Homoeopathy in lumbar spondylosis

Dr Ananya K

ABSTRACT:
One of the conditions that contribute to lower back discomfort and limits activity and job absences around the globe is lumbar spondylosis, which places a significant financial burden on individuals, families, communities, businesses, and governments. Although there isn’t a gold standard treatment for lumbar spondylosis in traditional medicine, the condition continues to have an influence on a person’s quality of life.

This article mainly deals with an overview of lumbar spondylosis focusing upon its various aspect along with homoeopathic therapeutics and attempts to correlate the rubrics from various repertories with the symptoms of lumbar spondylosis.

Keywords: Lower back pain, Lumbar spondylosis, Kellgran- Lawrence scale, Homoeopathy

INTRODUCTION:
Lower back pain is neither a disease nor a diagnostic entity; rather it’s just a constellation of symptoms. It is an important clinical, social, economic, and public health problem affecting approximately 60-85% of the adults during some point in their lives.¹ Of all the causes for lower back pain, lumbar spondylosis is the major cause, that poses a severe impact on the disability adjusted life year. Lumbar spondylosis is a disorder comprising of wide spectrum of conditions involving degeneration of intervertebral disc or facet joints, formation of bony spurs, vertebral body or endplate sclerosis, hypertrophy of ligaments and narrowing of spinal line or disc space causing disability.²

EPIDEMIOLOGY:
The lower back pain associated with lumbar spondylosis often causes disability and loss of work days and therefore represents a heavy disease burden throughout the world. In a WHO-ILAR COPCORD study, the prevalence of lumbar spondylosis in the Indian population was found to be 2.53%.³According to world health organization [WHO] 9.6 % of men and 18% of women aged over 60 years have symptomatic lumbar spondylosis world-wide. 80% of those with spondylosis have limitation in movement and 20% cannot perform their major daily activities of life.⁴

ETIOLOGY AND RISK FACTORS:
Lumbar spondylosis is caused by the interplay of both environmental and genetic factors. The environmental risk factors include age, occupational physical loading (twisting, lifting, bending, and sustained nonneutral posture), back injury, smoking, whole body vibration (vehicular driving), obesity, and diabetes (causing ossification of the posterior longitudinal ligament and bone, which leads to spinal stenosis and nerve pressure).⁵ It is more prevalent among women compared to men. And commonly affects the 3rd and 5th decades of life.

PATHOGENESIS:

Farfan and colleagues have highlighted three crucial elements in the pathophysiology of lumbar spondylosis.

• The two posterior joints and the disc together make up the three joint complex at each level of the lumbar spine. The disc is also affected by lesions that affect the posterior joints, and vice versa.
• The posterior joints at the bottom two levels are obliquely oriented, which increases the likelihood of recurring rotational load on these joints.
• The wedge-shaped discs at the same two levels are higher anteriorly than posteriorly, which also puts the joints at danger.

The same authors have highlighted that the degenerative alterations in the three joint complexes are brought on by 2 different types of injuries:

• Recurrent rotational strain, which can quickly cause disc and posterior joint degeneration
• Minor compression injuries sometimes with rupture of a cartilage plate, leading to more slowly degenerative changes in the disc and later posterior joints.⁶

The changes occurring in the posterior joints include Synovial reaction, Fibrillation of articular cartilage, Gross degeneration and irregularity of articular cartilage, Formation of osteophytes, fracture of an articular process, loose bodies in the joint and laxity of the joint capsule resulting in instability.⁶

According to Kirkaldy Willis and Bernard, intervertebral discs go through a “degenerative cascade” of three overlapping phases that could take place over many years.

Phase I (Dysfunction Phase) outlines the early consequences of repeated microtrauma with the emergence of circumferential painful tears of the outer, innervated anulus and related endplate separation that may impair the nutritional supply and waste clearance of the disc. These tears may combine to form radial tears, which are more likely to protrude, and which affect the disk’s ability to retain water, leading to desiccation and a decreased disc height. Vascular tissue and nerve endings may grow into fissures, boosting innervation and the disk’s ability to transmit pain signals.

Phase II (Instability Phase) is characterised by the loss of mechanical integrity, progressive disc alterations, including internal disruption, further annular rips, and disc resorption, along with further facet degeneration that may lead to instability and subluxation.

