Review and Case study on the Chronic Disorder Program

Tony Nader, MD PhD1,3 Stuart Rothenberg, MD2,3 Richard Averbach, MD, 3,4 Barry Charles, MD3,6 Jeremy Z. Fields, PhD 3,5 and Robert H. Schneider, MD 3

1 Maharishi Ayurveda University, Vlodrop, The Netherlands; 2Center For Chronic Disorders, Dallas TX; 3The Center for Health and Aging Studies, Maharishi University of Management, College of Maharishi Ayurveda, Fairfield IA; 4Center for Chronic Disorders, Chicago, IL; 5Center for Healthy Aging, Saint Joseph Hospital, Chicago, IL; 6 Physicians Association for Eradicating Chronic Diseases

Financial support: This study was supported by the Dallas Center for Chronic Disorders (SR), the Chicago Center for Chronic Disorders (RA), Maharishi Ayurveda University (TN), Maharishi University of Management (SR, RA, RS), Physicians Association for Eradicating Chronic Diseases (SR, RA, BC), and an NIH-National Institute on Aging Senior Fellowship Award (JF).

Request for Reprints:
Stuart Rothenberg, MD
Director, Center For Chronic Disorders
5600 North Central Expressway, Suite 400
Dallas, TX 75206;

or

Professor Tony Nader, MD, PhD
Maharishi Ayurveda University
Station 24
6063 - NP Vlodrop
The Netherlands

ABSTRACT

Chronic diseases are a major public health problem in the US. Approximately one third of the US population has turned to providers of complementary and alternative medicine for relief from chronic and other disorders. Maharishi Ayurveda (Maharishi Ayurveda) is a comprehensive system of traditional medicine. Although numerous reports have suggested health benefits from single approaches of Maharishi Ayurveda, there has been a lack of clinical data when practiced as a multi-modality system. Therefore, this study was designed to investigate the clinical effectiveness of an integrated, multi-modality Maharishi Ayurveda program on a range of chronic diseases. This report describes the outcomes in a series of four patients with: sarcoidosis; Parkinson's disease; renal hypertension; and diabetes/essential hypertension/anxiety disorder. Standard clinical signs, outcomes and self-reports were evaluated before, during and after intervention administration. During the three-week In-residence treatment phase and continuing through the home follow-up program, there were substantial improvements of all patients, highlighted by a lessening or disappearance of major signs and symptoms and reductions in medication requirements. This case series suggest that multi-modality Maharishi Ayurveda may be an effective and safe treatment for some chronic disorders and that further controlled research is warranted.

Key words: chronic disease, natural medicine, Maharishi Vedic Approach to Health, Maharishi Ayurveda

INTRODUCTION

Chronic diseases are a major public health problem in the US. Currently, the prevalence of chronic diseases is about 40% in the US population with approximately 100 million Americans suffering from at least one chronic disorder (1). This high prevalence of chronic disease raises concerns about the efficacy and limitations of conventional health care approaches in preventing and treating these disorders (1, 2). Such concerns may contribute to the increasing public and professional interest in alternatives to conventional modern medicine. Indeed, Eisenberg (2) reported that the use of unconventional or alternative therapies is widespread in the United States. For example, in 1990 approximately one third of the US population consulted alternative providers. These 425 million visits/year were more numerous than visits to primary care physicians (2). Data from a 1997 report indicate an even higher rate of complementary and alternative medicine utilization in the US (3). However, despite increasing public demand for complementary and alternative therapies, it has been noted that scientific data on safety and efficacy are often lacking (2, 4-6).

