This study assesses the interrater reliability of Ayurvedic pulse (
In Ayurveda, the physician’s bimodal approach of clinical examination (disease diagnosis and patient diagnosis) is used to determine the root cause of the disease and to determine the treatment selection [
In the clinical settings, interrater reliability is the degree to which two or more raters agree on a diagnosis of the same subject under identical assessment conditions. Reliability studies are necessary because they provide information about the quality of measurements and also play an important role in the process of developing effective diagnostic procedures [
The Ayurvedic concepts of physiology, pathology, diagnosis, medicine, and therapeutics are based on the doctrine of the three
Thus, pulse, tongue, and
In the present study, we assess the interrater reliability of the pulse, tongue, and
Pulse examination was done by placing the index, middle, and ring fingers at the root of the thumb of the subjects. For female subjects, the pulse was taken from the left side, and in the case of male subjects, the pulse was taken from the right side. The sensation of the
Doctors assessed the degree of tongue coating. Tongue coating is defined as no coating (
The
Body constitution assessment.
Diagnostic technique | Variable | Characteristic investigated | Specific characteristics for body constitution | ||
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Inspection | Physique | Head, forehead, face, eyes, lips, jaws, shoulder, chest, hands, palms, nails, legs, soles, joints, blood vessels, tendons. | Thin and slim physique, prominent bones | Moderately developed physique | Stout, well developed, large forehead |
Eyes | Colour and appearance | Small, dry, dull, muddy sclera, brown eyes | Reddish tinges to sclera, medium size, piercing eyes | White sclera, attractive, large eyes with thick eyelashes | |
Skin | Texture, appearance, colour | Thin, hard, rough, cracked, dark, skin, superficial veins and tendons | Reddish, pink skin often with moles and acne | Thick, white, pale, yellow, oily | |
Scalp hair, body hair | Texture, nature, growth, colour, body hair (colour) | Scanty, thin, coarse, dry, wavy hair | Fine, soft, red or gray hair often balding in early age | Dark, thick, dense, oily, lustrous hair | |
Teeth | Size, appearance, shape and colour | Brittle/cracked, too large, uneven, dull blackish irregular | Yellowish, loose, medium | Milky white, lustrous, even large, regular | |
Walking | Style, speed | Quick, fast or variable excessive unsteady | Medium, sharp accurate | Slow, firm/steady, less | |
Complexion | Colour, nature | Dark complexion, Tans easily, rough, wrinkled, brittle | Reddish, pink, smooth, soft skin, sunburns easily | White, pale, tans evenly | |
Voice | Quality | Low, weak, hoarse voice | High pitch, sharp voice | Deep tone, pleasant | |
Speech | Content of speech | Quick, adaptable, indecisive mental nature, excessive, irrelevant in between | Intelligent, sharp, accurate, penetrative, critical, argumentative | Slow, steady, convincing, sweet and pleasing to ears, well thought of | |
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Touch | Skin | Nature, texture, temperature | Thin, dry, cold | Warm, moist | Oily, smooth, and soft skin |
Hair | Nature, texture | Dry, hard, coarse | Soft | Smooth, oily | |
Pulse | Location, pattern | Felt under the index finger like a snake crawling | Felt under the middle finger like frog’s jumping | Felt under the ring finger slow, steady like pigeons movement | |
Joint | Movement | Cracking sound | |||
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Questioning | Appetite | Frequency, amount | Appetite is variable, infrequent | Strong appetite. Irritable if you miss a meal | Regular, low, can skip meals easily |
Thirst | Frequency, amount | Variable, infrequent | Strong, large amount of water needed | Low, less amount of water | |
Food habits | Type of food liking, suit | Hot, oily | Cold, sweet | Hot, dry | |
Bowel and bladder habit | Frequency, amount | Irregular, variable, tendency towards constipation, hard stool | Regular, tendency towards loose motion, loose soft, semisolid stool | Regular, no constipation or loose motion medium | |
Strength | Physical, mental, resistance power, healing power | Low | Medium | Good | |
Perspiration | Amount, odour | Scanty sweat often without smell | Profuse, hot sweat often with strong smell | Moderate, cold sweat | |
Sleep | Amount, nature, quality | Light, disturbed sleep. Tends towards insomnia | Moderate sleep. Wakes up at the smallest sound sleep | Sound sleep, difficulty in waking up | |
Dreams | Type of dreams | Flying, moving, restless in dreams and has nightmares | Colourful (specially red), passionate, fighting, fire in dreams | Few, sentimental water, rivers in dreams | |
Body weight | Body weight changes | Low, difficulty in putting on weight | Stable | Gain easily and lose with difficulty | |
Weather | Preference and tolerance | Prefer warm climate, sunshine, and moisture |
Prefer cool and well ventilated place | Any climate is fine as long as it is not humid |
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Working/Activity | Style, speed | Fast, quick, variable, wavering, and easily deviated | Moderate, sharp, accurate | Slow, steady, well thought of | |
Psychological characteristics | Memory | Poor memory, observation good but forgets easily | Sharp, clear memory | Slow to take notice but will not forget easily | |
Emotions | Anxiety, fear, uncertainty | Anger, ambitious, practical | Calm, peaceful | ||
Anger | Quick and unstable | Quick and sustained | Always cool | ||
Others | Friends | Few | Medium | More |
The
We used
We included twenty healthy subjects (males:
Fifteen registered doctors, who have been practicing in Sri Sri College of Ayurvedic Science & Research Hospital, conducted the study. Ten were M.D. (Ayurveda) holders, two had M.S. in Ayurveda, and three had a B.A.M.S. (Bachelor of Ayurveda, Medicine and Surgery) in Ayurveda and had completed a pulse diagnosis course (Figure
The experience and educational level of the 15 doctors.
