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Dosha dhatu mala mulam hi shariram (1). Doshas, dhatus and malas are the foundations of the body.
Osteoporosis is a common condition affecting as many as ten million Americans, with an additional 34 million suffering from osteopenia. It occurs most commonly in post-menopausal white women but may affect all ages, sexes and ethnicities. Many older women either come to see an Ayurvedic practitioner because they are concerned to prevent or treat osteoporosis, or list this condition as an additional concern alongside their main complaint. In this article we will examine the Ayurvedic approach to osteoporosis and its treatment.
Within bone, the trimurti functions of Brahma, creator, Vishnu, preserver and Shiva, destroyer are clearly seen. Osteoblasts are the Brahma force, building bone, making collagen and hydroxyapatite. Osteocytes, buried within the bone matrix, are the Vishnu force, maintaining bone and preventing bone resorption. Osteoclasts are the Shiva force, dissolving and breaking down bone (3).
The function of asthi dahtu is dharana, support of the body, along with nourishing majja (4). When it is deficient (asthi kshaya) it gives rise to pain in the bone, breaking of teeth and nails and dryness (5). Oseopenia is the puravarupa and osteoporosis is the full-blown rupa (6). Vagbhat points out that, " In asthi resides vayu" (7). Asthi and vayu in the bones are in an inverse relationship, so that factors that increase vata decrease bone mineral density (7). As with any dhatu, there are several factors that can lead to dhatu kshay. If jatharagni is affected there will be lack of poshana (nutrition) to asthi dhatu, leading to asthi kshay. For example, undiagnosed celiac disease can lead to osteoporosis (8). If bhutagni is disturbed, particularly parthiva agni, calcium and phosphate metabolism in the body will be affected. Again, there will be lack of poshana of asthi, leading to ostepenia and osteoporosis (6). If asthi dhatu agni is increased, there will be excess resorption of bone, or excess osteoclast activity, again leading to asthi kshaya (6). And if asthi dhatu agni is diminished, there may be decreased bone formation or diminished activity of osteoblasts in building bone.
Osteoporosis is particularly common in the elderly population--affecting men as well as women. This is the vata time of life, and as we have mentioned, there is an inverse relationship between vata and asthi. Furthermore, it is more difficult for geriatric patients to build the dhatus. Sa evannaraso vriddhanam jaraparipakwa shariratwat aprinano bhavati--The essence of food will not be able to build the tissues of elderly patients by nourishing them because these tissues are over-matured due to age (9). Osteoporosis due to old age is known as Type II or senile osteoporosis, and affects both men and women over the age of 70. Postmenopausal osteoporosis due to estrogen deficiency is known as Type I osteoporosis and affects women age 50-65 (2). Type I osteoporosis mainly affects trabecular bone. Fractures of the distal forearm such as Colles fracture are quite common in this cohort, as are vertebral fractures (10, 2). Type II osteoporosis affects both cortical and trabecular bone. Hip fractures are common among elderly patients with osteoporosis, as well as wrist and vertebral fractures (2). In addition to these primary types of osteoporosis, secondary osteoporosis may occur due to diseases which affect jathar agni, bhutagni or asthi dhatu agni. Many individual patients may have a combination of primary and secondary causes, leading to a complex clinical picture of multifactorial disease (2).
Causes of secondary osteoporosis include genetic disorders such as cystic fibrosis, Ehrler Danlos Disease, glycogen storage disease, Gaucher disease, hemochromatosis, Marfan syndrome and hypophosphatasia. Hypogonadal conditions can also cause osteoporosis; these include anorexia nervosa, bulimia, female athlete triad (eating disorder, amenorrhea and osteoporosis in female athletes participating in sports that emphasize thinness), hyperprolactinemia, premature menopause, Turner syndrome (XO) and Klinefelter syndrome (XXY). Endocrine disorders such as adrenal insufficiency, Cushing syndrome, Diabetes, hyperparathyroidism and hyperthyroidism are causes of secondary osteoporosis, and the hormonal changes of pregnancy can also trigger osteoporosis in susceptible individuals (2). Deficiencies of calcium, magnesium, protein and vitamin D are causes, as are inflammatory conditions including inflammatory bowel disease, Rheumatoid Arthritis, Ankylosis Spondylitis and Systemic Lupus Erythematosus. Leukemia, lymphoma, metastatic cancer and multiple myeloma should also be considered in osteoporosis. Symptoms of osteoporosis may be the first warning of an illness such a multiple myeloma. Note that many medications are implicated in the causation of osteoporosis, including several that are taken long term such as anti-convulsants, anti-retrovirals (AIDS medications), antipsychotics and excess thyroxine (2). Additional causes of secondary osteoprosis include alcoholism, congestive cardiac failure, depression, HIV and chronic liver disease.
Maria is a fifty eight year old white post-menopausal woman suffering from hepatitis C and HIV co-infection. For the last fifteen years, she has had an alcohol problem. She has been clinically depressed since taking Interferon for hepatitis C. She currently takes anti-retrovirals for HIV and has done so for several years. Recently she suffered a severe Colles fracture requiring surgery. It is easy to infer that Maria has significant osteoporosis but more difficult to pin down a cause. As a post-menopausal woman, she is a candidate for primary type I osteoporosis. But possible contributing secondary causes include HIV, hepatitis C, depression, alcoholism, and antiretrovirals. Some causes cannot be removed. For example, her anti-retroviral medication is obligatory. Therefore, vigorous effort should be made to remove treatable co-factors such as alcoholism, lack of exercise and poor diet. It would be valuable to assess her vitamin D levels. She should also be checked for non-Hodgkins lymphoma, common in HIV patients.
