Journal of Acuherb in Medicine


Osteoporosis

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Osteoporosis is a debilitating condition of skeletal fragility that predominantly affects women and is particularly common in the elderly. It is a metabolic bone disease characterized by a parallel reduction in bone mineral density and bone matrix, leading to deterioration of the micro-architecture of bone tissue and impairment of the structural integrity of trabecular bone (the inner part of bone that consists of a meshwork of bony bars with numerous interconnecting spaces containing marrow). The consequence is that although the bone tissue has normal composition and proper mineralization, the bone mass (density) is reduced and the bone becomes more fragile. To establish a diagnosis of osteoporosis, the individual bone mineral density is compared with the peak bone mass measurement in the healthy young adult. This comparison is made by means of standard deviation (SD) units (T scores). Clinically, a patient is said to suffer from osteoporosis if his/her bone density falls 2.5 SD below the mean of normally mineralized bone, calculated in comparison to age-, sex-, and race-matched controls (a T score of  2.5). For example, compared to standardized bone density measurements of the total hip of 833 mg/cm2, in osteoporosis, the same measurements will be lower than 648 mg/cm2(World Health Organization). If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks. Any bone can be affected, but of special concern are fractures of the hip and spine. A hip fracture almost always requires hospitalization and major surgery. It can impair the ability to walk unassisted and may cause prolonged or permanent disability, or even death. Spinal or vertebral fractures also have serious consequences, including loss of height, severe back pain and deformity.

Multiple etiologic factors of osteoporosis have been identified, which give the various disease types their names.

Postmenopausal, estrogen-deficient osteoporosis
Age-related osteoporosis
Diet-related bone loss
Disuse osteoporosis
Endocrine-mediated bone loss
Disease-related bone loss
Drug-induced bone loss
Heritable osteoporosis

Statistics

Osteoporosis is a major public health concern that affects more than 28 million Americans, 80 per cent of whom are women. Women are more likely than men to develop osteoporosis because, as a group, they have lighter bones, less total calcium, and also lose bone at a rate three times greater than that of men. In the US today, 10 million individuals have the disease and 18 million more have low bone mass, placing them at increased risk for osteoporosis. Ten per cent of African-American women over the age of 50 years have osteoporosis; an additional 30 per cent have low bone density that puts them at risk of developing osteoporosis. Significant risk has been reported in people of all ethnic backgrounds.

The disease accounts for more than 1.5 million fractures per year in the US: one out of every four women by the age of 70 develops an osteoporotic fracture; and one in two women and one in eight men over the age of 50 will have an osteoporosis-related fracture in their lifetime. These fractures include the following (approximate figures):

300,000 hip fractures
700,000 vertebral fractures
250,000 wrist fractures
300,000 fractures at other sites

Osteoporosis is defined in Western medicine as loss of bone density. The disease is most commonly seen in women and is characterized by reduced bone mass, deterioration of bone tissue and an increased risk of bone fractures. It is induced by a physiological degeneration within the body that affects the formation and loss of bone tissue.

The skeleton is the frame of body that protects the internal organs and allows movement. Cavities within the bone store bone marrow, which nourishes the bones and helps manufacture cells such as red and white blood cells and platelets. TCM believes that bone growth is controlled by the kidneys and that the bone marrow is derived from the essential qi or essence of the kidney, called jing. In recent years, many bone disorders have been successfully cured by TCM practitioners through treatment of the kidney

In the traditional Chinese medicine (TCM) classic Huang Di Nei Jing (The Yellow Emperor’s Medicine Classic), bone diseases with similar symptoms to osteoporosis were given names like “bone flaccidity syndrome,” “withered bone syndrome,” “arthralgia syndrome” and “bone atrophy syndrome.” These syndromes refer to various kinds of bone diseases, but share the common symptom of reduced bone mass. Modern TCM practitioners believe that the features of “bone flaccidity syndrome” and “bone atrophy syndrome” are most consistent with today’s understanding of osteoporosis.

