THE TREATMENT OF OSTEOARTHRITIS
WITH CHINESE HERBAL MEDICINE
A Narrative Literature Review
Chris Wilson
Abstract
This is a narrative literature review to give insight into
whether Chinese herbal medicine (CHM) is a valid form
of treatment for osteoarthritis (OA). Current western
medical thought is migrating away from classifying OA
as an aging related disease to one caused by loading
and frequency of joint use. TCM considers OA to be
bi syndrome where qi and blood stagnation manifests
locally at the joints. The deformity is a result of fluid
accumulation and long term blood stagnation that
leads to malnutrition and eventual deformity of the
joints. Pubescent Angelica and Taxillus Decoction (du
huo ji sheng tang) was found to be the most commonly
prescribed formulae with the greatest volume of
research. Results were constantly positive, but a large
scale trial would be desirable.
and wears away, the bones rub together. This causes
the pain, swelling, and stiffness of OA. As OA worsens,
bony spurs or extra bone may form around the joint. The
ligaments and muscles around the joint may become
weaker and stiffer”. (U.S. National Library of Medicine,
2015)
It is apparent from these definitions that there is a lack
of clarity in relation to the structural, functional and
pain aspects of OA. Further confusion is created since
the highest incidence of OA is in the hand joints yet
most of the research is based around the knee. (Pereira,
et al., 2011)
Three standards, WOMAC (Rheumatology, 2015), SF-36
(Optimum.com, 2015) and VAS (Gillian A. Hawker*, 2011)
can be applied to measure clinical outcomes. Prevention
Keywords
has been mainly focused on comorbidity factors such
Traditional Chinese Medicine, TCM, Chinese Herbal
as weight loss (Vincent, et al., 2012) dietary supplements
Medicine, Osteoarthritis, OA, Bi Syndrome, Literature
(Neil, et al., 2005) and exercise. (Valderrabano & Steiger,
Review, du huo ji sheng tang
2011) Contra to the body of evidence that exercise is
beneficial to the management of OA (Uthman, et al.,
2013) a study revealed that there is a high prevalence
INTRODUCTION
of OA in rural workers who by the nature of their
occupation do more exercise and have a lowered
OA is defined by the NHS as “a condition that causes the prevalence of obesity. (Kang, et al., 2009) (Arthritis
joints to become painful and stiff. It is the most common Research Campaign, 2005) Although some work has
type of arthritis in the UK”. (NHS, 2015) NICE defines
been done (Neumann & Cook, 1985) (Kujala, et al., 1994)
OA as “a clinical syndrome of joint pain accompanied
to investigate loads on joints more research is required to
by varying degrees of function limitation and reduced
ascertain which weight bearing loads lead to OA.
quality of life”. (NICE, 2014) Arthritis Care defines OA
A geographical study in France linked the distribution
as “changes in cartilage that affect how joints work”.
of OA incidence to obesity (Guillemin, et al., 2011).
(Athritis Care, 2015) The US National Library of Medicine However, there are too few cases to study risk factors for
defines OA as “When cartilage breaks down
disease onset. (Felson & Nevitt, 2004)
The Register of Chinese Herbal Medicine Journal
39
Epidemiology
Epidemiological studies have found that musculoskeletal
diseases which include OA are one of the most common
causes for long term pain and disability. It is estimated
to be the fourth leading cause of disability. (Fransen,
et al., 2011) The cost to the public health system can
be broken into 3 areas: direct costs, indirect costs and
intangible costs. (Chen, et al., 2012) Direct costs did not
include any complementary medicines at all. NICE
estimated the prevalence of OA in the UK to be a total of
2.8 million patients, based on symptomatic diagnosis in
patients aged over 45 (NICE, 2014) with no estimates of
undiagnosed patients, which could be paralleled with the
US where 27 million people are diagnosed and 47 million
people may be undiagnosed. (Caceres, 2010) A significant
difference was made in cost saving for patients who
were diagnosed and subsequently treated. (Carlo, et
al., 2014) The World Health Organisation (WHO) has
reported that “over one-third of the population in
developing countries lack access to essential medicines.
The provision of safe and effective Traditional /
Complementary therapies could become a critical
tool to increase access to healthcare”. (WHO, 2003).
