Chronic lower back pain is one of the most commonly encountered complaints in a student or professional clinic. The traditions of traditional Chinese medicine and ayurveda offer a diverse array of effective therapies for addressing this painful condition.
One of the main TCM diagnostic errors I've seen in lower back pain scenarios is treating the condition as a sole pattern of qi stagnation/blood stasis. In any painful condition, it's obvious that qi stagnation and blood stasis are present to some extent. However, it's rarely a standalone pattern in chronic lower back pain patients. Typically, in these scenarios, there are other factors involving some type of vacuity. Two statements of fact in traditional Chinese medicine are that the lower back is the mansion of the kidneys and the kidneys govern the low back and lower legs. It's important to keep these statements in mind when treating chronic lower back pain. One of the patho- gnomonic symptoms of kidney vacuity is low back pain. Another statement of fact in TCM is that enduring disease reaches the kidneys. Therefore, any chronic pain, even if initially caused by qi stagnation/blood stasis eventually will damage the kidneys. With this in mind, it becomes obvious that treating just the stagnation aspect of low back pain will only provide temporary results. For lasting clinical results, one must bank or supplement the kidneys.
When using TCM formulas in low back pain presentations, it's helpful to have what I refer to as "skeleton" formulas one can "flesh out" to address particular aspects of an individual's pattern. One such skeleton formula I frequently use and have on hand for low back pain consists of du zhong, gu sui bu, sang ji sheng, bai shao and gan cao. The first three medicinals are home to the kidneys, while the last two comprise an elegantly simple formula from the Jin Gui Yao Lue for spasms and pain in the legs, shao yao gan cao tang. This skeleton can be fleshed out in numerous ways. For qi stagnation/blood stasis, one can add ru xiang, mo yao and yan hu suo. For kidney yin vacuity, add er zhi wan (nu zhen zi and han lian cao). For kidney yang vacuity, add tu si zi and rou gui. For vacuity heat, add zhi mu and huang bai. Since the liver and the kidneys share a common source, using a higher dose of bai shao with dang gui can soften and emoliate the liver viscus, enabling its qi mechanism to function smoothly and freely, and supporting the liver's function of storing the blood.
In TCM, we know that blood enriches and nourishes the whole body's channels and network vessels. Therefore, ensuring the liver is adequately nourished by blood assists in any body pain scenario. TCM also states that enduring diseases enter the network vessels, and if the liver and kidney network vessels are empty, low back pain will not stop. This supplies another logical connection for adding blood-nourishing medicinals to a chronic pain formula vis-a-vis blood nourishing the channels and network vessels.
Ayurvedic medicine also can be used to assuage chronic low back pain. The term for lower back pain in Sanskrit is kati shula, with "kati" referring to the lower back and "shula" referring to pain. Ayurveda differentiates low back pain into three basic subtypes or doshas: vata, pitta and kapha. These categories are used to both classify a patient's individual body type, or prakriti, and the individual's disease state, or vikriti. This type of differential diagnosis allows the practitioner to "treat the patient, not the disease" a la traditional Chinese medicine. An individual's disease state or vikriti is quite similar to a TCM pattern of disharmony. The doshas represent psychophysiological factors that maintain homeostasis (or initiate disease, if out of balance) much like the delicate dance of yin and yang.
Like TCM, ayurveda stresses the importance of an individual's intimate relationship with the universe. In ayurveda, the five elements influence and interact with the body via the doshas, each of which are comprised of two elements. Vata dosha is comprised of Air and Ether; pitta dosha is comprised of Fire and Water; and kapha dosha is comprised of Water and Earth. These elemental constituents influence the symptomatic expression of the doshas in low back pain scenarios. In vata presentations, the pain is severe, migratory and unpredictable, much like wind in TCM; in pitta presentations, the low back feels hot, appears red, and the pain is burning, much like damp heat bi in TCM; and in kapha presentations, the area feels cold and stiff, and the pain tends to be dull, fixed and constant, similar to wind cold bi in TCM.