Causes

Bone quality is a significant factor that affects the development of osteoporosis. This parameter is determined by bone mass (as measured by bone density) and also by the micro-architecture of bone. Bone density at any given time depends on both the peak bone density achieved during development and subsequent adult bone loss. Collectively, these affect the relative intactness of bones, with respect to tensile strength, fragility and freedom from fatigue damage. Many studies demonstrate the ability of bone density to predict fractures, especially fragility fractures (those caused by minor trauma). The risks vary depending on the populations studied and on the technique of measuring the bone density.

Nonmodifiable risk factors

Advanced age : Bone density increases dramatically during puberty in response to gonadal hormone release and eventually reaches values in young adults that are nearly double those of children. After peak bone density is reached, bone density remains stable for years and then declines.
Gender : Considerable evidence suggests that bone loss begins before menses cease in women and in the third to fifth decade in men. In women, once the menopause is established, the rate of bone loss is accelerated several-fold. The chances of developing osteoporosis are greater for woman because they have less initial bone tissue and lose it more rapidly because of the changes involved in the menopause.
Family history and personal history of fractures as an adult : Susceptibility to fracture may be, in part, hereditary. Young women whose mothers have a history of vertebral fractures also seem to have reduced bone mass. A personal history of a fracture as an adult also increases fracture risk.
Race : Caucasian and Asian women are more likely to develop osteoporosis..


Potentially modifiable risk factors 

Bone structure and body weight : Small-boned, fair-skinned, and thin women are at greater risk.
Estrogen deficiency : Normal or early menopause (brought about naturally or because of surgical removal of the ovaries) increases the risk of developing osteoporosis. A menstrual history of late-onset menses, or of amenorrhea (absence of menstrual periods) also increases risk.
Lifestyle : Stress, smoking, excess alcohol consumption, and a sedentary lifestyle are associated with the development of osteoporosis.
Diet : A high intake of caffeine, phosphorous, or protein, and a diet poor in calcium and vitamin D affect bone formation.
Poor eyesight : Impaired eyesight despite adequate correction can lead to falls.
Poor health/frailty Medications : A number of drugs taken for other conditions can have an affect on osteoporosis, either because they interfere with bone formation or accelerate its loss.
Chronic health problems : Diseases such as chronic liver disease, chronic liver failure, endocrinopathies (eg, diabetes, hyperthyroidism), malabsorption syndromes, rheumatoid arthritis, and chronic anorexia can also be risk factors for osteoporosis.

From TCM’s viewpoint, osteoporosis is caused by a kidney deficiency. As people get older, the essential qi (jing) of the kidney gradually declines and results in a lack of nutrients for the bones to grow and function properly. This causes the bones to become fragile and break or deform easily. Bone fractures can be hard to heal due to the lack of nourishment and kidney deficiency.

The causes of kidney deficiency leading to osteoporosis are as follows: 

1. Exhaustion of kidney essence.
Kidney essence may be depleted in one of three ways:

A congenital deficiency (a deficiency you are born with) and the aggravation of external factors, such as excessive sexual activities and frequent childbirth, cause the kidney essence to become severely depleted. This leads to loss of bone nutrients.
The elderly are especially vulnerable to osteoporosis if they do not take good care of their bodies because the depletion of kidney essence accelerates with age.
Exogenous pathogens can easily invade and damage the kidney when vital qi (energy) is insufficient. This causes the development of osteoporosis. .
2. Acquired Deficiency
Under normal conditions, the spleen and stomach are responsible for changing digested nutrients into qiblood, and acquired (postnatal) jing. Over-consumption of alcohol and food can damage the spleen and stomach and reduces the amount of jing available to nourish the bone, bone marrow and muscle. Additionally, when the stomach and spleen dysfunction, a decline in formation of qi and blood results and this can contribute to osteoporosis development.
3. Invasion of exogenous pathogens
Osteoporosis can occur when external cold and dampness evils, which are exogenous pathogens, invade the body and impair the vital qi (energy) and kidney qi. This leads to a deficiency of kidney essence (jing) and a failure in the bone marrow to replenish the nutrients needed to retain bone strength. Other symptoms such as lumbago (back pain) and arthralgia (joint pain) can occur when cold and dampness evils stagnate in the tendons and joints, blocking the circulation of qi and blood in that area. 

