|Year : 2023 | Volume
| Issue : 1 | Page : 41-47
Repeatability of arterial pulse-based diagnosis (Naadi pariksha) by test–retest method: An observation study
Usharani S Sanu1, BS Prasad2, Rudramma R Hiremath3, Sunil S Vernekar4
1 Department of Kriya Shareera, KLE Academy of Higher Education and Research's Shri. B. M. Kankanwadi Ayurveda Mahavidhyalaya, Belagavi, Karnataka, India
2 President, NCISM, New Delhi, India
3 Department of Agada Tantra, KLE Academy of Higher Education and Research's Shri. B. M. Kankanwadi Ayurveda Mahavidhyalaya, Belagavi, Karnataka, India
4 Department of Physiology, KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
|Date of Submission||25-Dec-2021|
|Date of Acceptance||02-Sep-2022|
|Date of Web Publication||21-Jan-2023|
Dr. Usharani S Sanu
Department of Kriya Shareera, KLE Academy of Higher Education and Research's Shri. B. M. Kankanwadi Ayurveda Mahavidhyalaya, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Naadi pariksha is a historical diagnostic skill of physicians to examine the state of dosha (dosha avasta) in patients. Although this is a commonly used examination, there is still a need for standardization in the collection of data and reliability of the diagnostic technique. Considerable researchers have been conducted on the pulse classification based on its characters but this study was conducted to analyze the repeatability of arterial pulse-based diagnosis (Naadi pariksha) by test–retest method in a single group.
AIM: The study aims to test and retest the repeatability of the arterial pulse-based diagnosis. The naadi parameters such as pulse wavelength and pulse character were tested for repeatability in the gap period of 9–18 min in a controlled environment.
MATERIALS AND METHODS: This was an observational study conducted in Belagavi. An Ayurveda physician examined the pulse of 30 healthy volunteers twice, within an interval of 9–18 min. A random sampling of volunteers was adopted (to avoid bias), and the data were recorded graphically as per the study protocol. This study was conducted for 6 days with five participants per day for examination. The Naadi pariksha was done to examine the pulse wavelength and pulse character. The data obtained from the test and retest of Naadi pariksha were statistically analyzed using paired t-test to study the difference between both the test–retest methods.
RESULTS: All the data collected from the naadi examination were statistically analyzed using IBM SPSS Statistics 26. The mean difference in pulse wavelength was 0.004 mm (standard deviation [SD]: 0.2067 mm, degree of freedom (df): 29, and t: 0.106). There was no statistically significant difference between the two variables: test and retest pulse wavelength (P > 0.05). The mean difference in pulse character was 0.333 mm (SD: 1.64177 mm, df: 29, and t value: 1.112). There was no statistically significant difference between the two variables: test and retest pulse wavelength (P > 0.05).
CONCLUSION: The reliability and repeatability of pulse-based diagnosis depend on the adaptation of standardized techniques in arterial pulse data collection along with the training, maintaining the controlled environment, and experience of a physician in naadi pariksha. Quantification of the physiological signals has become more important to create evidence and research documentation. The results of this study suggest that an identical report may be obtained on repetition of the test within 9–18 min. This demonstrates the repeatability of arterial pulse-based diagnosis (naadi pariksha).
