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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 108-112

Understanding transient osteoporosis of hip (Asthi-Majjagatavata) and management through Ayurveda


National Ayurveda Research Institute for Panchakarma (NARIP), Cheruthuruthy, Kerala, India

Date of Submission28-May-2020
Date of Acceptance11-Dec-2020
Date of Web Publication18-Jan-2021

Correspondence Address:
Dr. K M Pratap Shankar
National Ayurveda Research Institute for Panchakarma (NARIP), Cheruthuruthy, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JACR.JACR_29_20

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  Abstract 


Transient osteoporosis of the hip (TOH) is a rare musculoskeletal disease characterized by acute pain and disability and is often missed during clinical diagnosis. This is a case report of TOH, which was effectively managed with a combination of Panchakarma procedures and oral medicines. The case was diagnosed and treated as Asthi-Majjagatavata (~vata disorder involving bone and bone marrow). The treatment protocol included Snehapana (~internal oleation) with Guggulu tiktaka ghritam, Mridu virechana (~mild purgation), Abhyanga (~massage with Dhanvantaram taila), Patra pottali swedana (~sudation with bolus of leaves), and Panchatiktaka ksheera basti (~enema with medicated milk) for 21 days along with oral medications for three months. The patient's improvement was assessed with the Harris Hip Score. Substantial improvement was noted post-treatment and also after three months of follow-up. This case shows the successful management of TOH with Ayurvedic treatment after proper understanding of the pathology of the condition.

Keywords: Asthi-Majjagatavata, Harris Hip score, microvascular injury, Mridu virechana, musculoskeletal diseases, transient osteoporosis


How to cite this article:
Pratap Shankar K M, Akashlal M, Rohit K S. Understanding transient osteoporosis of hip (Asthi-Majjagatavata) and management through Ayurveda. J Ayurveda Case Rep 2020;3:108-12

How to cite this URL:
Pratap Shankar K M, Akashlal M, Rohit K S. Understanding transient osteoporosis of hip (Asthi-Majjagatavata) and management through Ayurveda. J Ayurveda Case Rep [serial online] 2020 [cited 2021 Feb 28];3:108-12. Available from: http://www.ayucare.org/text.asp?2020/3/3/108/307218




  Introduction Top


Transient osteoporosis of the hip (TOH) is a rare clinical condition unfortunately missed in the list of the differential diagnosis for hip pain in common clinical practice. TOH remains as a misrecognized clinical entity in Ayurvedic clinical practice also. TOH was first described as a syndrome occurring in pregnant women characterized with transient demineralization of the hip.[1] Later in 1968, TOH was considered as a variant of Sudeck-Leriche's dystrophy.[2] Several terms such as bone marrow edema syndrome, transient demineralization, complex regional pain syndrome type 1, migratory osteolysis, and algodystrophy of the hip are used to describe TOH.[3] It is reported as a self-limiting condition usually affecting middle-aged men and women in the third trimester of pregnancy.[4] Few studies have reported that health professionals are having more risk for developing TOH due to long periods of standing and long working hours.[5]

TOH is an idiopathic condition, characterized with spontaneous onset of hip pain usually unilateral associated with reduced mobility of the hip and disability. Diagnosis of TOH is usually delayed or missed due to lack of awareness, unspecific symptomatology, and uncertain radiographic findings.[3] Recently, due to increased utilization of magnetic resonance imaging, physicians have been able to detect “bone marrow edema” which was previously undetected on conventional radiographs.[5]

It is highly essential for the Ayurvedic clinicians to understand TOH as most of their work area deals with musculoskeletal diseases. The challenge arises when they have to differentiate from other hip pathologies such as avascular necrosis of the femoral head, infective and inflammatory arthritis, and insufficiency fractures. Proper understanding of the pathology of TOH will help Ayurvedic clinicians to frame treatments through the guidelines of Ayurvedic principles. This case of TOH did not respond to modern conservative and surgical management and it was successfully managed with Ayurvedic treatment protocol.