Phase III (Stabilisation Phase) sees the development of osteophytes, trans discal bridging, and continuing fibrosis and shrinking of the disc space.⁷

CLINICAL PRESENTATION:

Lumbar spondylosis is generally asymptomatic. But when symptomatic, it usually presents with

• chronic low back pain persisting for more than three months
• radiation of pain to limbs (sciatica)
• stiffness

Neurogenic claudication (NC) is the extreme condition that happens because of lumbar spinal stenosis and may present with leg pain, as well as numbness and motor weakness to lower extremities that worsen with upright stance and walking, and improve with sitting and supine positioning.⁷ Changes in sphincter capacity such as neurogenic bladder or neurogenic loss can be the aftereffect of spinal cord compression from extreme degeneration of lumbar spine.

DIAGNOSTIC CRITERIA:
Diagnosis is made from history, clinical presentation, physical examination and investigations.

Patients presenting with the clinical picture of

• Lower back pain persisting beyond 3 months
• Progressive loss of spinal function/ numbness in lower limbs
• Stiffness

X RAY of lumbar spine (AP and LATERAL view) is the first line of evaluation – showing features of degeneration and fulfilling Kellgrane and Lawrence scale for disc degeneration. CT and MRI are modalities for detailed investigation

Grade	Definition
0 1 2 3 4	Normal disc space with no osteophytes Slight anterior wear and osteophyte formation Definite anterior wear and mild disc narrowing with osteophyte formation Moderate disc narrowing with osteophyte and sclerosis Large osteophytes, marked disc space narrowing, and sclerosis of the vertebral end plates.

KL2 is commonly used as the diagnostic criteria for lumbar spondylosis.^8,9

MANAGEMENT:

The treatment option for people suffering with lumbar spondylosis could be categorised into following:

• Physical therapy
  1. Exercise therapy- one of the conservative mainstays of treatment for chronic lumbar spine pain which includes, aerobic exercise, muscle strengthening and stretching exercise
  2. Transcutaneous electrical nerve stimulation- a therapeutic modality involving skin surface electrodes which deliver electrical stimulation to peripheral nerves in an effort to relive the pain.
  3. Back school – minimizing lower back pain symptoms and their reoccurrence through review with patients of lumbar anatomy, concepts of posture, ergonomics, and appropriate back exercises
  4. Lumbar support/ orthosis- to limit the spine motion, stabilize, correct deformity and reduce mechanical forces.
  5. Traction- applies longitudinal force to the axial spine through use of harness attached to the iliac crest and lower rib cage, which opens the intervertebral space and decrease spine lordosis to relieve chronic low back pain. It improves the lower back pain by relieving mechanical stress, nerve compression and adhesion of facets and annulus.
  6. Spine manipulation
  7. Massage therapy
• Pharmacotherapy – NSAIDS, opioid medications, antidepressants, muscle relaxants.
• Injection therapy- epidural steroid injection, facet injection, SI joint injection etc.
• Surgical options- indicated when the conservative treatment fails to relive the pain.⁷

PREVIOUS STUDIES DONE ON THE EFFECTIVENESS OF HOMOEOPATHIC TREATMENT IN MANAGEMENT OF LUMBAR SPONDYLOSIS:

A prospective case series study, conducted at clinical research unit Siliguri showed that individualized homeopathic treatment was effective in treating lower back pain due to lumbar spondylosis and also improved the health-related QoL thereby reducing the use of other healthcare services.¹⁰

Another observational study conducted at the outpatient department of father muller homeopathic medical college, Mangalore to assess the effectiveness of homoeopathic treatment in lumbar spondylosis, showed that there was a drastic improvement in the vas score before and after treatment with homoeopathic medicines for lumbar spondylosis, with the mean improvement of 78% over the baseline.¹¹

A double-blind, randomized (1:1), placebo-controlled trial was conducted at the National Institute of Homoeopathy, West Bengal, India where the patients were randomized to receive IHMs or placebos, along with standardized concomitant care for both the groups .The  study results showed that there was statistically significant improvement in the short form of the McGill pain questionnaire (SF-MPQ) total score after 2 months (p = 0.030) thereby favouring the effectiveness of IHMs against placebos.¹²

HOMOEOPATHIC THERAPEUTICS: ^13,14

Aconite napellus– Sciatica in young people and from cold draughts; anxiety, pain unendurable. Numbness and tingling in extremities with shooting pain, associated with icy coldness of hands and feet. The pain is excited by touch.