The present report investigates the potential clinical effectiveness of a comprehensive system of natural medicine, Maharishi Ayurveda, practiced as an intact multi-modality system as classically described (7-9). Vedic medicine is reported to be the oldest continuously practiced medical system, having its heritage in the ancient Vedic civilization of India (8, 10-12). Vedic medicine, including Ayurveda, has been recognized by the World Health Organization as a sophisticated system of natural medicine with a detailed scientific literature consisting of classical medical texts, an uninterrupted oral tradition of classical knowledge predating the written texts, a comprehensive materia medica, and a wide breadth of clinical procedures relevant to prevention and treatment of acute and chronic diseases (10, 13). A modern revival of ancient Vedic medicine, taking into account an extensive range of diagnostic and therapeutic approaches in accordance with classical texts, is known as Maharishi Ayurveda (9, 14). These approaches are said to encompass mental, physical, behavioral, and environmental health (7-9, 15).

Over the past 30 years, several hundred studies have been published on the efficacy, safety, and mechanisms of individual treatment components of Maharishi Ayurveda, such as the Transcendental Meditation program and certain herbal preparations (16, 17). These studies suggest that specific approaches of Maharishi Ayurveda are associated with a lower risk of morbidity and mortality related to chronic disorders (16-19). However, recent consensus guidelines for research on complementary and alternative systems have recommended that traditional systems of medicine be studied in their intact form as clinically used (rather than as isolated components) for clinical efficacy and overall safety (4, 6, 20). Furthermore, it has been recently argued that the case study is a valuable method for preliminary studies of complementary and alternative medicine (21). Therefore, this first case series was designed to begin to evaluate the effectiveness of traditional multimodality Maharishi Ayurveda for the treatment of several chronic diseases. This report describes clinical outcomes in four patients with sarcoidosis, Parkinson's disease, renal hypertension, and diabetes/ essential hypertension/anxiety disorder treated with these protocols,

METHODS

Standard clinical signs, symptoms, and laboratory examinations for each disease were evaluated before, during, and after the treatment intervention. A standardized quality of life assessment battery, the SF-36 general health, physical functioning, rate-physical and mental health subscales was also administered to each patient before and after treatment (22). The multi-modality Vedic medicine program, also called the Maharishi Ayurveda Chronic Disease Program, studied in this series was applied in the context of a three-week program of In-residence care followed-by a three-month, home-based program. The key components of the program for all the patients included the following:

  1. Transcendental Meditation and TM-Sidhi program — The Transcendental Meditation (TM) program has been widely practiced and extensively researched and has been recommended for clinical study (19, 23). Meta-analyses indicate that effects of TM on several chronic disease risk factors appear to be larger than those produced by clinically devised or traditional relaxation programs. These include reduced sympathetic arousal (24, 25), smoking and excessive drinking (26) psychosocial stress (25-30) and psychosocial cushioning factors (31). Controlled trials show that TM reduces other physiologic contributors to chronic diseases, such as serum cholesterol (32), and HPA axis dysregulation (33).

    The Transcendental Meditation technique was introduced in the West by Maharishi Mahesh Yogi about 40 years ago and is a primary approach of stress reduction and self development of Maharishi Ayurveda (7, 34). The TM technique is a simple procedure, practiced twice a day for 20 minutes while sitting comfortably with the eyes closed. The practice of the TM technique does not require any changes in personal beliefs, philosophy or lifestyle. During the technique, the ordinary thinking process settles down and a distinctive psychophysiological state of "restful alertness" is gained as indicated by decreased respiration, skin conductance level, plasma lactate, and cortisol, and increased frontal alpha and theta EEG power and coherence, increased cerebral blood flow, faster H-reflex recovery, and shorter latency of auditory evoked potentials (27, 35-38).

