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Saturday, 7 February 2015

(First edited)) Most Common Diseases of Ages of 50 Plus - Musculoskeletal disorders (MSDs) -Osteoarthritis

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By Kyle J. Norton
Health article writer and researcher; Over 10.000 articles and research papers have been written and published on line, including world wide health, ezine articles, article base, healthblogs, selfgrowth, best before it's news, the karate GB daily, etc.,.
Named TOP 50 MEDICAL ESSAYS FOR ARTISTS & AUTHORS TO READ by Named 50 of the best health Tweeters Canada - Huffington Post
Nominated for shorty award over last 4 years
Some articles have been used as references in medical research, such as international journal Pharma and Bio science, ISSN 0975-6299.


I. Osteoarthritis
(OA), a form of arthritis, is a condition of aging causes of wear and tear on a joint, affecting over 25 million people in the United States in alone.

II. Symptoms 
Symptoms of  osteoarthritis are aching pain, stiffness, or difficulty moving of one or more joints. The pain usually gets worse in change of weather,  at night and in the advanced of the diseases, the pain can occur even at rest.
1. Pain in joints of the hand
Most commonly affected joints of the hand in osteoarthritis include the carpometacarpal joint of the thumb (CMC 1) and the distal (DIP) and proximal (PIP) interphalangeal joints. The pain is likely due to secondary synovitis caused by molecules released from the joint cartilage(3).

2. Knee and Hip
Osteoarthritis (OA) of the knee and hip is among the most frequent and debilitating arthritic conditions of osteoarthritis, caused by cartilage destruction by pro-inflammatory cytokines, matrix metalloproteinases and prostaglandins(4).

3. Spine 
Vertebral deformity, in particular wedging, of the thoracic spine is not exclusively characteristic for osteoporosis. Osteoarthritis affecting the low back can lead to chronic low back pain (lumbago) and degenerative disc disease (spondylosis). Lumbar spine disc degeneration are characterized by increased CII degradation(5).

III. Causes of Risk Factors
A. Causes

1. Process of wear and repair
Osteoarthritis (OA), a widespread degenerative disease of skeletal joints and is often associated with senescence in vertebrates. arising from long term wear and tear, heavy long-term use or specific injuries; yet, in the absence of injury, the aetiology of OA remains obscure(6)
Improper repair process of injure of joints can also result of symptoms of Osteoarthritis (OA) in old age, according to TCM.

2. Nutrient deficiency
Poor nutritional conditions experienced early in life are linked to greater prevalence of OA during senescence as well as reduced life expectancy(7).

3. Cartilage
Cartilage is a flexible connective tissue cushioned the ends of bones in your joints and allowed the joints to move smoothly. Rough  or wears down cartilage due to aging or damage can causes pain due to  bone in the joint rubbing against another bone.
The above causes of Osteoarthritis (OA) are the result of injure, overuse, Rheumatoid Arthritis, etc.
4. Etc.

B. Risk factors
Aging changes in the musculoskeletal system contribute to the development of OA by making the joint more susceptible to the effects of other OA risk factors 

1. Abnormal biomechanics
2. Joint injury andobesity
3. Age-related sarcopenia and  increased bone turnover may also contribute to the development of OA(8). Other suggested that Osteoarthritis development in the injured joints is caused by 
4. Intra-articular pathogenic processes initiated at the time of injury 
4. Age, sex, genetics, obesity, muscle strength, activity, and reinjury(8a)(11)(13).
5. Age  related sarcopenis
Normal aging in humans is associated with declines in skeletal muscle mass and strength and increased muscle fatigability (sarcopenia)(9). 
6. Race
Women and male Asian are at higher risk to develop osteoarthritis, according to research of Praxisklinik für Unfallchirurgie und Orthopädie(10) 
3. Deformation of bone
 People who were born with defective joints or cartilage are at increased risk of developing osteoarthritis.
4. Activity
People who involve in activity such as sport are at higher risk to develop osteoarthritis.(11).
6. Occupations 
Certain occupation are associated to the increased risk of osteoarthritis, especially to workers involving repetitive movements that stress on a particular joint(12). 

