Introduction and Overview

This chapter is a clinically-oriented discussion of the emotionally colored meanings that aging and declining physical status exert as life stressors in advancing years. Traditional Western and alternative Eastern medical perspectives, notably Ayurveda, are reviewed.

Older age brings numerous successes, healthy achievements, and pragmatic perspectives that enrich a meaningful life. Medical problems, however, challenge this. The aging spine, for example, typically becomes less agile; flexibility and the range of movements previously achieved with ease diminish. Pain and fatigue ensue. Activities of daily living become arduous. People notice these physical limitations in subtle and often disconcerting ways. The subliminal impact of age and physical changes is often insidious, and eventually adds to the burden that real physical limitations impose. As aging progresses and the recognition of progressive restrictions increases, quality-of-life challenges require action.

Aging is an inescapable process of metabolic and functional alterations, all of which have their sequelae. Resilience is more fragile; people take fewer risks and intentionally minimize change. Although everyone can expect the inevitable cast of aging, there is much variability in its effects. Genetic, environmental, traumatic, and lifestyle factors contribute to how health and disease interact. The way a person chooses to live can often influence genetic predispositions and ordinary wear and tear. Achieving and maintaining optimal health includes freedom from pain and its perception as suffering. Impairments in biopsychosocial functioning, especially related to musculoskeletal events, however, become a common challenge. A working knowledge of aging has pragmatic value. Screening for emerging disabilities affords the physician a valuable clinical perspective. When indicated, patients can be referred to specialists who conduct formal assessments of physical and mental function.

Wellness and healthy functioning are noticeably disturbed when decompensations in formerly healthy equilibriums occur. At this point, a physician may make a formal diagnosis. Disease and diagnosis, as such, do not denote “disability.” These say little about their functional impact. Signs and symptoms do reflect that some “impairment” has occurred.¹ Measuring diminished functioning adds to quantifying decompensations from previous baselines. A brief discussion of these concepts follows.

For these reasons, good clinical care requires that perceived impairments be carefully assessed using standardized protocols performed by specialists. Imaging studies are also invaluable. Evaluations must be correlated with the performance of a specific task or the overall performance of a complex range of defined tasks, particularly when a demand for action is required. “Tasks” are complex physical or mental actions having an intended result, for example, reading a book or riding a bicycle. Complex tasks, for example, are those encountered in occupational performance or “work.” These require the participation and coordination of multiple mental and physical systems. Other examples include time spent working at a computer, ability to lift items of a specific weight, walking, taking a shower, or driving a car. “Limitations” in these functions are ordinarily a reflection of an inability to intentionally accomplish these acts. These “impairments” denote derangements in the structure or function of organs or body parts and, to some extent, can be objectively measured. If, however, less defined syndromic symptoms are in excess of hard data measurements, estimated functional capacity can be ascertained by using clinical findings that have multidimensional consistency relative to typical reference populations. When a physician recommends that one or more behavioral tasks be curtailed because of “direct threat,” namely, risk of injury or harm to self or others, a provider “restriction” has been imposed.

After a range of therapeutic interventions and rehabilitative efforts has occurred, a functional capacity test of physical abilities measures the patient’s enduring impairments in ability to perform a defined task or tasks. Limitations in ability are called the “residual functional incapacity”; conversely, defined tasks that a patient is able to perform constitute the “residual functional capacity.” Capacity here denotes real-time ability to perform a task successfully. This is an individual’s current ability to work based on his or her capacity not only to tolerate symptoms but also to anticipate rewards and success.

The concept of “disability” is complex. It denotes an inability to perform or substantial limitations in major life activity spheres: personal, social, and occupational. Disabilities are due to limitations, especially impairments caused by medical and psychiatric conditions (including subjective pain reports) at the level of the whole person, not merely isolated parts or functions. From a functional perspective, “occupational disability” denotes current capacity insufficient to perform one or more material and substantial occupational duties currently demanded and accomplished previously. Last, the term “handicap” denotes an inability measured largely by the socially observable limitations it imposes. Handicap connotes the perception or assumption by an outside observer that the subject or patient suffers from a functional limitation or restriction. The term “handicap” implies that freedom to function in a social context has been lost. In this sense, people with handicaps can benefit from added supports. “Accommodations” that modify or reduce functional demands or barriers are given to them. Opportunities in social contexts, therefore, afford expanded freedom for more activities. In this way, participation restrictions diminish. Intolerance to pain and fatigue are the most frequent reasons patients stop working and claim disability.

Striving for and maintaining a good quality of life or better is a fundamental value for everyone. This encompasses not only developing new strengths both mentally and physically, but also preserving current assets. Efforts in this direction prevent functional limitations and ameliorate disabilities. These include, for example, maintaining upright and stable posture, agile ambulation, and freedom from the limitations and burdens that pain imposes. Routine medical care and available specialized care afford opportunities to benefit from the advances that rational scientific medicine has to offer. The progressive globalization of diverse cultures, moreover, has introduced Eastern systems of wellness and healthcare not previously recognized or even available in the West. One of the inestimable benefits of this expanding diversification is the widening scope of health-enhancing treatment options. The cultural diversity and traditions of both physicians and patients make it wise for the contemporary healthcare provider to be cognizant of medical systems other than those typically regarded as conventional in Western terms. The prudent physician must always distinguish what is merely wishful thinking from what is yet unproven but within the context of realistic discovery and future confirmation.

Among these, Ayurveda – Traditional Indian Medicine – will be introduced both theoretically and as a range of interventions dealing with the management of aging and orthopedic problems. Ayurveda is a novel treatment option or adjunct among more traditional Western modalities. Given such choices, each person has opportunities to choose proactively, while realistically assessing his or her own specific needs and preferences in selecting healthcare. Different approaches may complement one another or be used integratively. In an available framework of rational and diverse treatment options, choices grounded in scientific evidence and trusted traditions may serve as a basis for good, well-rounded clinical care.^2,3

Understanding the Patient’s Perspective

Adequately understanding how patients perceive their distress, and the problems involved in seeking help and choosing helpers, is fundamental to good care. The extent to which a provider appreciates and utilizes this understanding substantially contributes to patient compliance and better outcomes.

When a patient finally recognizes that signs and symptoms, especially pain, fatigue, and diminished functioning, are not transitory and may be progressively worsening, mixtures of distress, ambivalence, curiosity, and denial interact. Anxiety further blurs clear thinking and discrimination. For older patients, conscious fears about more permanent loss of functioning and subtle fears about reduced life span, even death, are present. Anxiety, fear, and inhibitions go hand-in-hand.

