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Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

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Open Access   Full Text Article                                                                                                                                                                   Case Report

Unani Integrative Approach for the Management of Sciatica, Employing Pharmacotherapy with Regimenal Therapy: A Case Report

Safia Abbasi ¹*, Uzair Yousf Mir ¹, Shaik Adeena Parveen ¹, Mohd Nayab ², Abdul Azeez ², Abdul Nasir Ansari ³

PG Scholar¹, Department of Regimenal therapies, NIUM, Bengaluru, Karnataka, India.

Associate Professor², Department of Regimenal therapies, NIUM, Bengaluru, Karnataka, India.

Professor and Head ³, Department of Regimenal therapies, NIUM, Bengaluru, Karnataka, India

 

 

INTRODUCTION

Sciatica is a common yet potentially disabling illness.¹ It is a disease of musculoskeletal system where pain originates from the lower back and radiates down one or both legs along the distribution of the sciatic nerve. The main cause of sciatica is the compression of L4-S1 nerve roots by herniated inter vertebral discs. The compression of L5 or S1 nerve roots causes pain from the back or side of the leg to the foot and toes, and compression of L4 nerve root causes pain in anterior and lateral thighs.² It may be accompanied by tingling, numbness, or weakness in the affected leg. The severity of sciatica can vary from mild discomfort to severe pain that can impact daily activities and quality of life. Low back pain is the major cause of years lived with disability worldwide, with 60% of these patients reporting symptoms of sciatica.³ Studies on the global burden of the disease from 1990-2020 showed substantial rise in the prevalence of low back pain over the years. In 1990 low back pain accounted for 43.4 million for all ages and genders globally, whereas in 2020, the number rose to 619 million cases. The number of cases of low back pain is predicted to rise to 843 million by 2050, with the biggest increases anticipated to occur throughout Africa and Asia. The risk of low back pain associated with smoking is highest in middle-aged (50–69 years old) males and lowest among women between 25–49 age range (5·7%) whereas the risk attributed to occupational ergonomic factors was highest among younger males between 25-49 years of age (34·3%) and lowest among females of 70 years of age or older (4·9%).⁴ As far as the management of sciatica is concerned, it is primarily managed with   conservative (non-operative) approach and in severe cases with surgical (operative) measures. Conservative approach which includes pharmacological as well as non-pharmacological management is preferred choice of treatment as it avoids or delays the need for surgical management. In Unani system of medicine , sciatica is known as Irq al-Nasa and Rengan which is a subtype of Waja-ul-Mafasil and has been described as a pain that initiates from lower back and radiates up to knee or ankle joint on the lateral aspect of the lower limbs.^5,6 According to some Unani scholars, Irq al-Nasa, or sciatica, is an Arabic term that literally translates to "name of a nerve." which starts from gluteal region and continues up to the ankle, and pain associated with nerve is termed as Irq al-Nasa.⁷ Ibn-e-Sina (Avicenna) (980-1037AD) elaborated Irq al-Nasa as one of the types of arthralgia characterized by hip pain which radiates toward the groin up to the ankle.⁸Mohammad Ismaeel Jurjani (930-994 AD) described the pain which originates from ischail joint and radiates toward leg is known as Irq al-Nasa^9.Ibn-e-Hubal Baghdadi (1213 A.D.) define Irq al-Nasa as Razi (865-925 A.D.) with the addition as “a pain starts from hip and radiates from the lateral of the thigh up to calf muscles.¹⁰ Abu Marwan Abdul Malik Ibne Zuhar (1092-1162) quoted about Irq al-Nasa that this pain sometimes originate from foot and radiates up to upper most part of the thigh and provides discomfort.¹¹ Considering the patho-physiology and causes of Irq al-Nasa, Unani scholars mentioned that the cause of Irq al-Nasa are derangement in Akhlat (Body fluids/humour’s) either Khilt-e- Damwi Ghaleez (viscid sanguineous humour) Khilt-e- Balghami Ghaleez(viscid phlegmatic humour) which deposit in Mafsil-i-Warik (hip joint) and leads to pain, sometimes it may cause dislocation of joint. There is involvement of maddah in Irq-al-Nasa, this maddah may be Khilt-e- Damwi. (sanguineous humours) Khilt-e- Balghami, (phlegmatic humour) Makhloot Balgham wa Safra (mixed phlegmatic bilious).¹² The management of sciatica according to Unani system of medicine is based on the basic fundamentals, which includes Tanqiya-e-Mawad-e-Fasida (Cleansing and elimination of morbid material), Tahleel-e-Warm (Resolution of inflammation) ,Taskeen-e-Dard (Pain relief) with a combination of various drugs and regimenal therapies having musakkin (Soothening) and muhallil (Anti-inflammatory) effects. We present a case of sciatica with a poor response to NSAIDs and other therapeutic measures. We combined unani pharmacological therapy with regimenal therapy (wet cupping or Hijamah) to provide a safe and effective early treatment option.

