Effect of Majja Basti (therapeutic enema) and Asthi Shrinkhala (Cissus quadrangularis) in the management of Osteoporosis (Asthi-Majjakshaya).

Osteoporosis is a systemic disorder that affects entire skeleton, which is a metabolic bone disease characterized by low bone mass and microarchitectural deterioration of the skeleton, leading to enhanced bone fragility and a consequent increase in fracture risk. In Ayurveda, it can be correlated with Asthi-Majjakshaya. Basti (therapeutic enema) is the prime therapy for Asthi related diseases and Asthi Shrinkhala (Cissus quadrangularis) is the drug which is being used for strengthening of bone by traditional Vaidya since long. It has been selected for oral administration. In clinical trial, 12 patients treated with Majja Basti along with Asthi Shrinkhala pulp capsules and results are very encouraging.

Introduction

Osteoporosis is defined as a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Primary, i.e., involutional, osteoporosis is clearly the most frequent and also clinically, the most important bone disease. Osteoporosis must therefore be viewed as the consequence of a specific imbalance of bone remodeling, which leads to net bone loss because formation of new bone by osteoblasts for several reasons does not match the extent of bone resorbed by osteoclast activity.

There are two major determinants of bone mass and mineral density in later life: (1) the extent of peak bone mass in early adulthood and (2) the rate of involutional bone loss thereafter. Both the determinants are governed by complex interactions of genetic, environmental, nutritional, hormonal, age-related, and lifestyle factors. Bones grow in size during the first two decades of life, with acceleration during adolescence. This is followed by a period of consolidation. Peak adult bone mass is reached at about the age of 35 years for cortical bone and a little earlier for trabecular bone. Bone mass subsequently declines with aging. This is a universal phenomenon, occurring in both sexes and in all races. At all ages, women have less bone mass than do men. With aging, this difference becomes more pronounced. With aging, there are changes seen in the microarchitecture of bone.[1]

Ayurveda is one of the most ancient medical sciences of the world. It conceives and describes the basis and applied aspect of life process, health, disease and its management in terms of its own principles and approaches. There is no exact clinical entity mentioned in classics, like osteoporosis, but there are two conditions mentioned in Ayurveda which may be discussed in this regard. One is Asthikshaya and another is Asthisaushirya. Asthisaushirya is not mentioned as a separate condition but as a symptom of Majjakshaya, whereas Asthikshaya is mentioned as an independent condition. Asthikshaya is “decrease in the bone tissue” and Asthisaushirya means “porous bones”. Hemadri has commented on the word “Saushirya” as “Sarandhratvam” which means “with pores”. This condition is explained in the context of Majjakshaya. Osteoporosis means the decrease in the bone tissue. Moreover, there is another condition termed as osteopenia, which is a pre-stage (prodromal symptom) of osteoporosis in which there is also decrease in the bone mineral density. But decrease is not so remarkable as compared to osteoporosis. Majja is the next Dhatu of Asthi. Hence, in the process of Kshaya, Majjakshaya also occurs. Thus, Majjakshaya may take place after Asthikshaya as per the basic principles of Anulomakshaya. Since there is decrease of bone tissue in both the conditions, i.e., osteopenia and osteoporosis, it can be considered as Asthi-Majjakshaya because of its core of pathogenesis: 1) degeneration of bone tissue and 2) vitiation of Vata, the classical aspects of Asthi-Majjakshaya can be implemented in the disease osteoporosis.

Aims and Objectives

The aim of the present study was to assess the effect of Majja Basti and Asthi Shrinkhala pulp capsules in the management of osteoporosis (Asthi-Majjakshaya).

Materials and Methods

A total of 12 patients of osteoporosis and osteopenia (Asthi-Majjakshaya) were registered on the basis of symptomatology and relevant Bone Mineral Density (BMD) test in camps organized at IPGT and RA Hospital, Jamnagar, irrespective of their sex, religion, etc. Written consent was taken from each patient after giving him/her detailed information about the treatment. Ethical clearance was also obtained from the Institutional Ethics Committee.

Inclusion criteria

Osteoporotic patients of either sex, whose BMD (t-score) was equal to or less than 1.

Patients presenting with the classical symptoms of osteoporosis, with special reference to Asthi-Majjakshaya.

Patients between the age group of 30 and 70 year.

Exclusion criteria

Patients of age below 30 years and above 70 years.

Patients with BMD (t-score) above – 1.

Patients with rheumatoid arthritis, gouty arthritis, and longstanding systemic disorders were excluded.

Patients having diabetes mellitus (DM), uncontrolled hypertension (HTN), thyrotoxicosis, hyperparathyroidism, Addison's disease, Paget's disease, Cushing's syndrome, tuberculosis of bone, osteomalacia, chronic renal disease, hepatic and cardiac failure.

Criteria for diagnosis

The criteria of diagnosis was based on the signs and symptoms of osteoporosis and osteopenia (Asthi-Majjakshaya) and relevant physical examination carried out. In addition to this, BMD test was carried out in all the patients to confirm the diagnosis as well as to exclude the normal patients.

