E-ISSN:2456-3110

Review Article

Asthikshaya

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 9 October
Publisherwww.maharshicharaka.in

Conceptual study on the etiopathogenesis of Asthikshaya w.s.r. to Postmenopausal Osteoporosis

Rotti K.1*, Poornima B.2, Walikar M.3
DOI:

1* Keerti Rotti, Post Graduate Scholar, Dept. of Roganidana evam Vikruti Vignyana, Ayurveda Mahavidyalaya, Hubbali, Karnataka, India.

2 B Poornima, Guide, Professor, Dept. of Roganidana evam Vikruti Vignyana, Ayurveda Mahavidyalaya, Hubbali, Karnataka, India.

3 Mamtaz Walikar, Co-Guide, Assistant Professor, Dept. of Roganidana evam Vikruti Vignyana, Ayurveda Mahavidyalaya, Hubbali, Karnataka, India.

World Health Organization defines osteoporosis as a “Progressive systemic skeletal disease characterized by low bone mass and micro architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture” Osteoporosis is considered a serious public health concern. Based on 2001 census approximately 163 million Indians are above the age of 50. This number is expected to increase to 230 million by 2015. Even conservative estimated suggest that of these, 20% of women and about 10-15% of men would be osteoporotic. The total effected population would, therefore, be around 25million, the figure can increase to 50 million. According to the classics, Asthi Kshaya is having the Lakshanas like Asthi Shoolam, Kesha, Loma, Nakha, Dwija Prapatanam, Sandhi Shaitilya. As some of the Laskshana of Asthi Kshaya resembles with the signs and symptoms of Osteoporosis, to certain extent it can be compared to Osteoporosis.

Keywords: Asthikshaya, Vata Dosha, Postmenopausal Osteoporosis

Corresponding Author How to Cite this Article To Browse
Keerti Rotti, Post Graduate Scholar, Dept. of Roganidana evam Vikruti Vignyana, Ayurveda Mahavidyalaya, Hubbali, Karnataka, India.
Email: 		Keerti Rotti, B Poornima, Mamtaz Walikar, Conceptual study on the etiopathogenesis of Asthikshaya w.s.r. to Postmenopausal Osteoporosis. J Ayu Int Med Sci. 2022;7(9):105-114.
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https://www.jaims.in/jaims/article/view/2084

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-08-27 2022-08-29 2022-09-05 2022-09-12 2022-09-18
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 16%

© 2022by Keerti Rotti, B Poornima, Mamtaz Walikarand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Ayurveda is an ancient science of life deals with the preventive as well as curative aspect. It explains human body as a ‘congenial homeostasis’ of Doṣha, Dhatu and Mala. The function of Dhatu is Dharana of the Sharira.[1]

Osteoporosis is one of the major signs that has increasingly been perceived as serious disabling disease in women aged above 40 years reaching Rajonivritti. It is not mentioned as disease in classical texts of Ayurveda. Yet, according to Acharya Sushruta it can be considered under Swabhavabala Pravritta Vyadhi.[2] Rajonivritti occurs at Sandhikala of Praudhawastha and Jarawastha, where Vata starts overpowering Pitta Dosha and leads to Kshaya of all Dhatus.[3]

According to the principles of Ashrayaashrayi Bhava by Acharya Vagbhata,[4] Asthi Dhatu is the seat of Vata Dosha[5] and is inversely related to each other i.e., if there is Vata Vruddhi there is Asthikshaya.

Asthikshaya occurs due to two main mechanisms, the first is deficiency of nutrients suitable for nourishing the bone because of malnutrition or the catabolic activity of Vata Dosha and the second is Srotoavarodha which obstructs supply of nutrition to the Asthivahasrotas as a result of imbalanced Agni i.e., with Jatharagnimandhaya and Dhatwagnimandhaya that leads to formation of Ama. It can also occur due to a combination of both.

World Health Organization defines Osteoporosis as “Progressive systemic skeletal disease characterized by low bone mass and micro architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture”.[6] Low levels of Estrogen cause imbalance in bone reabsorption and remodeling which leads to accelerated bone loss.[7]

Though most of the Samhita explained about Asthi Dhatu, its structure, function and its various diseases, Detail description about Nidana Panchakas of Asthikshaya is not available in our classics.