Despite the WHO recommendation, no expenditure on
Complementary and Alternative Medicine (CAM) based
interventions has been recommended, while the costs of
OA are set to soar.
CAM and costs of OA
There is insufficient reliable evidence for the cost
effectiveness of CAM based interventions. This was
highlighted by the Smallwood report (Smallwood,
2005), which was further dissected by (Ernst, 2006) for
inaccuracies and short comings. This does not mean
that CAM is ineffective, it has just not been adequately
researched. It is estimated that the direct costs of OA
at adjusted 2010 prices were £19.2million for topical
NSAID, £25.65million for oral NSAID, £98million for
NSAID iatrogenesis , £11.6 million for proton pump
inhibitor drugs, £1.3 million for arthroscopy and £852
million for joint replacement, which equates to £1007.75
million per year. This does not include indirect costs that
in 2002 resulted in loss of economic production of £3.2
billion and £258 million in social services. A clear need
for better quality of data for OA is needed. (Chen, et al.,
2012) These numbers are set to significantly increase
with the aging population where one in five people will
be over 65 by 2030. (Oliver, et al., 2014)
Aetiology
40
An understanding of the aetiology of OA relied on a
number of earlier papers (Murray, 1964) (Isdale, 1975)
(Fergusson, 1987) until a more recent discussion by
Weiss. (Weiss, 2007) OA is considered to be the most
ubiquitous pathological musculoskeletal condition.
Previous definitions did not include inflammation but
are now considered crucial to the pathogenesis of OA
(Punzi, et al., 2005). A number of palaeopathological /
palaeoepidemiological studies by anthropologists have
revealed that the cause of historical OA is from repetitive
mechanical loading from continued use of specific
muscles and joints in day to day tasks, corroborated by
Kang. (Kang, et al., 2009) This was a study on a modern
population of subsistence farmers in China with low
incidence of obesity and high prevalence of OA.
Modern aetiology considers genetics, anatomical
issues, Body Mass Index and mechanical lifestyle as
the primary causes of OA. The NICE guidelines (NICE,
2014) fail to adequately address these preventative
issues as their guidelines only focus on weight loss,
braces/supports and fitness training. A series of genetic
screening tests have been developed which could
be implemented. (Weiss, 2007) Anatomical issues
could be addressed with chiropractic and osteopathic
interventions. (Beyerman, et al., 2006) Mechanical
lifestyle could improve with workplace assessments and
ergonomic interventions. (Palmer, 2012) (Baldwin, et al.,
2012) Larger studies have been conducted which support
the conclusion that OA can be linked to an occupation
and is not an inevitable disease of aging. (Rossinghnol, et
al., 2003)
Chinese Medicine Understanding of OA
OA is categorised as bi syndrome, in particular bi
syndrome of the bone and Kidney. (Ni, 1995) (Maciocia,
2005) Bi syndrome’s main etiological classifications are
wind bi, cold bi, damp bi and heat bi which can affect the
five tissues, fu organs and zang organs. (Vagermeersh &
Pei-Lin, 1994)
The circulation of qi and blood are obstructed by an
externally invading pathogen which is indicated by
stiffness, numbness and/or pain in the joints. The
external pathogens penetrate the skin via the pores
where they can affect the whole jing luo system
and results in peripheral blockages of qi and blood
circulation. In OA pain is a result of excess and/or
deficiency which can manifest in stabbing, distending,
contracting and severe pain. Alternatively it can be
dull, intermittent and mild or a mix of both. Numbness
can be as a result of both conditions where damp has
accumulated or there has been deficiency of qi and blood
to the joints. Limited mobility is a result of the qi and
The Register of Chinese Herbal Medicine Journal
blood blockages locally. The deformity of joints is a result
of fluid accumulation and long term blood stagnation
that leads to malnutrition and eventual deformity of
the joints. It has been suggested that OA in the initial
stages is bi syndrome but the later stages of atrophy
of the muscles could be considered a major feature of
wei syndrome. (Hua & O’Brien, 2010) There is further
speculation that because the Kidney begins to decline
(Ni, 1995) there will be a resulting decline in the blood
which leads to OA being linked with age (Hua & O’Brien,
2010) but other epidemiological studies have shown that
OA may not be linked to age but work environment and
lifestyle which raises important questions regarding the
focus on the Kidney. (Rossinghnol, et al., 2003)
From a zang fu perspective bi syndrome is considered
to be a depletion of the Kidney and Liver that allows
for external pathogenic invasion. (Hua & O’Brien, 2010)
concluded that the 2 main agreed diagnostic zang fu
organs were the Spleen 23.1% and the Kidney 12.8% but
the sample size was not sufficient to justify that claim.