Totally, 12 patients fulfilling the criteria of diagnosis of osteoporosis (Asthi-Majjakshaya) were selected for the present study. They were treated with Majja Basti and Asthi Shrinkhala pulp capsule. Eight patients completed the treatment.

Drug, dose and duration

Majja Basti was administered for 16 days as a Matra Basti with 60 ml buffalo Majja (bone marrow of buffalo) along with Asthi Shrinkhala pulp powder filled in capsule (500 mg), two capsules three times daily for 3 months with milk.

The patients were advised to avoid the following: Apathya diet such as bitter, pungent, astringent taste dominant substances; dry, cold, light, etc. property predominant substances; Shushkamamsa (dry meat); Shushkashaka (dry vegetable); Madya (alcohol); excessive eating; fasting; heavy exercise; excessive sexual intercourse; day sleep; night awakening; suppression of natural urges; medicines like corticosteroid, anticonvulsant, etc.; smoking and other etiological factors which cause aggravation of Vata.

Criteria for assessment

Improvement in the patients was assessed on the basis of relief in signs and symptoms of the disease. All the signs and symptoms were given scoring depending upon their severity to assess the effect of the treatment objectively.

Parameters of the study: Subjective parameters

Shoola (Pain)

Grade 0 – No pain

Grade 1 – Mild pain

Grade 2 – Discomforting pain

Grade 3 – Distressing pain

Grade 4 – Horrible

Sparshasahyata (Tenderness)

Grade 0 – No tenderness

Grade 1 – Mild tenderness without any sudden response on pressure

Grade 2 – Wincing of face on pressure

Grade 3 – Wincing of face and withdrawal of the affected part on pressure

Grade 4 – Resist touch due to tenderness

Dourbalya (General debility)

Grade 0 – No Dourbalya

Grade 1 – Not able to perform strenuous activity

Grade 2 – Not able to perform moderate activity

Grade 3 – Cannot perform moderate activity but can perform mild activity without any difficulty

Grade 4 – Even mild activities cannot be performed

Total score: BT AT

Objective parameter

Bone mineral density (t-score): WHO criteria for assessing osteoporosis.

Normal – “t” score greater than – 1; osteopenia – “t” score between – 1 and – 2.5; osteoporosis – “t” score less than or equal to – 2.5 and severe osteoporosis – “t” score less than – 2.5 with fracture.

Overall effect of therapy

Marked improvement: >75–100% improvement

Moderate improvement: >50 to <75% improvement

Mild improvement: >25 to <50% improvement

Poor improvement: less than 25% improvement

Observations and Results

Out of 12 patients of osteoporosis selected (Asthi–Majjakshaya), 66.67% belonged to 51–60 years of age, 58.33% were males and 41.67% were females, 41.67% belonged to lower socioeconomic status, 33.33% patients were having the habit of tobacco chewing, 83.33% patients were having disease chronicity between 1 and 5 years, 66.67% patients were having Krurakoshtha, family history was present in 8.33% of patients, and 50% patients were having Avara Vyayama Shakti. Maximum, i.e., 66.67% patients, were taking Ruksha Ahara, followed by 33.33% taking Seeta Ahara, and 50% patients were taking Laghu Ahara and Vistambhi Ahara each. 83.33% patients of this series had history of Diva-Swapna (day sleep), whereas 74.44% patients had the history of Ratrijagarana (insomnia), and Vega-Sandharana (suppressed natural urge) and Ati-Sankshobha were found in 41.67% and 50% patients, respectively, whereas Ati Vyayama (>8 hours) was found in 33.33% patients. Also, 66.67% patients of this series reported to have Bhaya (fear) as one of the causes of their disease, and Shoka (grief) and Chinta (anxiety) were found in 24.44% and 50% patients, respectively.

Marked improvement and mild improvement were found in 12.50% patients each, whereas moderate improvement was found in 75% patients, and no patient remained unchanged in this study.

Discussion

Vitiation of Vata and deterioration of all Dhatu is a natural phenomenon occur in old age. Provocation of Vata occurs by two processes, either Samtarpana or Apatarpana. Provocation of Vata caused by Apatarpan is due to taking diet and Vihara (living habits) which vitiate Vata or due to Jarajanya (old age). Samtarpana is due to creating Margavarodha causing vitiation of Vata. Reviewing all the available literature related to Asthidhatu and Majja Dhatu, the final diagnosis of the disease was given as Asthisaushirya.

Vata Dosha contributes largely for occurrence of Asthi related diseases because of unique relationship of Vata and Asthi. Gambhira Dhatu (deep-seated tissue), Svabhava Balapravritta Vyadhi (natural phenomenon due to old age) and Bhedawastha (complicated stage) make this disease Asadhya (incurable). Management of established bone porosity is difficult. Hence, prevention of the condition becomes all important. This disease can become Yapya by intervention at proper level, followed with Pathyapathaya. Prevention of Asthisaushirya should be commenced at the level of Asthi-Majjakshaya, which is precursor of Asthisaushirya (bone porosity).