Older patients are acutely aware of changes in physical and psychological functioning. Identifying and adequately adapting to these degenerative changes is difficult, since even acclimating to the inevitable, ordinary changes met with in daily life can be trying. Patients often dread the efforts required to undergo a variety of tests, some of which are arduous and time-consuming, and others that are, in fact, painful (for example, discogram). A patient’s insurance may not adequately cover some diagnostic procedures, or even some recommended surgery. This can present not only a financial burden but also an important psychological stressor to older patients whose incomes and earning capacities are limited.

Often, patients talk with family members and friends before deciding to consult a physician. Although many patients are now more knowledgeable about medical illnesses and treatments than in the past, especially because of media exposure and availability of internet data, the personal nature of the problem and its attendant emotional conflicts continue to exert significant cognitive dissonance and avoidance. It is not uncommon for patients to become clinically depressed secondary to the stress and diminished functioning resulting from orthopedic problems. Developing a stooped posture or various degrees of kyphosis, for example, affects one’s physical appearance and adds to lowered self-esteem and withdrawal. Many become progressively isolated and remain homebound. In previous generations, the phrase “shut-in” described such confinement.

These considerations highlight the importance of the initial diagnostic process for the physician. Surgeons need to consider possible referral for further psychiatric assessment and treatment of anxiety and depression. The art and science of medicine, interviewing, and the physician-patient relationship intersect here. In contrast to problems in older patients, an often overlooked issue is the presentation of pain with or without orthopedic injury in the young adult. Behaviors with a high risk for orthopedic injury, such as motorcycle and race car driving, are more common in this population. Previous histories of substance abuse, even current malingering, must be high on one’s clinical index of suspicion to help avoid wrong and puzzling diagnoses, and treatments that appear to fail or seem resistant.

Explicit and subtle factors contribute to a good interview. Attentiveness, composure, active listening, and sensitive responsiveness are fundamental. A recognition of the inevitable anxiety and cognitive strain under which a patient in distress labors should remind the physician to go slowly in questioning, speak clearly, and reiterate important diagnostic questions. Most patients, because of anxiety, have a difficult time hearing and understanding discussions with the doctor. Older patients, in addition, may be less receptive because of the aging process itself. People in pain show irritability and impatience. The physician’s attentiveness to these and other features of the patient’s presentation will facilitate a meaningful yield in accurately assessing signs, symptoms, and history. Listening attentively to what is said and what seems left out is important. Carefully assessing the extent of a patient’s expectations for recovery from pain and limited functioning is important. Written materials outlined by the surgeon before, during, and after a surgical procedure are often useful. When tailored to the specific patient and his or her particular condition, they are seen as believable and help consolidate diagnostic and treatment information, and minimize misunderstanding and error. All aspects of patient-physician contact should facilitate the entire diagnostic and treatment process. Telephone inquiries, waiting rooms, and administrative and nursing personnel can set the stage for a productive interview and more accurate data collection. Tightly managed pre-op assessments also ensure better post-op compliance with rehabilitative recommendations such as adherence to physical therapy.

Last, orthopedic surgery teams tend to have multiple participants. With so many caregivers in the field, the wise chief surgeon intentionally takes the lead and orchestrates, within reason, the specific and overall flow of care, always keeping the needs of the individual patient in mind. Ideally, a designated contact person will be assigned to the patient throughout the process. Patients are aware of this. Compliance and better outcomes result.

Western Perspectives on the Psychology of Aging

Aging denotes the effects of the passage of time on the body as well as its interpretation, as felt in emotional terms. Physical changes and attendant pathology are typically tangible and measureable. Emotional changes are much more subtle. These progressive changes are reflections of the continuing process of crossing “chronological thresholds.” Each person’s life is an autobiography of both change and continuity. A “considered” life has been looked at in a purposeful way. In the process, real opportunities open. One can choose to take an active role rather than merely being passive. Ongoing self-examination, self-exploration, and action are basic tools. Transformations of perspective, if purposely thought out, become essential for successfully traversing the inevitable changes that occur across the lifespan. Creative and lively attitudes bring rewarding results.

Why would a person want to be proactive? This chapter will make it clear that aiming for optimal health and biopsychosocial balance is essential to a sound lifestyle. The motivations for this are grounded in both biology and psychology. Biological survival means adapting to the constantly changing environment in as healthy a way possible. Psychological survival means creating conditions that strive for positive quality of life and result in meaningful satisfaction. Survival presumes intelligence, flexibility, and recognition of novel opportunities for success. This shores up functional viability on all levels, physical and psychological.

A new conceptual paradigm called the biopsychospiritual model⁴ has recently been advanced. This enriched perspective recognizes the integral nature of body, mind, and spirit and includes such considerations as sacredness of life, refinement of consciousness, and the deepening fruitfulness that a proactive life may take over the lifespan. Profound respect for life and a renewed humane outlook underlie this approach. These considerations have pragmatic value. They can result in a sense of self-empowered creativeness that engenders the rational therapeutic optimism so essential to functional generativity across life’s chronological thresholds and challenges.

The passage of time changes both body and mind, often in incompatible ways that can be confusing. The enrichments that adaptive intelligence brings over the years also enable people to more sharply sense their developing medical problems. Biological aging denotes the effects of internal physicochemical changes. Menopause and andropause are well known conditions. “Osteopause”—a decline in robust bone integrity—is also real. These include both decelerations in functioning and the impact of external aggressions such as trauma, disease, sun, wind, ionizing radiation, and extremes of temperature, to name just a few. Psychological aging is affected by perceptions of self and others: a sense of self and self-image, and earlier experiences with others. Viewing and identifying with how parents and grandparents age undeniably shapes one’s self-image. How significant others physically change over time never goes unnoticed. Although our “biological clock” is out of our personal control, our “psychological clock” is, in fact, the timing we create for ourselves. Forced retirement, for example, solely owing to pain and health challenges, some of which may be treatable, repairable, or reversible, is a prime instance of biology colliding with psychology.