TCM followers believe that external cold and dampness pathogens can invade the body under the following conditions:

Living in cold and moist areas for a long time
Exposure in a windy place while drinking alcohol
Bathing or taking a shower while sweating
Eating too much cold food and
Lying in damp and moist open areas such as wet grassy fields.

Symptoms

The clinical symptoms of primary osteoporosis are:

Lumbago (back pain)
Decrease in body height and /or hump back (kyphosis) giving a stooped appearance
Bones that easily fracture
Difficulty in breathing due to malformation of the back limiting the amount of air that can be inhaled.

Persons with osteoporosis will also be diagnosed with a TCM disharmony pattern. (See diagnosis section). Each disharmony pattern displays different symptoms, which are described as follows:

1. Yin deficiency of the liver and kidneys
  The individual experiences soreness and pain in the back and loins, weakness in the loins and knee joints, general weakness and fatigue, dryness of the mouth and throat, a hot sensation in palms and soles, and night sweating or spontaneous sweating.
2. Blood deficiency and excessive dampness
  This manifests as soreness and pain in the back and loins, a hump back, pale complexion, heart palpitations and dizziness. There may also be pain and soreness in the joints or the lower limbs may be swollen.
3. Retention of dampness and kidney deficiency
  This disharmony pattern is characterized by lower back pain, localized chills, weakness and soreness in the loins and knees. In severe cases the lumbar vertebrae (lower back bones may collapse or a hump back develop. Additional symptoms are a cold feeling in the limbs, urinary frequency, and an aversion to the cold. The symptoms may be aggravated in a cold environment or with a drop in the ambient temperature.
4. Asthenia-syndrome of superficies and interior dampness retention
  The individual suffers from pain in the hip and back, joint swelling, sweating and has an aversion to wind (coldness). A sense of heaviness may also be felt.
5. Cold in the superficies and heat in the interior
  The symptoms here are body aches and sweating, and an aversion to cold temperatures. Additional symptoms can include dry mouth, thirst, and constipation.
6. Marrow deficiency and channel bi-syndrome
  The individual experiences pain in lumbar region. In severe cases, the lumbar vertebrae may collapse or a hump back may occur. Joints can become deformed and develop limited movement. Individuals may also experience dizziness, heart palpitations, and shortness of breath.

Diagnosis

Osteoporosis is an insidious disease that can remain silent for decades before the bone is weakened to the point that it sustains a spontaneous fracture. The earliest signs of osteoporosis are often associated with compression fractures of the spine characterized by an episode of acute pain in the middle to low thoracic or high lumbar region . Decrease in height and appearance of a dowager’s hump are reliable indicators of the early progress of the disease. Also, the patient often reports early satiety and a bloated feeling after eating only a small amount of food. 

A bone mineral density (BMD) test is the only way to diagnose osteoporosis and determine an individual’s risk for future fracture. It measures the density of the bones (bone mass) and will indicate whether medication is needed to help maintain bone mass, prevent further bone loss and reduce fracture risk. The BMD test is accurate, painless and noninvasive. It is also possible to determine the rate of bone loss and/or monitor the effects of treatment if tests are conducted at intervals of a year or more.

Criteria approved for BMD tests are summarized below:

estrogen-deficient women at clinical risk of osteoporosis.
vertebrate abnormalities on x-ray suggestive of osteoporosis (osteopenia, vertebral fracture)
primary hyperparathyroidism – abnormal function of the parathyroid glands itself which result in high level of blood calcium.
monitoring response to an FDA-approved medication for osteoporosis.

For an uncomplicated patient with osteoporosis, a laboratory work-up may be recommended in addition to a BMD test. 

Based on four examination techniques, TCM practitioners will diagnosis osteoporosis according to its clinical symptoms and further characterize it by the disharmony patterns displayed by each individual. At various stages of disease, different disharmony patterns are present and individuals with the same disease will be treated differently depending on the type of disharmony pattern they have. 