Keywords: Dosha avasta, Naadi, pulse wave amplitude, pulse wavelength, radial arterial pulse
|How to cite this article:|
Sanu US, Prasad B S, Hiremath RR, Vernekar SS. Repeatability of arterial pulse-based diagnosis (Naadi pariksha) by test–retest method: An observation study. Indian J Health Sci Biomed Res 2023;16:41-7
|How to cite this URL:|
Sanu US, Prasad B S, Hiremath RR, Vernekar SS. Repeatability of arterial pulse-based diagnosis (Naadi pariksha) by test–retest method: An observation study. Indian J Health Sci Biomed Res [serial online] 2023 [cited 2023 Jan 28];16:41-7. Available from: https://www.ijournalhs.org/text.asp?2023/16/1/41/368323
| Introduction|| |
Ayurvedic pulse diagnosis represents a major untapped area for research. Naadi examination is practiced to assess the physiological conditions of doshas which govern the body functions and to evaluate the disease conditions. Naadi Pariksha (arterial pulse diagnosis) is a diagnostic skill based on the tactile sensitivity of the physician. Naadi (arterial pulse) is a pulsatile vibration of the bodily dosha circulating through the blood. Changes in the proportion of doshas cause some standard hemodynamic wave changes seen in the arterial pulse wave. This diagnostic modality is used in Ayurveda to assess the stages of doshas in the diagnosis and prognosis of disease states., The methodology, while important in Ayurveda, has not been validated to conventional standards. Naadi pariksha is a subjective examination hence there is difficulty in teaching. These skills were reinforced by the use of deep meditative practices. Conventional medical sciences use the examination of the arterial pulse as an important predictor of cardiovascular disease. However, literature in Ayurveda cites naadi pariksha as a component for the critical analysis of dosha avastha (state of vata, pitta, and kapha) which relates to the overall governance of complete body homeostasis. There is a high need to demonstrate the reliability and repeatability of arterial pulse-based diagnosis to establish appropriate teaching and research methods. This study aims to study the repeatability of hemodynamic features of naadi (radial arterial pulse-pulse wavelength and pulse wave character) with the gold standard palpatory method explained in classics, using the test–retest method on 30 healthy volunteers and further testing the association between test–retest methods.
| Materials and Methods|| |
This is a simple noninvasive observational study on the historically effective diagnostic examination conducted at the screening ward in healthy volunteers. Appropriate ethical committee approvals were obtained with ref.no KAHER/Ethic/2018-19/D124 dated 29-5-2018. The CTRI registration was obtained with Reference No. CTRI/2021/04/032940. A total of 35 healthy volunteers were initially screened with inclusion and exclusion criteria. A total of 30 healthy volunteers fulfilling screening criteria were further examined for radial arterial pulse (naadi) parameters. The study was conducted by an Ayurveda physician certified with basic training and advanced training in naadi pariksha. The parameters of naadi such as rate, rhythm, pulse wave character, the position of the vessel, and condition of the blood vessel were measured in healthy volunteers and documented. Inclusion criteria: participants of 18–40 years of age were included in this study. Exclusion criteria: patients with any physical or mental illness and on any medication were excluded from this study. Informed written consent was taken from every patient in their own language.
Standard operative procedures of Naadi pareeksha,
Preparation of subject:
- Maintenance of a controlled environment where the participants are not allowed to eat, not do any laborious activities, and not undergo any emotional stress between the test and retest period
- The participants were asked to relax for 15 min, and later, the naadi of the left hand (female) and right hand (male) was examined totally for 3.5 min manually
- The investigator placed his right index finger below the radial styloid on the radial artery at a gap of 1 anguli (breath of the distal phalanx middle finger of an individual approximately 1.37 inches) from the wrist joint with semi-flexion of the palm of the participant
- The middle and ring fingers were placed next to the index finger without any gap junction
- The position (sthana) of the radial artery was examined, normally felt over the radial bone
- The arterial pulse is palpated for evaluation of rate, rhythm, character, and symmetry
- The pulse is examined at three levels – immediate expressions, superficial expression, and deep expression
- First minute-in immediate expression-the fingers are positioned on the radial artery with a gentle touch and with no pressure. Here, the activity of the dosha, the position of the radial artery, and the condition of the blood vessel (elastic soft/superficial elastic thick/deep thick/deep thin) are noted as shown in [Table 1]
- A standard chart was developed to grade the pulsation. The information collected without affecting the pulse pressure (immediate expression) was noted and pulsation felt under each fingertip was graded. Here for the study convenience, the activity is graded from 0 to 3 which represents the activity of the dosha
- Second min: in superficial expression, minimum pressure is exerted on the radial artery, and the activity of doshas on three fingers is noted
- Third min: in deep expressions, more pressure is put on the radial artery for palpation and the state of dhatu. This deep expression is not included in this study
- The activity of the dosha is documented as mentioned in [Table 2].