Traditional interpreted zang fu theory does state that
Kidney and Liver have a common source that combine
with the Spleen to form blood. (Maciocia, 2005) It was
noted that the top 3 zang Organs referred to were Kidney
(70%), Liver (42.5%), and Spleen (35%). (Hua & O’Brien,
2010)
Methodology
Databases searched were RCHM, JSTOR, PubMed,
MEDLINE, Cochrane, Google Scholar, EMBASE, Google
and Bing. English language sources were used. Animal
trials were included.
Keywords searched included OA, OA Chinese Medicine,
OA Chinese Herbal Medicine, Rheumatoid Arthritis,
DHJST,
A narrative literature review & critique of papers was
conducted and the following criteria for critiquing the
papers was used:
Conceptual framework:
• Are the aims clearly stated and research questions
clearly identified?
• Does the author link the work to an existing body of
knowledge?
Study design:
• Are the methods appropriate and clearly described?
• Is the context of the study well set out? Did the
research design account for possible bias?
• Are the limitations of research explicitly identified?
Research analysis:
•
•
Are the results clearly described, valid and reliable?
Is the analysis clearly described?
Conclusions:
• Are all possible influences on the observed outcomes
considered?
• Are the conclusions linked to the aims of study?
• Are the conclusions linked to analysis and
interpretation of data?
Chinese Herbal Medicine
(Chen, et al., 2014) analysed Taiwan’s national dataset
for the prescription of herbal formulas used in the
treatment of OA. They found the most prevalent formula
prescribed was du huo ji sheng tang (DHJS) followed by
Relax the Channels and Invigorate the Blood Decoction
(shu jiang huo xie tang) and Tangkuei Decoction to Pry
out Pain (dang gui nian tong tang). (Table 1 - The top 10
Chinese herbal formulae prescribed for OA in Taiwan
during 2002). The most frequently used individual herbs
were du zhong (Eucommia ulmoides Oliv.), xu duan
(Dipsacus asperoides C.Y.Cheng & T.M. Ai), and niu xi
(Achyranthes bidentate Blume). (Table 2 - The top 10
individual Chinese herbs prescribed for OA in Taiwan
during 2002). (Chen, et al., 2014)
Du Huo Ji Sheng Tang
DHJS is the primary formulae used for Bi Syndrome
(Chen, et al., 2014). It is contraindicated in strong excess
conditions or damp heat. (Bensky, et al., 5 Mar 2009)
The CAM report (Arthritis Research UK, 2014, p. 27)
concluded that the effectiveness score was only 2/5
even though (Teekachunhatean, et al., 2004) found the
formulae to have a NSAID effect and that it was as
efficacious as diclofenac which is used as a second/
third line treatment in the NICE Guidelines. (NICE, 2014)
(Arthritis Research UK, 2014) Both alluded to this even
though it was the only research available, with at least 20
supporting papers for the formula and herbs. Follow up
research was conducted to confirm anti-nociceptive and
anti-inflammatory activities in animal models, however
(Kunanusorn P, 2009) could not ascertain a significant
result in another animal trial. DHJS was found to
be slower acting than diclofenac with equal adverse
reactions which was not proven. There are significant
questions about the safety of long term NSAID treatment
which was found to increase the rate of heart disease
(Kearney PM, 2006) and adversely affect the kidneys.
(Brater, 2002)
Questions were raised about safety concerns with the
inclusion of xi xin (Asarum heterotropoides Fr. Var.
Mandshuricum (Maxim.) Kitag.). A four week study
The Register of Chinese Herbal Medicine Journal
41
was conducted with xi xin (Hsieh, et al., 2010) which
concluded that adverse effects were mild to moderate
and did not exceed a mild 2 hour headache. Unlike the
use of diclofenac no lifestyle or long term health issues
were reported when using xi xin (Zheng, et al., 2013) but
further research is required.