The common disharmony patterns of osteoporosis are:

1. Yin deficiency of the liver and kidneys
  When the body perceives that it is inadequate in bone marrow, the liver and kidney will hyper-function to compensate. This results in a relative yin deficiency inside the body. Virtual “fire” is produced and presents as heat symptoms. On examination, the tongue is red with a scanty thin fur coating. The pulse feels thready and rapid.
2. Blood deficiency and excessive dampness
  Improper functions of the spleen and stomach lead to a decline in the production of blood and bone marrow, plus an accumulation of dampness. It gives rise to a non-smooth flow of blood and qi, which in turn supply inadequate nutrients to the bones. People may feel weakness, back pain or joint pain. On examination, the tongue is pale and covered with greasy fur. The pulse sign is deep and rolling.
3. Retention of dampness and kidney deficiency
  The kidneys govern water, produce marrow, dominate the bones and manufacture blood. The kidney yang energy is the source of all heat in the body. Kidney deficiency occurs when cold and dampness evils damage the kidneys. This results in inadequate kidney essence (jing) to supply the bone marrow and causes deterioration of the bones. Symptoms can manifest as back pain and hump back. On examination, the tongue is pale and covered with white greasy fur. The pulse feels deep, thready and stringy.
4. Asthenia-syndrome of superficies and interior dampness retention
  This is a morbid condition resulting from the exposure to exogenous pathogens in a person whose organs, like the spleen and stomach, are in a hypo-functioning state. When the body accumulates lot of evils (most likely dampness and coldness), stagnation of qi flow in the meridians and the joints occurs and results in impairment of organ and bones, which leads to symptoms of sluggishness, tired and heavy limbs, and joint pain. On examination, the tongue has a white coating. The pulse sign is deep and rolling.
5. Cold in the superficies and heat in the interior
  This morbid condition results from the wind and cold evils that accumulated in the superficial regions of body has invaded interiorly and transformed into heat evil. This process manifests as both heat and cold syndromes clinically. These syndromes cause kidney damage and lead to failure supply of kidney essence (jing) for bone growth. On examination, the tongue is red and covered with white greasy fur, or yellow-colored fur. The pulse feels thready, stringy and rapid.
6. Marrow deficiency and channel bi-syndrome
  When marrow is seriously exhausted, the body skeleton loses nutrients. The accumulated evils block the channels or meridians that are the paths for transportation of nutrients and this accelerates the bone deterioration. The person presents with serious symptoms like severe bone or joint pain and bone distortion. On examination, the complexion may appear pale or dark in color. The tongue is dark red, and covered with white greasy fur. The pulse feels deep and stringy.

Treatment

A blend of Western and TCM approaches can be of benefit in the treatment of osteoporosis. Often a combined treatment produces better outcomes than the exclusive use of one method. It is best to get the advice of a TCM practitioner who knows what is best for you and your condition. The treatments described below are some approaches that may be taken to treat the different TCM syndromes associated with osteoporosis.

1. Yin deficiency of liver and kidney


Therapeutic aim:Nourishes yin for kidney and liver, replenishes jing and marrow.

Prescription:
 liuwei dihuang pellet with modification

gan di huang dry rehmannia root
shan yu rou Asiatic cornelian cherry fruit
huai shan yao common yam root
fu ling Indian bread
dan pi tree peony bark
gou qi chi Barbary wolfberry fruit
chuan duan Himalayan teasel root

In this prescription, rehmannia, cornelian cherry and wolfberry are used to nourish the yin of the liver and kidneys; peony bark clears away heat evil and nourishes yin. Common yam and Indian bread invigorate the spleen and eliminate dampness evil; they also counteract the greasy properties of the other herbs. Teasel root tonifies the kidneys and strengthens tendons and bones. 

2. Blood deficiency and excessive dampness


Therapeutic aim:
 Nourishes the blood and dispels dampness evils. 

Prescription: Danggui Shaoyao powder plus additional supplement

dang gui Chinese angelica
bai shao white peony root
fu ling Indian bread
bai zhu large head atractylodes root
ze xie oriental waterplantain rhizome
chuan xiong Szechuan lovage root
fang ji four stamen stephania root
gui zhi cassia twig
gan jiang dried ginger
gan cao liquorice root

In the prescription, angelica, peony root and lovage root are used to activate blood circulation and nourish the blood. Cassia can remove obstruction in the meridians, activate blood circulation, and relieve joint pain. Indian bread, atractylodes root, waterplantain rhizome, and stephania root are used to invigorate the spleen and eliminate dampness evil. Ginger and liquorice root warm the middle burner and ease the stomach. Additionally, angelica, peony root, and lovage root can stimulate blood production. Indian bread, atractylodes root and cassia also eliminate the dampness evil and relax the tendons, as well as nourishing the tendons and bones.

