Case Report

Role of Complementary and Alternative Therapies to Reduce Morbidity in Oestrogen Deficiency Associated Osteoporosis: A Review

Kaveri Kuttappa¹*, Amulya Cherukumudi² and Roopa Mahinder¹

¹Ayurveda Specialist, Wellbeing Multispecialty Clinic, India

²General Physician, Wellbeing Multispecialty Clinic, India

Submission:February 17, 2020; Published:March 04, 2020

*Corresponding author:Kaveri Kuttappa, Ayurveda Specialist, Wellbeing Multispecialty Clinic Bangalore, India

How to cite this article:Kaveri K, Amulya C, Roopa M. Role of Complementary and Alternative Therapies to Reduce Morbidity in Oestrogen Deficiency Associated Osteoporosis: A Review. J Complement Med Alt Healthcare. 2020; 11(2): 555808.DOI: 10.19080/JCMAH.2020.11.555808

Abstract

Objective: To review and analyze the clinical studies performed on the role of complementary and alternative medicine, individually or combined, in reducing morbidity in estrogen deficiency associated osteoporosis. The morbidity is assessed in terms of the frequency of fractures, improvement in bone marrow density (BMD) and change in bone turnover parameters.

Background: with increasing age, there is a decreased absorption and storage of vitamin D and calcium, which are essential for maintaining bone health. This condition is further worsened estrogen deficiency, as well as in postmenopausal women. When faced with such a scenario, the body resorbs calcium from the bones to overcome the loss, and causes subsequent weakening of the bones and thus, increased susceptibility to frequent fractures and decreases in bone density.

Search methods: The study is based on review of clinical studies sourced from PubMed, Medline, Cochrane Database, and Journals specific to studies related to yoga, Ayurveda and naturopathy, with correlation to Ayurveda & Modern text.

Result: 16 out of the 17 research articles that have been reviewed showed that yoga, Ayurveda and naturopathy have a positive effect on BMD, bone growth and preserving the bone architecture.

Keywords:Estrogen deficiency; Postmenopausal; Osteoporosis; Bone marrow density; Complementary medicine; Alternate medicine; Ayurveda; Yoga

Introduction

Osteoporosis, a chronic and progressive disease is one of the most common metabolic bone diseases in the geriatric age group. It is essentially a systemic skeletal disease, characterized by low bone mass, and micro architectural breakdown of bone tissue, causing decrease in bone density and increase in bone fragility. The disease often does not become clinically apparent, until a fracture occurs, usually hip fracture. The fracture is usually a result of a trivial injury, like fall during bath. Fractures caused by major trauma like road traffic accidents etc. are not considered in this group. This review is aimed at studying the effectiveness of complementary and alternative therapies (yoga, Ayurveda and naturopathy only) to reduce the incidence of fractures as well as to improve bone density is those with osteoporosis.

