Osteoporosis (osteoporosis) is a systemic bone disease characterized by a decrease in bone mass and destruction of the microstructure of bone, manifested by an increased brittleness of the bone and therefore a much higher risk of fracture, even with minor trauma or in the absence of trauma. Osteoporosis is a chronic disease caused by multiple factors. There are usually no specific clinical manifestations until a fracture occurs. The disease is more common in women than men, and is commonly seen in postmenopausal women and the elderly. With the increase of the elderly population in China, the incidence of osteoporosis is on the rise and is a health concern in China and worldwide.
Causes of morbidity
The specific causes of osteoporosis have not been fully clarified, and are generally considered to be related to the following factors.
1. Endocrine factors
Female patients suffer from osteoporosis due to estrogen deficiency, while men suffer from decreased testosterone levels due to hypogonadism. Osteoporosis is particularly common in postmenopausal women, and premature ovarian failure causes osteoporosis to appear earlier, suggesting that a decrease in estrogen is an important factor in the occurrence of osteoporosis. There is a sudden and significant acceleration of bone loss within 5 years after menopause, with an annual bone loss of 2% to 5% being common. About 20% to 30% of early menopausal women have a bone loss of >3%/year, called rapid bone loss, while 70% to 80% of women have a bone loss of <3%/year, called normal bone loss.
Lean women are more prone to osteoporosis and fractures than fat women, as a result of the conversion of androgens to estrogens in the latter’s adipose tissue. Compared with normal women of similar age, no significant differences in blood estrogen levels are seen in patients with osteoporosis, indicating that estrogen reduction is not the only factor causing osteoporosis.
2. Genetic factors
Osteoporosis is more common in whites, especially in northern Europeans, followed by Asians, and less common in blacks. Bone density is an important indicator for the diagnosis of osteoporosis, and the value of bone density is mainly determined by genetic factors, followed by the influence of environmental factors.
3.Nutritional factors
Calcium intake in adolescence has been found to be directly related to peak bone mass in adulthood. Calcium deficiency leads to increased PTH secretion and bone resorption, and those on low-calcium diets are prone to osteoporosis. Vitamin D deficiency leads to impaired mineralization of the bone matrix and can lead to osteochondrosis. Long-term protein deficiency causes insufficient synthesis of bone mechanism protein, resulting in backward new bone production, and if there is also calcium deficiency, osteoporosis will appear faster. Vitamin C is indispensable in the synthesis of bone matrix hydroxyproline, which can maintain the normal growth of bone matrix and maintain bone cells to produce sufficient amount of alkaline phosphatase, such as lack of vitamin C can reduce the synthesis of bone matrix.
4.Waste factor
Muscles produce mechanical force on bone tissue, muscles developed strong bones, then high bone density value. Due to the reduced activity of the elderly, muscle strength is weakened, mechanical stimulation is less, bone volume is reduced, and the weakened muscle strength and coordination disorders make the elderly more prone to fall, accompanied by a reduction in bone volume is prone to fracture. When the elderly suffer from stroke and other diseases, they are bedridden for a long time and do not move, which leads to bone loss and osteoporosis due to disuse factors.
5.Drugs and diseases
Anticonvulsants, such as sodium phenytoin, phenobarbital, and carbamazepine, cause treatment-related vitamin D deficiency, as well as impaired intestinal calcium absorption and secondary hyperparathyroidism. Excessive use of acid-forming agents, including aluminum preparations, can inhibit phosphate absorption and lead to the breakdown of bone minerals. Glucocorticoids directly inhibit bone formation, reduce intestinal calcium absorption, increase renal excretion of calcium, and cause secondary parathyroid dysfunction and sex hormone production.
6.Other factors
Alcohol abuse has a direct toxic effect on bone. Smoking can increase the liver’s metabolism of estrogen and the direct effect on bone, in addition to causing weight loss and early menopause. Prolonged heavy exercise can lead to idiopathic osteoporosis.