Aesculus hippocastanum– Dull backache, walking almost impossible, scarcely able to stoop, or rise after sitting; especially with constipation and piles.

Actea racemosa– Spine is extremely sensitive. If with the muscular pains there is restlessness and sleeplessness, then Actea racemosa is indicated. Cannot walk erect.

Ammonium muriaticum– Backache as if in a Vise, when sitting. Sciatica < sitting and relieved by walking or lying down with sensation as if hamstrings muscles were too short

Arnica montana– Pain in the back as if bruised. Cannot walk erect on account of bruised pain. Soreness after overexertion, or any injury. Everything on which he lies seems too hard. Great fear of being approached or touched

Bryonia alba– When the pain and stiffness is worse on every motion and better by lying down and complete rest. Stitching type of pain in small of back, from sudden changes in weather. Wants pressure or something hard under the back.

Calcarea fluorica– Chronic lumbago aggravated on beginning to move and ameliorated on continuous motion. Indicated for osseous growth and exostosis.

Capsicum – Shooting tearing pain from hip to knee; sciatica worse bending backward and when coughing.

Cobaltum – Pain in back and sacrum, worse when sitting; better by walking and lying. Weakness in legs and backache after emissions.

Dioscorea – Lameness in the back on stooping. Sciatica, pain shoot down the thigh; worse on right side and the pain is better when perfectly still.

Gnaphalium- Chronic backache in lumbar region, better by resting on the back. Sciatica when pain is associated with numbness. Pain better by drawing up the limbs.

Kali carb – Lumbago with sudden sharp pains extending up and down back and thigh. Backpain associated with weakness and perspiration. Severe backache during pregnancy and after miscarriage.

Nux vomica– Backache in lumbar region worse 3- 4 am. Must sit up in order to turn in the bed.

Phytolacca – Aching pain in the lumbar region, pains streaking up and down the spine into sacrum. Back stiff especially in the morning on rising and during damp weather.

Rhus tox– Stiffness in the back, painful on first motion; bruised or burning pain, better by continuous motion. Pain aggravated during damp weather.

Ruta graveolens– Backache better by pressure and lying on the back. Lumbago worse morning before rising.

Xanthophylum– neuralgic shooting pains as from electricity, all over the limbs. Sciatica worse during hot weather.

Zincum metallicum– dull aching about the last dorsal or first lumbar vertebra, worse by sitting. burning along the spine.  Cannot bear to be touched.

RUBRICS RELATED TO LUMBAR SPONDYLOSIS FROM VARIOUS REPERTORIES:

Some of the rubrics that could be taken for lumbar spondylosis in various repertories is mentioned below

Boger Boenninghausen’s Characteristics and Repertory- Dr. C. M. Boger¹⁵

CHAPTER: BACK – LUMBAR REGION- SMALL OF BACK IN GENERAL

• Lumbar region (also loins)
  • Vertebra of
• Beaten, bruised as if
• Beating, throbbing
• Burning
• Compression, squeezing
• Crampy pain
• Downward pain extend to
• Dragging
• Drawing
• Heaviness, load
• Lameness
• Legs extending to
• Lumbago
• Numbness
• Overlifting pain as from
• Pain
• Paralytic, laming pain
• Shotting
• Sprained or dislocated pain as if
• Stiffness
• Stitches, sticking
• Tearing, shooting
• Thighs pain extending to
• Weakness

BACK – AGGRAVATION

• Ascending on
• Cold in
• Descending
• Driving
• Fall after a
• Injuries from
• Lying
• Motion
• Overlifting from
• Pressure
• Raising up
• Rising after
• Standing
• Turning the body
• Walking

BACK AMELIROTION

• Lying
• Motion
• Rest
• Sitting
• Supporting back

Repertory of the Homoeopathic Materia medica – Dr J.T Kent¹⁶

CHAPTER: BACK

• Pain – lumbar region
  • Time- morning, forenoon, noon, afternoon, evening, night
  • Ascending stairs
  • Exertion
  • Injury after
  • Lifting
  • Lying on back amel
  • Motion during
  • Rheumatic
  • Rising from seat
  • Sitting while
  • Standing
  • Turning
  • Walking while
  • Extending – legs down the
• Pain – lumbosacral region
• Pain – Aching – lumbar region
• Pain – Burning – lumbar region
• Pain – dragging – lumbar region
• Pain- drawing – lumbar region
• Pain – lameness -lumbar region
  • Pain – sore – lumbar region
  • Pain – stitching – lumbar region
  • Pain- tearing – lumbar region
• Stiffness
• Weakness – lumbar region