CASE REPORT

A 52 year old male came to Department of Regimenal therapies, National Institute of Unani Medicine, Bengaluru with complaints of lower back pain and left buttock pain radiating down the posterior aspect of his left lower limb into his foot from last 6 months with alleged history of heavy weight lifting. Patient stated that, he had constant low back pain from last 6 months, which has exaggerated in severity from the last 2 months. The patient had taken NSAIDs and also have also consulted a physiotherapist. He also visited a chiropractor and acupuncturist for the same complaint but had limited results. The pain aggravated on walking, lifting some heavy weight and sitting or standing for a prolonged duration and after bike or car driving. The patient has done MRI two months back, which revealed multilevel disc degeneration at L4/L5, L5/S1 with moderate lumbar stenosis at L4–L5 secondary to an annular bulge and facet hypertrophy. Along with physical examination, various tests and assessments were performed at baseline and post intervention using various scales to determine the actual condition of the patient.

The assessment parameters used were:

• Visual Analog Scale (VAS) for pain
• Straight Leg Raise Test (SLR) to assess degree of nerve root compression
• Roland-Morris Disability Questionnaire (RMDQ) to assess the impact of low back pain on daily life.

INTERVENTION

The patient underwent wet cupping therapy (WCT) once a week for 4 weeks. All the required investigations namely Hb%, BT, CT, HBsAg, HIV I, HIV II and FBS were done before WCT. Total 6 cups of large size (6.5 cm diameter) were applied from area of hip joint to left lower limb in the following manner, 1 cup at L4/L5, 1 cup at L5/S1, 2 cups at back of thigh and 2 cups in calf muscles. 

The following procedure was followed for Hijama:

STEP 1- Patient was asked to lie in prone position and the targeted area was exposed, shaved and cleaned with antiseptic solution.

STEP 2- Mild suction was given to create negative pressure for 1 minute and then 12-15 small longitudinal, superficial incisions were made with 11 No. surgical blades followed by strong suction so that the cups will tightly adhere to the skin.

STEP-3 - The blood was allowed to flow freely from the incisions, till it coagulates or till the requisite blood was evacuated.

STEP 4- Once the blood flow had stopped, the vacuum pressure was released, followed by collecting the blood and cleaning the incisions properly with antiseptic solution followed by proper dressing.

Patient was advised to abstain from any exertional activity on that day. Along with regimenal therapy, patient was prescribed an oral drug, Habbe gul-e-aakh , two tablets to be taken twice daily for 4 weeks as analgesic. The tablets were prepared in the pharmacy of National Institute of Unani Medicine, Bengaluru, as per guidelines of NFUM (National Formulary of Unani Medicine) or Al Qarabadeen.

 

 

 

 

 

 

INGREDIENTS OF HABBE GUL-E-AAKH ¹³

Unani name	Botanical names	Weight (g)	Parts used
Zanjabeel	Zingiber officinalis Roscoe.	100g	Rhizome
FilfilSiyah	Pipernigrum Linn.	100g	Fruit
GuleMadar	Calotropis gigantea Linn	100g	Flower
Barge Bans	Bambusa arundinacea Willd.	100g	Leaf

 

 

 

RESULTS

Visual Analogue Scale (VAS) 

The patient was asked to rate his back pain on VAS scale at the baseline and post intervention on 4^th week as shown in Table 1. The VAS scale is used for assessment of severity of pain, where 0 indicates no pain at all and 10 indicates extreme pain which requires immediate medical attention.

Table 1: Showing VAS Scores at Baseline, and 4^th week.