  Case Report Top


A 41-year-old male patient, a welder by occupation presented with complaints of pain in the right hip joint restricting movements for nine months. The pain was increasing during getting up from sitting position. Subsequently, he was admitted to inpatient department (IPD) for Panchakarma procedures. It was noted that the patient did not have any history of trauma, or any other comorbidities or rheumatic complaints. He had a history of smoking. On examination, there was tenderness (Grade II) over the right hip. All movements of the right hip were restricted and painful. Assisted Trendelenburg test and Thomas test were positive. Active straight leg raising was possible up to 20°. The past medical history of the patient was suggestive of TOH [Table 1]. The patient had Vata-kapha prakriti with Vishama agni (~unstable metabolism) and Mrdukoshta (~bowel easy to purgate). He had Madhyama (~medium) Satvam (~mental strength), Satmya (~homologation), Aharashakti (~intake of food), and Jarana shakti (~digestive fire). Further, he had Avara (~least) Vyayama shakti (~ability to physical activities), Sara (~purest body tissue), Samhanana (~body built), and Pramana (~body proportion). Involved Dosha and Dushya were Vata and Asthi-Majja, respectively. Asthivaha sroto dusti (~pathology in the bone) and Majjavaha srotodusti (~pathology in bone marrow) were more prominent.
Table 1: Timeline of the case

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Diagnostic focus and assessment

Several theories have been posited for the etiopathogenesis of TOH. Microvascular injury, metabolic, vascular, neurogenic, and endocrine factors are included in the pathology of TOH.[3] Compression of mother's obturator nerve by child's head is also considered to be one of the contributing factors.[1] There is strong evidence proving the theory of ischemia causing bone marrow edema surrounding the femoral head. Improper venous drainage is considered to be causing ischemia.[6] This transient ischemic episode results in cell necrosis and ultimately causing TOH.[7] This pathology can be understood through the Ayurvedic perspective in the following way. Vata prakopa occurs at Sakti (~hip region) due to Rakta dhatu kshaya (~decreased blood flow) resulting in Asthisosha (~osteopenia). As Asthi and Majja dhatu are interlinked, Asthisosha will cause Majja kshaya (~decrease of the bone marrow). The patient initially had pain and restricted movements of the hip and later developed symptoms like severe pain in the right hip joint (Sandhi-Asthisoola), loss of strength (~Bala kshaya), and features of osteoporosis (~Asthisoushiryam), hence considering these factors the condition can be diagnosed as Asthi-Majjagatavata.[8]

Therapeutic focus and assessment

Bahya-abhyantaram snehana (~external and internal oleation) is the treatment for Asthi-Majjagatavata.[9] Mridu virechana with Sneha dravya (~mild laxative with oil/ghee) is mentioned in the management of Vata vyadhi.[9],[10] Decreased state of Asthi dhatu is to be treated with Basti (~enema) using Ksira (~milk), Ghrita (~ghee), and Tikta rasa dravya (~drugs possessing bitter taste).[11] Considering these treatment principles, a management protocol was planned [Table 2]. At the beginning of treatment, it was made sure that the patient was in Niramavastha (~stage of disease without Ama) and his appetite was normal. Initially, Deepana-Pachana was done with Vaiswanara churna[12] and Chitrakadi vati.[13] After three days, Snehapana (~internal administration of unctuous substance) was started with Guggulu tiktaka ghrita.[14] On the 5th day, Snehapana was withdrawn as the patient showed the signs and symptoms of Samyak sneha lakshana (~perfect unctuous).[15] Following three days, Abhyanga (~oil massage) with Dhanvantaram taila[16] and Usma swedana (~sudation) was done. On the 4th day (after stopping Snehapana), Mrdu virechana was done with Gandharvahasta eranda taila.[17] After one day of rest, again Abhyanga was initiated with Dhanvantaram taila and continued for five days. During this time, internal medication was started. Mahatiktaka ghrita and Gandha taila were administered orally [Table 3]. After five days, the patient was treated with Patra pottali swedana (~sudation with bolus of leaves) and Panchatiktaka ksheera basti[11] for three days. After completion of treatment, the patient was discharged on October 24, 2019 with an advice to take internal medication [Table 3] and external application of Dhanvantaram taila (once in a day before morning bath) over the affected part for three months. During this period, no concomitant allopathic medication was taken by the patient. For assessment, Harris Hip Score was used.[18]
Table 2: Panchakarma procedures

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Table 3: Internal medications administered during Panchakarma procedure* and during follow-up

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  Timeline Top


The timeline is given in [Table 1].


