key: cord-0699286-k0b76c6o authors: Umesh, Chikkanna; Ramakrishna, Kishore Kumar; Jasti, Nishitha; Bhargav, Hemant; Varambally, Shivarama title: Role of Ayurveda and Yoga-Based lifestyle in the COVID-19 Pandemic – A Narrative Review date: 2021-07-19 journal: J Ayurveda Integr Med DOI: 10.1016/j.jaim.2021.07.009 sha: 5cd8f840f22e381bc0be3e5397407fa93ac7142b doc_id: 699286 cord_uid: k0b76c6o The COVID-19 pandemic has posed an immense challenge to health care systems around the globe in terms of limited health care facilities and proven medical therapeutics to address the symptoms of the infection. The current health care strategies have primarily focused on either the pathogen on the environmental factors. However, efforts towards strengthening the host immunity are important from public health perspective to prevent the spread of infection and downregulate the potency of the agent. While a vaccine can induce specific immunity in the host, non-specific ways of improving overall host immunity are the need. This scenario has paved the way for the use of traditional Indian therapies such as Ayurveda and Yoga. This review aims at collating available evidence on Ayurveda, Yoga and COVID-19. Further, it draws inferences from recent studies on Yoga and Ayurveda on immunity, respiratory health and mental health respectively to approximate its probable role in prophylaxis and as an add-on management option for the current pandemic. The COVID-19 pandemic has become a major global challenge,especially for the Health care sector. In the current situation where the number of positive cases of COVID-19 is outstripping existing healthcare facilities, an economically feasible therapeutic option is of critical importance. Strategies that can improve immune surveillance and resilience in terms of reduction in inflammatory markers and improvement in the activity of the specific immune cells involved in the pathogenesis of COVID-19 is the need of the hour. Conti et al, suggested that reduction of inflammatory responses is a relevant strategy to reduce the severity of the COVID-19 disease, which could potentially reduce the number of cases requiring critical care [1] . The current health care strategies have primarily focussed on either the pathogen or on the environmental factors. However, the efforts towards strengthening the host immunity are important from public health perspective to prevent the spread of infection and downregulate the potency of the agent. While a vaccine can induce specific immunity to the host [2] , non-specific ways of improving overall host immunity are the need of the hour. Thus, traditional Indian systems of medicine such as Ayurveda and Yoga should be explored for their potential role in improving host immunity and reducing severity of the infection. This review aims at consolidating the existent literature available on Yoga and Ayurveda for COVID-19. Further, it infers the ancilliary evidences for utlity of Yoga and Ayurveda in enhancing health in three major domains: 1) Immune system, 2) Respiratory system and 3) Mental health, that are more vulnerable during COVID-19 infection. Understanding COVID-19 According to Ayurveda classics, the term Janapadodhwaṃsa (epidemic diseases) has been used to describe epidemics/pandemics which manifest due to polluted vāyu (air), bhūmi (land), jala(water) and kāla (vitiated seasons). These are considered to be consequences of 'prajn͂ aparādha' (crime against wisdom) and 'adharma'(Unrighteousness) [3] . Ayurveda classics have described the concept of sūkshmakr ̥ mi/ bhūta (organisms invisible to naked eye). The term bhūtabis ̣anga (exogenous cause) has been used to describe diseases caused by them [4] . Fever due to bhūtabis ̣anga is similar to the conditions explained during the epidemics/pandemics. In the Ayurveda context of epidemic diseases, terms such as saṃ sargaja and upsargaja have been used to indicate transmission from infected to the healthy through contact including exhaled air. The modes of spread in janapadodhwaṃ sa has been described as through gātrasaṃ spars͘ a (touch), nis ̣wāsa (inhalation), sahabhojana (eating together), sahāsana J o u r n a l P r e -p r o o f (sleeping together) and sahagandhamālyānulepana(use of infected articles) [5] . Interestingly, Sus͘ ruta has also described a condition that mimics all symptoms of an influenza-like illness such as the current COVID-19 viz., jwara (fever), s͘ wāsa (difficulty in breathing), kāsa (cough), s͘ iroruk (head ache), pratis͘ yāya (common cold), gandhaajn͂ ana (anosmia), bhrama (giddiness/postural instability), and vamathu (vomiting) [6] . Clinical symptoms reported by Huang et al., from heavily affected places of COVID-19 suggests, 98% patients had mild to moderate fever (jwara), 76% had cough (kāsa) and 44% had myalgia (an͘ gamarda) and fatigue (tandrā). Among those who developed pneumonia, 99% had fever (jwara), 70% had fatigue (tandrā), 59% dry cough (vātikakāsa), 40% anorexia (aruci), 35% had myalgia (an͘ gamarda),31% had dyspnea (s͘ wāsa) and 27% had sputum production (kaphajakāsa) [7] . Considering all these factors, COVID-19 can be considered as a kapha-vātasaṃ sargajajwara (a febrile condition with predominance of kapha and vāta) [3] , with pitta association [3] , in the initial stages. At advanced stages it acquires that status of overt sannipātajwara (a febrile condition with predominance of all tridos ̣aḥ viz., vāta pitta and kaphaa disease involving all tridos ̣aḥ in its pathophysiology) which has been described in Ayurveda as difficult to cure) [4] . Yoga therapy emphasises on modulation of host factors such as regulation and moderation of the lifestyle factors [8] . Host immunity is downregulated due to altered lifestyle patterns such as consumption of unwholesome food, physical inactivity, improper sleep-wake cycle, increase in workload, stress and addictions [9, 10] . This results in fragility of the immune resilience that makes the host succumb to the virulence of the virus. Thus, the aim of Ayurveda and Yoga therapeutics is to enhance host immunity and reduce the extent of infection and inflammation in the body by balancing body humors and lifestyle factors. To understand the role, we have categorized our literature search into three domains which are commonly involved in COVID-19 infection: 1) Immune system, 2) Respiratory System and 3) Using the key words "Ayurveda" and "COVID" in search engine PubMed till 20 th December 2020. We found 218 articles; out of these 218 articles 63 Resveratrol, quercetin, luteolin, naringenin, zingiberene, and gallic acid has the significant binding affinity towards ACE2 receptor only and therefore may be used for ACE2-mediated attachment inhibition of SARS-CoV-2 [11] . Study with Asparagus Racemosus (Willd.) found Asparoside-C, Asparoside-D and Asparoside -F were most effective against NSP15 Endoribonuclease and spike receptor-binding domain [12] . Further studies demonstrated Berberine a chemical constituent of Tinospora cordifolia can regulate 3CLpro protein's function due to its easy inhibition and thus can control viral replication [13] . Among twenty-five phytocomponents of Nigella sativa; alpha-spinasterol, beta-sitosterol, campesterol, taraxerol and 24-methylene-cycloartanol showed best binding affinity against N-terminal RNA binding domain of nucleocapsid protein and papain-like protease of SARS-CoV-2 [14] . Docking study with Withania somnifera (Ashwagandha) found four constituents; Withanoside II, Withanoside IV, Withanoside V and Sitoindoside IX exhibited potential inhibition against main protein (Mpro)of SARS-CoV-2 [15] . Similar observations were observed with Andrographolide from Andrographis paniculate exhibited potential inhibition against main protein (Mpro) of SARS-CoV-2 [16] . In another docking study 6 gingesulphonic acid which is present in Sunthi (Zingiber officinale Roscoe) showed higher binding energy and inhibition to protein molecule of SARS-CoV-2 compared to hydroxychloroquine and quinine [17] . In a Prospective clinical study comprising Daśmūlakat ̣trayādi kas ̣āya and Guḍ ūcyādi kvātha tablets as add on to standard care showed a faster recovery from breathlessness with reduced ageusia and accelerate recovery in terms of reduction of symptoms and duration of hospital stay [18] . Using the key words "Yoga" or "meditation" and "COVID" or "corona virus" or "SARS" in PubMed search engine, we found 29 articles till December 2020. Out of these 29 articles, 18 articles were on Yoga and COVID-19. Out of 18 articles, 9 were review articles discussing the role of yoga in the pandemic [19] [20] [21] [22] [23] [24] [25] [26] [27] , 4 were letters to editor and short communications [28] [29] [30] [31] , 2 were research protocols of randomized controlled trials, first one to study the efficacy of online Sudarshan Kriya Yoga (SKY) for frontline hospital staff [32] and the other to examine the effect of meditation app on anxiety and wellbeing [33] , 2 were cross-sectional observational studies [34] [35] , 2 articles were on cancer care during pandemic [36] [37] , 1 on modifications