  2. Pulse Diagnosis - The Vedic diagnostic approach to the patient includes a classical system of pulse diagnosis whereby the physician palpates the radial pulse to assess wave form patterns that are described as corresponding with specific modes of physiological functioning and pathophysiological processes (8, 39). Based on this assessment, as well as history and clinical examination, standardized protocols are prescribed for diet, herbal preparations, physiological purification procedures, exercise, and daily and seasonal behavioral routines (see below) (8) (40). Participants are also taught a method of self-pulse reading to be used at home.
  3. Vedic Sound - Participants received Vedic sound therapy on a daily basis. This included listening to traditional recitations of selected portions of the classical Veda and Vedic Literature, which have been suggested to correspond to specific areas of the human physiology and promote homeostatic self-repair processes in those respective areas (7, 15). The effects of Vedic sound programs may be consistent with modern conceptualizations of the effects of different types of music and sound on the autonomic nervous system and other psychoneurophysiologic processes (41, 42). Although Vedic sound therapy has been classically recommended, this is, to our knowledge, the first report available on the use of Vedic sound therapy within a multi-modality traditional Vedic medicine program for the treatment of chronic diseases.
  4. Diet - A traditional Vedic diet was provided in residence and recommended for outpatient follow-up. This diet emphasizes fresh vegetables, fruits, grains, nuts, high fiber content, and dietary sources of antioxidants, vitamins and minerals; it is similar to other therapeutic diets previously associated with reduced morbidity and mortality from chronic diseases (43-45). Within this broad context, each patient's diet is tailored to compensate for his or her specific physiological imbalances and pathophysiological processes.
  5. Herbal Preparations - Herbal preparations from the traditional Ayurveda materia medica are utilized according to clinical indications (46). These preparations have been used extensively in traditional and modern clinical settings (8, 47). Because of putative synergistic effects (48), multiple herbs are often combined in a single preparation. Thus, each herbal preparation used in the present trial contained up to 20 individual herbs and fruit extracts. One example is Maharishi Amrit Kalash which has been extensively evaluated for its antioxidant properties (49, 50).
  6. Physiological purification procedures - The In-residence phase of the program included a series of classical Vedic physical therapies used for physiological purification (8, 51, 52). These therapies are described as eliminating waste products and toxins from the body (e.g. oxidized lipids(53)), that accumulate over time from improper diet, poor digestion, stress and other factors, and which are held to obstruct the flow of the body's "inner intelligence" (54).

    These purification procedures consisted of daily sessions of approximately three hours in duration and included specific herbalized oil massages, external heat applications, herbalized steam baths, warm oil applications, and gastrointestinal elimination therapies.

  7. Vedic exercise - Participants were instructed to practice a set of classical Vedic exercises for approximately 10-15 minutes twice a day. These included physical exercises for neuromuscular integration and slow breathing exercises. These exercises have been used in Vedic medical practice for treatment of disease and promotion of health, especially for mind-body integration (54) and are derived from the Yoga aspect of Maharishi Ayurveda. Previous research studies on these Vedic exercises have found significant reductions in cardiovascular risk factors and in stress-related neuroendocrine markers, and enhanced psychological health (39, 55, 56).
  8. Environmental health - effects of the near environment - Analysis of the influence on health of the patient's home and work environments is based on the classical texts of Vedic architecture called Maharishi Sthapatya-Veda (7, 14, 54). This field includes knowledge and practices for the beneficial orientation and layout of homes and office buildings. This approach is consistent with the recently described syndrome of building-related illness or "sick building syndrome" (57) although its principles and practice extend beyond considerations of materials toxicity, ventilation, etc. Each participant in the program received an analysis of his or her home and work environments and recommendations were made based on this analysis.
  9. Environmental health - effects of the distant environment - The Vedic approach to the patient considers that the individual is in a dynamic state of equilibrium with the entire environment, extending to the universe as a whole, including the influences of the cycles and rhythms of the sun, moon, stars and planets. This may correspond in part to modern understandings of chronobiology (58). The current program included assessment of risk factors, future health trends and recommendations for prevention derived from this traditional approach (7).
  10. Collective health - Previous research has shown that practice of the Transcendental Meditation program and its advanced program (TM-Sidhi program) in groups has beneficial effects on health (16, 17, 59). Group meditation was recommended for participants in this study.