Considering the above factors in this present study, an effort is made to understand the Nidana Panchaka of Asthikshaya with special reference to Postmenopausal Osteoporosis.


Nidana

Samanya Dhatukshaya Nidana[8]

  • Ativyayama (excessive exercise
  • Anashana (fasting)
  • Ati Chinta (worry)
  • Rukshashana (intake of dry food)
  • Alpaashana (intake of less food)
  • Vataatapa Sevana (exposure to dust and sunlight)
  • Bhaya, Shoka (excess of worry, grief, fear,)
  • Rukshapana (intake of dry liquid like Ruksha Madya)
  • Prajagara (waking at nights)
  • Ativartana (Atyadhika Pravrutti) of Kapha, Rakta, Shukra, Mala,
  • Kala (time factor (Adana Kala and Vridhavasta)
  • Bhutopaghata (invasion of Bhuta, Preta)

Asthivaha Srotodushti Nidana

  • Vyayama (excessive exercise)
  • Ati Sankshobha (excessive irritation)
  • Asthi Vighattana (repeated trauma)
  • Vatala Ahara Sevana (excessive consumption of Vata aggravating food)

Majjavahasrotodushti Nidana[9]

  • Utpeshana (being crushed)
  • Ati Abhishyandana (being filled with wet components of Kapha)
  • Abhighata (trauma)
  • Prapeedana (compressed)
  • Virudha Ahara Sevana (consumption of incompatible and unwholesome food)

Purishava Srotodushti Nidana[10]

  • Sandharana (withholding urge of defecation)
  • Ati Ashana (excessive eating)
  • Ajeerna (indigestion)
  • Adhyashana (repeated eating)
  • Durbalagni (weak digestion)
  • Krusha (in emaciated persons)



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Medovaha Srotodushti Nidana

  • Avyayama (lack of exercise)
  • Diva Swapna (sleeping during day time)
  • Medhyanam Ati Sevanat (excessive intake of fatty, fried and caloric foods)
  • Varuni (an alcoholic product).

Vishishta Nidana

Sahaja Nidana:

  • Beeja,[11] Beejabhaga, Beejabhagavayava
  • Pitrija Bhava[12]
  • Kulaja (Caucasians)
  • Prakriti (Vata dominant Prakriti)

Jataja Nidana[13]: Vatakara Ahara, Vihara

Swabhavaja Nidana[14][15]: more in women and old age

Samprapti: Acharayas have mentioned about the Ashrayaashrayi Bhava which beautifully explains the relationship of various Doshas with the Dhatus.As per this theory Vata is the Ashrayi of Asthi Dhatu and only these two share a reciprocally proportional relationship. Owing to this peculiar relationship, all Vata Nidana becomes the Nidana for Asthi Kshaya. Keeping in mind all the Nidanas explained under Vata Vyadhi an attempt has been made here to formulate and explain the Samprapti of Asthi Kshaya. In order to have a proper interpretation of the Samprapti of Asthi Kshaya, apart from the normal Vata Prakopa Nidana, the main factors for the materialization of the disease, Srotopradusaka Nidanas of Medovaha, Asthivaha, Majjavaha and Purisavaha Srotas should not be neglected, as they also play a definite role, either directly or indirectly in the pathogenesis of Asthi Kshaya. The proper functioning of Jataragni, Bhutagni, Dhatwagni is essential for the “Samyak Dhatu Posana Prakriya” [16] in order to maintain the qualitative and quantitative normalcy of the Dhatus while explaining concept of Dhatu Utpatti.

Functional deformity in any of these Agnis especially the Dhatwagni leads to the Vikruti in the transformation of Posaka Dhatu (Dhatu specific nutrients) into Posya or Sthayi Dhatu, resulting in Dhatuvikruti. Hence, adaptation of the principles of Dhatu Posana Krama is also carried out in this regard to explain the Samprapti of Asthi Kshaya.

