Osteoporosis is characterized by low bone mass, microarchitectural disruption, and skeletal fragility, which results in decreased bone strength and increased risk of fracture. The World Health Organization has defined diagnostic thresholds for low bone mass and osteoporosis based upon bone mineral density (BMD).1 Normally it is an asymptomatic condition, therefore, is often undiagnosed until it manifests as a low-trauma fracture of hip, femur, spine, proximal humerus, pelvis, and/or wrist. It is often associated with postmenopausal women; however, it also occurs in men, who account for an estimated 1 in 5 of Americans who have osteoporosis or low BMD.
The etiology can be divided into 2 categories, primary and secondary osteoporosis: the first is associated with age and estrogen deficiency and the second is associated with several comorbid diseases and/or medications.2 Also, factors such as smoking, excessive alcohol, physical inactivity, poor nutrition, and glucocorticoid therapy contribute to the decrease of bone mass.1 There is a great array of treatment with no pharmacologic methods, and pharmacologic methods utilizing antireabsorptive agents (bisphosphonates, denosumab) and hormonal therapies (estrogen agonist/antagonists, estrogen–progestin therapy). There are still emerging therapies and investigational drugs to be studied.2
Studies suggest that acupuncture could change bone mass by regulating neuroendocrine hormones. Combining the Traditional Chinese Medicine theory that “kidney controls bones and marrow moistens bones” with the theory of brain–bone mass regulation, researchers believe that acupoints for “tonifying kidney and benefiting marrow” could influence bone metabolism, being useful for osteoporosis treatment.3
Previous animal studies have shown that acupuncture and moxibustion improve BMD, bone strength, and hormone levels. Although the evidence that acupuncture can have beneficial effects on osteoporosis is moderately convincing in animal experiments, there is still not enough or strong evidence that acupuncture and moxibustion work in human subjects.4 In addition, other studies suggest that Chinese medicinal plants can contribute to treat osteoporosis by immunologic regulation, but still further investigation is needed to elucidate this mechanism.5
The authors' opinion is that the lack of scientific evidence that acupuncture or Chinese herbs are efficient for the prevention and treatment of osteoporosis makes it inadequate to adopt those treatments as the main option on clinical practice. In contrast, using them as adjuvant measures would be acceptable, if it is made clear to the patient that the level of evidence is low. Our treatment strategy is the same as that in the literature, that is tonifying Kidney (Shen). For this treatment we suggest using acupoints from the Kidney and CV (Ren Mai) meridians, and also the Back Shu point of the Kidney (BL23), with tonifying technique, using needles, warm needles, or moxibustion.
Acupuncture is also very useful for controlling symptoms of a classical complication of osteoporosis, the bone fractures already mentioned. Many of those fractures demand surgical treatment, and acupuncture is very effective for controlling pain caused either by fractures, or by their surgical correction. Osteoporotic spine fractures usually occur on low thoracic and lumbar region. Acupuncture points we suggest for the treatment of pain on this region are SI3, local or distant points of GV (Du Mai), and also points of the Bladder meridian, either local or distant, which relieve pain of the paravertebral muscles. Pain caused by femur neck fracture may be treated using points of Gallbladder meridian, particularly GB34 and GB30. Symptoms related to humerus fracture may be treated by the points SI11, BL11, LI11, LI4, and Triple Warmer meridian points.
Pain relief not only enhances quality of life, but also allows a more effective rehabilitation, with improvement of muscle and bone mass. A common side-effect of the pharmacologic treatment of osteoporosis is the epigastric discomfort and heartburn caused by biphosphonates and calcium supplements. Those symptoms may be controlled by the points LI4, LI11, CV12, CV17, and PC6; points of Stomach and Spleen meridians are also useful. In conclusion, acupuncture and Chinese herbs have a role in the treatment of osteoporosis, but new and better studies are necessary for better understanding all their possible benefits.
References
Rosen HN, Drezner MK. Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women. UpToDate. 2021. Online document at: https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-evaluation-of-osteoporosis-in-postmenopausal-women?search=osteoporosis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 Accessed April 30, 2021.
Tu KN, Lie JD, Wan CKV, et al. Osteoporosis: A review of treatment options. P T. 2018;43(2):92–104.