After young adulthood, at about age 30, a perceptible decline occurs in the physical self, the body. In middle adulthood, the 40s, one becomes more realistically able to assess both one’s positive assets and those considered less desirable. After 50, noticeable declines in mental flexibility make it more of a challenge to implement change based on one’s recognition of real and subtle limitations. At this time, the ill health of others seems to stand out. The death of a loved one or spouse is not uncommon. After 60, stark awareness of aging and some degree of chronic pain confront most people. This results in less energy, mobility, and stamina. One’s memory tends to decline as well. Stressors become more frequent; adaptation to stressful life events is less resilient in advancing years. Dysphoria and clinical depression, at times, may add to the burden of aging. The National Center for Health Statistics in the United States shows that the suicide rate rises after age 65, especially for the Caucasian male population.

Anxiety accompanies tangible limitations of functioning in the course of aging. Anxiety, often felt as a low-grade sense of malaise, also tends to intensify with age. Irrational fears may develop. Pain and progressive functional limitations exacerbate feelings of harsh loneliness. Many older adults wish to remain in the workforce, and dread the occupational limitations that health challenges impose. Experts in work-related disability research have shown that the beneficial effects of work do outweigh the risks related to work. The far-reaching rewards associated with work are substantially greater than the harmful effects of a long-term lack of meaningful work. Aside from the financial advantages, work enhances self-esteem, structure, and social affiliation.

As aging and the concomitant suffering associated with pain increase, the problem of isolation becomes pronounced. Isolation is not only purely social. More important, the negative effects of isolation derive from subjectively interpreted feelings of withdrawal, disinterest, and anhedonia. These typically provoke subtle feelings of unconscious envy and conscious feelings of jealousy in complicated ways that further exacerbate mental equanimity. Such complex emotions elicit excessive anxiety, which tends to destabilize the mind. Less than optimal thinking processes, poorer decision-making skills, and a hypervigilant state marked by dysphoria result.

Various degrees of emotional contentment, to be sure, also accompany the aging process. The core of the biopsychosocial self has its base in the physical body. The conscious and unconscious sense of this awareness is termed “body image.” Identity, confidence, and mental equanimity are stabilized to the extent that body image is ego-syntonic or pleasurably felt. Self-esteem strengthens. As the body and its functioning naturally decline, however, body image suffers. People then experience various degrees of emotional malaise, discomfort, and unhappiness.

The patient’s physical appearance and perception of being fit, attractive, beautiful, or handsome are intimately involved in the aging process. The attendant decline in functioning makes this more poignantly felt. The aesthetic sense of beauty is based on innate biological and evolutionary programs along with individually-acquired learning. The roots of the perception of attractiveness rest on the perception of symmetry, proportion, and novel complexity. Attractiveness results more from biological characteristics whereas beauty and self-confidence add emotional depth, the psychological dimension. As aging and illness occur, the physical body becomes less symmetrical. Female and male attractiveness appear to diminish. More rigidly fixed postures and their emotionally-laden facial expressions become etched in. Looking in the mirror is a distressing reminder. When others respond to the patient with disdain after noticing a less than attractive appearance, this distress is reinforced. These changes, moreover, signal that something should be done. The patient wonders what can be done to help or correct undesirable changes. Questions about how to repair the burgeoning deterioration that is perceived to be the source of distress come to the fore. The more that physical deterioration can be ameliorated, the more an individual’s sense of being fit is strengthened.

Typically, the decade of the sixties introduces the inevitability of bodily aches and pains, less than optimal posture, and, perhaps, some degree of structural deformity. This stark confrontation with the reality of the physical side of the self spares few. The perception and interpretation of this painful recognition stimulate upset, ambivalence, and emotional discomfort. An individual’s emotional response to pain is felt as suffering. The patient’s description of pain is often inarticulate and requires the sensitive, explorative questioning of the physician. This again attests to the importance of diagnostic interviewing and establishing a positive therapeutic relationship.

Although natural decline over the course of chronological thresholds is inevitable, it is possible to manage these in ways that optimize overall health. This can restore a more harmonious physical appearance, a goal most patients eagerly desire. The upshot of this is a more confident mental attitude.

Western Perspectives on Managing the Aging Process

People perceive and handle stressful life events situationally; moreover, stressors and their management change over time. The cumulative effects of stress and life’s complexities add to existing anxieties and may exacerbate chronic physical ailments.

As aging progresses, emerging medical problems and the process of effectively dealing with them take on increased importance. In addition to the burdens that the possible development of heart disease, hypertension, and diabetes may have for patients, the aging spine can suffer a variety of structural and functional changes. With age, disks in the spine dehydrate and lose their function as shock absorbers. Adjoining bones and ligaments thicken and become less pliable. Disks may then pinch and put pressure on nearby nerve roots and spinal cord, causing pain and diminished functioning.

Age-related modeling of bone is associated with ligamentous laxity, facet hypertrophy, and an unstable spine. The clinical presentation of back pain, deformities, and shortened stature typically results from disk degeneration, vertebral wedging, and vertebral collapse. Back pain can have cervical, thoracic, or lumbar etiologies. Musculoskeletal problems include lumbar back sprains and strains, osteoarthritic degenerative disk disease, rheumatoid arthritis, spondylosis, ankylosing spondylitis, lumbar spinal stenosis, spondylolisthesis, and herniated disks. Osteoporosis can cause spinal compression fractures, kyphosis, and pain. Besides genetic factors, trauma, and aging, the combination of poor diet, less-than-optimal exercise, and smoking contributes to bone problems.

Western medicine offers a range of conservative medical and surgical interventions. Conservative therapies include dietary modification, exercise, and medications such as nonsteroidal antiinflammatories, analgesics (acetaminophen, aspirin), opioids to block pain impulses to the brain and modulate the perception of pain, muscle relaxants, tricyclic antidepressants, antiseizure medications, cortisone injections, and nerve blocks. In addition, physical therapy, chiropractic, and orthotics such as spinal bracing are employed. When these are not adequate to restore functioning, surgical interventions provide more options. Orthopedic implants are arguably a major innovation that can return patients to the workforce and ultimately cut healthcare costs on all levels.

Psychiatry offers help in its treatments to reduce anxiety, depression, and help modulate the impact of stress. Managing the mind through various types of psychotherapies helps enhance generativity. This, in turn, fosters health enthusiasm, productivity, a meaningful life, supportive relationships, and minimizes stagnation. Psychopharmacological interventions complement psychotherapies.