7. Deficiency in DNA repair
Progeroid human DNA repair syndrome trichothiodystrophy may be associated to the
to the development of osteoarthritis(14).
9. Other diseases and conditions may have a higher risk of developing the condition.
a. Gout
Gout is a type of arthritis as a result of uric acid builds up in blood causes ofo joint inflammation. According to a total of 4249 completed questionnaires were returned (32%). From 359 attendees, 164 cases of gout were clinically confirmed, there is highly significant association existed between the site of acute attacks of gout and the presence of OA(15).
b. Rheumatoid arthritis
Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease, causing the attack of flexible (synovial) joints, inflammation of the surrounding tissues and many tissues and organs. Patients with heumatoid arthritis (RA) are associated to increase risk of OA due to progression of aging(15a).
c. Paget’s disease of the bone
Paget’s disease of bone is a condition a chronic disorder of enlarged and misshapen bones resulting in excessive breakdown and formation of bone tissue causing pain, misshapen bones, fractures, and arthritis in the joints near the affected bones(16) with prevalence trends of doubling each decade from the age of 50 onwards, causing bone pain, depending on skeletal sites involved and range from secondary osteoarthritis to malignant degeneration(17).
d. Septic arthritis
Septic arthritis is a condition of  inflammation of a joint as a result of bacterial or fungal infection causes of osteoarthritis(18).
e. Etc.
9. Etc.

IV.  Diseases associated with osteoarthritis
Researchers suggested that
OA is not simply a disease related to aging or mechanical stress of joints but rather a “metabolic disorder” interrelated  to lipid, metabolic, and humoral mediators. Indeed, OA has been linked not only to obesity but also to other cardiovascular risk factors, namely, diabetes, dyslipidemia, hypertension, and insulin resistance(19a).
Most people with osteoarthritis also suffer from one or more below comorbidities(19b)
1.  Hypertension
According to the University Health Network Research Institute, the economic burden incurred by RA significantly exceeds that related to OA and HBP(19). 

2. Cardiovascular disease
According to Erasmus University Medical Centre, there is an associations of atherosclerosis with osteoarthritis of the knee and hand joints in womens(20).

3. Peripheral vascular disease, 
The average vessel wall thickness of the popliteal artery was 1.09 mm in patients with generalized OA, and 0.96 mm in the matched normal reference population(21).

4. Congestive heart failure
  Hypertension, diabetes, and older age have shown to increased risk of
Congestive heart failure modestly.  Etoricoxib, an annti-inflammatory painkillers showed a statistically significant inhibition at 90 mg in patients with osteoarthritis and rheumatoid arthritis(22).

5. Renal function impairment 
Median excretion of pyridinoline and deoxypyridinoline in the OA patients as a whole was raised above values found in a healthy control population(23).

6. Diabetes 
Several epidemiological and experimental data support the hypothesis that diabetes could be an independent risk factor for osteoarthritis (OA)(24).

7. Respiratory disease
People with Respiratory disease is also at a higher risk to develop osteoarthritis (OA), such as  chronic cough and bilateral infiltrates on chest roentgenogram(25).
8. Etc.

V. Diagnosis 

The aim of the diagnosis is to differentiate the diseases against other types of arthritis to avoid misdiagnosis and to rule out the other (secondary osteoarthritis)causes of osteoarthritis (OA).
After taking the complex physical examination and careful exam the physical symptoms such as, joint swelling, Joint tenderness, decreased range of motion in joints, Visible joint damage, etc. some of the below tests may be necessary
1. Blood Test
Although blood test is not necessary in many cases of osteoarthritis (OA), it can be helpful tool to rule other causes of the disease. 

2.  Synovial fluid analysis 
Synovial fluid analysis is the test to exam the joint synovial fluid. Abnormal joint fluid may look cloudy or abnormally thick may be a indication of inflammation or osteoarthritis.

3. X-rays 
X rays beside is one of the common used to diagnosed for findings of osteoarthritis (OA) such as abnormal joints, bone, joint space between adjacent bone, loss of joint cartilage, etc., it is a heltful tool  to rule out other causes of pain and assist the decision-making when surgical intervention is found to be necessary.

