The use of integrative therapy based on Yoga and Ayurveda in the treatment of a high-risk case of COVID-19/SARS-CoV-2 with multiple comorbidities: a case report

The coronavirus disease 2019 (COVID-19) pandemic has wreaked havoc on every aspect of human life on planet Earth. As on August 28, 2020, more than 24.4 million cases of COVID-19 have been reported in more than 227 countries and territories, resulting in more than 831,827 deaths [1]. Although there are several clinical trials underway, no cure has yet been found for COVID-19 in modern western medicine (MWM).

The presence of comorbidities such as diabetes mellitus (DM), hypertension (HTN), chronic obstructive pulmonary disease (COPD) or old age leads to poorer clinical outcomes in COVID-19 patients [2‐5], and presents additional challenges in the management of the illness. Physical inactivity, high-fat diet and uncontrolled HTN in addition to superposed infection are strong risk factors for cardiovascular complications such as myocardial toxicity in COVID-19 [6, 7]. The mortality rate for hospitalized COVID-19 patients in China has been reported as \(3.1\%\) [2], while among these hospitalized patients, for those who have one or more of the nine comorbidities (DM, HTN, COPD, cardiovascular disease, cerebrovascular disease, hepatitis B infection, malignancy, chronic kidney disease [CKD], immunodeficiency), the mortality rate has been reported as \(8.8\%\) [2]. In the same cohort, the percentage of patients for whom the illness progresses to a severe stage has been reported at \(16\%\), whereas for patients with comorbidities, the corresponding percentage is substantially higher, at \(32.8\%\). Although the precise figures may vary with geography, the fact that the presence of comorbidities leads to poor clinical outcomes in COVID-19 patients has been independently confirmed in many studies from various countries [3, 4, 8, 9].

Ayurveda is a system of traditional Indian medicine which is based on sound therapeutic principles and has a proven history of empirical use [10, 11]. It is one of the world’s oldest holistic healing systems. According to the Ayurvedic system of medicine, a healthy person should have a stable equilibrium (congenial homeostasis) of Doshas (Vata, Pitta, Kapha—psycho-biological rhythms), Agni (metabolism/digestion), Dhatu (body tissues/elements that provide them nourishment) and Mala (excreta), and the well-being of senses, mind and soul [10]. Every individual has a unique combination of these constituent elements, which is known as the individual’s Prakruti or unique mind-body constitution (Ashtanga Hridaya, Sharira Sthana, Chapter 3, Verse 83) [12]. When an imbalance occurs in this equilibrium, it causes disease, and the Ayurvedic system of medicine seeks to remove this imbalance, to regain a healthy state [10, 11].

The occurrence of disease can be further understood as follows: the abovementioned constituent elements have a propensity to change, influenced by various factors such as the environment we live in, change in seasons, the food that is consumed, negative experiences, presence of physical toxins, irritants, microorganism or impurities, unhealthy habits and emotions. These influences distort the natural balance of these elements in an individual, increase ama (toxins), contributing to vikruti (vitiation of the constituent elements); this imbalance manifests as a lack of energy, excess mucous, inflammation, and a wide variety of dysfunction and diseases [10, 11, 13]. By using the Ayurvedic principles, the unique Prakruti (constitution) of the individual is assessed, the vikruti (vitiation) that has occurred is diagnosed and a personalized treatment plan is advised accordingly. Thus, the Ayurveda system of medicine is inherently personalized, which treats the patient by considering the individual constitution (Prakruti) as well as the causes of the symptoms (vikruti).

Classical Ayurveda texts such as Charaka Samhita (Vimana Sthana, Chapter 3) [11] and Sushruta Samhita (Sutra Sthana, Chapter 6, Verses 19, 20) [10] contain descriptions of pandemics and describe them as Janapadoddhvansa—Jana-pada (meaning community) + Udhvansa (meaning destruction), literally translating to “destruction of communities.” These texts offer specific guidelines with regard to the treatment of diseases that affect people during Janapadoddhvansa.

Yoga is yet another ancient wisdom from India, which is an extremely deep science that helps one lead a harmonious life [14]. The classical text Yoga Vasishta [15] (Book 6, Chapter 81) describes a healthy person as one who is free from physical disease as well as from erroneous affections of the mind. Yoga deals with the holistic principle of body-mind-soul, which proclaims that a human being can experience five dimensions of gross and subtle existence, called Pancha kosha, or five sheaths, namely Annamaya (physical body), Pranamaya (energy field), Manomaya (mental dimension), Vijnanamaya (related to intuitive knowledge) and Anandamaya (level of bliss) kosha (Taittiriya Upanishad) [16, 17]. Prana (the vital life force that is responsible for all the gross and subtle activities) pervades all five sheaths, and nourishes and sustains them [17]. Yogic practices are aimed at achieving the proper distribution and circulation of Prana within the gross and subtle realms of existence, for holistic well-being.

Ayurveda also describes the concept of Panchaprana or Pancha Vayu (five manifestations of the vital life force in the human body) (Ashtanga Hridaya, Sutra Sthan, Chapter 12, Verse 4) [12]. Panchaprana govern different areas of the body and different physical, neurological and mental activities. When they are functioning harmoniously, they promote the health and vitality of the body and mind, and elevate one spiritually.