Eastern Perspectives on Medicine and Psychology

Western European and North American evidenced-based conventional medicine is called allopathic medicine. This “technomedicine” rests on tangible data. Standardized protocols objectively test its hypotheses and offer pragmatic clinical approaches. Building on its several thousand-year-old Greek and Latin foundations, it has become increasingly scientific over the last centuries. Its methodology and findings are objectively verifiable using statistically valid and reliable parameters. In contrast, Eastern medical systems originating in ancient India and China reputedly have their roots in traditions that span thousands of years, well into the pre-Christian era. Eastern medical systems are clinical, at times philosophical, and exceedingly subtle. They espouse axiomatic ontological hypotheses, some of which appear as untestable assertions. Their epistemological methodologies, however, are strong, although entirely empirical. This non-Western orientation is best viewed by Westerners in its own native métier for it to be grasped, understood, and not distorted by the truncating effects of partisan bias.

Traditional Chinese Medicine (TCM) and Indian medicine (Ayurveda) are the two most established medical systems in Eastern medical traditions. TCM and Acupuncture have been increasingly available in the West for the last 25 years. Ayurveda has only recently emerged in Western countries. This chapter introduces Ayurveda as a primary complementary and alternative treatment option.

Ayurveda is Traditional Indian Medicine (TIM). Its adherents regard it as originating roughly 6,000 years ago. Through the travels of its Hindu and Buddhist followers, it spread to Tibet, China, Japan, Korea, and other Far East regions between 1,500 and 2,000 years ago. Today, the clinical practice of Ayurveda retains many perspectives and methods rooted in its origins. In the last 25 years, it has been introduced in Europe and only recently in the United States. In terms of the translation of its age-old concepts into Western ideas and testable hypotheses, Ayurveda in America remains in its infancy. Modern scientific methodologies are only now being used to examine the safety and effectiveness of treatments that have been empirically used for thousands of years. Western training programs, especially those affiliated with large universities and medical schools, have only just begun offering standardized curricula. Contemporary Ayurveda is a medical system in statu nascendi, in the process of being born.

In modern-day India, tribal peoples called adivasis living in central and southern geographical areas (for example, Kerala) are believed by archaeologists to be descendants of Bhimbetkans, Indian aboriginals whose origins date back to the Mesolithic period, roughly circa 30,000 BC to 7,000 BC. These indigenous people, who make up about 8 % of the total population, are not generally integrated in mainstream Indian society. They practice what they call “tribal medicine,” using single herb remedies, many of which are still referred to by idiosyncratic names. Current studies, however, demonstrate that these herbs correlate directly with the range of herbs used in standard Ayurvedic practice for the last several thousand years until now.

Ayurveda is preeminently a health and wellness system. Nevertheless, a wide variety of integrated propositions from biological, psychological, philosophical, and spiritual sources frame it as a foremost system of medical treatment. In many ways, it is a philosophy of medicine pragmatically applied. The roots of Ayurveda remain deeply planted in its cultural origins and may appear unfathomable, even fanciful, to Western thinkers. In terms of understandability, much less acceptance, it is hoped that Ayurveda’s epistemological style with its ontological orientation (for example, the concept of the Five Great Gross Elements) will present an inviting challenge rather than evoke an automatic dismissal merely because of the apparent “foreignness” of such unfamiliar conceptualizations.

Medical science in Ayurveda begins with the individual. Each person is an integral whole composed of three principal dimensions: physical body, mental functioning, and a spiritual/consciousness base. This perspective is, in essence, a monistic one that eschews dualisms of all sorts. To understand the naturally integrated operation of these component dimensions, however, careful distinctions are made for heuristic purposes. Assessments and treatments, therefore, are based on recognizing complex dynamic interactions among biological, psychological, social, environmental, and spiritual/consciousness factors. Mutative subtle energies believed to be essential forces on all these levels drive their organization into patterns experienced in the form of wellness and disease presentations discernable in terms specific to Ayurvedic theory.

Ayurveda: Traditional Indian Medicine

Introducing Ayurveda, with its almost 6,000 years of prehistory, history, and development, in a few paragraphs is a formidable task. In order not to misrepresent or oversimplify this complex edifice of ideas, the following schematic outline is presented. Only the outer edges of Ayurveda’s Weltanschauung (German), darshana (Sanskrit), or worldview can be addressed in this brief primer.⁴

The history and development of Ayurveda reputedly spans 6,000 years, for most of which time, only an oral tradition existed. When the sacred scriptures of ancient India emerged in the Vedic period (circa 3,000 BC to 600 BC) in the four Vedas – Rig, Sama, Yajur, and Atharva, Ayurveda gradually became formally organized. Its three great fathers, in the respective foundational texts that bear their names, later codified it: Charaka Samhita (c. 1,000 BC), Sushruta Samhita (c. 660 BC and supplemented by Nagarjuna c. AD 100), and Asthanga Sangraha of Vagbhata (c. AD 7^th century).^5,6,7

The word “Ayurveda” derives from two Sanskrit terms, ayus meaning life or the course of living, and veda meaning knowledge, science, or wisdom. Ayurveda as the wisdom of life denotes an organized set of propositions that contain philosophical, ethical, cosmological, medical, and therapeutic principles aimed at generating, maintaining, optimizing, and restoring physical health and psychological well-being. This implies the absence of illness, disease, and suffering. The well-known system of yoga, in fact, originally came from the Vedas and later codifications arranged by the Indian sage, Patanjali (circa AD 100). Yoga practices differ in emphasis from Ayurveda but are an ancillary part of it. They complement Ayurvedic treatments.

As a medical and surgical system, Ayurveda has main subspecialties: internal medicine, surgery, otolaryngology, ophthalmology, obstetrics, gynecology, pediatrics, toxicology, psychiatry, anti-aging, rejuvenation, reproductive, and aphrodisiac medicine.

Each individual is considered an integral triune to the extent that active work is directed toward integration of bodily needs (sharira), refinement of psychological abilities (manas), and sensitivity to the consciousness-enhancing practices that stabilize these. Responsiveness to seasons and the changing environment (kala parinama) makes Ayurveda exceedingly aware of the inevitable imbalances and disease processes that present themselves and require attention at these times. I refer to this self-environment connectivity as “eco-concordance.”

A strong ethical framework is an intrinsic part of Ayurveda. The standard of care aims for continuing improvement toward the recognition and treatment of mental and physical disorders. Not only does this add to good patient care but also to the refinement of diagnostic acumen and the effectiveness of treatment interventions. Saving life and easing suffering are axiomatic values. Ayurveda’s three great texts make this explicit. Patient beneficence, protecting from harm together with actively promoting wellness, respect for all persons and individual self-direction, and fair and just socially responsible practices are the training standards of Ayurvedic practitioners. The Ayurvedic Oath (Sisyopanayaniya Ayurveda), in fact, may have preceded the Hippocratic Oath; both have striking correlations in their guidelines.

