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Open Access Full Text Article   Case Reoprt

Effect of Habb-e-Gule-Aak (Unani pharmacopeial compound formulation) and Riyazat in the management of Non-specific Low back pain (Waja’ uz-Zahr): A Case series 

Sadaf T.A. Shaikh ¹, Mohd. Anwar ², Mohammad Saad Ahmad Khan ³

¹ PG Scholar. Dept. of Ilaj Bit Tadbeer, F/o Unani Medicine, AMU, Aligarh;

² Professor. Dept. of Ilaj Bit Tadbeer, F/o Unani Medicine, AMU, Aligarh; 

³ Assistant Professor. Dept. of Ilaj Bit Tadbeer, F/o Unani Medicine, AMU, Aligarh.

 

 

Introduction

The most prevalent kind of musculoskeletal disorders associated with the spine is low back pain, which affects 84% of people. Additionally, 23% of all occurrences of low back pain are found to have chronic low back pain, which is low back pain that is untreated and lasts longer than 12 weeks¹. According to Ribeiro et al. (2018), over 85% of chronic low back pain has no known cause or diagnosis and is categorized as chronic non-specific low back pain. The term "non-specific low back pain" (NSLBP) refers to a type of low back pain that is not caused by a specific pathology (such as osteoporosis, radicular syndrome, tumor, structural deformity, infection such as pott’s spine, or cauda equina syndrome)². It is usually defined as pain, muscle tension, or stiffness localised below the costal margin and above the inferior gluteal folds. The most important symptoms of non-specific low back pain are pain and disability³. The term Waja’ uz-Zahr is used to describe the Low back pain under the broad heading Waja’ al-Mafasil in Unani medicine. Hakim Ghulam Jeelani (20th century) described different causative factors of Waja-uz-Zahr such as Takan, Laghri and excessive labour etc. He stated that the main causes of Waja’ uz-Zahr and Waja’ al-Mafasil is the Kham Madda (morbid matter) which gets accumulated of in joint spaces⁴. Eminent Unani physicians described a number of treatments including pharmacological and non-pharmacological approaches under two essential modes i.e., ‘Ilaj Bit Tadbir (Regimenal therapy) and ‘Ilaj bi’d Dawa’ (pharmacotherapy) in the management of NSLBP in their manuscripts such as Zarawand, Hulba, Tukm-e-karafs, Habb-ul-rshad, Ajwain, Darchini, Zanjbeel, Ushq, Sakbeenaj, Anzroot, Hilliyoon, Suranjan, Sibr, Hijamah (Cupping therapy), Takmeed (fomentations), Dalk (Massage therapy), Riyazat (Exercise therapy) and Inkebab (steam therapy) etc^5,6.  There is some evidence that analgesics, antidepressants and nonsteroidal anti-inflammatory medications are helpful treatments in NSLBP. Other therapies (such as steroid injections, lumbar supports, and traction) are not supported by any research⁷. Dyspepsia or vomiting to more serious injuries including gastroduodenal ulceration, bleeding, and gastrointestinal lesions are among the GI system side effects associated with the use of NSAIDs⁸. Additionally, several studies have shown hepatotoxicity^9-11. Due to these significant adverse effects of pharmacological medications in conventional medicine an attempt has been made to evaluate the effects of Habb-e-Gule-Aak (Unani pharmacopeial compound formulation) and Riyazat in the management of Non-specific Low back pain (Waja’ uz-Zahr).

Habb-e-Gul-e-Aak (HGA), a polyherbal pharmaceutical drug (pills), is mentioned in almost all pharmacopoeias, formularies, and Qarabadeen in Unani system of medicine. It has been used for a long time to treat inflammatory disorders, both acute and chronic, although it has been noted to be most beneficial in chronic conditions, particularly those affecting the joints and bones, such as Waja’ al-Mafasil, Niqris, Waja’ al-Warik, etc. Available literature state that it is an effective drug for treating Waja’ al-Mafasil patients^12-14. Hippocrates, father of medicine, wrote in the fifth century BC: "All parts of the body, if used in moderation and exercised in labours to which each is accustomed, become thereby healthy and well developed and age slowly; but if they are unused and left idle, they become liable to disease, defective in growth, and age quickly." Several ancient Unani Scholars, including Hippocrates, Galen, Razi, and Avicenna, wrote about the curative properties of Riyazat. Riyazat is an action that is taken voluntarily with the intent of Tanqiyae mawad (evacuating waste material). It is crucial for both the preservation of health and the avoidance of sickness, as well as the treatment of some illnesses^15,16. When joint mobilization is used to treat NSLBP, the distribution of synovial fluid in the joint cartilages and disc improves, which results in lessening the resistance to joint movement¹⁷. Additionally, lumbopelvic stabilization training improves motor control in NSLBP by stabilizing the muscles responsible for maintaining posture¹⁸. Patients with LBP have showed pain relief from stretching exercises involving the lumbopelvic supporting muscles, such as the gluteal, hamstring, and quadriceps muscles¹⁹.