Chen G, Liu H, Wu X, Wang X, Liang J, Xu Y. Biomarkers of postmenopausal osteoporosis and interventive mechanism of catgut embedding in acupoints. Medicine. 2020;99(37):e22178.
Xu G, Xiao Q, Zhou J, et al. Acupuncture and moxibustion for primary osteoporosis: An overview of systematic review. Medicine (Baltimore). 2020;99(9):e19334.
Zhao H, Zhao N, Zheng P, et al. Prevention and treatment of osteoporosis using Chinese medicinal plants: Special emphasis on mechanisms of immune modulation. J Immunol Res. 2018;2018:6345857.
Address correspondence to:
Yolanda Maria Garcia, MD, PhD
Internal Medicine Department
São Paulo University Medical School
R. Dr. Eneas de Carvalho Aguiar, 455, 8th Floor
São Paulo 05403-000
Brazil
E-mail: yolanda@usp.br
Gustavo Ryo Morioka, MD
Orthopedics and Traumatology Department
São Paulo University Medical School
Rua Dr. Ovídio Pires de Campos, 333 – 3rd Floor, Room 311B
São Paulo 05403-010
Brazil
Taís Pinto Paula, MD
Orthopedics and Traumatology Department
São Paulo University Medical School
Rua Dr. Ovídio Pires de Campos, 333 – 3rd Floor, Room 311B
São Paulo 05403-010
Brazil
Osteoporosis (OP) is a systemic metabolic bone disease that causes fragility due to decrease in bone density, bone mass, and degeneration of bone tissue microstructure. OP can happen at any age, but primary OP is commonly seen in postmenopausal women and older men. Risk of OP will increase as the population ages.1 The high prevalence of OP and the rapid rise in fracture rates indicate that OP has become a serious public health problem.1 International Osteoporosis Foundation estimates suggest that 200 million osteoporotic women in the world suffer from osteoporotic fracture every 3 seconds.2 The purpose of anti-OP treatment is to reduce pain, prevent fractures, and improve the quality of life of patients.
Currently the main prevention and treatment methods for OP include anti-OP drugs along with proper nutrition, sun exposure, calcium supplements, or vitamin D.3 Among them, bisphosphonates are the most widely used in clinical practice, such as alendronate sodium, zoledronate sodium, and risedronate sodium. Alendronate can reduce bone loss, increase bone density, and reduce fracture risk.4 However, a recent meta-analysis showed that oral alendronate and parenteral injection of zoledronate had no statistical significance in preventing postmenopausal hip fractures.5 In addition, the use of bisphosphonates may bring rare side-effects such as joint pain and jaw necrosis.6 This suggests the need for an effective complementary therapy in addition to the conventional treatment to reduce pain and disability in these patients.
OP in Traditional Chinese Medicine
Acupuncture is a widely used traditional Chinese medical practice. OP can be classified into the category of Guwei (bone atrophy–flaccidity) and Guku (bone wilt) in Traditional Chinese Medicine (TCM), which is closely related to “kidney deficiency,” “spleen deficiency,” and “blood stasis,” and results from aging when the overall body functions decline.7
Acupuncture and moxibustion are widely used in the treatment of OP due to their effective analgesic effects and fewer side-effects. Studies have shown that moxibustion plus anti-OP drugs may be more effective in alleviating osteoporotic pain, increase bone density in the femoral neck, and improve bone calcium and bone alkalinity phosphatase levels compared with anti-OP drugs alone.8 Studies on acupuncture and moxibustion therapy have demonstrated their ability to improve the quality of life of patients with OP and prevent the occurrence of OP fractures.9
Illustrative Case
A 74-year-old man presented with history of moderate to severe low back pain for duration of 1 month. He is nonobese, nonsmoker, and not a case of Type 2 diabetes mellitus and hypertension. The pain radiated to both lower limbs (more on the left side). Rest relieved the pain slightly, whereas bending forward, walking, or any simple physical task exaggerated the pain. He found some relief with analgesics and pregabalin tablets (75 mg/day). However, his pain was recurrent. On visual analog scale (VAS), the patient rated the intensity of the pain at 9 out of 10. He reported severe disability in performing his day-to-day activities. Patient scored 56% on Oswestry low back pain disability scale suggesting severe disability. His sleep was disturbed due to the intensity of the pain. Sleep latency was 15–30 minutes but maintenance was compromised (cannot sleep >3–4 hours). Magnetic resonance imaging revealed spondylolisthesis in lumbar spine at L4–L5 and L3–L4 levels, posterior disk bulge with moderate narrowing of spinal foramina, and mild compression of nerve roots. It also revealed osteoporotic features at multiple levels of lumbar vertebrae. At the baseline evaluation, his vitamin D level was 27 ng/mL, the inflammatory markers were within the range, whereas serum alkaline phosphatise levels were elevated (168 IU/L). He did not report any symptoms related to prostate gland enlargement. However, ultrasonography of abdomen and pelvis in addition to prostate specific antigen levels was evaluated to rule out prostate involvement.