Bone imaging and bone density
1. X-rays can detect fractures and other pathologies such as osteoarthritis, intervertebral disc disease, and anterior displacement of the spine. Increased bone translucency, reduced bone trabeculae and widening of their gaps, loss of transverse bone trabeculae, and blurred bone structure are seen on radiographs of reduced bone mass (low bone density), but usually require a 30% or greater decrease in bone volume to be observed. The biconcave deformation of the vertebral body due to disc bulge and the collapse of the anterior edge of the vertebral body in a wedge shape, also known as compression fracture, are commonly seen in the 11th and 12th thoracic vertebrae and the 1st and 2nd lumbar vertebrae.
Bone mineral density (BMD) is the best predictor of fracture. Measuring BMD at any site can be used to assess the overall risk of fracture; measuring BMD at a specific site can predict the risk of local fracture.
Quantitative ultrasound of the heel bone (available at the Weifang Hospital of Traditional Chinese Medicine Orthopaedic Joint Clinic) can be used for general screening, which is a low-cost, portable and ionizing radiation-free method.
Clinical manifestations
(1) Pain.
The most common symptom of primary osteoporosis is low back pain, which accounts for 70%-80% of the patients with pain. Pain spreads along the spine to both sides, decreases when supine or sitting, increases when posterior extension or prolonged standing or sitting, is light during the day, increases at night and when waking up in the morning, and increases when bending, muscle movement, coughing, and bowel straining. Bone pain generally occurs when 12% or more of bone mass is lost.
In elderly osteoporosis, the vertebral trabeculae atrophy and decrease in number, the vertebral body compresses and deforms, the spine flexes forward, and the lumbar rash muscle doubles its contraction in order to correct the forward flexion of the spine, resulting in muscle fatigue and even spasm, producing pain. A recent compression fracture of the thoracolumbar spine can also produce acute pain, with strong pressure pain and percussion pain in the spinal spinous process at the corresponding site, which can generally be gradually reduced after 2-3 weeks, and some patients can present with chronic low back pain. If the corresponding spinal nerve is compressed, radiating pain in the extremities, sensory-motor disorders in both lower extremities, intercostal neuralgia, retrosternal pain similar to angina pectoris, or epigastric pain similar to acute abdomen may occur. If compression of the spinal cord and cauda equina also affects bladder and rectal function.
(2) Shortening of body length and hunchback.
Most of them appear after the pain. The anterior part of the vertebrae of the spine is almost mostly composed of cancellous bone, and this part is the pillar of the body with a large weight, especially the 11th and 12th thoracic vertebrae and the 3rd lumbar vertebrae, which have a greater load and are easily compressed and deformed, causing the spine to tilt forward and the dorsal curvature to increase, resulting in a hunchback. Each person has 24 vertebrae, the height of each vertebra is about 2cm in normal people, the vertebrae compress when the elderly osteoporosis, each vertebrae shorten about 2mm, the average length of the body shortened 3-6cm.
(3) Fracture.
This is the most common and serious complication of degenerative osteoporosis, which not only increases the patient’s pain, aggravates the economic responsibility, and seriously limits the patient’s activities, and even shortens life expectancy. According to our statistics, the incidence of fractures in the elderly is 6.3%-24.4, especially in elderly women of advanced age (80 years or older). Fractures caused by osteoporosis are more common in the early stages of old age with distal radius fractures (Colles fractures) and later in old age with fractures of the lumbar spine and upper femur. Fractures generally occur when 20% or more of bone mass is lost, and for every 1.0 DS decrease in BMD, the incidence of vertebral fractures increases 1.5-2 times. About 20%-50% of patients with vertebral compression fractures have no obvious symptoms.
(4) Decreased respiratory function.