4. MRI (magnetic resonance imaging)
While MRI (magnetic resonance imaging) is a more sensitive imaging method, it is used less often than x-rays due to cost and availability. MRI scans show cartilage, bone, and ligaments.
5. Etc.

VI. Prevention
A. The Do and do not’s list
1. Prevention recurrent injure to damage menisci

  Meniscus damage or
recurrent injure might be considered as a signifying feature of incipient OA in middle-aged and elderly people(26). 

2. Take precaution if your occupation is at increased risk of osteoarthritis
Osteoarthritis (OA) is one of the most important diseases as it frequently affects the active age group of the population contributed to loss of working hours and of disability. Compressive, torsional, pulling and angular movements common in certain occupations or sports may result in injuries of soft tissue, thus increasing the development of OA(27).

3.  Muscle strengthening and aerobic exercises
Muscle strengthening and aerobic exercises are effective in reducing pain and improving physical function in patients with mild to moderate OA of the knee(28).

4. Maintain a healthy weight
  Increased BMI is associated with more severe cartilage degeneration as assessed by both morphological and quantitative MRI measurements(29).

5.  Avoid dehydration
According to the  University of Michigan, dehydration reduced the mobility of collagen amino acid residues and carbon sugar ring structures in glycosaminoglycans but dehydration effects are reversible, through the restoration of molecular structure and mobility(30).

6. Avoid intake of inflammatory foods
Loading up on junk foods and fast foods contains high amount of trans fat of that increases the risk of inflammation causes of osteoarthritis (OA). Red meat, eggs, and wheat products all contain high amount of arachidonic acid, too much arachidonic acid may be worsen the inflammation process, etc.

7. Eat your fruits and vegetables
Fruits and vegetables containning high amount of nutrients and antioxidant, can enhance immune defense system within the joint through direct infleuences of transferrin performance for reduction of inflammation as well as suppressing
free radicals and the chain of free radicals reaction cause of elevating the swelling and promoting degeneration(31).

8. Replace regular beverage with green tea
Epigallocatechin-3-gallate, a green tea polyphenol, was found to be effective in reducing inflammatory cytokines induced inflammatory diseases(32).
9. Etc.

B. The Diet
The aims of the diet is to provide protection to avoid elevation of the swelling and induced-degeneration aging causes of osteoarthritis
1. Green tea
Epigallocatechin 3-gallate (EGCG), according to the College of Pharmacy, found a bundantly in green tea showed to exhibit its anti 
anti-rheumatic activity in patients with joint diseases(33). 

2. Salmon is the common name for Salmonidae, born in fresh water, migrate to the ocean, then travel thousands of miles in the deep sea cold water throughout their life cycle and within  five years returning to the exacted location where they were born to reproduce and die.
a. Weight loss
  n3 long-chain polyunsaturated fatty acids (n3-LCPUFA) exhited its effect in body weight, at the end of the 1-month period in 16 children through deduction of
insulin resistance and beta-cell in Homeostatic model assessment(HOMA-IR)(34).
b. Antioxidants
  Megadoses of vitamin E, beside having pro-oxidative activity, it actually increase the anti-oxidative capacity of the liver,  after ingestion of salmon oil(35).
c. Omega 3 fatty acids
Omega 3 fatty acids is necessary to maintain the ratio of good and bad cholesterol, thus reducing the risk of cholesterol inflammation cause of
heart diseases (36).
d.  Anti inflammation 

Omega 3 fatty acids not only reduces the risk of inflammatory effects on our joints and improved blood flow, by regulating the migration of inflammatory cells, but also reduce the elevation of the proinflammatory leukotriene LTB(4) causes of autoimmune diseases(37).