in tele-training and tele-assessment in alternative therapies for multiple sclerosis during COVID-19 pandemic [38] . Out of 18 articles, 3 articles exclusively focused on the role of yoga in elderly [25, [29] [30] and 2 were related to maternal health during the pandemic times [24, 26] . Only 4 articles discussed specific yoga modules for COVID-19 [19] [20] [28] [29] . Here below, we aim at providing the contextual summary of the available reviews primarily focusing on yoga for COVID-19. A study exploring the patterns of physical activity across genders during the pandemic revealed a significant increase in women opting yoga along with reduction in walking and marching outdoors [35] . Yoga has been considered as one of the homebased activities that can be utilized to improve mental wellbeing amidst the pandemic [27] . to moderate cases of COVID-19 [39] . However, results from these registered trials are still awaited. Every improves the immunity in infants and children [43] . Out Wisconsin Upper Respiratory Symptom Survey (WURSS-24)] was lesser in in meditation group than the exercise group and was significantly lower when compared to control group [44] . Another study demonstrated that regular practice of integrated yoga program (joint loosening, sun salutations, breathing practices, prānayāma and relaxation techniques) for a month could boost the immunity and psychological health in patients with HIV [45, 46] . Yoga has also been found beneficial as an adjunct to anti-tuberculosis treatment (ATT) in patients with pulmonary tuberculosis by reducing the symptom scores, sputum conversion on microscopy, improvement in the lung capacity and radiographic pictures [47] . A number of RCTs demonstrate the efficacy of yoga in regulating inflammatory markers. Ujjāyi and Bhastrika practices has been found to lower blood lactate levels, enhance antioxidant defence [53] and improve Natural Killer (NK) cell counts [54] . Also, studies have reported that practice of yoga for 4 to 12 weeks can improve anti-oxidant status of an individual by improving the levels of glutathione and superoxide dismutase [55] [56] . These evidences suggest the role of yoga in reducing the severity of infections by regulating the immune responses. reported improvement in sinus ventilation and 15-fold increase in nasal nitric oxide (NO) levels (involved in host defence functions) [73] . During the current pandemic, Rajkumar et al reported that 28% of the screened subjects (general public and healthcare professionals) reported stress, symptoms of anxiety and depression [74] . A meta-analysis of 300 studies concluded that chronic stressors reduce both cell mediated and humoral immunity of the host [9] . On the other hand, reduction in stress hormones, psychological stress, anxiety and depression are associated with better functioning of the immune system. This emphasizes the need for addressing mental health issues during the current pandemic. Both Physical and psychological disorders have the capacity to exert mutual effects on each other. Conditions like fever can exert its effect over mind and can lead to psychological manifestations and on other hand psychological conditions can lead the physical manifestations (ca.vi 6/7). Ātma (soul) Manaḥ (mind) and Indriyāḥ (senses) [6] . Caraka has advocated Āchara rasāyana (code of behavioral conduct) for perfect mental, physical, social, spiritual health of human beings. It includes moral, ethical, and benevolent conduct: truth, nonviolence, personal and public cleanliness, mental and personal hygiene, devotion, compassion, and a yogic lifestyle [4] . A study suggested that individual who strongly follow Āchara rasāyana were good at academics, enjoying good physical and mental health and friendly reputation among peers [75] . Further acharyas advocated intake of Medhya rasāyana (psychotropic Ayurvedic pharmacological interventions) for maintenance of mental health. Medhya rasāyana include drugs which help in cognition enhancement and act as brain tonics or rejuvenators e.g., mandūkaparṇ i (Centella asicatica), Yas ̣timadhu (Glycerrhiza glabra), Gudūci (Tinospora cordifilia) and Sankhapus ̣pi (clitoria ternacia) [4] . These drugs promote Dhi (Intellect) Dhr ̥ ti (power of self-control), and Sṃ r̥ ti (memory). Further, Medhya rasāyanas balance Manodos ̣as (humours that control the mind) viz., rajas (speed) and tamas (indolence) thereby regulating and promoting healthy mental functions [76] . Another study revealed that consumption of As͘ wagandha 600 mg/day for 12 weeks led