Compression fractures of the thoracic and lumbar spine, backward curvature of the spine, and thoracic deformity can significantly reduce lung capacity and maximum ventilation, and the incidence of lobar emphysema in the anterior region of the upper lobe of the lung can be as high as 40%. Most elderly people have no degree of emphysema, lung function decreases with age, and if combined with thoracic deformity caused by osteoporosis, patients often have symptoms such as chest tightness, shortness of breath and dyspnea.
Western medicine treatment
The following five types of drugs are available for the treatment of osteoporosis.
1. Hormone supplementation therapy: estrogen plus luteinizing hormone can prevent and treat osteoporosis. If there is no uterus, progesterone is not needed.
2, alendronate (alendronate): the trade name Fosamax inhibits the role of osteoclasts, while having the effect of prevention and treatment of osteoporosis.
3.Calcitonin: absorbed by subcutaneous, intramuscular injection or nostril, effective for women with osteoporosis who have stopped menstruation for more than five years. Side effects include loss of appetite, flushing, rash, nausea and dizziness. However, as soon as the medication is stopped, the rate of bone loss will begin to accelerate, so long-term treatment is necessary.
4.Calcium and vitamin D: the combination is more effective.
5.Bone peptide preparation, which is a new clinical drug used to treat rheumatoid rheumatism, is effective for osteoporosis.
Chinese medicine treatment
1.Yin deficiency of liver and kidney
Symptoms: soreness of the waist and knees, dizziness and tinnitus, insomnia and dreaminess, softness and heat of the affected area, stiffness of the joints. Men’s Yang is strong and easy to lift, spermatorrhea, women’s menstruation is low and menstruation is closed, or the collapse of leakage, the body is thin, hot flashes and night sweats, the five hearts are hot and bothered, the throat is dry and the cheek is red, the urine is yellow and the stool is dry, the tongue is red and less rhythmical, the pulse is fine.
Treatment: Nourishing Yin and strengthening bones, benefiting kidney and filling essence.
Remedy: Zuo Gui Wan or Zhi Yin Da Teng Wan plus reduction. Radix Rehmanniae Praeparata 24g, Rhizoma Dioscoreae 12g, Cornu Cervi Pantotrichum 12g, Fructus Lycii 12g, Antler Gum 12g, Tortoise Plate Gum 12g, Semen Cuscutae 12g, Radix Achyranthes Bidentatae 9g, Rhizoma Polygonati 8g, Phellodendron Bidentatae 6g.
Usage: Decoction with water, 1 dose daily, 1 month as a course of treatment, usually 1-3 courses of treatment can be improved or cured.
2.Spleen qi deficiency type
Symptoms: low back pain, weakness in walking on both knees, even slight movement can cause severe pain in the chest and back, or stooped back, less nasal, abdominal distension, especially after meals, loose stools, tired limbs, less breath and lazy speech, withered or puffy face, or thinning, light tongue with white fur, slow and weak pulse.
Treatment: Strengthening the spleen and benefiting Qi, warming Yang and tonifying the kidney.
Remedy: Ginseng and Atractylodes macrocephala plus reduction. 8 grams of lotus seeds, 10 grams of coix seeds, 3 grams of sand, 6 grams of orris, 12 grams of white lentils, 15 grams of poria, 10 grams of ginseng, 8 grams of licorice, 10 grams of atractylodes, 12 grams of yam, 10 grams of Chen Pi.
Usage: Decoction with water, 1 dose daily, 1 month for a course of treatment, generally 1-3 courses of treatment can be improved or cured.
3. Kidney Yang deficiency type
Symptoms: Soreness and pain in the waist and knees, coldness and cold limbs. Especially in the lower limbs, dizziness of the head and eyes, mental depression, pale face, or black, light fat tongue with white fur, sunken and weak pulse. Or impotence, infertility in women with cold uterus; or prolonged defecation, complete grain does not change, five night diarrhea; or swelling, especially below the waist, pressed sunken, even the abdomen is full, the whole body is swollen, palpitations and coughing.
