The concept and practice of
Low back pain management at
Vaidyaratnam Nursing Home
Anand P.K.V.
Vaidyaratnam Ayurveda College
Abstract:
Conventional clinical practice of low back pain treatment is widely varying in the concept about the disease, the causative factors, rationales and choice of treatments. This paper discusses the practices in Ashtavaidya tradition in the management of low back pain at Vaidyaratnam Nursing Home.
Introduction:
The holistic approach of Ayurveda trains the physician to attend each and every thing in the body that has a relation with the manifested disorder while making a prescription. The abstract nature of the science offers immense freedom for the Vaidya for customizing the application of treatment principles according to the patient's clinical manifestation. This makes diagnosis of a single case different for each Vaidya, which in turn makes the treatments different from case to case. Successful treatments in low back pain are one of the examples for which the Ayurvedic practice has acquired popularity in the modern society. A closer look to the treated cases reveals wide variations in the prescriptions, which may not be this frequent in other systems of practice. Vaidya prefers to treat the cause, or the disease or both as the condition asks for. For this purpose, he differentiates causes and places them in a list according to their importance (Pradhanika), chronological distance from manifestations (Sannikrishta & Viprakrishta) and their aberrant involvement (Vyabhichari). Every prescription is so carefully prepared so that it attends each factor that gets involved in the development of illness. The causative diseases for the manifestation of the symptom low back ache falls into at least 5 categories. All of these five diseases develop by its own causes among which some causes might be common for more than one disease.
Being its primary location and the root of channels & structures that has a bony orientation, Vaatha provocation at pelvis holds immense importance. We find lumbago among the list of diseases among which the involvement of Vaatha is inevitable. Low back pain is also a symptom in many illnesses. Diagnosing low back pain confirms the presence of a disease with broader, multisystemic manifestations called Pakwasayagatha Vaatha, which is one among the Vaathavyadhi. Low back pain can also manifest in other diseases. Prevalent ones among them are Vaathasonitha, AamaVaatha, diseases like piles, stones, herniations, gynecological disorders and as a consequential manifestation to the strain of parturition. There are other diseases with a bearing in this region like Rajayakshma, fever of Vaatha dominance, bowel inflammations, visceral pathologies etc. The disease Sandhigathavaatha & Urusthambha are also frequent diagnostic considerations in low back pain which can be differentiated by their unique features. Physical strain is a transient cause of back ache which responds to rest and relaxation techniques. It can appear as a somatic manifestation of psychological causes also. Low back pain is a manifestation in many diseases as listed in table below. The sequence of events which precipitates this symptom might be same for all such as an IVDP, spondylosis, muscular spasms, etc. The principal complaints are stiffness, pain and numbness, all of which originates in response to a spastic static status of muscles of lower back.
| Low back pain described as a symptom of some of the diseases or an event |
| Vidavrutha Vaatha |
| Medakshaya |
| Gudasritha Vaatha |
| Pakwasayagatha Vaatha |
| Grudhrasi |
| Prakcharana |
| Pariplutha |
| Vathika Pradara |
| Vathika Arsas |
| Ajeerna |
| Madathyaya |
| Vaathaja pakwathisara |
| Urakshatha / Kshathakasa |
| Vrikkavidradhi |
| Vaathaja Jwara |
| Thritheeyaka Jwara |
| Udara & Vathikodara |
| Soolaroga |
| Dandaka |
| The seventh Vega of both Sthavara and Darvikara Vishas |
| Aasanna prasava |
Even with a varied list of etiology, we may find similarities and comparisons in the pathogenesis, which forms patters that gets identified as a single disease. The convergence of all these varied etiopathogenic activities undergo a very similar course of events to be manifested as the same symptom in the same location. The sequential progress of events invariably ends up in developing inflammatory, disease prone and tense environment in the region. This in turn gives rise to painful tissue structures, sustained partial spasm of supporting musculature, impingement of nerves and nerve roots and inflammation of the connective tissues & nerves. Such a tense environment is always prone to IVDP, nerve impingements, entrapment of nerves, vessels or other structures in a congested area. Insignificant incidences like sneezing, a usual abrupt twist, lifting a usual weight etc, becomes the instrumental causes (Nimitha karana) for acute manifestations due to IVDP, scoliosis etc.
The disease low back pain is seen traditionally as a group of symptoms among which the prominent one is low back pain. Those symptoms which accompany this major symptom explain the nature and background pathology of low back pain. Ayurvedic physician attends both symptoms and causes in consideration to their relative positions in the clinical picture. The primary concern of the patient is to get relieved of the acute manifestation. Many of them might not be aware or bothered in the settings that generate an acute manifestation. Practitioners are supposed to attend all such events comprehensively while planning the management. A profile of treatment records can reveal the prevalent clinical conditions precipitating low back pain when analyzed from the list of treatments provided in such group.