Manasika factors also play a vital role in the pathogenesis of Asthikshaya. The role of manas in the causation of a disease is very well explained in our classics. Thus, these factors are also considered to frame up and explain the samprapti of Asthikshaya effectively. Considering the above said factors it is learnt that the Pathogenic mechanism of Asthikshaya is not single mechanism whereas it is a complex mechanism.

Samprapti Ghataka of Asthikshaya

Dosha: Vata Pradhana (Vyana ,Udana, Samana), Pitta (Pachaka), Kapha (Kledaka, Shleshaka) Vata is the leading Dosha, as this is a disease related to Jara and Asthi Dhatu. Also, as vata gets provocated Kapha Kshaya takes place. Vata Prakopa and Kapha Kshaya manifests symptoms such as Shoola, Rukshata, Ruja, Shrama etc.

Dushya: Asthi is main Dushya in this disease with its Mala, Nakha and Kesha. But Kshaya of all Dhatus also occurs in later stage, hence all Dhatu including their Upadhatus can be c onsidered under Dusya.

Agni: In old age, Jatharagni Vaishamya leads to poor Dhatu formation, by affecting Dhatvagni and Bhutagni.

Ama: Jatharagnijanya Ama and Dhatvagnijanya Ama

Srotas: Medavaha, Asthivaha, Majjavaha, Purishavaha Srotas.

Sroto Dushti Laxshana: Sanga.

Udbhava Sthana: Ama Pakwashaya.

Sanchara Sthana: Rasayani.

Vyakta Sthana: Asthi Dhatu, its Upadhatu Danta and Mala Kesha, Nakha, Roma and Sandhi.

Adhisthana: Asthi and Sandhi.

Roga Marga: Madhyama Roga Marga.

Roga Prakriti: Chirakari.

Purvarupa: As we go through the classics, we cannot find about the Poorvarupa of Asthikshaya. Vatavardhaka Nidana along with the other Nidana itself forms the Nidana for the Asthikshaya due to the Ashraya Ashrayi Bhava of the Vata and Asthi. So Vriddhavata causes the disease Asthi Kshaya. As we all know that the Poorvaroopa in Vatavyadhi is Avyakta.


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Chakrapani in his commentary has clarified that Avyakta can be taken as Alpavyaktata or as Asampoornalakshana or as mild Lakshana. So, the Lakshana in their mild form can be taken as the Poorvaroopa of Asthikshaya in the initial stage of the disease. Manda Vedana (dull aching type of pain) in the Asthi, Sandhi, and Mildness of other Lakshana such as Kesha, Roma, Nakha, Danta Vikara (Shadana and Bhanga) may be taken as the Purvarupa of the disease Asthikshaya.

Rupa

SN Lakshanas Ch Su A.S A.H H.S
1. Asthibheda + - + - -
2. Asthitoda - + + + -
3. Ruja - - - - +
4. Asthi Shula + + - - -
5. Kesha Vikara and Patina + - + + -
6. Loma/Roma Vikara and Patana + - + + -
7. Nakha Vikara and Patana + + + + -
8. Smashru Vikara and Patana + - - - -
9. Danta Vikara and Patana + + + + -
10. Shrama + - - - -
11. Sandhi shaitilya + - + - -
12. Ruksha - + + - -
13. Parushya - - + - -
14. Asthibadda - - + - -
15. Mamsabhilasha - - + - -
16. Anga Bhanga - - - - +
17. Ati Manda Chesta - - - - +
18. Bala Kshaya - + + + -
19. Medo Kshaya + - - - +
20. Viryasya Mandya (Utsaha Hani) - - - - +
21. Vikampana - - - - +
22 Vamana - - - - +
23. Visangnata - - - - +
24. Shosha - - - - +
25. Kathorata - - - - +
26. Shophita - - - - +