3. Walnut tree,
cultivated for its nut and kernel and for commercial purpose all over the world, is one of the Genus plant belong to the family Juglandaceae about 30–130 ft).
a. Antioxidant effects
Even lthough walnuts consumption did not significantly change the plasma antioxidant capacity of healthy, well-nourished older adults but
chronic consumption, it improved linoleic acid and pyridoxal phosphate in enhancing total plasma thiols(38).
b.  Inflammation defense
Intake of walnuts is shown to promote manganese superoxide dismutase (MnSOD), an enzyme located in mitochondria, is the key enzyme in protection of the energy-generating mitochondria from oxidative damage caused by free radicals(39).
c. Diabetes risk
Deficiency (too little) and efficiency (too much) of some essential trace metals may play a role in the development of diabetes mellitus(40).

4. Dulse,
commonly used in Ireland and Atlantic Canada both as foods and medicines, is a red seaweed of genus Palmaria, belong to Family Palmariaceae grown attached to rocks by a “holdfast” in the North Atlantic and Northwest Pacific. Dulse is found in many health food stores or fish markets or can be ordered directly from local distributors.
a. Health benefits
  Seaweeds, including dulse, showed to consist a important functional activities, such as antioxidant, antimutagenic and anticoagulant effect, antitumor activity, and modification of lipid metabolism(41).
b. Antioxidants
Dulse extracts showed to inhibit certain lipid peroxidations(42).
c. Weigh loss
As a rich source of fiber, dulse enhances the process of digestion, for making the stomach feeling fullness, thus reducing the risk of insulin cause of food craving(43).

5. Lime (Lemon)
Lime, a
around shape with green to yellow in color and 3–6 cm in diameter, is a species of Citrus Aurantifolia, belongs to the family Rutaceae, native to Southeast Asia.
a. Antioxidant
  Lime flower extract may contain high levels of antioxidant but lesser than the ethanol extract of cinnamon(44).
b. Vitamin C
Besides preventing the breaking off small vein cause of hardening of the vessel wall, vitamin C also improves the digestive system in maximum absorption of vital nutrients and plays an important role in enhancing immune system fighting against the forming of free radicals that cause muscle damage(45).
c. Immune system
Flavonoid , found abundantly in lime, improved the immune system in fighting against forming of free radical causes of tumor and cancer(46).
6. Etc.

C. The Antioxidants
1. Immune system and functioning (Free radical scavengers) 

Free Radicals play an important role in the function of the Immune System. The immune systen produces free radicals to kill foreign microbes, but the production of free radical sometime can be excessive, leading to formation of a large number of free radicals. The domino effects have shown to induce many chronic illness.
a. Vitamin A
vitamin A plays an essential roles in enhancing a broad range of immune processes, including white blood cells activation and proliferation, T-helper-cell differentiation, the production of specific antibody in regulation of the immune response(46a).
b. Vitamin C
Researchers found that vitamin C raised the concentration in the blood of total immunoglobulin(46b) in promotion of the ability of antibodies and phagocytic cells to clear pathogens(46c).
c. Vitamin E
  Vitamin E not only increased both cell-dividing and IL-producing capacities of naive T cells but also enhanced the immune functions in association with significant improvement in resistance to influenza infection.
d. Zinc
Zinc, as a antioxidant is essential mineral improved immune system by enhancing the proper function of T cells which belong to a group of white blood cells known as lymphocytes, in fighting against damaging free radicals.

2. Antioxidants and osteoarthritis
a. Vitamin E and fish oil
  Diet included fish oil plus vitamin E significantly reduce the levels of inflammation by analyzing the pro and anti-inflammatory cytokines in the blood serum.
b. Glucosamine
Glucosamine, a compound of the simple sugar glucose and the amino acid glutamine, is a precursor for glycosaminoglycans, a major component of joint cartilage. Supplemental glucosamine showed to prevent cartilage degeneration and treat arthritis, according to study.
c. DLPA (dl- phenylalanine)
DLPA, a mixture of D-Phenylalanine and L-Phenylalanine, is a nutritional supplement amino acid. showed effectively reduces arthritis pain and joint inflammation in many patients.
d. Glucosamine and Methylsulfonylmethane
In a double-blind, placebo-controlled study with osteoarthritis of the knee were given a combination of glucosamine and MSM, or placebo. After 12 weeks, Combination of MSM and glucosamine may improve arthritis symptoms, according to a
double-blind, placebo-controlled study
3. Etc.