Ayurveda’s conceptual models imply a complex and multitiered worldview. Key ideas often present as metaphors. These suggest overarching principles; what they actually refer to remains open to examination in terms of Western concepts of physics and physiology. Sanskrit names are included here in italics.

Fundamental Ayurvedic propositions include the following: the Five Great Gross Elements (Pancha Mahabhutanis) – Ether, Air, Fire, Water, and Earth; the biological doshas –Vata, Pitta, Kapha; Agni – how cells and tissues process molecules, the digestive and assimilative processes, metabolic rate, and cellular transport mechanisms; the seven bodily tissues (sapta dhatus) – plasma, blood, muscle, fat, bone, marrow and nerve tissue, and reproductive tissue; Ojas – immunity, stress modulation, and resistance to disease; Prakruti – an individual’s “biopsychospiritual” constitutional type; Samprapti – pathogenesis; Vikruti – specific disease syndromes in an individual; Ahara – diet; Vihara – lifestyle; Dravyaguna Shastra – pharmacognosy, pharmacology, materia medica, and therapeutics.

The Five Great Gross Elements are concepts that reside on the borders of philosophy, cosmology, and the material world of atoms and molecules. These five Elements – Ether, Air, Fire, Water, and Earth – are considered primary pentads, elemental substances composing matter in all its varied states of density. The Elements are the building blocks of tissues. As protosubstances, Elements carry strong metaphorical and emblematic connotations that imply a representation of physiological functioning when considered from the viewpoint of biological life. For example, each bodily tissue has a varied composition of Elements suggesting its character, especially useful as it relates to choosing specific therapeutic herbs of similar Elemental composition. Ginger (Zingiber officinale), for example, is thought to have a high Fire content and is used to stimulate digestive processes (Agni), which require such a “hot” (actively potent) energy to promote optimal functioning.

The three biological doshas – Vata, Pitta, and Kapha – are the backbone of Ayurveda. These doshas had traditionally been termed “humors” in historically Western medical systems such as those of ancient Greece and Rome, as travelers from the East influenced these developing medical systems. The original idea of a dosha, a biological and energetic substance, however, originated much earlier in ancient India. The work of Charaka, the internist, and subsequently the compilations of Sushruta, the surgeon, codified this. The word dosha literally means spoiling, fault, or darkener. This refers to the dosha’s inherent ability to become vitiated or agitated. This disruption then alters the condition of tissues and the body’s equilibrium. This action is, in fact, a positive homeostatic mechanism regulating the health of the body. There are only three doshas. In biological organisms, each operates as both a bioenergetic substance and a regulatory force. Doshas are biopsychological principles of organization both structurally and functionally, the least common organizational denominator of tissues and mind.

Vata connotes wind, movement, and flow. Its principal characteristic is propulsion. It is responsible for all motion in the body from cellular to tissue and musculoskeletal systems, acuity and coordination of the senses of perception, equilibrium of tissues, respiration, and nerve transmission. It is said to possess erratic, cold, dry, and clear qualities. Vata underlies the body’s symmetry and proportion. When the proper flow of Vata through the body is impaired, pain is felt and distortions in form appear.

Pitta is described as the biological fire humor. Its etymological derivation is associated with digestion, heating, thermogenesis, and transformation. Pitta’s chief action is digestion or transformation occurring through cellular, tissue, and organ levels to psychological, cognitive, and emotional spheres of mind (Manas). It is said to possess hot, flowing, and sharp qualities. The fundamental Ayurvedic conception of Agni, the energy of the digestive fire, is inextricably tied to the activity of its biological container, Pitta dosha.

Kapha is the biological water humor. Its chief characteristic is cohesion and binding. The word Kapha means phlegm and water flourishing, and suggests qualities of cohesiveness and firmness. Kapha maintains the stability of bodily tissues and imparts protection, structure, and denseness. It is said to possess heavy, dense, solid, and cold qualities, and the attribute of mass.

Each individual possesses a unique composition of all three doshas, each one contributing qualitative and quantitative uniqueness to that person. They are the overarching regulators of biopsychological functioning in health and disease.

Agni, a central Ayurvedic concept, refers to the way one’s genetic constitution programs basic metabolic processes, the dynamics of anabolism and catabolism. Its centrality is only second to the conception of the doshasAgni was described historically in various ways (for example, fire itself; the sun; and the divine force) as early as the Rig-Veda and Atharva-Veda. In ancient times, it was seen as the power behind all forms of transformation, the mediator between macrocosm and individual. As the primordial energetic dimension of Pitta dosha, Agni functions to control the rate and quality of all biological and mental dynamic processes. Thirteen subspecies of Agni are described in relation to their respective actions at cellular, tissue, and system levels. Agni as the heat element in processes of thermogenesis also aids the body’s own infection control self-management.

In Ayurveda, Agni and the concept of digestion are interchangeable as functional ideas. Agni, however, far transcends the more circumscribed meaning that digestion denotes in Western physiology (for example, intraluminal hydrolysis of fats, proteins, and carbohydrates by enzymes and bile salts, digestion by brush border enzymes and uptake of end-products, and lymphatic transport of nutrients). Digestion in Ayurveda includes processes that transform raw, nonhuman substances (foods, herbs, sensory impressions, and so forth) by using material and psychological “digestive” mechanisms. Vata, Pitta, Kapha, and Agni handle these in order for those raw nutrients to become actively utilizable, assimilable, and form part of the biopsychological structure of the person. Clinically, the condition of one’s Agni correlates with current health or disease. Optimizing Agni by diet, herbs, and lifestyle is fundamental to all treatments.

The physical body is composed of seven bodily tissues (sapta dhatus): plasma, blood, muscle, fat, bone, marrow and nerve tissue, and reproductive tissue. Each has micro-sized (subtle and invisible) and macro-sized (gross and visible) channels of circulation (srotas) that function to transport nutrients, wastes, and other substances both in their respective tissues and to other bodily tissues, organs, and systems. Plasma (rasa) as the total water content of the body, holds a special place since it is considered to pervade the entire body with essential nutrients and the moisture that sustains the fullness of vitality (prinana).