The presented case shows definitive kidney deficiency and shows the presentations of Guwei syndrome from the perspective of TCM. Taking the mentioned clinical presentations into consideration, the acupuncture points in Table 1 were selected.
Table 1.
Acupuncture Points Selected
| S. no. | Acupuncture point | Bilateral/unilateral | Type of stimulation |
|---|---|---|---|
| 1 | Bladder 11 (Dayu) | Bilateral | None |
| 2 | Bladder 23 (Shenshu) | Bilateral | Electrical stimulation |
| 3 | Stomach 36 (Zusanli) | Bilateral | Electrical stimulation |
| 4 | Governing vessel 4 (Ming Men) | Unilateral | None |
| 5 | Kidney 3 (Taixi) | Unilateral | None |
| 6 | Spleen 6 (Sanyinjiao) | Unilateral | None |
| 7 | Bladder 20 (Pi Shu) | Unilateral | None |
| 8 | Bladder 17 (Geyu) | Unilateral | None |
The acupuncture sessions were given thrice a week for 2 weeks. After 2 weeks, the patient reported significant reduction in the severity (reported VAS score of 2 out of 10) and frequency of the pain in his lower back. After 2-week treatment, he scored 18% on Oswestry low back pain disability scale, suggesting mild disability. However, the patient has reported significant improvement in ability to perform his daily activities. He also reported significant improvement in his quality of sleep.
References
Atik OS, Gunal I, Korkusuz F. Burden of osteoporosis. Clin Orthop Relat Res. 2006;443:19–24.
Ström O, Borgström F, Kanis JA, Compston J, Cooper C, McCloskey EV, Jönsson B. Osteoporosis: Burden, health care provision and opportunities in the EU. Arch Osteoporos. 2011;6(1):59–155.
Urgell CV, Mesquida MM, Fernandez RV, et al. Adequacy of treatment for osteoporosis in primary prevention. Quantitative and qualitative study. [Spanish]. Aten Primaria. 2018;50(1):6–15.
Unnanuntana A, Jarusriwanna A, Songcharoen P. Randomized clinical trial comparing efficacy and safety of brand versus generic alendronate (Bonmax®) for osteoporosis treatment. PLoS One. 2017;12(7):e0180325.
Albert SG, Reddy S. Clinical evaluation of cost efficacy of drugs for treatment of osteoporosis: A meta-analysis. Endocr Pract. 2017;23(7):841–856.
Khosla S, Hofbauer LC. Osteoporosis treatment: Recent developments and ongoing challenges. Lancet Diabetes Endocrinol. 2017;5(11):898–907.
Ellis N. The synthesis of western medicine and TCM in treating conditions met in clinical practice. In: Campling J, ed. Acupuncture in Clinical Practice, 1st ed. Hong Kong: Chapman and Hall;1994.
Xu F, Huang M, Jin Y, Kong Q, Lei Z, Wei X. Moxibustion treatment for primary osteoporosis: A systematic review of randomized controlled trials. PLoS One. 2017;12(6):e0178688.
Pan H, Jin R, Li M, Liu Z, Xie Q, Wang P. The effectiveness of acupuncture for osteoporosis: A systematic review and meta-analysis. Am J Chin Med. 2018;46(3):489–513.
Address correspondence to:
Sandesh Biradar, BNYS, PGCAcu
Chanre Rheumatology and Immunology Centre
Bangalore 560010
India
E-mail: sandesh.biradaro@gmail.com
Nishitha Jasti, BNYS, MSc, PGCAcu
Department of Integrative Medicine
NIMHANS
Bangalore 560029
India
Hemant Bhargav, MD, PhD
Department of Integrative Medicine
NIMHANS
Bangalore 560029
India