Upashaya

1. Madhura Rasa Pradhana Dravya like Shali, Rakta Shali, Masha

2. Amla and Lavana Rasa Pradhana Dravya.

3. Dugdha, Dadhi, Takra and Ghrta.

4. Mamsa, Mamsa Rasa

5. Niyamita Vyayama.

6. Abhyanga and Swedana.

7. Vata Nashaka and Vedana Shamaka Oushadhi.

Anupashaya

1. Shushka Shaka, Mamsa, Mudga, Masura, Adhaki, Kalaya

2. Madya.

3. Ati Vyayama, Sahasa

Sadhyasadhyata: Asthi is Gambhira Dhatu i.e., deeply situated. The disease of Gambhira Dhatu are said to be Yapya or Kashta Sadhya. [17] The disease Asthikshaya is Asadhya because of its occurrence in Jarawastha. Also, when the disease Asthikshaya is manifested, in condition of bhedawastha i.e., last stage of Kriya Kala. Where as long as the disease is treated, it is Yapya and if not treated, the disease becomes Asadhya. [18]

Upadrava: if the disease is not treated properly it can lead to Kshaya of other Dhatu such as Majja Kshaya, Shukra Kshaya and other Dhatu Kshaya leading to Bala and Oja Kshaya. Due to the Kshaya of Asthi Dhathu, it loses its normal texture, strength and density leading to Asthi Bhagna (fractures) which are the commonest Upadrava of Asthi Kshaya. Modern science also agrees that the fractures are the major risk factors of Osteoporosis.

Pathya-Apathya

SN Varga Pathya Apathya
1. Rasa Madhura-Amla-Lavana Katu-Tikta-Kashaya
2. Shukadhanya Nava Godhuma, Nava Shali, Rakta Shali, Shashtika Shali Rajamasha, Nishpava, Mudga, Kalaya
3. Shimbi Varga Nava tila, Masha, Kulattha Truna, Koradusha
4. Shaka Varga Patola, Shigru, Vartaka, Lashuna Jambu, Udambara, Kramuka, Tinduka
5. Mamsa Varga Ushtra, Go, Varaha, Mahisha, Mayura, Bheka, Nakula Shushka Mamsa, Kapota, Paravata
6. Jala Varga Ushnajala, Shritasheetajala Sheetajala
7. Dugdha Varga Go, Aja, Dadhi (Svadu Dadhi and Amla Dadhi, curd prepared from buffalo milk), Ghrita, Kilata -
8. Mutra Varga Gomutra -
9. Madhya Varga Dhanyamla, Sura -
10. Sneha Varga Tilaja, Ghrita, Vasa, Majja -
11. Vihara Veshtana, Trasana, Mardana, Snana Ratri Jagarana, Ativyayama, Adhika Shrama,Ativyavaya, Ati Chankramana, Vegadharana
12. Manasika Sukha Atichinta, Atibhaya, Atishoka

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Osteoporosis

Etymology

Osteoporosis is derived from Latin.

Osteon - bone; Porosis – porous Hence it means porous bones.

Definition

World Health Organisation defines osteoporosis as a “progressive systemic skeletal disease characterized by low bone mass and micro architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture”.

Classification of Osteoporosis

Primary Osteoporosis

1. Post menopausal: type I

2. Age related: type II

Secondary Osteoporosis

1. Endocrine: Cushing’s syndrome

  • Thyrotoxicosis
  • Hypogonadism
  • Pituitary insufficiency
  • Athletic amenorrhoea

2. Drugs

  • Corticosteroids
  • Long term heparin use
  • Anticonvulsant drugs
  • Cytotoxic drugs

3. Inherited

  • Turner’s syndrome
  • Osteogenesis imperfecta
  • Homocystinuria

4. Nutritional

  • Anorexia nervosa
  • Alcoholism
  • Malabsorption syndrome

5. Immobility

  • General (lack of weight bearing exercises)
  • Local (e.g. rheumatoid arthritis, hemiplegia, fracture)

6. Other (rare)

  • Chronic hepatic disease
  • Juvenile
  • Pregnancy
  • Masto cytosis

Postmenopausal Osteoporosis

Mechanism of Estrogen Effects on Bone

An influence of estrogens on bone mass prior to the menopause was suggested by number of observations in reproductive state. Some studies have shown positive association between bone mass and parity in premenopausal women.[19] Also, oral contraceptive use has been associated with higher bone mass in some women, but not in all studies. A number of hypo-estrogenic states in premenopausal women are associated with reduced bone mass. Amenorrhoea in female athletes and ballet dancers is associated with low bone mass and fracture risk. The mechanism of action of estrogen on bone turnover still remains unknown. Yet, a number of hypotheses have been suggested. Estrogen induced effects on skeleton may be exerted via either genomic or non-genomic actions.