2. Materials and Methods

2.1 Inclusion Criteria

Five patients selected from the OPD of Ajmal Khan Tibbia College, AMU, Aligarh with the persistent LBP as their primary complaint were assessed. Patients having a primary report of LBP (between T12 and the gluteal fold) qualified as inclusion criteria for the present study. Age between 18 and 65, low back pain without radiating below the knee from 6 months or more than 6 months duration, and a modified Oswestry disability index (ODI) score of greater than 30.

2.2 Exclusion Criteria

Patients on surgical or non-surgical management within the past six months, signs of nerve root compression (muscle weakness, hyporeflexia, and paresthesia), and any medical red flags such as tumor, vertebral fracture, osteoporosis, prolonged history of steroid use, ankylosing spondylitis, severe liver disorders and kidney impairments were excluded.

2. Procedure of application of Interventions

Five patients selected from the OPD of Ajmal Khan Tibbia College, AMU, Aligarh with the complaints of pain over lower back which aggravates during prolonged sitting, bending and walking from last 6 months to 2 years. On examination there are restriction in movements without local tenderness and swelling. Patients had no history of metabolic disease, hypertension and tuberculosis. On general examination their vitals were within normal limit and no abnormality was detected through systemic examination. Habb-e-Gule-Aak (HGA) prepared in the Ajmal Khan Tibbia College dawakhana as per the guidelines of the Bayaz-e-Kabeer, Vol. 1¹². HGA 2 pills has been given twice daily for 30 days. Information about ethnopharmacological properties of ingredients of Habb-e-Gule-Aak are listed in table1. Patients have been explained about strengthening and stretching of lumbo-pelvic muscles. Four exercises have been selected for this case series (1) supine abdominal draw-in (2) double leg bridge (3) side plank static holds (4) prone bridging on elbows with single leg hip extension. All exercises have been advised for 10 repetitions twice daily²⁰.

 

 

Table 1: Ethnopharmacological properties of ingredients Habb-e-Gule-Aak

 

 

3. Case presentation

3.1 Case report 1

A 34 years old male with a history of severe, intermittent low back pain since eight months with a chief complaint of non-radiating low back pain. He was assessed on NRS and found the score 7 on 10 points Likert’s scale, pain aggravated while bending and climbing stairs. His ODI score was 52 (severe disability).

3.2 Case report 2

A 26 years old female with a history of severe, intermittent low back pain since 1 year with a chief complaint of non-radiating low back pain. She was assessed on NRS and found the score 5 on 10 points Likert’s scale, with severe pain while bending and climbing stairs. His ODI score was 36 (moderate disability).

3.3. Case report 3

A 61 years old female with a history of low back pain which was non radiating in nature since 6 months. Pain was started after prolonged travelling. Pain score was 4 at NRS and ODI was 48 (severe disability).

3.4. Case report 4

A 47 years old female with a history of low back pain which was non radiating in nature started after lifting heavy weight since 2 years. Pain was started after prolonged travelling. Pain score was 8 at NRS and ODI was 57 (severe disability).

3.5. Case report 5

A 20 years old female student with a history of low back pain which was non radiating in nature aggravated by prolonged sitting since 18 months. Pain score was 6 at NRS and ODI was 41 (moderate disability).