CHAPTER: EXTREMITIES

• Formication – lower limbs
• Numbness – lower limbs
• Pain – lower limbs- sciatica
• Tingling – lower limbs
• Weakness- lower limbs

Boenninghausens Therapeutic Pocket Book:¹⁷

CHAPTER: PARTS OF THE BODY AND ORGANS

• Back – lumbar and sacral region (including small of back)

CHAPTER: SENSATION

• Blow pain as after
• Bruised
• Cramps – joints of
• Debility sensation of
• Drawing downward sensation
• Formication
• Motion difficult
• Numbness
• Pain dull
• Rigidity of joints
• Sprained
• Sticking
• Weakness

A Concise Repertory of Homeoepathic Medicine – Dr S.R. Phatak¹⁸

LUMBAR BACK

• Compression
• Cramps
• Dislocative pain
• Exertion agg
• Injury after
• Lame
• Liffting agg
• Numb
• Pain lumbago
• Radiating from
• Standing agg
• Stiff
• Vertebra of
• Walking agg
• weakness

NUMBNESS

• affected parts of
• pain from
• spinal affection in

SCIATICA

• chronic
• descending
• formication with
• injury after
• numbness with
• shooting pain
• spine painful with
• vertebral origin

STIFFENESS RIGIDITY

Pockect Manual of Homoeopathic Materia medica and Repertory – William Boericke¹³

CHAPTER: LOCOMOTOR SYSTEM

• Back
  • pain in general
    • aching as if it would break and give out
    • aching dull constant (backache)
    • bruised
    • crampy
    • drawing
    • heaviness, dragging, weight
    • lancinating extending down thighs and legs
    • paralytic
    • stitching piercing pricking
  • modalities- agg
    • from cold exposure
    • from damp exposure
    • from exertion
    • from motion beginning
    • from motion walking
    • from standing
    • in morning
    • when rising from seat
  • modalities – amelioration
    • from lying on back
    • lying on something hard or firm support
    • from lying, sitting
    • From motion, walking
    • From rest
  • Weakness of back
  • Loins – lumbago

CHAPTER: NERVOUS SYSTEM

• Sciatica
  • Sciatica – acute cases
  • Sciatica – chronic cases
  • Sciatica, rheumatic
  • Sciatica, vertebral origin
  • Spine
  • Type of pain- bruised, burning, cramp like, drawing etc
  • Concomitants
    • Anaesthesia
    • Hyperesthesia
    • Nervous agitation
    • Numbness
    • Weakness
  • Modalities – agg and amelioration
• Weakness of spine

Homoeopathic Medical Repertory – Dr Robin Murphy¹⁹

CHAPTER: BACK

• Back remedies – lifting ailments from
• Aching pain lumbar
• Burrowing pain lumbar
• Compression lumbar
• Constriction lumbar
• Cram, lumbar
• Dragging pain lumbar
• Formication – formication lumbar
• Injuries, ailments after
• Pain -lumbar
• Numbness- numbness, lumbar region -extending to lower limbs
• Lifting ailments from
• Sore pain lumbar
• Stiffness

CHAPTER: DISEASES- sciatica pain

CONCLUSION:
There isn’t a gold standard treatment for lumbar spondylosis. The conventional treatment indicated above only temporarily relieves the symptoms and has a number of negative side effects, which lowers a person’s quality of life. The scope of homoeopathy is found here. The person is treated as a whole in homoeopathy. The patient as a whole is prioritised during homoeopathic treatment in addition to his pathological condition. This article primarily focuses on several homoeopathic remedies that is effective in treating lumbar spondylosis, as well as rubrics that are related to the condition’s symptoms. These, however, are merely suggestions for choosing the simillimum; the choice of the right remedy for each unique case, is instead largely dependent on a thorough investigation and individualization of the case.

REFERENCES:

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Dr Ananya K
MD(HOM) Part 1-PG Scholar
Department of Case taking and Repertory
Government Homoeopathic Medical College and Hospital, Bengaluru.

UNDER THE GUIDANCE OF
Dr Anusuya M Akareddy MD (HOM)
Associate professor and PG guide