Calcitonin theory: This theory proposes that estrogen deficiency is associated with reduced calcitonin production, leading to increased bone resorption, increased serum calcium levels, reduced parathyroid hormone secretion and hence reduced production of 1,25 dihydroxy vitamin D3; this chain of events would result in reduced intestinal calcium absorption and reduced serum calcium levels.[20]

Other theory proposes indirect effect of estrogen on bone resorption including reduced production of end organ resistance to 1,25-dihydroxyvitamin D3, resulting in decreased calcium absorption from intestine, increased parathyroid hormone secretion and increased bone turnover .[21]

Estrogen receptors theory: There are two main subtypes of estrogen receptor ER- namely ERα and Erβ. Both receptor subtypes have been reported in human bone. Recent evidence suggests that ERα is predominant in cortical bone whereas ERβ is the main form in cancellous bone. Estrogen receptors have been described on all the main cell types of bone, namely, osteoclasts, osteoblasts and osteocytes.


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Estrogen has effects on the production of a number of cytokines and growth factors, which are involved in the regulation of bone remodelling. The bone preserving effect of estrogen is mediated largely through its effect on osteoclast number and activity. In postmenopausal women, estrogen deficiency is associated with increased production of interleukin 1 (IL-1), tumour necrosis factor α (TNFα) and granulocyte macrophage colony stimulating factor (GMCSF), cytokines that increase osteoclast genesis and IL-1 and TNFα also increase osteoclastic activity. Estrogen also inhibits the production of interleukin -6 (IL-6), and more recently, has been shown to stimulate the production of osteoprotegerin in osteoblastic cells. Osteoprotegerin functions as a soluble decoy receptor for the cytokine RANKL (receptor activator of NFκB ligand), which is essential for osteoclast genesis. Effects of estrogen on osteoclast activity are also mediated via stimulation of apoptosis. IL-1, IL-6 and M-CSF have all shown to inhibit apoptosis in osteoclasts, whereas transforming growth factor β (TGF β) production is decreased in estrogen deficient states, stimulates apoptosis. Thus, the loss of estrogen at the menopause results in accelerated bone loss and is a major pathogenic factor in postmenopausal osteoporosis.

Signs and Symptoms: Osteoporosis is a silent disease, until a fracture is sustained.

Clinical Findings

  • In early stages, following acute thoracic compression fracture, patients exhibit marked discomfort on sitting and standing.
  • Gait is normal but slow. Spinal movements considerably reduced, with more restriction in flexion than in extension.
  • Dowager’s hump (thoracic kyphosis) may be present as a result of previous anterior compression fractures.
  • Involvement of lumber spine is noted by progressive loss in lumber lordosis.
  • Axial height may be decreased.
  • Paravertebral muscle spasms are palpable and often visible. Spine and paravertebral muscles are tender on palpation and percussion over the level of fracture.
  • Bony point tenderness is usually absent as the fracture is in the anterior vertebral body of spine which are not palpable.
  • Most patients are totally pain free during the intervals between compression fractures; whereas some may complain of chronic, dull, aching postural pain in mild thoracic and upper lumbar region. This responds symptomatically to frequent, intermittent horizontal rest.
  • Loss of height may be up to 2 to 4 cm with each episode of segmental vertebral collapse and progressive kyphosis.
  • There is no significant loss of height when the lower ribs come to rest on iliac crest due to collapsed spine., yet loss of bone mass continues.
  • This results in decrease in size of thoracic and abdominal cavities, which are responsible for clinically disturbing side effects – exercise tolerance is reduced.
  • Abdominal distention, protrusion is a common manifestation secondary to severe lumbar vertebral collapse.
  • Circumferential pachydermal skin folds develop at the rib and pelvic margins as the disease progresses.