The investigator's eyes were tied with a cloth for blinding. The volunteers were asked to relax for 15 min before the examination. There was attainder to send the volunteers for examination. Five volunteers were examined in a day time at 11 am, with both the first round and second round of examination conducted on the same day as mentioned in [Table 3] and [Table 4]. Thus, the test was done twice. In each round, the volunteers were assigned numbers and randomly sent by the attainder for pulse examination. An alarm clock was set to intimate the time for examination. The investigator did not speak to any of the participants until the completion of the session. The volunteers were reshuffled and sent for the examination. Each volunteer was tested (first round) and retested (second round) with a time gap of 9–18 min. The obtained data was analyzed to determine the naadi type as shown in [Table 5].
Randomization of volunteers for examination
Data collection and recording
The pulse rate was calculated per minute (60 s). A graph was designed with 25 boxes (5 × 5), with reading 0, 0.5, 1.0, 1.5, and 2.0 mm. The pulse wavelength was calculated by dividing the obtained pulse rate by 60 to get the pulse wavelength in millimeters. As the pulse character is subjective in the examination, its grading was done from 0 to 3 as shown in [Table 1]. These data were graphically recorded, as shown in [Figure 1].
All the data collected from the naadi examination are subjective and these were collected from a single group of healthy participants (n = 30) and statistically analyzed using SPSS statistical software 21 version IBM, Chicago.
As Naadi (radial pulse parameters) is a common phenomenon, a minimum sampling of 30 volunteers was adapted as mentioned in the Z test to fulfill the normal distribution. Paired t-test was employed to check the significant difference between the results of the test and retest methods of examination of Naadi parameters of the healthy volunteers.
| Observations and Results|| |
The pulse wavelength in first round (test) with a mean of 0.9320 mm and second round (retest) had a mean of 0.9280 mm, with a mean difference of 0.0040 mm and 0.9280 mm, standard deviation (SD) of 0.2067 mm as shown in [Table 6]. The obtained t-value is 0.106 with a degree of freedom (df) 29 at a 5% level of statistical significance, as shown in [Table 7] and [Figure 2]. As the P value is more than 0.05 which shows no statistically significant difference. Hence, the null hypothesis is accepted which shows that there is no statistically significant difference between the two variables (test and retest pulse wavelength).
The pulse wave characters in the first round (test) with a mean of 1.93 and the second round (retest) had a mean of 1.83, with a mean difference of 0.1 and SD of 0.75 as shown in [Table 8]. The obtained t-value is 0.722 with a df 29 at 5% level of statistical significance, as shown in [Table 9] and [Figure 3]. As the P value is more than 0.05 which shows no statistical significance. Hence, the null hypothesis is accepted which shows that there is no statistical significant difference between the two variables (test and retest pulse wave amplitude).
|Figure 3: Association of naadi with pulse wave character in test–retest methods|
Click here to view
| Discussion|| |
Naadi examination is a traditional diagnostic skill to detect the dosha and their functioning in the body. There are seven naadi patterns explained in the classics which represent the status of doshas as shown in [Figure 4]. There are various determinants affecting the naadi patterns such as mental stress, anxiety, depression, and physical activities such as bath, food intake, running, and natural urges. The naadi pattern changes from time to time. Early morning naadi exhibits prakriti of a person in healthy individuals. In the next hours of the morning, kaphaja naadi is seen, in the afternoon, there is pittaja naadi, and in the evening, there is vataja naadi. Kapha dosha predominant naadi is stable, rhythmic, and moderate pressure, with thick and broad blood vessels in palpation. The pitta predominant naadi is quick, rhythmic, and high pressure, with elastic soft blood vessels in palpation. In healthy individuals, the vata predominant naadi is rhythmic, stable, less pressure, deep inside, or easily felt with thin blood vessels in palpation. The reliability and repeatability of pulse-based diagnosis depend on the adaptation of standardized techniques in arterial pulse data collection along with the training and experience of physician in naadi pariksha. Maintenance of a controlled environment where the participants are not allowed to eat, not do any laborious activities, and not undergo any emotional stress between the test and retest period. Hence, this study was planned to study the repeatability of naadi parameters with a time gap of 9–18 min.