3. Retention of dampness due to kidney deficiency

Therapeutic aim: Warms the yang and dispels dampness evils. 

Prescription: zhenwu decoction plus additional supplement 

zhi fu pian prepared common monkshood daughter root
bai shao white peony root
sheng jiang fresh ginger
fu ling Indian bread
bai zhu large head atractylodes root
gui zhi cassia twig
bu gu zhi malaytea scurfpea fruit
chuan duan Himalayan teasel root
sang ji sheng Chinese taxillus herb
xing ling pi epimedium herb
ji xue teng suberect spatholobus stem

In the prescription, monkshood and epimedium are used to warm the yang or the body. Ginger, Indian bread and atractylodes warm the middle burner (spleen and stomach) and promote the secretion of urine. Peony root, cassia and spatholobus nourish the blood and remove obstruction in all the meridians. Scurfpea, teasel and taxillus nourish the kidney and strengthen the bones, loins, and legs. 

4. Asthenia-syndrome of superficies with interior dampness retention

Therapeutic aim: Strengthens the middle burner, benefits the qi, harmonizes nutrients and defends qi. It does this by providing a yang energy in the body derived from the digestion and absorption of foods by the spleen and stomach. This helps protect the skin and muscle, provides resistance against the exogenous pathogens and regulates the secretion of sweat.

Prescription:fangyi huangqi decoction with modification

sheng huang qi fresh milkvetch root
fang ji four-stamen stephania root
sheng jiang fresh ginger
da zao Chinese date
gan cao liquorice root
gui zhi cassia twig
bai shao white peony rooti
cang zhu atractylodes root
sheng long ku unprocessed fossil fragment
sheng mu li fresh oyster shell

In the prescription, cassia, ginger, date, liquorice and milkvetch are used to tonify the stomach, nourish the middle burner, and benefit the qi. Peony root nourishes the qi and regulates the blood circulation. Stephania and atractylodes eliminate dampness evil and relieve joint pain. Fossil and oyster shell arrest premature ejaculation and sweating. The synergistic action of the herbs in this recipe consolidate body resistance, eliminate fluid retention, replenish the kidney and blood, and nourish muscles and bones. 

5. Cold in the superficies and heat in the interior

Therapeutic aim: Expels superficial pathogens and clears away heat evil.

Prescription: Yuebi Jiashu decoction with modification

ma huang ephedra
cang zhu atractylodes root
sheng jiang fresh ginger
da zao Chinese date
jiu gan cao liquorice root
shang shi gao unprocessed gypsum
fang ji four-stamen stephania root
mu gua papaya

In the prescription, ephedra, ginger, date and liquorice provide pungent and warming properties to warm the middle burner, invigorate the stomach, and relieve the exterior symptoms. Gypsum can clear away interior heat evil. Stephania, papaya, and atractylodes eliminate dampness evil and relieve joint pain.

6. Marrow deficiency and channels bi-syndrome

Therapeutic aim: Nourishes the marrow and smoothes the flow of qi and blood in all meridians.

Prescription: yougui pellet with modification

shu di huang processed rehmannia root
shan yao common yam root
shan zhu yu Asiatic cornelian cherry fruit
gou qi chi Barbary wolfberry fruit
jiu gan cao liquorice root
du zhong eucommia bark
rou gui cassia bark
zhi fu zi prepared common monkshood daughter root
wu she black snake
xing ling pi epimedium herb
cang zhu atractylodes root
gou ji cibot rhizome
sang ji sheng Chinese taxillus herb

In the prescription, monkshood, rehmannia, cassia, cornelian cherry, eucommia, cibot and epimedium invigorate the kidneys and strengthen the tendons and bones. Atractylodes and taxillus eliminate dampness evil and relieve joint pain. Liquorice helps regulate stomach function and benefits vital qi (energy).

 

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