Review of Clinical Studies

Postmenopausal osteoporosis is a major cause of debility in elderly women, due to estrogen deficiency associated with the biological process of menopause. This reduction in bone marrow density and increase in bone turnover markers, makes postmenopausal women susceptible to fractures with trivial falls, increased morbidity and restriction of routine activities. Keeping all this in mind, and considering the parameters of the review, 17 clinical studies were identified. Of these, 5 were randomized control trials spanning across yoga and Ayurveda and naturopathy. Jasmine et al conducted a study on Shatavari moola churna and Kukkutanda twak bhasma in postmenopausal osteoporosis, concluding that Shatavari showed encouraging results in improving bone metabolism and enhancing bone formation. Eleven randomized control trials, have been conducted on the use of herbal formulation; Reosto introduced by Himalaya drug company pvt ltd, performed a RCT double blinded phase III clinical trial on two sets of postmenopausal woman: 100 Reddy J, et al. [1] and 105 Dongaokar et al. [2] postmenopausal women with osteoporosis respectively. The results for both drug trials, showed a statistically significant increase in BMD, serum calcium, and serum phosphorus, with decrease in serum alkaline phosphatase, which overall helps maintain the bone architecture. Using ovariectomized mice, Sung et al. showed, that the use of Saurures chinensis could prevent loss of bone and maintain integrity of the bone. Using a similar study, Mitra et al. showed that OST-6(Osteocare) at the dose of 500mg/kg BW for 90 days significantly increased BMD, serum calcium and decreased urinary calcium excretion with Pyridium links. These parameters are required to assess the bone strength, the trabecular meshwork and its integrity. Another RCT study, by Aswar UM et al, separated the phytoestrogen-rich fraction (IND-HE) from aerial parts of Cissus quadrangularis L. and evaluated its effect on osteoporosis caused by ovariectomy in rats; IND-HE showed increased bone thickness, reduced alkaline phosphatase and prevented bone loss. A similar RCT study, by Shirwaikar et al. showed, that the ethanol extract of Cissus quadrangularis L on ovariectomized mice, showed a positive change in the biomechanical, biochemical, and histological parameters, concluding the anti-osteoporotic effect of the plant. Further strengthening the theory of Cissus quadrangularis L being anti-osteoporotic, an RCT by Potu BK et al. used petroleum ether derived extract of Cissus quadrangularis in ovariectomized rats to show that CQ significantly increased the thickness of both cortical and trabecular bone. In another study Shirke SS et al. used methanolic extract of P vulgaris L seeds on ovariectomized mice, and they observed increases in BMD, reduced bone turnover markers, increased ash density, increased bone mechanical strength, and significantly increased bone Ca. The same author of the study, involving P vulgaris L seeds, Shirke SS et al. also evaluated the anti-osteoporotic benefits of phytoestrogenrich plant Cuminum cyminum, commonly known as cumin, which showed greater Bhasma (coral calyx) was tested on ovariectomized mice as part of the study by Reddy PN et al. where it improved the bone density and Ca: P ratio in comparison to those mice, that were fed a calcium rich diet. After analysis of the above studies, it shows that there is scope for application of Ayurveda and naturopathy in the treatment of osteoporosis in postmenopausal women. bone and ash densities with improved microarchitecture of bone; this was comparable to osteoprotective effect of estradiol. In the study using methanol extract of Berberis aristata daily for 42 days, Yogesh HS et al. observed that the BMD, biochemical and histological parameters improved, pointing attention to its anti-osteoporotic benefit. There are several natural sources of calcium available, and several are being used in daily Ayurveda practice. One such source, Praval as a complement to Ayurveda and Naturopathy, yoga is always found to further the improvement of the condition in any disease. With this in view, we have tried to establish the role yoga can play, in improving the parameters in oestrogen deficiency induced osteoporosis. As observed in the randomized control trial Bezerra L et al. yoga done for 6 months, failed to improve BMD, but it did improve the bone formation markers. This, however, is contradicted by the remaining 4 studies performed to evaluate the benefit of yoga on oestrogen deficiency induced osteoporosis. In a study by Motorwala et al. performing yoga regularly for 6 months, significantly improved the BMD in postmenopausal women. On putting postmenopausal women through a 12week programme of weight bearing yoga, Phoosowan et al. observed that there was a slowing of the bone resorption, which would be beneficial in postmenopausal osteoporosis. In a study by Sangiorgio SN et al. postmenopausal women practicing and teaching Bikram yoga, were followed up for 5 years, and there was a significant improvement in the BMD. Apart from improving bone marrow density, study conducted by Tazun S et al. found, yoga to improve the pain, physical functions, and social functions, improving the overall balance in postmenopausal osteoporosis (Table 1).

Discussion

WHO defines osteoporosis on the basis of bone density; Low bone mass is an important feature Total and regional as well as mineral and osteoid bone mass are reduced There is micro architectural deterioration of bone tissue, leading to increased bone fragility. Fragility means compromised bone strength, which reflects integration of two main features, bone density and bone quality. Increased bone fragility leads to increase in fracture risk. WHO defines low bone mass on the basis of T score i.e. standard deviation (SD) of bone mineral density (BMD), with reference to mean of young adult population T Score: 0.00 to -1.00 Normal -1.00 to -2.5 Osteopenia < -2.5 Osteoporosis. In case of established osteoporosis, there is an added component of fragility fractures as well. A fragility fracture is one, which occurs due to fall from no greater than standing height of an individual or with normal use. The present epidemiological data and research studies on osteoporosis are based on these definitions. Bone has 2 components: 1) Fibrous tissue which gives resilience and toughness and 2) Mineral which gives hardness and rigidity. Collagen fibres are responsible for the tensile strength like tendons, while mineral salts have compressional strength. Minerals i.e. calcium, phosphorus, zinc, magnesium, fluoride, etc. are in the form of needle shaped crystals of hydroxyapatite and are arranged around collagen fibres. 35% of dry bone is osteoid i.e. organic ground substance (matrix made up of glycoprotein and collagen fibres Type 1). Osteoporosis is one of the most common cause of debility in the elderly age group, as with progressing age, there is an impaired bone formation and increased bone resorption. There are broadly two types of osteoporosis- senile and postmenopausal. Apart from the age factor, there exists several risk factors that increase the chance of developing osteoporosis: family history, gender (women are 6 to 8 times more likely than men), being postmenopausal, advanced age, race (Caucasians are the most likely), low calcium intake, smoking, alcohol consumption, a sedentary lifestyle [3] and soft drink consumption [4,5]. Hormone replacement therapy was previously touted as a treatment for osteoporosis, and may, in fact, be quite useful for decreasing bone loss. However, this benefit decreases, if hormone therapy is discontinued. In addition, many women refuse hormone therapy, due to other known or perceived adverse effects [6,7]. Although pharmaceutical agents can be effective, there is an increased interest in non-pharmacological prevention and treatment of osteoporosis [8]. Although HRT and synthetic hormones are shown to recompense for the depletion of the hormone, and to impede the bone loss, the treatment is controversial and has been associated with a number of complications and adverse effects [9,10]. Traditional therapies for postmenopausal osteoporosis have emphasized agents that inhibit bone resorption, such as oestrogen and calcitonin]. Although the most effective method to reduce the rate of postmenopausal bone loss is oestrogen replacement therapy, it may be accompanied by side effects. It is recommended only for woman, who are at high risk of osteoporosis and have no contraindications for oestrogen.