Ojas is the Sanskrit term referring to the bioenergetic bodily substance of immunity, strength, and vital energy reserves. It is the crucial Ayurvedic theory of the body’s innate capacity for immune resistance to disease. In Traditional Chinese Medicine, the concept of Yin and Jing or “Life Essence” believed to reside in the kidneys compares with the Ayurvedic concept of Ojas. Some contemporary Ayurvedic researchers have suggested that the entire conceptualization of Ojas and its implications might correlate with the functioning of the hypothalamus in terms of the stress response, and with the energy of cellular mitochondria as the powerhouses of the cell. In Ayurveda’s materia medica, for example, the herb ashwaganda (Withania somnifera) has been used for thousands of years as a powerful adaptogen, increasing resistance to cellular, physiological, and mental stress, restoring homeostasis, and enhancing stamina and mental performance. It is believed to contain and enhance the body’s store of Ojas.

The Ayurvedic idea of individualized constitutional types or prakruti is a cornerstone of basic theory and practical therapeutics. The sine qua non of constructing individualized treatment plans rests on this. Prakruti denotes a person’s unique biopsychological (anatomical, physiological, and psychological) template of predispositions, capacities, abilities, preferences, strengths, and vulnerabilities. It is a quotient of the endowment and interactions of each of the three doshas (Vata, Pitta, and Kapha) from birth onward. It is measured and determined solely on clinical grounds, and includes physical appearance, strength, quality of digestive processes, and psychological attributes. Prakruti does not essentially change throughout the lifetime. It is an important criterion for determining and recommending individualized diet and lifestyle choices.

Vikruti is the clinically observable imbalance of the doshas that pathological processes impose on the prakruti. Disease (roga) plays itself out within the field of the ill person (vikruti).

Disease etiology (nidana) is multifactorial. In addition to microbes (krimi), trauma (pidaja), genetic predispositions (sahaja roga), congenital (garbhaja), acquired (jataja), seasonal (kalaja), and inevitable, for example, aging (swabhavaja) influences, Ayurveda has traditionally espoused an agriculturally-oriented metaphor of “field and seed.” The field is the prakruti – body, mind, and consciousness ground of strength. The seeds of illness are its genetic and acquired proneness to vulnerabilities. If prakruti and Ojas are balanced, the body and mind are less susceptible to disease. Whatever the precipitating causes of illness, the balance and integrity of doshas inevitably become disrupted, and, if left unchecked, lead to disease.

Samprapti denotes pathogenesis proper. When Agni or digestive and assimilative strength becomes impaired, an individual’s dosha complement becomes unbalanced; for example, the level of Pitta is too low and the force of Vata too high. This leads to an abnormal buildup of toxic substances (Ama) in the body. They, along with congenital and acquired defective tissue and organ sites, launch the pathogenic process that gradually results in manifest disease. The six stages of Samprapti are the following:

Diagnostic methods in Ayurveda are essentially clinical. Diagnostic evaluation of the patient follows a tenfold process originally outlined by Charaka. Some of its features include assessing prakruti, vikruti with its pain and signs and symptoms of illness, tissue quality by inspection of morphology and functional status, body proportions, mental and emotional characteristics, digestive strength, energy level and stamina, and age-related abilities and limitations. An additional eightfold examination formulated in the 1500s also includes Ayurvedic pulse diagnosis.

Ayurveda has developed systems of nutrition as dietetics and specific food intake (ahara) over the course of thousands of years. It is a unique system incorporating the aforementioned theoretical elements and matching their analyses to recommendations for food options. An individual’s prakruti and vikruti in the context of prevailing seasonal influences are taken into account. Foods function to maintain and enhance health, and, at specific times, act therapeutically. Ayurvedic therapy aims at balancing the doshas and restoring their optimal proportions for each dosha’s single and coordinated efficiency. When doshas are properly aligned, Agni’s operation optimizes and reinforces dosha stabilization.

Lifestyle and behavioral practices (vihara) are crucial features of Ayurveda’s pursuit of wellness. Based on constitutional predispositions, strengths, weaknesses, and current needs at a specific age and in a specific season, recommendations for daily hygiene, exercise, development of mental faculties (for example, study, yoga postures, breath expansions/pranayama, and meditation), and suitable recreational activities are suggested. Guidelines for highly ethical standards (sadvritta) closely related to classical Western values and behaviors considered righteous and reasonable are included. Without requiring the ritualized constraints of a religion, Ayurveda incorporates the Hindu and Buddhist doctrine of karma, which ethically denotes accountability and taking personal responsibility for thoughts and actions. A proactive life by choice and adherence to medical guidelines includes a specific diet to maintain constitutional balance, appropriate responsiveness to the effects of time (for example, chronological age, diurnal variations, and seasons), and a suitable lifestyle. Besides the absence of disease and disability, wellness promotes functional integrity, strength, endurance, flexibility, and balance. Changes promoting wellness also presume newly-gained insights into motivations, attitudes, emotional dispositions, and behaviors. Moreover, a realization of belonging to the shared community of the one human family and the ultimate unity of all nature counters unrealistic feelings of isolation or narcissistically-based specialness.

Dravyaguna Shastra is Ayurveda’s age-old science of medicine, a herbo-mineral pharmacopoeia. Herbal supplementation (aushadha) is used both prophylactically and as active treatment for disorders. About 700 herbs are recognized and used, although there are thousands more being employed in less standardized ways.

Modern research in the therapeutic effectiveness of Ayurvedic herbs has laid particular emphasis on the role of phytochemicals and natural antioxidants contained in these traditional herbal and spice substances. Phytochemicals are nonessential nutrients. The function of these micronutrients is protection against tissue damage and for disease prevention. Some of the proposed mechanisms for these effects include antioxidant activity, anti-inflammatory action, glutathione synthesis, effects on biotransformation enzymes involved in carcinogen metabolism, induction of cell cycle arrest and apoptosis, and inhibition of tumor invasion and angiogenesis.

Specific fractions of edible substances contain phytochemicals. These are flavonoids, isoflavones, allyl sulfides, catechins, anthocyanins, polyphenols, carotenoids, terpenes, and plant sterols. All phytonutrients are of plant origin – fruits, vegetables, herbs, and spices. They target unstable free radicals, known as reactive oxygen species (atoms, ions, or molecules with one or more unpaired electrons that bind to and destroy cellular components) both in general and specific ways to scavenge them and prevent pathogenic membrane disruption. This beneficial action is accomplished by neutralizing damaging ions and thereby reducing the oxidative stress that impairs endothelial cell integrity throughout the entire circulatory system. For example, phytonutrients make low density lipoproteins (LDL cholesterol) less likely to be oxidized by free radicals, become trapped in the intravascular lumen, attract calcium, and form plaques that narrow arterial patency and encourage blood clot formation. Additionally, antioxidant activity reduces excessive crosslinking of collagen molecules, thus strengthening connective tissue throughout the body and benefiting bone, ligaments, and joints. Another important mechanism of herbal treatments is the role of nitric oxide production by the endothelium to enhance vasodilation and arterial perfusion.