RESULTS

Case 1: Sarcoidosis

A 56 year-old Caucasian female patient presented to The Center for Chronic Disorders (CCD) in Dallas with classical signs and symptoms of multisystem Stage II sarcoidosis (see Table 1). Nine months previously the patient had noted the appearance of bilateral olecranon masses. Two months later she began to experience severe fatigue, episodic iritis and other symptoms that substantially reduced her quality of life. The patient was evaluated in early June 1997 at an academic medical center in New Orleans, where chest radiography and CT scan revealed mediastinal and hilar lymphadenopathy, multiple pulmonary nodules, interstitial pulmonary findings, and a mass in the region of the porta hepatis. KUB tomograms revealed renal calculi. Blood chemistries revealed elevated levels of angiotensin converting enzyme (ACE) (see Table 1 b.), ESR (27, normal 0-20 mm/min), and C reactive protein (CRP) 1.2 (normal 0.2-0.8 mg/dl). The diagnosis of sarcoidosis was made when biopsy of pretibial skin lesions revealed non-caseating granulomatous dermatitis. The patient refused oral corticosteroid therapy but did consent to intermittent ophthalmic steroid drops.

Physical exam revealed an obese women (220lbs) complaining of worsening symptoms. Lungs were clear. Multiple small nodules were noted over both eyelids and olecranon masses were noted bilaterally. Small non-nodular erythematous skin lesions were noted over the left proximal anterior tibia and dorsum of the right foot. Screening biochemistries were normal except for sedimentation rate which was elevated at 85 mm/min (normal 0-30 mm/min).

After admission to The Raj, the patient underwent a 26-day course of traditional Vedic medicine therapy as described in Methods above.

During treatment, the patient reported diminished joint and muscle pains and improvement in her breathing. By discharge (Day 27), the olecranon masses and eyelid nodules had decreased and she reported improvements in breathing, energy and physical exertion, and decreases in fatigue and other symptoms. ESR and CRP had improved. ACE was essentially unchanged. A chest radiograph showed diminishment in bilateral hilar adenopathy (see table I). The patient also improved significantly on the standardized self-assessment battery SF-36 (see Table 1 b.).

The patient was placed on a home-care program including dietary recommendations and herbal food supplements and continued to improve. One month post-discharge, a CT chest scan at The Raj in New Orleans showed a decrease in size of hilar and paratracheal lymph nodes and improvement in interstitial disease. Pulmonary function tests revealed mild small airways obstruction with normal diffusion capacity and oximetry. Skin lesions were noted to be resolving, olecranon masses and eyelid nodules were substantially reduced in size, and no clinical evidence of iritis was found. Previously abnormal ESR and CRP values were all reduced and ACE values had decreased substantially (See Table 1b.). Eight months following treatment, the patient remained free of dyspnea, iritis, fatigue, and other symptoms. Physical examination revealed resolution of olecranon masses and eyelid nodules.

Eighteen months following discharge, the patient remained free of dyspnea, iritis, fatigue, fevers, and other symptoms. She had normal energy and reported being able to engage in vigorous activity (e.g., shoveling earth in her garden) without shortness of breath or fatigue. Physical examination revealed complete resolution of olecranon masses, skin rashes, and eyelid nodules.

Case 2. Diabetes Mellitus, Essential Hypertension, Anxiety Disorder

A 55 year-old Caucasian male patient presented for admission to the Dallas CCD on 11/5/97 with diagnoses of non-insulin dependent diabetes mellitus (of 12 years duration), hypertension (20 years), and anxiety disorder (20 years) (Table 2). His diabetes had been managed on diet therapy alone until 3 years prior to admission at which time he started glyburide and metformin. Home fingerstick fasting blood sugars (mean 212 for 30 days prior) and hemoglobin A1C values (8.4 one week prior) were elevated preceding admission. Weight was low-normal at 147 pounds (height 69 inches). The patient had a history of Stage 1 hypertension treated with an ACE inhibitor (enalapril) for 2.5 years. A brief trial off medication three months prior to admission had resulted in return of elevated blood pressure (160/90). For the preceding 20 years, patient had panic disorder with depression features which was treated with sertraline for 2 years prior to admission. There was no other history of diabetic complications.