Measurement of Bone Mass or Bone Mineral Density (BMD)

Clinical application of bone densitometry has been one of the advances in Osteoporosis that has directed to the increased patient awareness of this increasingly prevalent disease. With bone densitometry it is possible for clinician to diagnose Osteoporosis before the first fracture has occurred; predict risk for fracture in postmenopausal women; men and in patients receiving gluco-corticoids. Three reasons clinicians do bone mineral density measurements are

1. Diagnosis using the WHO criteria for Osteoporosis.

2. Fracture risk prediction, and

3. Monitoring the natural progression of diseases that affect BMD or monitoring the therapeutic response to Osteoporosis specific treatments.

  • T scores between -1 and -2.5 represents osteopenia, clinical significance of which is not completely understood.
  • T score below -2.5 represents osteoporosis and a high risk of fracture.

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  • T score below -2.5 plus one or more fragility fractures is indicative of established osteoporosis.

Bone densitometry measures bone density, not bone turnover or bone stability.

Treatment of Osteoporosis: “Prevention Is Better Than Cure” is accepted as the crucial step in managing osteoporosis according to the contemporary science. Only when the disease is manifested and starts increasing the risk of complications, thereby becoming a threat to the patients‟ life, medical intervention is needed.

Prevention: According to R Handa in his textbook of Orthopaedics Routine physical activity, proper intake of nutritious food containing dietary calcium, magnesium, phosphorus and other minerals, Vitamin-D (dietary & auto-synthesis by exposure to sun), avoiding smoking, tobacco intake and alcohol consumption, avoiding the prolonged use of certain drugs such as cortico-steroids, anticonvulsants, heparin etc. and maintaining a disease free healthy body and mind are the golden tips for the prevention of Osteoporosis.

Discussion

Nidana: In classics there is no direct mentioning about the Asthikshaya Nidana or the factors that cause AsthiKshaya. But the relationship between Asthi Dhatu and Vatadosha is beautifully explained through Ashrayaashrayi Bhava mentioned in our classics. According to this rationale, when Vata increases, Asthikshaya occurs and vice versa.

Keeping this particular concept in mind we can say that the Nidana responsible for the increase of Vata Dosha is responsible for the Asthi Kshaya.Various symptoms of Jarawastha are more likely observed in Rajonivrittijanya Avastha also. So, it can be stated that Rajonivritti is one of the parts of the process of aging, specific to female. Akalaja Jara (Rajonivritti), Ruksha Ahara Sevana for lifetime, sedentary life style, and low intake of Asthi Posaka Amsa in diet serves as Nidana of Asthi Kshaya.

Apart from this, factors like Manasika Nidana, Sroto Dushti Nidana of Medovaha, Asthivaha, Majja Vaha and Purisha Vaha Srotas and also the factors that affects Jatharagni, Bhutagnis, especially Parthivagni, Vayuvyagni and Tejasagni and both Upachayakaraka and Apachayakaraka Asthi Dhatwagnis are also responsible for Asthi Kshaya.

Functional deformity in any of these Agnis especially the Dhatwagni leads to the Vikrti in the transformation of Posaka Dhatu into Poshya or Sthayi Dhatu, resulting in Dhatuvikrti. Hence adaptation of the principles of Dhatu Posana Krama is also carried out in this regard to explain the Samprapti of Asthikshaya.

Discussion on Samprapti: Samprapti of Asthikshaya is not a single pathogenic mechanism, whereas it is a complex mechanism. Hence the Samprapti of Asthi Kshaya is explained under two different headings Samanya Samprapti and Vishesha Samprapti.

According to Acharya Charaka, Avruta Marga of Vata causes it to become Prakupita and causes Rasadi Dhatu Shoshana. Obstruction of normal Gati of Vata (Vyana Vata) occurs due to the Margavarana. By this the ahara rasa viksepa (rasa samvahana), dhatu vyuhana and agni samirana functions of vyana Vata are affected. As a result of this, the Ahara Rasa containing the posakamsas to the Dhatus will not be able to reach and nourish the Sthayi Dhatus, Dhatu Vyuhana i.e., specific arrangement and permeability of the posakamsas inside the Sthayi Dhatus will not be possible and the functions of the Dhatwagnis are also affected. This signifies the importance of Medodhatvagni. Vitamin D, which is derived from sterols, is essential for absorption of calcium in the body. Hence the Moola of Asthi Vaha Srotas is rightly considered as Meda. Imbalance in Asthi Dhatvagni leads to improper formation of Sthayi Asthi Dhatu from Poshaka Asthi Dhatu. Parathyroid hormone, calcitonin, estrogen etc. play significant role in metabolism of bone. These all can be classified under types of Agni acting at different levels. The Ashrayashraayi relationship of Vata Dosha and Asthi Dhatu forms a fundamental base to understand any pathological condition related to Asthi Dhatu.