to overall improvement in the general wellbeing, sleep quality and mental alertness of healthy subjects [77] . Meta-analysis on Centella asicatica suggested improvement in alertness and reduction in anger outbursts [78] . Similarly, a study on Sankhapus ̣pi demonstrated its memory-enhancing, anxiolytic, antidepressant and memory-enhancing activity [79] . Hence psychotropic Ayurvedic pharmacological interventions may benefit in managing stress, anxiety and depression. Mental health plays a pivotal role in regulation of proper immune responses and homeostasis. However, mental health has taken a greater toll in all the sections of the society due to the COVID-19 pandemic [20] . This has resulted in increase incidences of anxiety, depression and leaving the vulnerable population such as healthcare worker at the risk of Post Traumatic Stress Disorder (PTSD) [31] . Yoga has been included as one of the home-based activities to improve mental health during the current pandemic [27] . There are evidences on the efficacy of yoga in previous similar natural disasters [80] [81] . There are two studies that have reported improvement in mental health during the current pandemic period. A cross sectional study has reported that higher percentage of non-practitioners (33%) of Sudarshan kriya yoga (SKY) have reported anxiety and negative effects on their mental health that SKY practitioners (17.7%) during the current pandemic [34] . With a view point of prevention and improving the host defence mechanism when the contact of the pathogen with the host is unavoidable the above narrated measures helps to overcome/minimize the severity of the infection. Rasāyana dravyas may stimulate humoral immunity in terms of antibody production and cell-mediated immunity in terms of delayed-type hypersensitivity (DTH) [42] . They may diminish the release of TNFα, IL-1, inhibit NF-kB, increase B cell proliferation and act by chain braking and scavenging of free radicles [88] . Study has suggested that Svarṇ a bindhu prāśana may enhance differentiation immature dendritic cells into mature dendritic cells through expression of CD83 and CD86 which may effectively strengthen the immune system [43] . Copper impregnated water has been found to have antimicrobial, antioxidant, anti-carcinogenic and anti-inflammatory properties [57] . Mouth rinsing with warm liquids and medicated oil may help in excretion of toxic heavy metals by saliva, may activate salivary enzymes, thus detoxifying the entire body [58] . Nasal installation of medicated oils and vegetable oils such as sesame oil may act as protective layer and trap virus particles thereby preventing direct contact and binding of virus onto the surface of nasal mucosa [59] . Ingredients of AYUSH kvātha possess antiviral, anti-inflammatory and antioxidant properties. Active constituents of these drugs like eugenol, linoleic acid in holy basil, cinnamaldehyde in cinnamon, gingerols, shogaols in ginger and piperine in pepper scan has been found to downregulate the proinflammatory pathways thereby decreasing INF-γ, IL-4 and exerting anti-atherosclerotic, anti-coagulative and anti-platelet activity [89] . Yogic practices (particularly prānayāma and meditation) have exhibited significant immunomodulatory effects such as increase in production of immunoglobulins, activation of phagocytic functions and enhancement in humoral as well as cell-mediated immunity [49] [50] [51] 54] . Further, they have been found to reduce inflammatory cytokines such as IL-6, IL-1b, TNF-a which are part of the 'cytokine storm' reported in COVID-19. They have also been shown to improve the levels of anti-inflammatory cytokines (IL-10 and IL-12) and anti-oxidant status of individuals [44, [51] [52] . Yoga induces neuro-hormonal modulation via HPA axis resulting in reduction of cortisol levels and balance in sympathetic and parasympathetic nervous system. Further, practice of yoga increases GABA levels that also stimulates vagus nerve resulting in parasympathetic predominance and optimization of proper immune responses [82, 90] . Psychological stress, anxiety and deterioration of sleep quality have increased during the pandemic [20] . These symptoms may be downregulated by the promotive effects of yoga on Collaborative multi-centric trials to evaluate the safety, feasibility and efficacy of Ayurveda and Yoga lifestyle interventions in treating various stages and severity of the COVID-19 infection are the need of the hour. This will enable recommendation of specific Ayurveda and Yoga protocols for each