Following admission, the patient began a 21-day In-residence program of treatment which included the Maharishi Ayurveda components described above (see "Methods"). Blood pressure was in the range of 100-115/60-75 during the first three days and enalapril was tapered and then discontinued on Day 6. Blood pressures remained in the low-normal range without medication throughout the remainder of the treatment program (Days 12-21). Daily fasting blood sugars also decreased substantially (see Table 2). Two-hour post-prandial blood sugars were 143 on Day 13 and 137 on Day 20. The decreases in blood sugar occurred even though metformin was tapered four- fold by Day 12. The patient's mood improved considerably during the course of treatment, and anxiety and depression were absent. Sertraline was discontinued on day 13. Evaluation of SF-36 indicated improvements in the general health subscale, the mental health subscale, the composite physical outcome score and the composite mental outcomes score.

At discharge, the patient was asymptomatic and was placed on a home regimen of dietary therapy, herbal supplements, the Transcendental Meditation and TM-Sidhi program, Vedic daily health routine, and exercise. He was also instructed to continue glyburide 2.5 mg and metformin 500 to 1000 mg daily. A follow-up Hemoglobin A1C test at 3 months showed a significant decrease (7.4) that appeared to reflect the reduction of blood sugar levels during the preceding 90 days. Blood pressure and mood remained normal off medication 3 months post-discharge.

Case 3. Renal Hypertension

A 47 year old female presented to The Center for Chronic Disorders in Chicago with a 30 year history of hypertension from renal parenchymal disease secondary to obstructive uropathy. At age 17, the right ureter was surgically repaired. Blood pressures were in the Stage I-II hypertension range for most of her adult life. Home blood pressures during the two months prior to admission averaged 146/97 mmHg.

On admission, patient's physical examination and routine blood and urine biochemistries were normal, except that creatinine clearance was reduced at 67 ml/min. and office BP averaged 150/105 mmHg. During the three weeks of the In-residence program, BP's remained essentially unchanged. However, creatinine clearance at discharge was 85 ml/min (within normal range).

Follow-up during the two months following discharge revealed home blood pressures had decreased to the normal range, averaging 129/85 mmHg without medication with improvements in quality of life assessed by SF-36 (see Table 3).

One year later, patient continued to be normotensive without medication, with home blood pressures during the twelfth post- discharge month averaging 130/84 (average of 8 readings).

Case 4. Parkinson's Disease

A 49 year-old woman diagnosed with Parkinson's Disease (PD) and treated regularly by a neurologist, presented for admission to the Dallas Center for Chronic Disorders (see Table 4). On carbidopa-levodopa since 1992 (CR preparation), symptoms had recently worsened. Despite her use of the long-acting drug preparation, she reported that the carbidopa-levodopa effect wore off after 3-4 h. Selegiline and bromocriptine were tried but the patient was unable to tolerate these due to adverse drug reactions. In the month prior to admission the patient reported increasingly frequent episodes of freezing-up, immobility, and other symptoms. Her family history was negative for neurological diseases. Following admission, the patient began a 21-day In-residence program, which included the Maharishi Ayurveda components described above (see "Methods")

During treatment, the patient showed significant generalized improvement (eg. dyskinesia markedly reduced; gait, speech, handwriting, postural stability improved). These improvements continued until discharge.

The patient was evaluated twice by a neurologist after completing the program. On the Short Parkinson's Evaluation Scale and the SF-36 Health Survey, the patient showed noticeable improvement (see Table 4). The patient had experienced some increase in tremor during this period and was taking carbidopa-levodopa 700 mg daily. The neurologist reported that her gait, postural stability, and dyskinesia were clearly improved.