Materials and methods
Low back pain patients at Vaidyaratnam Nursing Home, during a period of one year in 2006-07, receiving treatment from Astavaidyan E.T.Narayanan Mooss were observed closely. Their clinical features along with the treatments and responses were recorded, listed and interpreted. From the cases reported to have low back pain, 76 cases for which low back pain was the major presenting complaints were selected for the study, using an inclusion - exclusion criteria.
Results
The mean age of the patients was 46.9 + or - 13.3(range 21 to 67 yrs). The prevalent symptoms observed in comparison to the textual descriptions are depicted in the table below. Manifestations below hip were of varying nature such as pain, weakness, numbness, black discoloration, varicose vein, swellings, burning pains, spasm & stiffness of leg muscles, cramps, sciatic pain, etc., radiating downwards and difficulty to sit, lie down and walk.
| Clinical profile of the patients | |
| Signs and symptoms | % |
| Colic pain (soola) | 3.333333333 |
| Bloatulance (Anaha) | 16.66666667 |
| Borborrigmi (Anthrakoojanam) | 10 |
| Constipation (Malarodham) | 30 |
| Piles (Arsa) | 20 |
| Upper & Lower back pain (Thrika-prishtagraham) | 60 |
| Manifestations below hip (Adhah Kaye Upadravah) | 88 |
| Low back pain (Kateegraha) | 100 |
Females constituted 47% of the group under study. 72% of them were suffering from mild to moderate menstrual or gynecological complaints. This is another evidence of unsound Apanavayu, which prevails in Pakwasaya. The symptoms like herniation, calculi, colic pain etc, were rare presentations. Since low back pain derives from musculoskeletal causes like physical strains, bad postures and events like degeneration or disc injuries, the manifestation extends to upper back region also in many cases. The lower gastro intestinal symptoms due to Apana involvement like flatulence, piles, etc., were also prevalent among the patients.
Symptoms which can be included under the title Pakwasayagatha vaatha, of which low back pain is one of the symptoms was of more of diagnostic relevance here. Proximity and mutual relation between the Pakwasaya and Katee region could be the important consideration which makes it an exclusive Vaatha disease. When the predisposition, systemic symptoms and specific features were considered, the manifestations could also be discussed under other diseases involving musculoskeletal systems. But they can be excluded considering the absence of involvement of other joints, joint swellings, nature of pain, presence of Ama, favorable response to Snehana treatments, fatigue, etc. The percentage of patients with presence of some of the symptoms of those diseases in the study group is tabulated below. However this gives an idea about possible overlapping of symptoms and the clue to variations possibilities in the diagnosis of low back pain, which depends more on the physician's discrimination.
| Disease category | % |
| SandhigathaVaatha signs | 6 |
| Vaathasonitha signs | 43 |
| Urusthambha signs | 4 |
| AmaVaatha signs | 30 |
| PakwasayagathaVaatha signs | 100 |
Many patients were presented with multiple joint pains along with low back ache. Although some of the symptoms like constipation, swellings etc. were suggestive of AmaVaatha, in 30% of the cases, the cardinal clinical evidences of the same were insufficient or absent. The pain was also not characteristic of AamaVaatha in any of cases. 77% of the cases were having pain radiating down through thighs while some of them had variable degree of tightness and feeling of heaviness. In addition to these 4% of the cases had the possibility of getting diagnosed as Urusthambha. But the compiled symptoms and the nature of responses to treatments were strong enough to pull them into a broader category like Pakwasayagatha Vaatha. SandhigathaVaatha was a diagnostic consideration in 6% of the cases by the presence of pain and stiffness related to movements involving the location. Still the absence of ballooned swellings and non specificity of the joint involvement in most of the cases makes it a less possible diagnosis. 43% of the cases could also be diagnosed as Vaathasonitha by the presence of multiple joint involvements along with presence of other variants of pain, numbness, cramps etc. Many were also having the characteristic features of Vaathasonitha like frequent remissions and exacerbations, fatigue, etc. But majority of symptoms of Vaathasonitha were not perceivable which provides lesser chances to make such a diagnosis. There can be so much overlapping of symptoms making different chances of diagnosis even when the prominent feature remain low back pain.