The intent of this review was not only to review articles related to yoga, Ayurveda and naturopathy to manage osteoporosis, but it also to reduce dependence or supplement the pre-existing medications being used for oestrogen deficiency associated osteoporosis, which is primarily postmenopausal in nature. Plants containing phytoestrogen and triterpenoids have been used since time immemorial, in traditional system of medicine for the treatment of osteoporosis. Cissus quadrangularis L. (Vitaceae), a climbing shrub, characterized by a thick quadrangular fleshy stem, is an edible plant found in hotter parts of India, Sri Lanka, Malaya, Java and West Africa. Commonly known as the “bone setter,” [11] the plant is referred to as “Asthisamdhani” in Sanskrit and “Hadjod” in Hindi because of its ability to join bones [12]. The root is reported as most useful for the fractures of bones, with the same effects as plaster externally. The phytochemical analysis of the plant showed the presence of vitamin C, β-carotene, two symmetric tetracyclic triterpenoids, β-sitosterol, α-amyrin, α-amyrone and three stilbene derivatives and quandragularins A, B, C. In addition to vitamin C, it also contains a high amount of carotene A, anabolic steroidal substance and calcium. The phytoestrogen steroid isolated has been shown, to influence early regeneration and quick mineralization of bone.

Four Indian plants, traditionally used in Ayurvedic medicine: Asparagus racemosus Wild, Emblica officinalis Gaertn, Hemidesmus indicus R. Br., and Rubia cordifolia L. were selected on the basis of their ethnobotanical use and of scientific evidence, that suggests a potential efficacy in the treatment of bone-loss diseases. Hemidesmus indicus showed the greatest antiosteoclastic activity, without toxic effect on osteogenic precursors. Therefore, Hemidesmus indicus exhibits the properties of an antiresorptive drug, and represents the ideal candidate for further clinical investigations. Fortyfive patients with Osteopenia/ Osteoporosis were taken to evaluate the efficacy and safety of Laksha gugglu and Mukta shukti pishti in the management of Osteopenia/Osteoporosis [13]. The effect of Laksha Guggulu and Mukta Shukti Pishti on pain, activities of daily living, Jobs around the house, mobility, leisure, social activities, general health perception, mental functions (QUALIFFO-41) were encouraging i.e. statistically highly significant(p<0.001) in the management of Osteopenia/Osteoporosis (Asthi Kshaya).