The patient returned to the CCD for two subsequent 21-day courses of therapy, four months and 11 months respectively after discharge from the first treatment. During these subsequent treatments, freezing episodes ceased and further improvements in tremor, fingertapping, handwriting, gait, and postural instability were noted. Carbidopa-levodopa was reduced to 600 mg. Subsequent evaluation by her regular neurologist following discharge from each of these programs (two weeks and six weeks respectively after discharge) demonstrated further improvement on the Short Parkinson's Evaluation Scale and the SF-36 battery. Short Parkinson's Evaluation motor subscale score decreased markedly to 4 after the second course of treatment and to 3 after the third course; complications of therapy subscale decreased to 1 and then to zero; both the mental subscale and activities of daily living subscale decreased to zero and remained at this level after the third treatment course. Three months following discharge from the third treatment course, she continued on carbidopa-levodopa 600 mg per day and reported she was maintaining these improvements.

DISCUSSION

The present series of patients with sarcoidosis, renal hypertension, diabetes /essential hypertension/anxiety disorder, and Parkinson's disease demonstrated a range of clinically significant improvements after participating in an intensive multimodality program of traditional natural medicine -- Maharishi Ayurveda. These findings extend previous controlled studies on individual modalities of Maharishi Ayurveda which have shown reductions in chronic disease risk factors, morbidity and mortality (16-18, 60-63).

The present study utilized an integrated set of diagnostic and therapeutic modalities, as is traditionally used in the classical Vedic approach to the treatment of chronic disorders. To our knowledge, this is the first report in the modern medical literature of the application of Vedic medicine in its complete, traditional form for the treatment of chronic diseases. The approach of studying traditional systems of as intact multimodality systems has been recommended in recent consensus guidelines for research on complementary and alternative medicine (4, 6, 20).

Regarding sarcoidosis, prognosis typically depends on stage and clinical factors (64). The present patient was Stage II (pulmonary interstitial disease and hilar adenopathy) with four of seven clinical markers of poor prognosis (64). At the time of admission, the patient had been deteriorating clinically. Conventional treatment with corticosteroids may reduce symptoms but is associated with substantial adverse effects and risk for iatrogenic disease (65). While the physiological mechanisms for the presumed regression of the sarcoidosis were not evaluated in this study, modulation of immune functioning through various Maharishi Ayurveda modalities may have contributed to the overall therapeutic effect (66-68).

Regarding hypertension, previous research has reported that the Transcendental Meditation technique and its advanced TM-Sidhi program are effective in treating and preventing hypertension (25, 69, 70). Also, several Vedic herbal preparations, as well as certain yoga exercises, have been found to reduce cardiovascular risk factors, including blood pressure (46, 55, 71, 72). These effects may be mediated in part through the sympathetic nervous system (25, 73). In addition, the improved creatinine clearance in the patient with renal parenchymal hypertension suggests improvement in renal function perhaps via enhanced renal blood flow (74). The present approaches are consistent with the recommendations of the Joint National Committee (JNC-VI) for nonpharmacological treatment of hypertension as initial or adjunctive therapy for all patients with hypertension (75). This alternative program may obviate the need for pharmacologic therapy which is often associated with adverse effects, relatively high cost, and low compliance over the long-term (25, 75).

Regarding diabetes mellitus, previous data on herbal preparations and stress reduction approaches included in the Maharishi Ayurveda chronic disease program suggest these may have contributed to the improved glucose tolerance(76, 77) documented in the present study. In addition, the therapeutic diet in this program included features recommended for nutritional treatment of diabetes(78). Regarding anxiety, previous meta-analysis has reported on the effectiveness of the stress reduction component of Maharishi Ayurveda (29) and one randomized controlled study found significant improvements in psychiatric patients with anxiety disorder (79).

Parkinson's disease is chronically progressive with no known reports of spontaneous remission. Treatment with dopamine mimetics modulates symptoms but is usually time limited in effectiveness (80), thus it appears the short-and long-term improvements in this patient's signs and symptoms are noteworthy. These data are consistent with cohort studies reporting substantial reductions in the rates of serious neurological diseases in long-term participants in Maharishi Ayurveda programs (18, 61). Given that regrowth of nigrostriatal neurons has not been previously documented, compensatory mechanisms by other neural networks may be a more likely explanation.