Treatment of asthi kshaya falls into four stages
1. Hetu viparita chikitsa: removal of the cause
2. Agni deepan: Treat the affected agnis
3. Vata shamak: Pacify vata
4. Dahtu rasayana: Build bone
Hetu viparita chikitsa
Since osteoporosis is multifactorial in so many cases, begin with a hetu (causation) worksheet. Is the condition primary, secondary, or both simultaneously, as in the case of Maria? List all the secondary factors: prajanaparadh, diet, lifestyle, genetic, inflammatory, iatrogenic etc. Now note which of those factors can be removed. For example, Maria had the option of going sober and removing one cause of her osteoporosis completely, or a patient of celiac disease could go off gluten completely. Next note causes which may not be able to be removed completely but could be modified. For example, the patient could discuss with their MD any possible changes to their medication schedule, for greater bone health. By removing or modifying any aspects of hetu that are amenable to being addressed, an optimal outcome can be obtained.
Next, use an agni worksheet to think carefully through all the agnis involved. Again, in a multifactorial situation, several agnis may be involved. If jatharagni is involved, it may be rehabilitated using suitable teas, herbs and spice blends, as well as home remedies such as grated fresh ginger marinaded in lemon juice with a little rock salt. If bhutagnis are involved, herbs that target the liver, such as guduchi, neem or kalmegh, along with anupans such as aloe vera may be helpful. Be careful not to provoke vata. If asthi dhatu agni is involved, guggulu can be used to balance asthi dhatu agni.
The patient with osteoporosis requires pacification of vata, because of the inverse relationship between vata and asthi. This will include use of vata pratyanika herbs such as ashwagandha and vidari, vata pacifying diet, daily self-abhyanga and lifestyle modifications. Basti treatments will be extremely helpful, alternating matra (oil) basti using sesame oil with niruha (decoction) bastis using dashamooal tea.
'For decrease of dhatus, counter-measures are this foods and substances that cause their increase' (11). Traditionally this is accompliashed by use of bhashmas of similar composition to bone, such as shankha bhasma (conch shell ash), praval panchamrit (combination of conch, coral, pearl, mother-of-pearl and cowrie). Nowadays, there are issues of both sustainability and mercury contamination in using marine bhasmas. Therefore it may be safer and simpler to select other substance endowed with the properties of asthi i.e. "guru (heavy), kathina(hard), khara (rough), sthula (bulk), sthira (remains for a long time) and murtimad (having shape)" (6). This includes milk, ghee, tikta ghee (tikta adds the khara property), turmeric milk (turmeric adds the khara property), urad dal, red rice, and for non-vegetarians, chicken soup. Yogaraj guggulu can be used to kindle asthi-dhatu agni and heal bony pain. Arjun is high in calcium and very good for healing bone and is traditionally used for fractures and osteoporosis in the form of kshirapak or medicated milk. Ashawagandha kshirapak may also be used. Ayurveda has its own methodology for providing Vitamin D in the form of early morning sunbaths. However, it should be considered that as people age, their ability to manufacture vitamin D from sunlight diminishes (12). Therefore Vitamin D3 supplementation is also advisable. Eating unhulled sesame seeds is recommended as a calcium supplement (13).
Using these four steps of Ayurvedic treatment, the multifactorial condition, asthi kshay or osteoporosis can be prevented, controlled or effectively managed for best outcomes.
1. Sushrut, Sutrasthana 15/3
2. Dana Jacobs-Kosmin Osteoporosis http://emedicine.medscape.com/article/330598-overview#a0156 accessed 27 Nov 2011.
3. Buckwalter JA, Cooper RR Bone structure and function.Instr Course Lect. 1987;36:27-48
4. Sushrut sutrasthana 15/6
5. ibid v 9
6. Kadlimatti SM, Maheshwari KS, Chandola HM, Critical Analysis of the Concept of Asthi Kshaya vis-à-vis Osteoporosis Ayu-Vol. 30, No. 4 (October-December) 2009, Pp. 447-458
7 .Vagbhat, sutrasthana 11/26-27.
8. Kemppainen T.; Kroger H.; et al Osteoporosis in adult patients with celiac disease - Frequent clinical onset during pregnancy or the puerperium Bone, Volume 24, Number 3, March 1999 , pp. 249-255(7)
9. Sushruta, sutrasthana, 14/19
10. S.A. Earnshaw, S.A. Cawte Colles' Fracture of the Wrist as an Indicator of Underlying Osteoporosis in Postmenopausal Women: A Prospective Study of Bone Mineral Density and Bone Turnover Rate Osteoporosis International Volume 8, Number 1, 53-60, DOI: 10.1007/s001980050048
11. Sushrut, Sutrasthana 15/10
12. John H. Lee, MD*, James H. O'Keefe, et al Vitamin D Deficiency
An Important, Common, and Easily Treatable Cardiovascular Risk Factor?
J Am Coll Cardiol, 2008; 52:1949-1956, doi:10.1016/j.jacc.2008.08.050