The study was conducted at Sri Sri College of Ayurvedic Science & Research Hospital in the morning. All subjects had been fasting for two hours. The doctors examined each subject independently. All doctors wrote their assessment of pulse, tongue, and
Flow chart of study procedure.
Both pulse patterns and the
Diagnosis classes and weights for each variable.
Diagnosis classes | Types of pulse | Body constitution ( |
Weights for each variable |
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(1, 0, 0) |
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(2/3, 1/3, 0) |
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(2/3, 0, 1/3) |
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(0, 1, 0) |
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(1/3, 2/3, 0) |
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(0, 2/3, 1/3) |
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(0, 0, 1) |
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(1/3, 0, 2/3) |
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(0, 1/3, 2/3) |
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(1/3, 1/3, 1/3) |
Distance matrix between categories in
Classes |
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0 | 0.106 | 0.106 | 1 | 0.553 | 1 | 1 | 0.553 | 1 | 0.423 |
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0.106 | 0 | 0.2 | 0.55 | 0.2 | 0.6 | 1 | 0.6 | 0.8 | 0.225 |
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0.106 | 0.2 | 0 | 1 | 0.6 | 0.8 | 0.553 | 0.2 | 0.6 | 0.225 |
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1 | 0.553 | 1 | 0 | 0.106 | 0.106 | 1 | 1 | 0.553 | 0.423 |
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0.553 | 0.2 | 0.6 | 0.106 | 0 | 0.2 | 1 | 0.8 | 0.6 | 0.225 |
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1 | 0.6 | 0.8 | 0.106 | 0.2 | 0 | 0.553 | 0.6 | 0.2 | 0.225 |
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1 | 1 | 0.553 | 1 | 1 | 0.553 | 0 | 0.106 | 0.106 | 0.423 |
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0.553 | 0.6 | 0.2 | 1 | 0.8 | 0.6 | 0.106 | 0 | 0.2 | 0.225 |
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1 | 0.8 | 0.6 | 0.553 | 0.6 | 0.2 | 0.106 | 0.2 | 0 | 0.225 |
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0.423 | 0.225 | 0.225 | 0.423 | 0.225 | 0.225 | 0.423 | 0.225 | 0.225 | 0 |
Distances between tongue diagnoses.
Tongue coating and classes |
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No coating: |
0 | 0.5 | 1 |
Medium coating: |
0.5 | 0 | 0.5 |
Tongue coating: |
1 | 0.5 | 0 |
Percentage of pairwise kappas within each LK category of reliability for pulse, tongue, and
Landis and Koch scale | Kappa range | Body constitution | Tongue | Pulse |
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Poor | (−1.0, 0.0) | 9 | 16 | 40 |
Slight | (0.01, 0.20) | 22 | 37 | 37 |
Fair | (0.21, 0.40) | 44 | 41 | 20 |
Moderate | (0.41, 0.60) | 22 | 6 | 3 |
Substantial | (0.61, 0.80) | 3 | 0 | 0 |
Almost perfect/perfect | (0.81, 1.00) | 0 | 0 | 0 |
Number of significant | — | 12 | 0 | 1 |
Distance between two classes,
For each data set and each pair of doctors, we tested the null hypothesis of random rating, where the probability that the doctor assigns a particular diagnosis to a subject does not depend on the subject. A minimal requirement for agreement between doctors is that each of them performs significantly better than a random rating. Therefore, if the data do not show strong evidence against
Flowchart for the permutation-type test for computing
To get an overall level of reproducibility for pulse, tongue, and
In this study, each doctor diagnosed
The percentages of pairwise kappas within each LK categories “poor,” “slight,” “fair,” and “moderate” were 40, 37, 20, and 3 percent, respectively (Table
The frequencies of diagnosis classes for all doctors for the pulse examination are shown in Figure
The average pairwise kappa, the corresponding
Diagnosis | Mean kappa |
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LK scale |
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0.28 |
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Fair |
Tongue | 0.17 |
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Slight |
Pulse | 0.066 |
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Slight |
For tongue diagnosis, the percentages of kappas in the LK categories “poor,” “slight,” “fair,” and “moderate” were 16, 35, 41, and 6 percent, respectively (Table
The level of reliability according to the LK scale is shown in Table
For each subject, we compared software and questionnaire diagnoses with the preferred assessment of the majority of the doctors. There was significant evidence against the hypothesis of random rating between software, questionnaire, and the preferred assessment of the majority of doctors. A moderate level of interrater reliability was present between the most frequent doctor’s assessment and the software assessment, and likewise, a moderate level of reliability was found between the doctor’s most frequent assessment and the questionnaire assessment. A fair level of reliability was found between the questionnaires and the software (Table