As a combined effect of these factors Dhatu Kshaya occurs. According to the principles of Ashrayaashrayibhava explained by Acharya Vagbhata, Asthi Dhathu among the Saptha Dhatu is most fictile to be affected since Vata and Asthi are inversely proportional. So, to sum up briefly, it can be said that Asthikshaya is caused due to the Dhathu Kshaya Karaka and Maragavarana Karaka, Nidana Sevana causing the Prakupita Vata to fill the Riktatata in Astivaha Srotases which are barren of Snehadi Gunas and cause Asthikshaya.



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Poorva Roopa: As we all know that the Poorva Roopa in Vata Vyadhi is Avyakta. Chakrapani in his commentary has clarified that Avyakta can be taken as Alpa Vyaktata or as Asampoorna Lakshanas or as mild Lakshanas. Like Asthishula, Toda, Bheda, Shrama, Sandhishaitilya, Danta Shadana, Nakha Shadana, Danta and Nakha Bhanga manifested in mild form.

Rupa: Acharya Caraka has mentioned it along with the Laxanas of Asthadasa (18 types) Kshaya.

In Harita Samhita the Laxanas of Asthikshaya are described along with the Laxanas of Kshaya (Rajayakshma). Pravrudha Vata Dosha is the main factor for the cause of Asthi Kshaya owing to the Asrayasrayi Bhava. So, the Laxanas are due to the Vata Vruddhi, hence various types of Vedanas are seen in the Asthis and Sandhis. Since the Dhatu metabolism involves two Pakas viz. Prasada Paka and Kitta Paka, the Dhatus when affected simultaneously affects the Upadhathu and Malas, as a common rule. When there is defect in Dhatu metabolism due to improper supply of nutrients, naturally the Prasada Paka and the Kitta Paka are affected leading to the Vikaras of Dhatu, Upadhatu and Mala also.

Conclusion

Asthikshaya is a disabling disease which renders women a bedridden life. The prevalence of postmenopausal Asthi Kshaya is more in people aged above 40 years. Peak bone mass is attained by the age of 30 years. Asthikshaya is one of the Swabhavabala Pravrutta Vyadhi as in this Vaya (Vriddhavastha) plays major role along with Vata as Pradhana Dosha and Asthi as Pradhana Dhatu. Analysis of textual references regarding aetiology of Asthikshaya discloses fact that Vatakara Nidana plays a significant role in manifestation of Asthikshaya. It is concluded that any abnormalities in Vyana Vata, Udana Vata, Samana Vata Pachaka Pitta, Shleshmaka Kapha, Kledaka Kapha and Aharaja, Viharaja Nidana result in Asthikshaya. There is no textual reference regarding the Purvarupa of Asthikshaya, so Laxanas of Asthikshaya when expressed in mild nature are considered as Purvarupa of Asthikshaya. Laxanas of Asthikshaya are Asthishula/Toda/Bheda, Sandhi Shaitilya, Shrama, Danta Kesha Nakha Prapatana, Danta Bhanga, Nakha Bhanga.

These Lakshanas have close resemblance with symptoms of postmenopausal osteoporosis in modern science which include pain in the back, deformity of spine, risk of developing fractures.Madhura Rasa Pradhana Dravya like Shali, Rakta Shali, Masha etc, Amla and Lavana Rasa Pradhana Dravya, Dugdha, Dadhi, Takra and Ghrta, Mamsa, Mamsa Rasa, Niyamita Vyayama, Abhyanga and Swedana,Vata Nashaka and Vedana Shamaka Oushadhi are said to be the Upashayas of the Asthikshaya. Majja Kshaya, Shukra Kshaya, Oja Kshaya and Fractures - Anga Bhanga should be considered as complication of Asthi Kshaya.

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