|Figure 4: Classical naadi patterns. Joluka, sarpa- for vata naadi, Manduka, kaka- for pitta naadi, Kapota, hamsa –for kapha naadi|
Click here to view
In the present study, 30 healthy volunteers of the age group 18–40 years were selected to examine the repeatability of pulse wavelength and pulse wave amplitude of naadi (arterial pulse wave). According to Acharya Charaka and Acharya Susruta, the age group of 16–40 years falls into madhya vaya (middle age) with well-developed dhatus (tissues) and is apparently healthy, hence this age group was selected for the study. Randomization in sampling with blinding of the physician was done to avoid a possible adjourn effect of the first diagnosis. Pulse wave amplitude is defined as the difference between systolic and diastolic pressure which is felt on palpation as a throbbing pulsation in an artery due to the expansion of the artery under the influence of cardiac systole by ventricular contraction. The amplitude of the naadi was analyzed in millimeters according to the throbbing pressure peaks (amplitude) obtained during the examination and recorded graphically. Pulse wavelength and pulse wave character in both test and retest, have shown no difference statistically, which demonstrates the repeatability of Ayurveda's pulse diagnosis.
A study conducted on the repeatability of pulse-based diagnosis by Kurande et al showed that the pulse-based diagnosis conducted by 10 trained and experienced physicians had a moderate agreement in pulse data collected. Many other studies have shown that the combination of training of professionals and the development of diagnostic instruments or methodologies play a significant role in repeatability and reliability tests. Dang et al. reported low levels of reliability for Traditional Chinese Medicine (TCM)-based pulse diagnosis in cystic fibrosis. Walsh et al. reported a moderate level of reliability with pulse-based diagnosis conducted by three groups of TCM students. Some studies with two blindfolded Korean doctors diagnosed eight constitutional types based on pulse diagnosis of 31 subjects with a mean inter-rater agreement for the repeated diagnosis of 89% and 66.83% for the two doctors which showed poor inter-rater reliability. Sanu et al. studied the different distal arterial dimensions in different body constitutions. Lisheng et al. in their studies have mentioned types of pulse depending on the characteristics. Seven types of pulse patterns are being observed by TCM physicians among which four are rhythmic and three are arrhythmic pulse patterns. In this study, the quantification of the physiological signals was done to identify the difference in pulse characteristics. The details of this are mentioned in [Table 10]. These previous studies have been a base for the identification of the different naadi patterns and their quantification and documentation for further research. The swift pulse has the character of vataja naadi, the rapid pulse is similar to pittaja naadi features, the kaphaja naadi resembles the slow pulse, and the sama naadi resembles the moderate pulse. In the present study, standard operating procedures were adapted for the data collection and a single physician had tested the naadi twice with a gap time of 9–18 min. The results of this study suggest that an identical report may be obtained on repetition of the test within 9–18 min in a controlled environment. This demonstrates the repeatability of arterial pulse-based diagnosis (naadi pariksha).
| Conclusion|| |
Several studies have been conducted to study the reliability of pulse-based diagnosis which has shown that experience and proper standardization in operational methods to collect the pulse data play a significant role in testing the repeatability of the pulse. The naadi pariksha (radial artery diagnosis) is a subjective assessment and hence its accuracy varies from physician to physician due to different opinions and practices of naadi pariksha skills. Further, the changes in naadi under the influence of time, food intake, activities, and emotional factors make this task more challenging. Hence, there is a need for standardization in naadi capturing skills and techniques and maintenance of a controlled environment to avoid fluctuations in pulse parameters. In the present study, the standard protocol was adapted to capture naadi data, and precaution was taken to maintain a time gap of 9–18 min between the test and retest for each volunteer. The results of the study showed no difference in test–retest values which show there is the repeatability of the pulse parameters in a controlled environment for 9–18 min. This study can be useful for further research on naadi pariksha (pulse-based diagnosis).
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]