Visual Analog Scale (VAS) scores for pain
	Baseline	4th Week
Lower back	6/10	5/10
Left Lower limb	6/10	4/10

 

Straight Leg Raise Test (SLRT) 

SLRT is primarily used to evaluate the presence of nerve root irritation or lumbar disc herniation. The score is between 0-3 depending upon the severity of pain and degree of leg raising, where 0 is (Normal) score for leg raising over 90°, 1 (mild) for 51-70°, 2 (moderate) for 31-50° and 3 (severe) score for leg raising upto 30°. Table 2 shows SLRT score for lower back and left lower limb at baseline and on 4^th week.

Table 2: Showing (SLRT) Scores at Baseline, and 4^th week.

Straight Leg Raise Test (SLRT)
	Baseline	4th Week
Rt leg	0 at 90°	0 at 90°
Lt leg	2 at 45°	1 at 70°

 

Roland-Morris Disability Questionnaire (RMDQ)

RMDQ is used to assess the impact of low back pain on daily life. It has scores from 0-24, where low score (0-4) indicates minimal disability with a low impact on daily activities, moderate score (5-14) suggests moderate disability and a noticeable impact on daily activities and high score (15-24) indicates severe disability and significant limitations in performing daily activities. Table 3 indicates RMDQ score at baseline and on 4^th week.

Table 3: Showing (RMDQ) Scores at Baseline, and 4^th week.

The Rolland Morris Low Back Ache and Disability questionnaire
	Baseline	4th Week
Rolland and Morris low back pain and disability questionnaire (RMQ)	18	11

 

DISCUSSION

LBP is becoming one of the leading causes of disability worldwide. Administration of NSAIDs provide short term relief for pain and are associated with additional adverse effects. The only possible intervention which can cure the condition is surgery. Therefore, to minimize the need for surgical interventions, there is increasing interest in complementary and alternative medicines for the management of low back pain (LBP). In the Unani System of Medicine, it is believed that diseases disturb the body's natural balance of temperament and humors. To address this, Regimenal Therapy (Ilaj bit Tadbeer) and Pharmacotherapy (Ilaj bil-Dawa) have been used since ancient times to restore this balance and correct any imbalances in temperament. This study represents the first documented case demonstrating the effects of combining pharmacotherapy with regimenal therapy for managing sciatica. The “Hijamah” was performed once a week for 4 weeks along with an oral medicine Habbe gul-e-aakh which has anti-inflammatory and analgesic properties.¹⁴ After the intervention, the patient reported amelioration of symptoms, which was also reflected by improved assessment scores. The differences in the assessment scores before and after treatment are illustrated in Figures A, B, and C below.

 

 

 

Figure A: Bar diagram showing VAS Scores at Baseline, and 4^th week.

Figure B: Bar diagram showing SLRT Scores at Baseline, and 4^th week.

Figure C: Bar diagram showing RMDQ Scores at Baseline, and 4^th week.

 

The actual mechanism behind the pain relief is not clearly understood. It is believed that cupping therapy enhances the blood circulation, drains excessive fluid and removes toxins and other waste from the body. The loss of blood due to incisions in the cupped region causes vasodilation which increases the parasympathetic activity and relaxes the body muscles which in turn reduces the pain scores. Moreover the loss blood, improves the quality of the remaining blood which helps in pain reduction^.15 This correlates well with the Unani concept which is based on the principle of evacuation (Tanqiya) which involves elimination of harmful humors (Akhlat-e-Faasida) and excess fluids from the body and diversion (Imaala) which refers to the diversion of the morbid fluids from the site of affected organ to the site from where it can be easily expelled from the body tissues. The effectiveness of this therapy may also be attributed to the antiinflammatory (Muhallil), and analgesic (MusakkinAlam) properties of Habbe gule aakh.

CONCLUSION

The results of the case study suggests that WCT might reduce inflammation and pain, making it a potential option for treating sciatica. Throughout the study, no local or systemic side effects, including localized reactions or itching, were noted. Therefore, it is advisable for sciatica patients to try this method to avoid the negative effects of long-term NSAIDs use and to consider it as an alternative, before opting for surgery, which is often unsuccessful and carries high risks.

Financial Support

All authors declare that no specific financial support was received for this study.

Ethical Clearance

This study is approved from Institutional Ethical Committee for Biomedical Research.

Acknowledgement 

I am thankful to my co-authors for their patience and support and also to the participant who extended her willingness to be part of the study and supportive staff of the hospital in providing necessary infrastructure.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper

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