Lastly, Ayurveda’s preeminent radical detoxification program – Panchakarma – is a five-step process that occurs over a period of several weeks and which must be closely supervised by a qualified practitioner. A few typically-used substances and modified treatment protocols will be discussed later in a consideration of orthopedic problems.

Ayurvedic Perspectives on Aging

Normative fluctuations of doshas and specific dosha dominance are metrics used to denote epochs in the lifecycle. Older age becomes progressively noticeable in the later 50s and increasingly thereafter. This correlates with a predominance of Vata dosha. All of Vata’s key qualities begin to affect the entire person: dryness, coldness, stiffness, rigidity, hardness, roughness, constriction/spasm versus looseness/hypermobility cycles, reduced tissue mass, and increased frailty. The body’s harmonious symmetry and its proportions diminish. For example, intervertebral disks tend to become dehydrated and exert pressure on adjacent nerve roots. Stature and posture change. The aberrant flow of Vata in vitiated tissues and channels of circulation signals pain. This influences an individual’s Biopsychospiritual makeup, and a general trend toward ungroundedness (unsteady gait, loss of confidence, and anxiety) becomes apparent. Cognition, although wiser from years of adaptive experience, may lack the swiftness, alacrity, and recall once present.

The appearance of aging is observed in face, body posture, and attitude. Older persons may look tired, downtrodden, burdened, dry, even sullen and angry. Much of this results from pain and the increasing constraints on previously enjoyed levels of functioning.

It is fair to add that an individual’s past history of learning, achievements, and successes on material, emotional, and spiritual levels also has etched multiple contours of self-confidence and pragmatic memory. These inner resources along with social ties counter isolation and loneliness. They add to the satisfaction a favorable quality of life has engendered as aging proceeds.

Ayurvedic Perspectives on Managing the Aging Process with Respect to Bone

A comprehensive discussion of optimal age-management strategies and therapies unique to Ayurveda is beyond the scope of this chapter. Ayurvedic interventions always involve a multitiered approach that aims to modulate the deterioration associated with aging by enhancing the competence of repair mechanisms. A strong emphasis on Vata modulation and normalization through diet, seasonal, and lifestyle recommendations is the basis of all treatments. Included are specific prescriptions for physical exercise (vyayama), oil massage, gentle yoga stretches for musculoskeletal flexibility, and herbal adjuncts. The entire field of Rasayanas or rejuvenation medicine affords an untapped treasure trove awaiting examination by Western research. Because Ayurveda is profoundly holistic, all the aforementioned are components of an intense, one-to-one therapeutic relationship with a practitioner who acts as physician, coach, and, at times, psychotherapist. In this way, anxiety, fear, and depression, at times the deepest unconscious sources of pain and suffering, are addressed and managed.

Bone (asthi) is considered one of the seven major tissues composing the material substance of the physical body (sharira). Bone, its membranous coverings (purishadhara kala), articular joints (sandhi), cartilage (tarunashti), and channels of circulation (asthivaha srotas) are major components of the skeletal system. It is primarily derived from three of the Five Great Gross Elements or principles of organization of matter: Earth and Water (Kapha dimension) and Air (Vata dimension). The Sanskrit term asthi means to stand and endure. A major function of bone is support (dharana); bone also acts to protect vital organs and contributes to the shape and form of the body. Vagbhata (c. AD 700) asserts that bone tissue nourishes nerve and marrow tissue (majja dhatu) in critical ways. In terms of doshas, the substance of bone is essentially of Kapha origin. Two subspecies of Kapha are dominant: Avalambaka Kapha, centered in the thorax and vertebral column, and Shleshaka Kapha, situated in joint fluids and apposing structures such as disks and articular surfaces.

Bone, moreover, is one of the body’s largest containers of Vata dosha, particularly Vyana Vata (pulsatile, rhythmic expansion and contraction) and Apana Vata (downward, eliminative action). Periosteal coverings are considered the membranes (purishadhara kala) containing and contributing to the nourishment of bone.

The principal repository of Vata in the entire body resides in the large intestine or colon. The colon’s own membranes share a functional tie and the same name with all osseous membranes. This important correlation links the health and pathology of the colon with the health and pathology of the skeletal system. Its implications for treatment are profound. Western science regards the colon as having several important functions including resorption of water, electrolytes, and minerals back into the body, further digestion of various kinds of sugars and fiber, production of vitamins, especially vitamin K (needed for blood clotting and bone nutrition), and storage of indigestible foodstuff as stool for eventual elimination. Ayurvedic theory asserts that Prana Vata carries Prana, the primary life force. The Indian concept of Prana is equivalent to the Chinese concept of Qi/ChiPrana Vata and minerals in foods and herbs rich in Prana are absorbed through the purishadhara kala membrane of the colon to directly supply bone tissue all over the body. In addition, Ayurveda regards the marrow internal to bone to be closely associated with nervous system functioning. This connection underscores the experience of pain associated with dysfunctions of bone and bone marrow.

Ayurveda’s three foundational texts, Charaka Samhita, Sushruta Samhita, and Asthanga Sangraha of Vagbhata describe pain syndromes related to bone. In addition, a later work, Madhava Nidana (c. AD 650–950)⁸ introduced the conceptualization of amavata. This toxic Vata condition has much in common with rheumatoid arthritis, and is marked by inflammation and edema.

The etiological field that sets the stage for the development of bone pathology and pain has general and specific triggers. Included are dietary practices that lead to impaired Agni and weakened digestive processes (for example, cold foods, and heavy foods, such as meat and cheeses, in excess), and Vata aggravating diets (for example, cold, dry foods, lack of sufficient oil in diet, excess of raw vegetables, use of traditionally incompatible food combinations: milk and fish, milk and fruit, milk and meat, milk and foods having sour tastes). Such disease-provoking dietary practices engender the metabolic toxin called Ama, which not only obstructs the proper flow of the doshas but also the distribution and assimilation of nutrients. Ama correlates with excess free radical production and inflammation, especially at the endothelial cell level.