Treatment: Warming the kidney and helping Yang to replenish deficiency.
Remedies: Add and subtract Right Return Pill. Radix Rehmanniae Praeparata 24g, Radix et Rhizoma Pinelliae 12g, Cinnamon 6g, Semen 12g, Semen Cuscutae 12g, Semen Gum 12g (melted), Fructus Lycii 12g, Eucommiae Tan 12g, Cornu Cervi Pantotrichum 9g, Radix Angelicae Sinensis 9g.
Usage: Decoction with water, 1 dose daily, 1 month as a course of treatment, usually 1-3 courses of treatment can be improved or cured.
4.Kidney essence deficiency type
Symptoms: Soreness and pain in the affected area, impotence and weakness of tendons and bones; manifesting as premature aging, hair loss and tooth shaking, forgetfulness and trance, red tongue and weak pulse.
Treatment: Nourishing the kidney, filling the essence and replenishing the blood.
Remedy: Haeche Dazao Wan plus reduction. Zi He Che 20 grams, Shu Di Huang 12 grams, Du Zhong 12 grams, Tian Men Dong 12 grams, Mai Men Dong 12 grams, Tortoise Plate 9 grams, Huang Bai 9 grams, Niubizi 6 grams.
Usage: Decoction with water, 1 dose daily, 1 month as a course of treatment, usually 1-3 courses of treatment can be improved or cured.
Prevention
Osteoporosis brings great inconvenience and pain to the patient’s life, and the treatment is very slow, once the fracture can be life-threatening, therefore, special emphasis should be placed on the implementation of three levels of prevention: 1.
1, primary prevention: should start from children and adolescents, such as pay attention to reasonable dietary nutrition, more food containing high Ca, P, such as fish, shrimp, shrimp, kelp, milk (250ml contains Ca300mg), dairy products, bone broth, eggs, beans, refined grains, sesame, melon seeds, green leafy vegetables, etc.. Try to get rid of “risk factors”;
Adhere to a scientific lifestyle, such as physical exercise, more sunbathing, no smoking, no alcohol, less coffee, strong tea and carbonated beverages, less sugar and salt, not too much animal protein, late marriage, less childbearing, not too long breastfeeding, as much as possible to preserve calcium in the body, enrich the calcium pool, and increase the peak bone mass to the maximum is the best measure to prevent osteoporosis later in life. Strengthen the basic research of osteoporosis, focus on follow-up and early prevention for the high-risk group with genetic genes.
2.Secondary prevention: bone loss accelerates in middle age, especially after menopause in women. Bone density examination should be conducted annually during this period, and prevention and control measures should be taken early for people with rapid bone loss. In recent years, most scholars in Europe and the United States advocate starting long-term estrogen replacement therapy within 3 years after menopause, and at the same time insisting on long-term preventive calcium supplementation or using bone peptide oral preparations of bone peptide tablets for preventive treatment, in order to safely and effectively prevent osteoporosis.
In Japan, it is mostly advocated to prevent osteoporosis with active Vit D (rocalciferol) and calcium, and to pay attention to the active treatment of diseases related to osteoporosis, such as diabetes, rheumatoid arthritis, steatorrhea, chronic nephritis, hyperparathyroidism/hyperthyroidism, bone metastasis cancer, chronic hepatitis, liver cirrhosis, etc.
3.Tertiary prevention: Patients with degenerative osteoporosis should be actively treated with medication to inhibit bone resorption (estrogen, CT, Ca), promote bone formation (active Vit D), oral preparation of bone peptide (bone peptide tablets), and should also strengthen measures to prevent falling, bumping, tripping and upsetting. For middle-aged and elderly fracture patients, they should be actively operated, implement strong internal fixation, early activity, physical therapy, physiotherapy psychological, nutrition, calcium supplementation, pain relief, promote bone growth, curb bone loss, improve immune function and overall quality and other comprehensive treatment.