D. The Phytochemicals 

1. Epigallocatechin, including catechins, found abundantly in green tea, St John wort, black Tea, carob flour, Fuji apples, etc. is a phytochemical of Flavan-3-ols, in the group of Flavonoids (polyphenols)
 a.  Inflammatory effects
Catechins might be useful therapeutically as an anti-inflammatory modulator of dental pulpal inflammation, thorugh
up-regulated expressions of IL-8 in fighting against infection or PGE(2) in response to infection or inflammation(47).
 b.  Antiviral activities
(-)-epigallocatechin (EGC) and green tea extract (GTE) inhibited the cytopathic effect of coxsackie B3 virus, but did not inhibit the cytopathic effects of HSV-1, HSV-2, influenza A or influenza B viruses(48)
c.  Antioxidants
Polyphenolic components extracted from green tea leaves, exhitbit antioxidative effects against free radical initiated and peroxidation of human low density lipoprotein(49).

2. Catechin is phytochemical of Flavan-3-ols, in the group of Flavonoids (polyphenols), found abundantly in white tea, green tea, black tea, grapes, wine, apple juice, cocoa, lentils, etc. 

a. Body-weight regulation
Green tea-caffeine mixture improves weight maintenance, through thermogenesis, fat oxidation, and sparing fat free mass(50).
b. Antioxidant activity
Polyphenolic compounds (included catechins) in the berries of edible honeysuckle exhibit the beneficial anti-adherence and chemo-protective activities in against a number of chronic conditions, e.g., cancer, diabetes mellitus, tumour growth or cardiovascular and neurodegenerative diseases(51).
c. Anti-inflammatory effect
Polymeric tannins and monomeric flavonoids, such as catechin and epicatechin found in green tea and pine bark, showed to exhibit theirs antioxidant capacity (TEAC), ferric reducing antioxidant power (FRAP) and oxygen radical absorbance capacity (ORAC)(52).

3. Theaflavin is phytochemicals of Flavan-3-ols, in the group of Flavonoids (polyphenols) found abundantly in black tea.
a. Antioxidant capacities
 Theaflavin-3′-gallate (TF(2)B), a derivative of theaflavin exhibits positive antioxidant capacities on singlet oxygen, hydrogen peroxide, hydroxyl radical, and the hydroxyl radical-induced DNA damage in vitro(53).
b. Antimicrobial activities
In the evaluation of the antimicrobial activities of seven green tea catechins and four black tea theaflavins, including (-)-gallocatechin-3-gallate, (-)-epigallocatechin-3-gallate, (-)-catechin-3-gallate, (-)-epicatechin-3-gallate, theaflavin-3, 3′-digallate, theaflavin-3′-gallate, and theaflavin-3-gallate exhibit antimicrobial activities, better than medicinal antibiotics, such as tetracycline or vancomycin, at comparable concentrations(54).
c. Anti inflammation
A single topical application of equimolar of black tea constituents (TF, theaflavin-3-gallate, theaflavin-3′-gallate, and theaflavin-3,3′-digallate) strongly inhibited TPA-induced edema of mouse ears, through its anti inflammatory activity(55).

4. Myricetin is a flavonol, belong to the flavonoid in Flavonoids (polyphenols), found in many grapes, berries, fruits, vegetables, herbs, as well as other plants. It has been used as antioxidant to lower cholesterol, treat certain types of cancer, etc.
a. Antioxidant and cytotoxic activity
  Extracted from plants containing phenolic compound, including flavonoid-galloyl glycoside [myricetin 3-O-(2',3'4'-tri-O-galloyl)-α-l-rhamnopyranoside] exhibited high antioxidant activity and cytotoxic activity against Hep G2 (IC(50)(56).
b.  Antitumour and anti-inflammatory activities
On mammary tumour cells LM2,
myricetin may be a promising agent in the treatment of murine breast cancer by immunomodulatory and antiproliferative activities due to its inhibitory activity to the release of NO(57).