stage of the illness. Though conclusive evidences on role of Yoga and Ayurveda on COVID-19 are lacking. The available ancillary evidences point towards the potential role of Yoga and Ayurveda in preventing and mitigating the infection through modulating our immune system, and strengthening respiratory and mental health respectively. This suggests an urgent need for conducting systematic clinical trials to investigate the add-on efficacy of Yoga and Ayurveda lifestyle interventions with current conventional treatment approaches. Authors declare no conflict of interest J o u r n a l P r e -p r o o f Induction of pro-inflammatory cytokines (IL-1 and IL-6) and lung inflammation by COVID-19: anti-inflammatory strategies COVID-19: combining antiviral and anti-inflammatory treatments. The Lancet Infectious Diseases Chaukhamba Sanskrit Sansthan Chaukhamba Sanskrit Sansthan Chaukhamba Sanskrit Sansthan Chaukhamba Sanskrit Sansthan Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet Promotion of Positive Health Psychological stress and the human immune system: a metaanalytic study of 30 years of inquiry Potential yoga modules for treatment of hematopoietic inhibition in HIV-1 infection Antiviral activity of traditional medicinal plants from Ayurveda against SARS-CoV-2 infection In-silico investigation of phytochemicals from Asparagus racemosus as plausible antiviral agent in COVID-19 In silico investigation of phytoconstituents from Indian medicinal herb 'Tinospora cordifolia (giloy)' against SARS-CoV-2 (COVID-19) by molecular dynamics approach Virtual screening of phytoconstituents from miracle herb nigella sativa targeting nucleocapsid protein and papain-like protease of SARS-CoV-2 for COVID-19 treatment Identification of bioactive molecule from Withania somnifera (Ashwagandha) as SARS-CoV-2 main protease inhibitor Andrographolide as a potential inhibitor of SARS-CoV-2 main protease: an in silico approach An ayurvedic perspective along with in silico study of the drugs for the management of SARS-CoV-2 A prospective clinical study of an Ayurveda regimen in COVID 19 patients A Perspective on Yoga as a Preventive Strategy for Coronavirus Disease The role of Yoga in working from home during the COVID-19 global lockdown Yoga for COVID-19 Public Health Approach of Ayurveda and Yoga for COVID-19 Prophylaxis Meditation and Yoga Practices as Potential Adjunctive Treatment of SARS-CoV-2 Infection and COVID-19: A Brief Overview of Key Subjects Potential benefits of Yoga in pregnancy-related complications during the COVID-19 pandemic and implications for working women Physical Activity for Improving the Immune System of Older Adults During the COVID-19 Pandemic. Altern Ther Health Med An Integrated Approach to Improve Maternal Mental Health and Well-Being During the COVID-19 Crisis. Front Psychiatry A rapid review of home-based activities that can promote mental wellness during the COVID-19 pandemic Tele-yoga for stress management: Need of the hour during the COVID-19 pandemic and beyond? Protecting the elders from COVID-19 impact-leveraging yoga Yoga for infirmity in geriatric population amidst COVID-19 pandemic: Comment on "Age and Ageism in COVID-19: Elderly mental health-care vulnerabilities and needs Yoga for COVID-19 and natural disaster related mental health issues: Challenges and perspectives Breath Regulation and yogic Exercise An online Therapy for calm and Happiness (BREATH) for frontline hospital and long-term care home staff managing the COVID-19 pandemic: A structured summary of a study protocol for a feasibility study for a randomised controlled trial Effectiveness of using a meditation app in reducing anxiety and improving well-being during the COVID-19 pandemic: A structured summary of a study protocol for a randomized controlled trial Association Between Yogic Breathing Practice With Perceived Impact of COVID-19: A Cross-Sectional Study From India Physical activity of Poles in the care for their health potential before and during the COVID-19 pandemic Rapid deployment of virtual mind-body interventions during the COVID-19 outbreak: feasibility, acceptability, and implications for future care. Support Care Cancer How Can Alternative Exercise Traditions Help Against the Background of the COVID-19 in Cancer Care? An Overview of Systematic Reviews COVID-19 Modifications for Remote Teleassessment and Teletraining of a Complementary Alternative Medicine J o u r n a l P r e -p r o o f Intervention for People With Multiple Sclerosis: Protocol for a Randomized Controlled Trial Emerging