Ayurvedic diagnosis states there is no pain without vata, no inflammation without pitta, and no stagnation without kapha. Therefore, all lower back pain scenarios have vata dosha as a significant diagnostic factor. While low back pain can have multiple doshic involvement, vata dosha typically is considered the catalyst. Ayurvedic theory considers pitta and kapha doshas as "lame" and unable to move without the motivating force of vata's cold, dry and unpredictable winds. Also, one of the main symptoms of vata vitiation is the severe pain so commonly encountered in low back pain. It's in this theory where we can find an interesting connection between ayurveda and traditional Chinese medicine. TCM states that wind is the initiator of hundreds of diseases and has a predilection to movement and many changes. These TCM statements of fact clearly share an affinity with ayurveda's idea of vata dosha as the prime motivating force behind the doshas and disease process. When we consider the power and unpredictability of wind in our environment and its ability to cause drastic change in all the elements, it makes sense to use this analogy to express changes within the microcosm of our bodies.
Vata dosha has five subtypes: prana vayu, udana vayu, samana vayu, vyana vayu and apana vayu. Apana vayu controls the entire pelvic cavity and its surrounding organs, bones and ligaments. The main site of accumulation for vata dosha is the large intestine; this organ is in the area of apana vayu's windy domain. When vata dosha is provoked via poor diet, stress, traveling, emotions or seasonal factors, apana vayu can possibly express itself as lower back pain. Vata can enter into the bone (ashthi) or muscle (mamsa) tissue and carry pitta and kapha along for the ride, so to speak. It's this factor that will influence the particular individual disease expression.
One of the main herbs for balancing and calming a windy vata dosha is withania somnifera or ashwagandha. This is one of the most commonly known ayurvedic herbs, and was renowned for its ability to impart the strength and virility of a horse to whoever consumed it. Ayurveda uses an herbal energetic system similar to TCM to classify and prescribe its medicinals. Ayurveda assigns an energy (virya), taste (rasa) and unique post-digestive effect (vipaka) to medicinals. Ashwagandha has a mildly bitter (tikta) and astringent taste. The vipaka is sweet (madhura) and the virya is warm (ushna). Ashwagandha has an anabolic (brimhana) and rejuvenating (rasayana) effect on the body's tissues (dhatus) and has a special affinity to restore the nervous system (medhya rasayana), promote calmness and act as an analgesic. These unique characteristics reveal clues that can illuminate ways to integrate ashwagandha into a TCM herbal protocol.
In TCM terms, ashwagandha appears to have a unique ability to supplement kidney yin and warm kidney yang. Its astringent and sweet tastes tend to nourish and consolidate tissues, while its warm and heavy nature provides an anabolic-supplementing effect. Scientific studies of ashwagandha have demonstrated adaptagenic and anti-inflammatory effects. Therefore, we have both traditional and modern support for potentially using ashwagandha in chronic lower back pain protocols. For example, in a patient with chronic back pain with an underlying kidney essence vacuity, ashwagandha could perhaps be an excellent addition to jin gui shen qi wan, zuo gui wan or you gui wan, or a variation of the aforementioned "skeleton" formula.
Ashwagandha is an excellent medicinal in cases where the patient has trouble sleeping due to chronic pain, or is suffering from fatigue due to sleep interruption. Deep restful sleep is critical for healing to occur. In TCM theory, during deep sleep the blood homes to the liver viscus. We also know that blood and essence share a common source and can mutually engender one another. If the essence is not discharged, it will gather in the liver and be transformed into "clear blood." This is an interesting idea when compared to the ayurvedic theory of ojas. Ojas is considered the surplus of the body's tissues (dhatus) and the deepest reservoir of vitality, very similar to kidney essence. In the ayurvedic text, Astanga Hrdayam, ojas is described as "the essence of the tissues," furthermore, "increase of ojas makes for contentment, nourishment of the body and increase of strength." Ojas is greasy, watery, clear and, when vacuous, "loss of vitality and life is sure to happen." This sounds remarkably similar to the surplus essence/clear blood idea referred to earlier. Adequate amounts of ojas in ayurveda and essence in TCM are crucial for deep restorative healing. Ashwagandha can assist in the production of ojas or clear blood/essence by assuring states of deep restful sleep and its action as a restorative medicinal or rasayana.
I hope this first part of our discussion allowed a collaborative vision to emerge between the interface of TCM and ayurveda when addressing chronic low back pain. In part two, we will discuss a unique ayurvedic diagnostic perspective on when not to use ashwagandha in pain scenarios, and explore the topical use of medicinals, ayurvedic marma points and yoga asanas to assist in relieving low back pain. Until then, take care and Namaskar!
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