Effect of therapy on Asthikshayatmaka Lakshana

Effect on pain

Acharya Sushruta said that pain is the cardinal symptom of vitiated Vata Dosha. Pain does not arise in the absence of Vata.[2] Therefore, a drug can relieve pain only by pacifying vitiated Vata Dosha. In the present study, 76.19% relief was found in pain which was statistically highly significant (P<0.001) [Table 1]. Acharya charak said Basti as the supreme therapy for alleviating vata.[3] Moreover, the constituent ingredients, like Majja, have Ushna Virya, Guru Vipaka and potent Vatahara properties. Asthishrinkhala also has analgesic and anti-inflammatory property.[4] By virtue of Ushna Virya, it pacifies Vata and provides relief.

Table 1

Effect of therapy on the subjective and objective parameters of the eight patients of osteoporosis (Asthi-Majjakshaya)

Effect on tenderness

In the present study, treatment with Majja Basti along with Asthi Shrinkhala showed better results (75%), which was statistically highly significant (P<0.001) [Table 1]. It is the symptom mostly related with the accumulation of Ama and involvement of Vatadosa. Acharya Sushruta mentioned tenderness as one of the symptoms in the Ama Shopha.[5] Inflammation and swelling in the joint and bone tissue are due to involvement of Pitta and Kaphadosa. Hence, an imbalance of Tridosa is seen. Acharya Sushruta mentioned Basti as Tridoshagna.[6] Equating Amadosa to free radicals, it is proved that Asthi Shrinkhala shows significant inhibition of DPPH [Di(phenyl)-(2,46-trintrophenyl)iminoazanium] free radical formation and superoxide radical production,[7] thereby scavenging the free radicals.

Effect on general debility

In the present study, treatment with Majja Basti along with Asthi Shrinkhala showed better results (72.72%), which was statistically highly significant (P<0.001) [Table 1]. Osteoporosis (Asthi-Majjakshaya) is a disease of elderly people, except in cases associated with malnutrition. Generally, with increase in age, there is depletion of Dhatu, Bala, etc.[8] This phase is also recognized with hyperactive Vatadosha resulting from Dhatukshaya. Treating debility to certain extent can control the process of osteoporosis (Asthi-Majjakshaya). Majja has the properties of increasing Bala, Shukra, Rasa, Shleshma, Meda and Majja. It has been described to rejuvenate especially Asthi Dhatu.[9] Moreover, Asthi Shrinkhala is a tissue-specific anabolic drug for bony tissue,[10-12] and this way it prevents further degeneration.

Effect on therapy on BMD

In the present study, BMD (t-score) increased by 30.98% after completion of duration of treatment, which was statistically highly significant (P<0.001) [Table 1]. This indicates that the drugs enhance bone formation as well as decrease bone resorption. Both the drugs act in both the ways and balance bone remodeling and hence can prevent bone loss and help in increasing the the bone density. This test is a direct indication of depletion of Asthi Dhatu. Majja, by virtue of its Asthi Balakrita properties, checks the osteoporosis (Asthi-Majjakshaya).

Asthi Shrinkhala has been described as Asthiyuka which means that it helps or promotes or maintains the conjugation of Asthi Dhatu. Majja has a significant effect on reducing the Asthi-Majjakshaya (osteoporosis), whereas Asthi Shrinkhala inhibits further degeneration. Researches prove that Asthi Shrinkhala[3] has an active ingredient known as ketosterone. On this basis, it performs multiple actions as follows.

1) It acts as an antagonist to the glucocorticoid receptor and promotes good bone health. 2) It shows anabolic steroid properties for healing of fracture. 3) It increases intramuscular creatinine levels. 4) It blocks the muscle damaging effect of cortisol and leads to the formation of new muscles. 5) It shows significant inhibition of DPPH free radical formation, superoxide radical production and lipid peroxide production in erythrocytes. 6) It shows sedative effect on the central nervous system. 7) It protects gastric mucosa against ulceration by its antisecretory and cytoprotective properties. 8) It mobilizes fibroblast and chondroblasts to an injured tissue and enhances regeneration. 9) It is helpful in the back and spine problems.

Moreover, it has been reported that Cissus quadrangularis extract is used as a dietary supplement or pharmaceutical composition. It is used to prevent and treat osteo-health related disorders and diseases.[13]

Apart from the statistical analysis, some interesting clinical effects of the therapy observed in individuals are reported below.

In the present study, two patients had associated complaints of chronic neck pain and stiffness; who were using cervical collar for a prolonged time. These patients have shown remarkable results in symptomatic relief from pain and stiffness after 16 days of administration of Majja Basti, and as a result they stopped wearing their cervical collar permanently.

Conclusion

From the above study, it is observed that effects of Majja Basti along with Asthi Shrinkhala are encouraging in the management of osteoporosis (Asthi-Majjakshaya) and it also improves the general health of the patients.