4. Results 

Low Back pain was assessed according to NRS and ODI on baseline, 15^th and 30^th day. As depicted in Table 2, NRS score in Case 1 was 7 at baseline, 5 on fifteenth day and 2 on thirtieth day. NRS score in Case 2 was 5 at baseline, 4 on fifteenth day and 3 on thirtieth day.   NRS score in Case 3 was 4 at baseline, 2 on fifteenth day and 1 on thirtieth day. In Case 4, NRS score was 8 at baseline, 6 on fifteenth day and 3 on thirtieth day. In Case 5, NRS score was 6 at baseline, 5 on fifteenth day and 3 on thirtieth day. ODI score in Case 1 was 52 at baseline, 43 on fifteenth day and 38 on thirtieth day. In Case 2, ODI score was 36 at baseline, 28 on fifteenth day and 20 on thirtieth day. In Case 3, ODI score was 48 at baseline, 39 on fifteenth day and 21 on thirtieth day. In Case 4, ODI score was 57 at baseline, 43 on fifteenth day and 31 on thirtieth day. In Case 5, ODI score was 41 at baseline, 32 on fifteenth day and 19 on thirtieth day (Figure 1& 2).

 

 

Table 2. Efficacy of Interventions on NRS

Parameters	Numeric Rating Scale (NRS)
	Case1	Case2	Case3	Case4	Case5	Mean±S.D
Baseline	7	5	4	8	6	6±1.58
15th day	5	4	2	6	5	4.4±1.51
30th day	3	4	2	5	4	3.6±1.14
Improvement in percentage	57%	40%	50%	37.5%	33.3%

 

Figure 1: Efficacy of intervention on NRS

 

Table 3: Efficacy of Interventions on ODI

Parameters	Oswestry disability index (ODI)
	Case1	Case2	Case3	Case4	Case5	Mean±S.D.
Baseline	52	36	48	57	41	46.8±8.4
15th day	43	28	39	43	32	38±8.0
30th day	38	20	21	31	19	25.8±8.3
Improvement in percentage	26.9%	44.4%	56.2%	45.6%	53.6%

 

Figure 2: Efficacy of intervention on ODI

 

Discussion

Low back pain, which affects 84% of people, is the type of musculoskeletal disorder that is related with the spine. A form of low back pain that is not caused by a specific pathology is referred to as "non-specific low back pain" (NSLBP). The adverse effects of commonly given drugs, such as NSAIDs for the treatment of pain, are well documented. Unani medicine is an ancient approach that can heal many diseases with minimal or no adverse effects. The Unani system of medicine is a traditional medical practice that focuses on the prevention and treatment of various illnesses. Under the umbrella term Waja' al-Mafasil, low back pain is referred to as Waja' uz-Zahr in Unani medicine. HGA, a pill form of the polyherbal Unani medication. Although it has been reported to be most helpful in chronic musculoskeletal disorders. Hippocrates, Galen, Razi, and Avicenna were a few of the early Unani scholars who wrote about Riyazat's therapeutic benefits. Patients with LBP have reported pain reduction from stretches and exercises that target the gluteal, hamstring, and quadriceps muscles, which support the lumbopelvic region²⁰. In the present case series HGA and Riyazat have been implicated in the management of NSLBP. The outcome measures NRS and ODI have been used for the assessment of the improvement in signs and symptoms at baseline, 15^th and 30^th day. On the analysis, there is significant reduction in the signs and symptoms has been noted. The positive effects noticed in this study were due to the synergistic effects of HGA and strengthening and stretching exercise of lumbopelvic muscles. Significant anti-inflammatory activity was present in the ethanol extract of the flowers of Calotropis procera²³. The methanol extract of Bambusa arundinacea's leaves has been investigated and found to have anti-inflammatory effects²⁹. Piperine's analgesic efficacy in mice was assessed was found significantly effective³¹. Zingiber officinale dense extract was found to have strong antinociceptive and anti-inflammatory effects on the model of AITC-induced inflammation in mice, Additionally, the antiarthritic properties of ginger and its bioactive ingredients were evaluated^25,33. 

Conclusion

This case series is preliminary multimodal research in the management of NSLBP. Based on this case series, it can be stated that lumbopelvic strengthening and stretching exercises combined with Unani drug formulation are effective in lowering NSLBP pain and disabilities. It is envisaged that additional experimental and clinical research should be carried out in order to demonstrate the efficacy of this combination in treating patients of NSLBP.

Conflict of Interest: The authors declare no potential conflict of interest concerning the contents, authorship, and/or publication of this article.

Author Contributions: All authors have equal contributions in the preparation of the manuscript and compilation.

Source of Support: Nil

Funding: The authors declared that this study has received no financial support.

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. 

Data Availability Statement: The data presented in this study are available on request from the corresponding author. 

Ethical approval: Not applicable.

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