5. Cyanidin is an anthocyanins (flavonals), in the group of Flavonoids (polyphenols), found abundantly in red apple and pear, bilberry, blackberry, blueberry, cherry, cranberry, peach, plum, hawthorn, etc.
a.  Antioxidants
Blackberries (BBs) containing mainly cyanidin 3-O-β-d-glucoside (C3G) exhibit its antioxidant effect in preventing bone loss in an ovariectomized (Ovx) rat model(58).
b. Anti-inflammatory Effects
A polyphenolic-enriched red raspberry extract (RRE; standardized to total polyphenol, anthocyanin, and ellagitannin contents),  decrease in the rate of degradation of both proteoglycan and type II collagen(59).
c. Obesity
Cyanidin-3-O-β-glucoside (Cy-3-g)-rich foods inhibited the onset of obesity, partly related to the activation of
skeletal muscle lipoprotein lipase(LPL), and inhibition of LPL in adipose tissue(59a)(60).
6. Etc.

VII. Treatments
A. In conventional medicine perspective

A.1. Medication
The aim of the treatment is to relieve symptoms of the disease
1. Acetaminophen
a. Acetaminophen such as Tylenol can help to relive the pain of Osteoarthritis. In the study to Tramadol/APAP add-on significantly improved knee OA pain which had been inadequately controlled by NSAIDs. Both tramadol/APAP and NSAIDs were effective at maintaining the pain-reduced state(61).
b. Side effects if overdose are not limit to
b.1. Nausea and vomiting     
b.2. Appetite loss     
b.3. Sweating     
b.4. Diarrhea     
b.5. Irritability
b.6. Abdominal pain
b.7. Etc.

2. Nonsteroidal anti-inflammatory drugs (NSAIDs).
a. The use of the medicine should be taken into account of in cost effectiveness, adverse event data and individual cardiovascular and gastrointestinal risks(62).
b. Side effects are not limit to 
According to King’s College School of Medicine and Dentistry, nonsteroidal anti-inflammatory drugs  may cause  

b.1. A nonspecific colitis (in particular, fenemates), and many patients with collagenous colitis are taking NSAIDs.  
b.2. Large intestinal ulcers, bleeding, and perforation
b.3. Relapse of classic inflammatory bowel disease
b.4. Serious complications of diverticular disease (fistula and perforation)
b.5. Small intestinal perforation, ulcers, and strictures requiring surgery
b.6. Specific biochemical and subcellular organelle damage(63).

3. Narcotics
Narcotics are natural opioid drugs derived from the Asian poppy may provide relief from more severe osteoarthritis pain, with additive effect
b. Side effects are not limit to
b.1. Risk of dependence
b.2. Dizziness and drowsiness
b.3. Nausea and vomiting
b.4. Headache and fatigue
b.5. Etc.
4. Etc.

A.2.. Non medication therapy
Non medication therapy depending to the individual needs, including patients education and self-management programs, weight loss if patient is overweight, physical therapy such as  muscle strengthening, aerobic conditioning and tai chi exercise, occupational therapy for joint protection, etc.
1.  Exercise therapy plus manual mobilisation showed a moderate effect size on pain compared to the small effect sizes for strength training or exercise therapy alone(64).

2.  Manual therapy is more effective than exercise for those with hip OA in the short and long-term(65).

A.3. Surgery
1. Arthrocentesis plus corticosteroid
Arthrocentesis is a medical procedure to remove joint fluid with a sterile needle for analysis through injection of corticosteroids into the joints to relieve pain, swelling, and inflammation. The number of cortisone shots is limit every year as overdoses the medication can cause joint damage.

2. Arthroscopy 
Arthroscopy is a minimally invasive surgical procedure to examine and treat  the abnormalities of and damage to the cartilage and ligaments through the arthroscope.

3. Lubrication injections
Injections of hyaluronic acid derivatives (Hyalgan, Synvisc) are recommended only to patients who have not found adequate pain relief conservative treatment options.

4. Realigning bones
Osteotomy is a surgical procedure used to realigning bones and cartilage and reposition the joint to reduce knee pain by shifting your body weight away from the worn-out part of your knee. 

