Participant H clarified how the conceptualization of the geographical place with ecoregion and biogeographical elements shaped the chronic pain management approach: “So many times I think desh is like the location where the person is staying … if the person is staying in all places, definitely their inflammation or pain increase and if you’re staying in some hot places, then pain would be less.” Conversely, “in the marshy places … where there is very less sunlight, can also increase the pain in the [p]atients.” Participant I elaborated: “With ahar (food) and vihar (place), at least desh (ecoregion) is related with the [flow of vata energy in the body, vata].” If the energy flow “is in apana kaksha, then the ahar will also depend on the pain, which will not increase in the apana kaksha (downward regions).” Accordingly, Participant I stated, “treatment will also differ according to the desh … suppose you have a knee joint pain, then you will have to prescribe … medicines, which will be given before the meals. That is, which works on the apana kaksha … considering the desh (ecoregion) as a body … as a kshetra (place) … [and as] … related to areas also.” The nature of the pain varies with the ecoregion and the treatment will consider guna (quality) pertaining to the five elements (panchamahabhuta): “the herbs will be different. We have to use more ushna (heat), tikshna (sharpness) … The intensity of the gunas, like ushna, guru (heavy), snigdha (unctuousness) will be more.” In Participant I’s description, the patient’s body is considered an ecoregion with analogous characteristics to the external environment and is assessed during chronic pain diagnosis and manifestation.
In the second theme, biogeographical and ecological regions with subjective pain perception
, the Ayurvedic physicians described the consideration of unique ecoregional and biogeographical elements (through desh
) in relationship with the energy dimension of pain and its physiological and anatomical perception (vata; Figure 2
). In tailoring care, the physicians described the relationship of the quality of the abiotic and biotic elements of the environment (e.g., acidic or alkaline soil) with the virya
(hot or cold potency) of vegetation consumed as food (e.g., mustard). Thus, the diagnosis and prognosis is tailored to each individual and is wholistic in its approach by taking into consideration its relationship with the ecological and biogeographical elements and systems in designing the chronic pain management protocol.