In this paper we report presumably the first high-risk case of COVID-19 (with reference to the studies available in peer-reviewed open literature), treated successfully using integrative therapy comprising Ayurveda and Yoga. Although there have been some case reports (see the section on Related Works) and theoretical works on the use of Ayurveda or Yoga for COVID-19, the authors are not aware of any published work reporting the successful treatment of high-risk cases of COVID-19 through Ayurveda or Yoga. The present case offers sufficiently supportive evidence that an integrative therapy plan based on Yoga and Ayurveda can be useful in treating even high-risk cases of COVID-19 with mild to moderate symptoms. With regard to the work ahead, a suitably designed case series or randomized controlled trial (RCT) would be advisable to further establish its efficacy for high-risk COVID-19 patients.

There is emerging evidence that Ayurvedic treatment methodologies and herbal medicines may be effective in combating COVID-19. Girijaa and Sivan [18] describe one of the first case reports of a patient with COVID-19 treated entirely with Ayurveda. In a study using molecular dynamics simulations, Kumar et al. [19] report that withaferin A (Wi-A) and withanone (Wi-N), derived from a common Ayurvedic herb called Ashwagandha, may block the entry of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into cells. Several herbs including Tulsi (Ocimum sanctum) and Haldi (Curcuma longa—turmeric) used as Ayurvedic medicines are well known for their immunomodulatory properties [20‐24]. Ayurvedic treatment has also been found to be effective in other COVID-like illnesses such as influenza [25‐27] and chikungunya [28]. Several studies have been conducted to understand the COVID-19 pandemic and the conditions that it causes from the perspective of Ayurveda [29‐35]. Based on these observations and the study of classical Ayurveda texts, several experts have proposed the use of Ayurveda for both prophylactic [36‐49] and therapeutic purposes [34, 38‐41, 43, 44, 50‐58] in COVID-19. Some studies have also suggested that lifestyle modifications, such as immunity-boosting food, can aid in fighting the current situation [59]. Many studies have come up with suggestions for reforms in policies enabling the adoption of Ayurveda in the treatment plan for COVID-19 patients [42, 60‐62]. The Government of India, Ministry of AYUSH, has issued an advisory comprising Ayurveda-based immunity-boosting measures for self-care during the COVID-19 crisis [63], and an advisory for the general public on the use of Ayurveda (and other traditional systems of medicine) as a preventive measure for COVID-19 as well as for managing the symptoms of COVID-19 [64]. The same department also issued guidelines for Ayurveda practitioners [65] and Yoga practitioners [66] for treating COVID-19 patients. Several ongoing clinical trials are evaluating the efficacy of Ayurveda-based interventions for both prophylactic and therapeutic use in patients with mild to moderate COVID-19 symptoms.

Traditional Chinese medicine (TCM), which is based on principles similar to those of Ayurveda, has been used extensively in China for treating COVID-19. The Chinese government has actively promoted the use of TCM for management of COVID-19. As a result, several studies have been published on the use of TCM for COVID-19 [67‐70]. The Chinese doctors now recommend the use of TCM along with western medicine in treating COVID-19 [71, 72]. According to Yang et al. [73], more than 85% of the cases in China have received TCM-based treatment. Several RCTs on TCM are presently in different stages of completion. Most of the reviews on RCTs on the efficacy of TCM for COVID-19 [74‐78] report positive findings (see [79, 80] for reviews on the mechanism of action of TCM). Several countries have issued guidelines for the use of traditional medicine for COVID-19. See [81, 82] for a review of such guidelines.

Despite the above studies on TCM, caution has also been advised in the use of TCM for COVID-19. For example, Gray and Belessis [83] state that the use of TCM may cause “more harm than good.” Cyranoski [84] argues that TCM is still an unproven treatment and is being excessively promoted by certain governments. A review by Pang et al. [85] reported that after a comprehensive literature search, they found 26 published clinical controlled trials of TCM for COVID-19, among which 11 were RCTs with 1301 patients, but none of the RCTs were placebo-controlled or double-blinded. There was significant variation in the types of patients, interventions and outcomes in different RCTs. Also, for most of the published trials, the protocols had not been registered before case recruitment. Thus, based on the above observations, it may be concluded that TCM may offer a promising option for treating COVID-19, yet suitably designed multi-country RCTs may be needed to assess its efficacy.

In light of the above observations, the present integrative therapy plan was designed, which comprises elements of Yoga and Ayurveda, along with dietary recommendations and lifestyle modifications, as a treatment option for COVID-19. It was hypothesized that integrative therapy based on Ayurveda and Yoga would be effective in treating COVID-19 patients.