The results of these four cases are generally consistent with epidemiological findings of reduced prevalence rates (indicated by hospital admission rate) in Maharishi Ayurveda participants for immune/endocrine/metabolic disorders, neurological disorders, and cardiovascular disease (18, 61) and of reduced overall health care expenditures (81). Furthermore, these initial findings confirm and extend a pilot study of 126 patients in Europe who showed clinical improvements in several chronic disorders, including diabetes, hypertension, asthma, chronic bronchitis, rheumatoid arthritis, eczema, chronic constipation and headache (82). In this earlier series of cases, patients were clinically treated with several, although not all, of the Vedic modalities utilized in the current case series.

In terms of a theoretical model, Maharishi Ayurveda traditionally describes these procedures as enlivening the body's "inner intelligence", which is proposed to be the fundamental set of organizing and coordinating principles at the basis of physiological function and structure. The fundamental etiology of disease is distortions in the relationship between the physiological level of functioning and its own inner intelligence which leads to breakdown in normal homeostatic and self-repair mechanisms. Enlivening this fundamental level of intelligence in the body is considered essential for optimizing innate homeostatic, self-repair and defense mechanisms and thereby preventing or treating chronic disease. Because it utilizes procedures to stimulate endogenous restorative mechanisms, the traditional Vedic approach to health may also avoid serious adverse effects (7, 9).

Maharishi Ayurveda includes 40 approaches, which derive from the 40 traditional aspects of the Veda and Vedic Literature (14). These aspects of Vedic literature are classically understood as describing different modes of operation of natural law, the fundamental intelligence displayed in the natural world (14). In recent work, Nader has related these aspects of Vedic Literature to 40 key areas of human anatomy and physiology. The discovery of this connection of natural law, as presented in the various aspects of the Vedic Literature, with the laws of nature displayed in systems of human physiology, as elaborated by modern biomedical science, forms the theoretical framework for the diagnostic and therapeutic strategies of Maharishi Ayurveda (7).

In this light, it is notable that most of the patients in this study reported that the Vedic sound therapy component of the program was associated with the most immediate and dramatic relief from symptoms. Patients reported such experiences as, "During Vedic sound therapy, I experienced profound inner silence and a sense of orderliness in mind and body that seemed the essence of healing. Following each session, my symptoms were clearly reduced." These results are consistent with a recent series of randomized, double-blind controlled trials on the efficacy of a related Vedic sound approach which reported immediate and significant improvements in several chronic neurological and musculoskeletal disorders (15). Nader suggests that the correspondence between Vedic literature and areas of human physiology account for these effects (7, 15). Previous data on effects of music and sound therapy on mental and physical health may support this hypothesis (41, 42).

In addition, the effects of positive mental and emotional states on the pathophysiological basis of disease and health may contribute to the understanding of this traditional program (83). Based on earlier studies, it may be that some of the mechanisms of the Maharishi Ayurveda multimodality program will be general, including reduction of stress responses (e.g., neuroendocrine stress and oxidative stress (84, 85), while some mechanisms may be specific, as suggested above. In addition to direct effects on disease processes, components of the Maharishi Ayurveda approach have been shown to have effects on improving cognitive abilities and mood (86). This may contribute to improved self-care, including adoption of positive, health-promoting behaviors and avoidance of negative health behaviors (87).

In conclusion, Eisenberg et al reported that patients' reasons for seeking alternative therapies include: "1} conventional therapies have been exhausted; 2} conventional therapies are of indeterminate effectiveness or are commonly associated with side effects or significant risk; 3} no conventional therapy is known to relieve the patient's condition; 4} the conventional approach is perceived to be emotionally or spiritually without benefit, and 5} patients are seeking health promotion and disease prevention " (2). The present series of cases suggest the potential of a traditional, comprehensive approach to natural medicine for responding to the perceived needs of at least certain patients with chronic diseases. Future research with experimental designs and long-term follow-up may be indicated to further evaluate these effects, especially given the social and individual burden of chronic disease in contemporary society (1, 88).

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