Editor's note: Part one of Mr. Williams' article on the role of TCM and ayurveda in treating chronic low back pain appeared in the April issue of Acupuncture Today.
In my last article, I discussed avenues for integrating TCM and ayurveda in chronic lower back pain and focused mainly on herbal therapies. In this article, I wish to expand this topic further and discuss clinical scenarios in which herbal medicine could potentially aggravate lower back pain, offer complementary yoga therapies to assuage back pain, discuss similarities between ayurvedic marma points and TCM acupuncture points, and introduce novel ways to use herbal therapies topically to improve clinical outcomes.
Both ayurveda and TCM agree that prior to any type of supplementation, the degree of stagnation present must be clinically evaluated. The clinician must "clear the way," so to speak, before introducing heavy and cloying tonics such as shu di huang or ashwagandha if large amounts of stagnation are present. Ayurveda uses the terms sama and nirama to address this issue. Sama means "with ama" and nirama means "without ama." Ama is a unique idea in ayurveda that is very similar to the TCM ideas of food stagnation, damp, and phlegm. The term ama means roughly "undigested food mass." Ama is sticky, wet and cloying, and by its very nature tends to clog up the channels or srotas, thereby disrupting cellular intelligence and the flow of prana or qi throughout the body. This is very similar to the idea of damp and phlegm gumming up the qi mechanism, preventing smooth flow throughout the body.
Signs of ama include a wet and sticky tongue coating, fat plump tongue body with teeth marks, bad breath, constipation, depression and recalcitrant/chronic symptoms. These clinical signs share many similarities with the TCM presentations of food stagnation, dampness and phlegm. The ayurvedic herbal formula trikatu can be used in these situations to help digest ama, strengthen the digestive fire or agni, and improve the bio-availability of herbal tonics. Trikatu is a simple formula consisting of ginger, black pepper, and pippali pepper, and typically is taken with honey as an anupan or vehicle to carry the herbs deep into the body. All of the ingredients of trikatu have shown antioxidant and anti-inflammatory actions in Western studies and have shown to dramatically improve the absorption of any substance taken concurrently. This has great clinical potential for use with heavy and hard-to-digest herbal medicines and could easily be added in small amounts to any TCM formula to improve its efficacy. Since trikatu does have a heating action, literally "cooking" the ama, clinicians should use it cautiously when heat signs are predominant, or use very small amounts to avoid adding excess heat.
The TCM formula yue ju wan (escape restraint pill) is an excellent formula to use in chronic back pain scenarios in which heavy, damp stagnation is present. Designed by Zhu Dan-Xi, yue ju wan addresses the six stagnations of qi: blood, fire, food, damp, and phlegm. It easily can be combined with trikatu and er zhi wan (two marvel pill) to avoid adding to the stagnation while still supplementing kidney yin and ojas. The herb turmeric also could be added to prevent stagnation and clearing of the channels or srotas. TCM uses this herb as jiang huang while ayurveda's sanskrit name is haridra. Both traditions use turmeric to clear the channels and move the qi, and modern Western studies have shown numerous anti-inflammatory compounds present in turmeric. When viewing both Western and Eastern views on turmeric, one can easily see the potential for its use in chronic lower back pain presentations.
The herb guggul also is used in ayurveda to treat pain in situations presenting with stagnation and/or ama. In my last article, I presented the ayurvedic diagnostic maxim that there is no pain without vata, no inflammation without pitta, and no congestion without kapha. With this in mind, the clinician can use guggul-based formulas to address the back pain at the root cause, the imbalanced dosha. For vata dosha, yogaraj guggulu is used; for pitta dosha, kaishor guggulu is used; for kapha dosha, punarnava guggulu is used. It is very easy for all three doshas to be involved, or for vata dosha to be the main cause, using its "windy" nature to push pitta and kapha out of balance. Therefore, it is common to use the aforementioned guggulu formulas in tandem or in rotation depending on the presentation or season. Triphala guggulu can be used along with trikatu in scenarios that are not responding to typical therapies or in difficult recalcitrant cases and can easily be used with shen tong zhu yu tang to improve clinical efficacy.
Marma therapy or marma chkitsa also is a highly effective complementary clinical therapy for chronic lower back pain. Marma points are almost identical to TCM's acupuncture points and can be used along the same lines as TCM meridian therapy. Marma means "vulnerable" or "sensitive" and can be used to affect a change in the body channels or srotas and deeper psycho-physiological systems or doshas. Clinicians trained in TCM can easily combine acupuncture or moxa on marma points in conjunction with herbal medicines to see quicker resolution of pain. One of my favorite ways to use marma points is with the topical use of medicated oils and moxa.
Two of my favorite ayurvedic medicated herbal oils are ashwagandha/bala oil and mahanarayan oil. These oils have been used clinically for thousands of years for relief of pain and to increase the healing capacity of the body. The healing aspect of touch is a crucial form of therapy in ayurveda, and the use of massage or abhyanga to stimulate the body's innate healing intelligence can act as a powerful catalyst for rejuvenation in chronic pain scenarios. The ayurvedic medical text Charaka Samhita states that abhyanga can be used to decrease the effects of aging; nourish and rejuvenate the body; increase longevity; strengthen the body's ability to adapt and recover from stress; stimulate the internal organs and circulation and pacify; and harmonize vata, pitta and kapha. All of these attributes of abhyanga can easily be tied into the idea of banking or supplementing the kidneys and increasing the body's reserves of jing or essence, and dispelling blood stasis in TCM.
The marma points I use most often in combination with medicated oils and moxa are gulpa, janu, and parshvasandhi. Gulpa is nearly identical to Bladder 62, janu is located in the center of the knee joint and parshvasandhi is located in the lumbar area near the upper hips. After gently applying the medicated oil, gentle circular strokes are used for about five minutes and then moxa or a TDP lamp can be used to further stimulate the marmas. Care must be taken to not irritate the skin with the heat or to use too harsh of a touch. The skin is a vata organ in ayurveda, so gentle, warm, consistent touch is crucial for effective results. I highly recommend the use of the text Ayruveda and Marma Therapy, by Frawley, Ranade and Lele for reference and further reading on the applications of marma therapy.
Ayurveda's sister science of yoga also has much to offer patients with chronic lower back pain. In the West, most view yoga as primarily a form of physical therapy using various poses or asanas to strengthen and stretch muscles and ligaments. Yoga, however, is not just a type of physical therapy. Numerous aspects of yoga can be used to assist the patient in the healing process, including pranayama or breathing exercises and meditation techniques or dhyana. Asana therapy can play a crucial role in healing lower back pain, but it must be integrated into a larger yogic paradigm to yield its fruits safely and consistently. Asanas by themselves are not yoga. Gentle standing forward bends, gentle spinal twists, and standing poses used in an integrated way with pranayama and dhyana can dramatically help spinal and lower back issues, but care must be taken when using these methods. It is important to consult a specialist trained in the proper integration of these therapies to avoid unneeded injury or aggravations.
I hope these articles on the care of lower back pain with TCM and ayurveda have provided new insights or stimulated new avenues of interest for clinicians and patients alike. Both ayurveda and TCM view health and healing as a delicate and dynamic balance. It is important that clinicians approach their patients and their studies with a sense of reverence, responsibility and respect. In many ways, the most powerful medicine is not herbs, needles or supplements, but kind words and a gentle touch which awaken the patient's own healing intelligence.
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