The first consultation with the patient was on July 1, 2020. He was under home isolation during the entire course of treatment. He started observing improvement in symptoms 2 days after the beginning of the treatment. The second RT-PCR was done on July 6, and was positive. A slight modification was made in the intervention on July 9, as reported in Table 3. By the ninth day after starting the treatment, all the symptoms reported by the patient were resolved, except mild heaviness in the abdomen. The third RT-PCR done on July 14 was inconclusive, and another test was done on July 20, which was negative. Moreover, the patient’s uncontrolled blood sugar level showed significant improvement, with FBS of 90 mg/dl and PPBS of 140 mg/dl. Most importantly, the patient was in a much better state of mind (as evident in his feedback during consultations) and sounded much more confident by the end of the treatment.

This study reports the successful treatment of a high-risk case of COVID-19 in a patient with several comorbidities, using an integrative therapy plan based on Yoga and Ayurveda, along with government-mandated modern western medicine treatment. Various unique aspects of this treatment approach are discussed below.

Since the patient’s fever was already controlled before enrollment in the integrative therapy, it is possible that he may have been in the convalescent phase at the time of enrollment. It must be noted that the Ayurveda system of medicine does not treat a disease condition in isolation; it treats a patient holistically for overall health while strengthening the body’s innate mechanisms involved in the restoration of health. The patient had uncontrolled blood sugar levels (which is known to adversely impact the immune system [88]) for the past 10 years despite MWM treatment. The rapid reduction in the blood sugar levels after the initiation of integrative therapy may have contributed to a rapid recovery from the other symptoms and provided a faster path to the patient’s overall well-being. Besides the data presented in Table 4, according to a more recent follow-up taken on October 23, 2020, the patient has continued to use the prescribed integrative therapy as an adjunct to his MWM treatment for DM and reported HbA1c within normal limits. His MWM dose for DM has been further reduced by his consulting physician.

Besides the variety and severity of physiological symptoms posed by COVID-19, it deeply affects patients psychologically as well [89, 90]. Owing to the highly contagious nature of the coronavirus, the social stigma associated with the disease and the mandated isolation period have a deep adverse impact on the already nervous patients [91]. This stress and anxiety may tend to further weaken the already compromised immune system, thereby potentially creating a vicious cycle. The patient treated in the present case was undergoing a similar situation at the time of the first consultation. With his symptoms prevailing for a long period, and two more of his family members being infected (one of them being hospitalized), the patient was in severe distress and exhibited anxiety. The integrative therapy administered to him not only helped manage his physiological symptoms, but also helped control his anxiety and stress (see for example [92, 93] for reviews on Yoga for anxiety). Within a week, an observable change in his confidence level was seen, and he appeared much more calm and peaceful. This change may be attributed to his regularity in attending the Yoga sessions, in addition to the relief experienced as his COVID-19 symptoms subsided. The authors believe that apart from boosting immunity, Yoga and Pranayama practices contributed immensely to his overall healing by inducing a relaxation response [94] in the body.

Promising results observed in several research studies suggest a favorable impact of Yoga on immune function, stress response, mental health and quality of life [95‐100]. The usefulness of nasal irrigation, a yogic practice, in improving the symptoms and health status of patients with sinonasal disease has also been observed [101]. A key symptom associated with COVID-19 is the onset of dyspnea between the fourth and tenth days of illness [102]. Studies suggest that COVID-19 patients with hypoxia or dyspnea may have a higher risk of mortality or developing severe symptoms [103, 104]. It has been reported that a simple intervention such as prone positioning improves clinical outcomes in such cases [105, 106]. Yoga and Pranayama have been found helpful in cases of high-altitude hypoxia [107] and several similar interventions in pulmonary rehabilitation for patients with acute respiratory distress syndrome (ARDS)/COPD [108‐114]. Owing to its role in stress reduction and immune modulation, Yoga has been proposed as a complementary therapy in the management of infectious conditions like COVID-19 [115]. Bushell et al. [116] suggest Yoga practices and meditation as a potential adjunctive treatment for COVID-19. In light of the above observations, and looking at the results of the present study, it is hypothesized that the integrative therapy plan, which comprises elements of Yoga and Ayurveda, along with dietary recommendations and lifestyle modifications, would be effective in treating COVID-19 patients, either as an adjunct to MWM or as a stand-alone treatment. A case series involving a larger number of high-risk patients or a suitably designed RCT is needed to systematically assess its efficacy.

The success of the integrative therapy in this high-risk case of COVID-19 is evident in that the patient not only recovered from the symptoms, but a sense of overall well-being was bestowed on him.

This successfully treated case certainly calls for more well-designed studies on the proposed integrative therapy approach, possibly leading to its adoption in the standard treatment provided to COVID-19 patients.

After recovery from symptoms and a negative RT-PCR report, a subjective feedback was taken from the patient to understand his perspective on the intervention. The patient expressed immense satisfaction and a sense of confidence. He was amazed and delighted to find that besides aiding in a speedy recovery from the symptoms of COVID-19, including weakness, anxiety and depression, Yoga and Ayurveda had managed to control his blood sugar level as well. The normal sugar levels observed by the end of the treatment were astounding given that regular allopathic medication could not achieve this. The patient was so convinced about the efficacy of Yoga and Ayurveda that he suggested his spouse (who was also tested positive for COVID-19 and had been pursuing only allopathic medication) seek Ayurvedic consultation. Most importantly, he is determined to adopt Yoga in his lifestyle.