Vata-aggravating lifestyle (for example, excess travel and physical activity, and excessive preoccupation with electronic media), microbial causes (krimi), trauma, genetic predisposition (sahaja hetu), and older age add to Vata vitiation and progression of disease. Improper breathing may limit the body’s adequate intake and absorption not only of oxygen but also of Prana in the lungs and the colon, both subsequently affecting bone. Proper oxygenation is a typical benefit of Ayurvedically-prescribed deep breathing practices. This contributes to natural infection control. Although Vata is the principal dosha associated with bone pathology, Pitta may also become involved and manifest as inflammation; when Kapha becomes involved, edema, osteophytes, and tumors emerge.

The specific form taken by bone pathology is the result of genetic, constitutional, and lifestyle factors, as well as acquired pathology. After careful assessment of the aforementioned factors and delineation of the course of pathogenesis, a specific treatment plan is constructed. To give a general idea of treatment guidelines, the following protocol is outlined. It may not be universally applicable since each patient and each disease process presents with unique features. Specific decompensations dictate the specifics of an individualized treatment regimen. Lower back pain with radiation to the leg (gridhrasi), for example, is well known in Ayurveda and its treatment follows protocols established thousands of years ago. A qualified practitioner, not self-help guidebooks, is needed to formulate diagnosis and treatment recommendations. Treatments may take place in a clinic and through outpatient recommendations for dietary protocols, herbo-mineral prescriptions, and other adjunctive techniques.

Ayurvedic treatments typically begin with procedures that target Ama detoxification and optimize the digestive process. In the context of a Vata-pacifying diet, various detoxifying herbs are used. These may include triphala (Emblica officinalis, Terminalia chebula, and Terminalia belerica), turmeric (Curcuma longa), guduchi (Tinea cordifolia),⁹ castor oil (Ricinus communis), and ginger (Zingiber officinale). Substances that reduce inflammation include Boswellia (Boswellia serrata) and guggul (Commiphora mukul). In osteoarthritis (Sandhigatavata) where degeneration is prominent, ashwaganda (Withania somnifera) and other highly tonic/nutritive herbs are given after a period of stabilization to promote healing and rebuild tissue. Turmeric (haridra in Sanskrit; jiang huang in Chinese) is used in Ayurveda and Chinese medicine to stimulate blood flow and reduce inflammation. Single herbs and compounds with several herbs are typically given.

Ayurvedic physicians recommend ghee, very modest amounts of highly-clarified butter, to facilitate the assimilation and efficacy of herbs. Ghee or butter oil is regarded as a medicine, not similar to ordinary butter with its possible deleterious effects on lipid profiles and cardiovascular system. Ghee has specific therapeutically targeted effects and is an adjuvant and potentiator of other medicinal substances. Ghee contains up to 27% monounsaturated and about 66% short-chain fatty acids along with about 3 % conjugated linoleic acid (CLA). This composition is a beneficial profile. Taken in moderation, ghee demonstrates antioxidant, antimicrobial, anticarcinogenic, and lipid nondysregulation properties.¹⁰ Ghee contains a fat-soluble fraction of vitamin K, K-2, or meanquinone-7 or menaquinone-7 (MK-7). K-2 produces gamma-carboxylated osteocalcin and facilitates the incorporation of calcium into bone matrix. In Japan, MK-7 is highly concentrated in a soybean food, “natto,” fermented by Bacillus subtilis. People with osteoporosis and those who might benefit from natto’s significant blood-thinning properties eat this food.

Ayurvedic treatment includes dietary recommendations that follow classically-established Vata-pacifying guidelines. These consist of regular, moderately-sized meals; food choices that include warm, moist foods emphasizing sweet, salty, and sour tastes in moderation; sweet fruits; most cooked vegetables excluding mushrooms and excess legumes (beans, peas, and lentils); rice; all nuts and seeds; dairy products in moderation; and mild spices such as cinnamon (Cinnamomum zeylanicum), basil (Ocinum spp.), cardamom (Eletarria cardamomum) and fennel (Foeniculum vulgare). These dietary guidelines are not mere culinary suggestions. They come from Ayurveda’s detailed and exacting analysis of the complex actions and therapeutic properties of food, herbal, and spice substances. Calcium-rich foods, a normal part of the Ayurvedic diet, include chickpeas, okra, almonds, sesame seeds, and milk drinks. Traditional cooking techniques for grains and legumes include presoaking and adequate cooking time to reduce excess phytic acid (inositol hexakisphosphate, IP6) that tends to chelate calcium and inactivate niacin. Although not a standard food in traditional Ayurveda, American practitioners recommend many marine macroalgae or seaweeds as dietary additions. For example, wakame (Undaria pinnatifida) frequently used in Japan (ito-wakame), China (qundaicai), and Korea (miyeok) as food and medicine contains about 980 to 1,300 mg assimilable calcium per 100 grams. Besides calcium, sea vegetables contain generous amounts of potassium, sodium, and magnesium; hence, judicious use of high-quality, guaranteed pure seaweed may be beneficial in patients whose sodium intake is not restricted.

In addition to diet and herbs, oils specially prepared for therapeutic massage (abhyanga) coupled with topical moist heat fomentation (swedhana) are a regular part of treatment protocols. Such intermittent mild temperature elevations aid in infection control. Commonly used therapeutic massage oils include sesame, castor, and a special compound called Mahanarayan. Efficacy lies in the mobilization of contracted tissues, alleviating pain, and reducing swelling and induration. Oil massage is a highly regarded treatment intervention, and one that patients perceive as helpful and valuable. In India, specially prepared herbalized oil enemas (basti) are also a regular part of specialized anti-Vata treatments.

Conclusion

The psychology of aging is an important consideration in understanding the needs of the rapidly emerging generation of older citizens in society. Physical illnesses, particularly orthopedic problems, cause distortions in body image, and diminish self-esteem. Limitations in functioning and pain force patients to become less productive personally, socially, and occupationally. Recent scientific advances in Western medicine provide many rational choices for remediation and repair. Eastern medical traditions, such as Ayurveda with its favorable record of accomplishment, have emerged as complementary adjuncts. Although currently unexplored by modern scientific methods, they offer relief and restoration of functioning. For these reasons, the complete physician, not to mention his or her patients, can benefit from a familiarity with newly emerging medical systems and their applications. A greater yield of sustained positive outcomes resulting in mental and physical wellness may be attainable.