The pairwise kappa, the
Kappa |
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LK scale | |
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Mode assessment versus Software |
0.487 | 2 |
Moderate |
Mode assessment versus Questionnaire |
0.497 | 0.0026* | Moderate |
Software versus Questionnaire |
0.336 | 0.0114* | Fair |
The distribution of all pairwise kappas for pulse, tongue, and
(a) to (c) show the histogram of all the pairwise kappas under permutation for the three datasets. The red “rug” (or ticks) below each plot shows the observed 105 pairwise kappas for comparison. (d) shows a Venn diagram of the significant
The frequencies accumulated for all doctors for pulse (a), tongue (b), and
To see whether pairs of doctors with a high degree of reliability (i.e., a high pairwise kappa) in one dataset also concur in another dataset, scatter plots of the pairwise kappa values between different diagnoses were made and shown in Figure
Scatter plots of the pairwise kappa values between different diagnoses. Shown in each panel are the Pearson correlation coefficient and a corresponding
The results showed low levels of interrater reliability. A blinded study on the intra-rater reliability of pulse examination in Ayurveda reported a favorable result (
Similarly, in traditional Chinese medicine and traditional Japanese Toyohari medicine, studies on pulse examination showed results ranging from a low to a good level of reliability [
The overall reliability for tongue diagnosis ranged from poor to moderate levels. Similarly, in TCM, interrater reliability was low (no formal statistical analysis used) for tongue examination [
As for tongue diagnosis, despite the rather small value 0.17 of the average kappa, the hypothesis of random rating was rejected for the overall test using the average pairwise kappa.
In comparison with the pulse and tongue diagnosis, the reliability of the
The present study was conducted without additional training of the doctors. It is necessary to assess the reliability of
In the present study, a comparison between the self-reported questionnaire and software and the assessment favored by most doctors was significant. The diagnosis given by the doctor was on average consistent with the questionnaire and software assessment. Hence, this suggests that there was much more variability in assessment among the doctors in comparison to the questionnaire or software. In the clinical practice, a good approach to improve the reliability of
For pulse examination, the group of
Seven different types of
Various factors can affect the consistency of the diagnoses such as variability in the experience, specialization, and the schooling of the doctors. The doctors in this study had different levels of clinical experience and different specializations. Participating doctors also pointed out that an inherent variability is due to different traditional backgrounds and a lack of standardization of diagnostic methods. Another factor that influences the reliability is changeable signs and symptoms within some time frame.
Intrarater reliability of pulse, tongue, and
In [
The number of subjects was limited to twenty to reduce chance of fatigue among the doctors. Another limitation of the study was the use of self-reported
This is the first study to comprehensively investigate the interrater reliability of the pulse, tongue, and
The main reason behind the poor reliability of Ayurveda diagnosis could be lack of a systematic objective methodology and a precise operational definition of the diagnostic methods. Additional research is needed to help improve the reliability for these diagnostic methods. Furthermore, future studies on reliability should be performed after establishing objective methodology and ensuring proper training.
In general, the interrater reliability was unimpressive, and there is room for improvement for all diagnostic methods. The best reliability of body constitution assessment was obtained when questionnaires and software were used. Accordingly, we suggest that standardization of diagnostic methods may improve the level of reliability.
For more details see supplementary material available online at
The authors have no conflict of interests.
The major contribution to this work was done by Vrinda Kurande. The remaining authors contributed equally.
This study is supported by the “Erasmus Mundus Mobility for Life” project CTIF section, at Aalborg University for the first author only. The authors wish to thank Dr. Ratnaprabha Mishra, Dr. Aparna Desai, Dr. Umesh C., Dr. Gopal Krishna, Dr. Nikhila Hiremath, Dr. Varuni S. J., Dr. Mahesh C. D., Dr. Naveen V., Dr. Sangeeta Rao, Dr. Shilpa Dhote, Dr. Vivek J., Dr. Ranjeet Shetty, Dr. Kirti Mehendale, Dr. Kshipra Srivastava, and Dr. Pritesh Patel for their participation in the study. They would like to thank Dr. Murlidharan, Dr. Sarvesh, HOD Roganidan Dr. Aparna Desai, and Research head Ghanashyam Shrivastav from Sri Sri Ayurveda Science and Research Hospital, Bangalore, India. Dr. Kirti Mehendale is thanked for her valuable help and support in making facilities and experimental setup available.