| Treatments selected in low back pain | % |
| Prishtavasthi | 73.80952381 |
| Pizhichil | 52.38095238 |
| Njavara kizhi in oil | 35.71428571 |
| Kolakulathadi churnam etc./ Dhanya kizhi / Rooksha kizhi / patrapota sweda | 71.42857143 |
| Madhuthailikam vasthy | 92.85714286 |
| Yapanavasthi | 4.761904762 |
| Upanaham | 54.76190476 |
| Pradesika lepanam | 61.9047619 |
| Abhyangam | 100 |
| Pichu | 9.523809524 |
All patients received Abhyangam, which is regarded as an important procedure for musculoskeletal complaints. 71% of the cases have received Potalasweda with Kolakulathadi / Kottamchukkadi / Dhanya choornas , Rookshasweda with Syamaka, or pathrpotalasweda which are important for the purpose of pain relief and to relieve the Kapha-medas - ama involvement, if any. Prishtavasthy was performed in 74% of cases, which is a simpler version and a region focused application of avagahasweda. Pichu, another simpler method of containing oil locally, was advised in 10% of cases. Local application of pastes were a choice in 62% cases which is intended to relieve pain and local inflammation or swelling. Upanaham is important in muscular disorders and has the added convenience of local specificity. This treatment was advised in 55% cases. Pizhichil was advised in 52% of the cases. Navarakizhi in oil in 35% of the cases. Niroohavasthy was done in 98% cases out of which 4% were yapanavasthy and the rest Madhuthailikavasthi.
Many of them had their investigations done and diagnosis made prior to approach for Ayurvedic treatments. 78% of the patients had approached English medical system prior to seeking advice on Ayurvedic treatments, out of which only 33% of the cases had a radiological investigation done. X-rays, MRI or bone scans revealed 45 % of cases them had intervertebral disc prolapse along with degenerative changes while others had degenerative disc changes but no prolapse.
Rasnasapthaka is a yoga mentioned in the context of AmaVaatha and specifically for pain in calf, thigh, upper and lower back and the flanks. Increased frequency of this kashaya in the prescriptions denotes the prevalence of Ama, found in the clinical observation. Dhanwantharam kashaya yogam is for all kinds of Vaatha vikaras and specifically indicated in traumatic, those involving marma, etc. Adarisahacharadi and Sahacharadi are yogas frequently prescribed when walking is affected due to involvement of lower limbs. Gandharvahasthadi, sapthasaram, chiruvilwadi, sukumaram and abhayapippaleemooladi are yogas which aim at correcting the movement of ApanaVaatha. The last yoga among them is also a moderate purgative. Other miscellaneous kashayas used include Balasathavaryadi, Dasamoolarasnadi, Ashtavargam, Bhadradi, Brihath nayopayam which are good in KevalaVaatha conditions. Sapthasaram, Dhanwantharam and Sukumaram are prescribed in gynecological disorders and also for relieving the Vaathakopa related to delivery and puerperal events.
The frequency of Kashayayogas used in percentage
Major site of action indicated disease
rasnasapthakam 29% lower limbs, back & flanks Pain in AmaVaatha
adarisahacharadi 13% Lower limbs &heels Vaathakandaka
sapthasaram 13% Pakwasaya Gulma
dhanwantharam 10% Marma Soothika
Other Vaathaharakwadhas 8% Vit-mutra Anulomaka & vatahara Kevala Vaatha
chiruvilwadi 8% Rectum Arsas
abhayapippaleemooladi of 8% Large intestine pain & constipation Vaathakaphajwara
sahacharadi 4% Lower limbs Kevala Vaatha
Sukumaram 4% Uterus and abdomen as a whole Vruddhi
gandarvahastadi 3% small & large intestine Kevala Vaatha
The list of kashyayogas selected shows us that this tradition approaches the disease low back pain mainly with pain specific formulae of AmaVaatha and location specific (lower limbs) medicines
A student in his early periods of practice of medicine may find it difficult to pass through such an intellectual exercise in the scientific instructions. But for experienced practitioners and for those who are trained in a particular tradition, it is an automatic reflex activity. It may not be easy to narrate the steps and sequences of the thought process. Even then managing the clinical conditions and fighting the causes goes on uninterrupted. This redefines the science to the needs of the era. The tradition of ashtavaidyas is such an important tradition which has offered much of updating of the scientific applications in the past. It offers an example to be followed in the flooding of various styles of practice and beacons the practitioner in an ever-changing and conflicting waves of information and clinical approaches.
Acknowledgment
K.Suresh, Sajith,, Lakshmipriya,Govind.N. Anil.V.Kaimal, Sudarsanan Nair* E.T.N.Mooss
Vaidyaratnam Ayurveda Foundation
*Central Research Institute, Cheruthuruthi
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