  Follow-up and outcomes Top


The outcome was assessed with Harris Hip Score on the day of admission, during discharge, and after three months of follow-up [Table 4]. There was considerable improvement in the score which was 52.05 (~poor condition of the hip) before treatment and 83.10 (~good condition of the hip) at the time of discharge. Further, the status was maintained and also improved to 89.40 (~good condition of the hip) at the time of follow-up (after 3 months).
Table 4: Harris Hip Score

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  Discussion Top


The case was diagnosed and treated as Asthi-Majjagatavata. Treatment for Vata roga and Asthi dhatu kshaya was also incorporated. Guggulu tiktaka ghrita is used for Snehapana and also as an ingredient in Panchatiktaka ksheera basti, as it is specifically indicated for Asthi-majjagataroga.[14] Dhanvantaram taila is considered to be Sarvavatavikarijith (~subsides all types of Vata disorders) and specifically indicated for Asthi diseases.[16] Hence, here, in this case, Dhanvantaram taila was used for Abhyanga and also as an ingredient in Ksheera basti. Panchatiktaka (~combination of five drugs, namely Nimba [Azadirachta indica A. Juss.], Amrita [Tinospora cordifolia (Willd.) Hook. f. and Thoms.] Vrisha [Justicia beddomei (Cl.) Bennet], Patola [Trichosanthes cucumerina L.], and Nidigdhika [Solanum virginianum L.]) is used in the form of Ksheera kashayam (~medicated milk) in Basti. Drugs possessing Snigdha (~unction) and Shoshana (~drying up) properties together will cause Kharatva (~rough), and as Asthi dhatu is Khara swabhavat (~rough in nature), they have the ability to increase Asthi dhatu. Hence, when Tikta rasa drugs (~possessing Shoshana guna) processed with Sneha dravyas (~possessing Snigdha guna) such as Ksheera and Ghrita will increase Khara swabhava and subsequently will nourish the Asthi dhatu.[19] This principle also holds good in selecting Maha tiktaka ghrita, as it is Tikta rasa pradhana and Rasayana yuktam (~rejuvenating property).[20] Osteoblasts help in regeneration and osteoclasts favor degeneration of bones and a continuous balance is required for bone homeostasis. Nuclear factor of activated T Cells 1 (NFATc1), a protein regulates osteoclastogenesis and osteoblastogenesis.[21] The drugs with bitter taste administered in lipid medium may target NFATc1 and maintain bone homeostasis.[22] Gandha taila is Asthi sthairyakrit (~improves bone mass and bone strength).[23] As these drugs and procedures have the properties to treat Asthi dhatu kshaya (~osteoporosis), they were administered and observed positive outcomes in the patient. At present, the patient is still in continuous observation and treatment. As of now (April 2020), his improvement is persisting and has a better quality of life.

Although TOH is a self-limiting condition and spontaneous recovery is noted within 2–9 months,[3] the present case reported no improvement even after surgery and conservative management for five months. Proper understanding of the pathology and treating through Ayurvedic principles found promising result in this present case.


  Conclusion Top


Transient osteoporosis of the hip (TOH) is an uncommon clinical condition in Ayurvedic practice. Its diagnosis is often difficult and commonly missed by the treating clinician. The present case managed with the combined treatment comprising of oral and Panchakarma procedures is helpful in treating TOH. This work may be taken into consideration for planning further research works for TOH.

Declaration of patient consent

The authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Vaishya R, Agarwal AK, Kumar V, Vijay V, Vaish A. Transient osteoporosis of the hip: A Mysterious cause of hip pain in adults. Indian J Orthop 2017;51:455-60.  Back to cited text no. 3
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Vaidya HP, editor. Astanga Hrdayam of Vagbhata, Nidana Sthana; Vata Vyadhi Nidana. 10th ed., Ch. 15., Ver. 12. Varanasi: Chaukambha Orientalia; 2011. p. 531.  Back to cited text no. 8
    
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21.
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Introduction
Case Report
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Follow-up and ou...
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