The study showed, that the raw material Muktā was calcium carbonate. The method followed in the study is not only quite safe, but also a natural source of nanonized pearl powder for adults. There are several other natural sources of calcium: Shankha Bhasma (conch shell- nanoparticle), Sambuka (snail shells), Mrgasrgna (Antelers), Sukti (oyster shell), Samudraphena (cuttlefish bone), Kurmaprastha asthi (Tortoise shell), Kukkuta anda twak (egg shell) and Aja Asthi (goats bone); all animal products mentioned having medicinal properties, but not primarily as a Calcium supplement. These undergo a complex process called MARANA & SHODANA to make it a nanoparticle and are, therefore, easily assimilated. These minerals, along with metals, precious stones & mercury is mentioned in Ayurveda chemistry books called Rasashastra [14]. This shows us that there are several natural alternatives, to the usual calcium supplements, that can be used safely in patients with osteoporosis. Additionally, there are certain plants from the following families, which have shown the greatest benefits on bone: Alliceae, Asteraceae, Thecaceae, Fabaceae, Oleaceae, Rosaceae, Ranunculaceae, Vitaceae, Zingiberaceae [15]. This review’s primary objective was, to analyse the various research articles published on the effect of yoga, Ayurveda and naturopathy, on postmenopausal osteoporosis [16]. The idea is to depict the benefit of these alternate therapies have, on increasing bone density and improving bone turnover markers, thereby potentially reducing the burden on medications and hormones replacement therapies, which have several side effects of their own. Tackling osteoporosis through the above mentioned complementary and alternative therapies, could be further improved by lifestyle modification, as osteoporosis is further worsened by obesity and lack of exercise. One of the safest preventative measures and treatments for osteoporosis and osteopenia is yoga. It’s something that anyone, at any age, can do anywhere; the benefits are many and risks are few if done correctly. A pilot study performed by Dr. Loren Fishman, Medical Director of Manhattan Physical Medicine and Rehabilitation in New York City, showed that when individuals practiced yoga for merely 10 minutes per day over a two-year period, their bone density increased [17]. In the 19th century, a German anatomist and surgeon, Julius Wolff, theorized that bone will adapt to the load which is placed on it, i.e., it becomes stronger to resist the load [18]. The inverse is also true; as the load decreases, bone becomes weaker. This phenomenon is perhaps best demonstrated by what happens to astronauts in space, who without the force of gravity working on their bones, are at a greater risk for developing osteoporosis. In holding yoga poses, tensile (stretching) force and isometric, compressive (weight-bearing) force stimulate the osteocytes (cells found in mature bone) to produce proteins and lay down new bone. Yoga produces both the stress of dynamic loading when moving into a pose and static loading by holding a pose. In addition, yoga stimulates the production of synovial fluid, which not only lubricates and nourishes the joints, but also activates chondrocytes (the cells found in healthy cartilage) to lay down new cartilage. Asanas that pull our muscles to act on the bone mobility, yoga surpasses the bone-strengthening benefits of gravity. These benefits are said to occur, when an Asana is held for anywhere between 12 and 72 seconds. Yoga, in practice, is found to be more effective when combined with some form of exercise. Exercise has an important impact on bone health. Several studies have increased awareness on how exercise can most constructively be used, to prevent the development of osteoporosis [19]. More specifically, researchers have discovered that weight-bearing exercises have the potential to bone mineral density [20]. Weightbearing exercises such as running and jogging, for example, have demonstrated more substantial increases in bone density, than other types of physical activity. Some of these potential benefits to maintaining BMD have been quantified, reporting decreases in the rate of bone mineral density deterioration [21]. Exercise at any age can improve bone health; Weight-bearing exercises, including weight training, hiking, climbing stairs, and walking, force the bones to work against gravity and are effective at increasing bone mass [22]. For most individuals, practicing weight-bearing exercise 3 times per week for 12 to 20 minutes, is sufficient to increase bone density. Since each joint will respond to the strain load individually, it’s best to rotate exercise on sites and focus on each one for a limited time period. Continuing to exercise throughout life helps to reduce bone loss and the risk of falls [23]. Just as with yoga and Ayurveda medications, naturopathy also plays a big role in managing osteoporosis. Since Naturopathy is nothing but a method of therapy, that diagnoses and recommend through the make use of water, air, diet, light, heat and all other kind of daily procedure and modalities [24]. There are several ways to increase the calcium in one’s diet; milk products are probably the top at the list. There are several foods that are rich in phytoestrogen: yams, chickpeas, soy etc. to name a few. There is also research in support of the positive effects of soy isoflavones, on reducing the risk of developing osteoporosis [25]. Diets high in soy may decrease bone reabsorption in postmenopausal women [26]. These are just a few examples of how a balanced natural diet, can improve the bone health in those with osteoporosis. None of the above mentioned methods, however, have been tried in combination. Most of the studies that have been analysed in this review have been in comparison, with one of the traditionally used drugs for osteoporosis (alendronate, raloxifene, oestrogen etc.) [27-29]. Each of these therapies has several merits, which could be added in combination, making it a better fit for someone with osteopenia or osteoporosis. Also, in combination, they have the ability to completely alleviate the need for hormone replacement therapy, in those with postmenopausal osteoporosis. These complementary and alternate therapies have an extra advantage of being beneficial in several other lifestyle disorders such as obesity, diabetes, hypertension etc., which may be associated with postmenopausal osteoporosis. The scope is endless, and this is definitely an avenue worth pursuing for the future, safe, balanced management of osteoporosis.

Conclusion

It is observed that Yoga, Ayurveda and Naturopathy are beneficial in improving BMD and preventing bone loss due to oestrogen deficiency. Naturopathy diet as such needs to be standardized and researched upon further. However, there is no study available where these have been used in combination. In combination, the benefits of each method are cumulative and can potentially rid the patient of medications. This requires further research and analysis, specifically for postmenopausal osteoporosis.

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