5. Joint replacement
Joint replacement is a surgical procedure of orthopedic surgery to remove the damaged joint surfaces and replaces them with plastic and metal devices called prostheses. Joint replacement is considered as a treatment only for patient with severe joint pain or dysfunction that can not be alleviated by other less invasive treatments.
6. Etc. 

B. In herbal medicine perspective
1. Stinging nettle

Stinging nettle showed beneficial to patients with osteoarthritis in 2 general ways: pain relief and disease process modification(66). 

2. Ginger 

Ginger compresses for patients with osteoarthritis, showed a unique qualities of heat, stimulation, anti-inflammation and analgesia(67).

3. Devil’s claw 

Harpagophytum procumbens(Devil’s claw) is among the most commonly used complementary and alternative medicine approaches utilized by patients suffering from osteoarthritis(68).

4. Hot Chilli (Capsaicin) Topical capsaicin is consideration as adjuvant therapy in conditions such as post-herpetic neuralgia, diabetic neuropathy and osteoarthritis, where the pain can be chronic and difficult to treat| without
any severe systemic adverse, according to Dr Rains C, and Bryson HM(69).
5. Etc.

In traditional Chinese medicine perspective According to the article of Osteoporosis & Osteoarthritis in TCM Therapy by Chun Yi, Lu O.M.D., LAc.(71), Osteoarthritis is caused by blood stagnation and blood stasis.
C. 1. Shu Jing Huo Xue Tang (Clematis and Stephania Combination) is used to activate the blood and dispels blood stasis, induce downward movement of the blood, and strengthen the tendons and bones, reduce pain and inflammation and swollen of the joint lining and improve joint function. 

Depending to the patients’ situations, the following modifications are recommended
1. For pain in the arm or upper body, add Gui Zhi (Cinnamomum cassia).
2. For foot pain or pain in the lower body, add Mu Gua (Chaenomeles speciosa) or Yi Yi Ren (SemenCoix).
3. For qi deficiency, add Ren Shen (Radix Ginseng) or Ci Wu Jia (Siberian Ginseng) 

C.2. Shen Tong Zhu Yu Tang (Cnidium and Chiang Huo Combination)
1. Shen Tong Zhu Yu Tang (Cnidium and Chiang Huo Combination) is used to activate the blood, dispel blood stasis and wind-dampness, alleviate pain, unblock the meridians, promote the flow of qi, etc.
2. The ingredients of this formula include Ren (Semen Prunus persica),
2.2. Hong Hua (Flos Carthamus tinctorius),
2.3.Wu Ling Zhi (Excrementum Trogopteri seu Pteromi),
2.4. Niu Xi (Radix Achyranthes bidentata) and
2.5. Dang Gui (Radix Angelica sinensis)
Depending to on the patients’ situations, the following modifications are recommended
a. For slight fever, add Cang Zhu (Atractylodes lancea)
or Hunag Bo (Cortex Phellodendron amurense).
b. For Weakness, add Huang Qi (Radix astragalus).

C.3. Yi Yi Ren Tang (Coix Combination)
1. The formula is affliction of wind-cold-dampness marked by painful joints and accompanied by numbness also difficulty in stretching and swelling in the joints. it typically works in about eight weeks, and reduces pain at least 50 %, but often leaves patients pain free.
2. Ingredients of the formula include
2.1 Ma Huang (Herba Ephedra sinica),
2.2. Yi Yi Ren (Semen Coix lacryma-jobi),
2.3. Gui Zhi (Ramulus Cinnarmomum Cassia),
2.4. Cang Zhu (Rhizoma Atractylodes lance),
2.5. Dang Gui (Radix Angelica sinensis),
2.6. Shao Yao (Radix Paeonia lactiflora) and
2.7. Zhi Gan Cao (Radix Glycyrrhiza uralaensis preparata)
Depending to the patients’ situations, the following modifications
are recommended
a. For upper joints pain, add Ge Gen (Radix Puerariae lonatae)
b. For lower joints pain, add Chuan Niu Xi (Radix Cyathulae)
c. For serious whole joints pain, add Yan Hu Suo (Rhizome Corydalis)
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