Abstract
Dear Editor,
We read with interest the case report by Kizhakkeveettil et al describing the Ayurvedic management of chronic low back pain (LBP) in a 66-year-old woman. 1 The patient experienced severe pain and functional disability for 2 years before receiving an 8-week multimodal Ayurvedic intervention, with notable improvement in pain scores and Oswestry Disability Index. While the outcome is encouraging, we wish to highlight a critical methodological concern: the absence of diagnostic imaging. The authors note that “radiological imaging was not considered necessary based on the clinical examination. 1 However, this approach diverges from international recommendations for older adults with chronic LBP. The American College of Physicians advises that adults older than 50 years with persistent or progressive back pain undergo diagnostic imaging, given the increased likelihood of vertebral fracture, malignancy, and spinal stenosis in this age group. 2 Similarly, the National Institute for Health and Care Excellence guideline recommends imaging when serious spinal pathology cannot be excluded clinically, particularly in older adults with disabling symptoms. 3 Deyo et al also emphasized that in patients with long-standing, disabling LBP, imaging is essential to exclude red-flag conditions before attributing recovery to conservative or complementary therapies. 4 In this case, the patient was 66 years old, had a 2-year history of severe pain (Oswestry Disability Index 55%), and reported significant limitations in walking, bending, and lifting. Without at least baseline radiographic or MRI evaluation, it is impossible to exclude common age-related conditions such as spinal stenosis, osteoporotic vertebral fracture, or malignancy. Improvement following multimodal care could therefore reflect the natural course of chronic LBP, regression to the mean, or nonspecific effects, rather than disease modification attributable to Ayurveda. We commend the authors for presenting an integrative approach to chronic LBP but respectfully suggest that future reports involving older patients with severe disability incorporate appropriate imaging. This would not only ensure diagnostic accuracy but also strengthen the interpretability of treatment outcomes and facilitate meaningful comparison with conventional standards of care.