trends from COVID-19 research registered in the Clinical Trials Registry -India Chaukhamba Sanskrit Sansthan Chaukhamba Sanskrit Sansthan Plant-based Rasayana drugs from Ayurveda Swarna Bindu Prashana-an Ancient Approach to Improve the Infant's Immunity Meditation or exercise for preventing acute respiratory infection: a randomized controlled trial Effect of Integrated Yoga (IY) on psychological states and CD4 counts of HIV-1 infected patients: a randomized controlled pilot study Effect of Yoga on Immune Parameters, Cognitive Functions, and Quality of Life among HIV-Positive Children/Adolescents: A Pilot Study Randomized trial of yoga as a complementary therapy for pulmonary tuberculosis Yoga and immune system functioning: a systematic review of randomized controlled trials Alterations in Brain and Immune Function Produced by Mindfulness Meditation Levels of immune cells in transcendental meditation practitioners Sudarshan kriya yoga: Breathing for health Correlation between alpha rhythms and natural killer cell activity during yogic respiratory exercise. Stress and Health Sudarshan Kriya practitioners exhibit better antioxidant status and lower blood lactate levels Effect of rhythmic breathing (Sudarshan Kriya and Pranayam) on immune functions and tobacco addiction Regular yoga practice improves antioxidant status, immune function, and stress hormone releases in young healthy people: a randomized, double-blind, controlled pilot study Sudarshan Kriya Yoga for Improving Antioxidant Status and Reducing Anxiety in Adults. Alternative and Complementary Therapies Study on antibacterial activity of various water storing vessels Oil pulling for maintaining oral hygiene -A review A theoretical discussion of the possibility and possible mechanisms of using sesame oil for prevention of 2019-nCoV (COVID-19 coronavirus) from the perspective of colloid and interface science Chaukhamba Sanskrit Sansthan Plant-based Rasayana drugs from Ayurveda. Chinese journal of integrative medicine Efficacy of Ashvagandha (Withania Somnifera) On Immunity Of Krisha (Underweight) Immunotherapeutic modification of experimental infections by Indian medicinal plants Immunomodulatory activity of Āmalaki Rasāyana: An experimental evaluation Effect of yoga training on reaction time, respiratory endurance and muscle strength Yoga respiratory training improves respiratory function and cardiac sympathovagal balance in elderly subjects: a randomised controlled trial Effect of yoga breathing exercises (pranayama) on airway reactivity in subjects with asthma. The Lancet The risks and benefits of yoga for patients with chronic obstructive pulmonary disease: a systematic review and metaanalysis Yoga for asthma Study of the effect of yoga training on diffusion capacity in chronic obstructive pulmonary disease patients: A controlled trial Effect of Two Yogic Breathing Techniques on Oxygen Saturation. Indian journal of physiology and pharmacology Humming greatly increases nasal nitric oxide. American journal of respiratory and critical care medicine COVID-19 and mental health: A review of the existing literature Assessment of Achara Rasayana in domain of physical, mental and social health in Ayurveda students Pharmaceutical and clinical studies on compound Ayurvedic formulation. Saraswata churna International research journal of pharmacy Use of Complementary and Alternative Medicine (CAM) and Home Remedies by COVID-19 Patients: A Telephonic Survey Effects of Centella asiatica (L.) Urb. on cognitive function and mood related outcomes: A Systematic Review and Meta-analysis anxiolytic and CNS-depressant studies on different plant sources of shankhpushpi Effects of a yoga breath intervention alone and in combination with an exposure therapy for post-traumatic stress disorder and depression in survivors of the 2004 South-East Asia tsunami Post traumatic stress symptoms and heart rate variability in Bihar flood survivors following yoga: a randomized controlled study Effects of yoga versus walking on mood, anxiety, and brain GABA levels: a randomized controlled MRS study Cortisol and antidepressant effects of yoga. Indian journal of psychiatry A systematic review of yoga for major depressive disorder The Use of Yoga to Manage Stress and Burnout in Healthcare Workers: A Systematic Review Effects of Yoga on Stress Among Healthy Adults: A Systematic Review. Altern Ther Health Med Chaukhamba Sanskrit Sansthan Beyond reverse pharmacology: Mechanism-based screening of Ayurvedic drugs Immunity against COVID-19: Potential role of Ayush Kwath