Other formulas have had limited research with mixed
results. Tortoise Shell and Deer Antler Two-Immortal
Syrup (gui lu er xian jiao) showed a significant decrease
in articular pain with OA.
It is often said that the actions and interactions in
Chinese herbal medicines are not understood but in the
case of DHJS a molecular study has been conducted
(Zheng, et al., 2013) which shows that it is drug-like and
contains multi target synergistic diverse combinations
binding to the OA targets.
Du zhong was found to inhibit the PI3K/Akt pathway
(an intracellular signalling pathway that has been
found to degrade cartilage), to reduce inflammatory
cytokines, delay cartilage degeneration and prevent
MMP-3 secretion (matrix metalloproteinase-3 is a
genetically encoded enzyme which is involved in tissue
remodelling). (Guo-ping Xie, 2015)
In the treatment of degenerative OA of the knee DHJS
was found to reduce pain, stiffness and improve
functioning. (Zheng CS1, 2007) DHJS treatment promotes
chondrocyte proliferation. This may explain its clinical
efficacy in the treatment of OA. (Wu, et al., 2013)
Regardless of all this evidence (Vijitha De Silva, 2011) on
behalf of the Arthritis Research UK group do not even
acknowledge the existence of DHJS for OA and have
inadequately evaluated DHJS for OA in other current
reports. This raises the question of biases that are
potentially shaping their recommendations instead of
the clinical evidence of treatment and outcomes.
Herbs
APS-3c a polysaccharide extracted from du huo
(Angelica pubescens Maxim f.f biserrata Shan & Yuan)
was found to improve the synthesis of chondrocytes
(cells that produce and maintain the cartilaginous
matrix) and suggest the relevance of APS-3c in the
treatment of OA. (Jun Qin, 2013) An intra-articular
injection of du huo and sodium hyaluronate may reduce
the degeneration of the cartilage. (Shiliang, 2009) There
was also a protective effect on the treatment of rabbit
knee arthritis (YI Jun, 2013)
Water extract of niu xi showed remarkable inhibition
of RANKL-treated osteoclasts (a type of membrane
Shu Jing Huo Xue
protein and member of the tumour necrosis factor (TNF)
This is the second most widely used formulae (Chen,
superfamily) that has been linked to the reduced risk of
et al., 2014) that focuses primarily on moving blood,
hip fracture. (Sato, et al., 2015) Water extract of niu xi
relaxing the channels and moving blood with deficiency. suppressed pro-inflammatory cytokines (cells involved
with signalling inflammation) and reduced bone erosion.
It was found to potentially increase blood flow in rats by (Kim, et al., 2010) A follow up study was conducted
the measure of tail surface temperature and locomotor
to confirm that there was a therapeutic potential in
activity. (Kanai, 2003) It was also found to reduce pain.
inflammatory joint diseases. (Kim & Park, 2010) Alcohol
(Shu H, 2010)
extracts of niu xi have also shown the ability to decrease
swelling and pain. (ZHAO Jia, 2008) Niu xi has been
Dang Gui Nian Tong Tang
found to be more effective when combined with hong
This formula was shown to be ineffective as an antihua (Carthamus tinctorius L) in reducing inflammation,
inflammatory and anti-hyperuricemic for arthritis (Chou activating blood circulation and dissipating blood stasis.
& Kuo, 1995). It did however reduce blood uric acid
(CHEN Hui, 2001) Niu xi has also been investigated to
levels in mice with hyperuricemia which would correlate ascertain if it can direct diclofenac to target areas, with
with the TCM theory of treating the Kidneys.
some success. (LIN Yuequan, 2009)
Other Formulas
A study was done on the metabolic regulatory and
anti-oxidative effects of modified bu shen huo xue
tang on an experimental rabbit model of OA with some
positive results. (Liu W, 2013) Fantastically Effective Pill
to Invigorate the Collaterals (huo luo xiao ling) was also
shown to have some positive results in a phase 2 human
clinical trial. (Lixing Laoa, 2015)
42
Rou gui (Cinnamomum cassia Presl) was also found
to have a chondroprotective effect (a compound or
chemical that delays progressive joint space narrowing
characteristic of OA) through anti-inflammatory and
anti-apoptotic properties. (Kim, et al., 2013)
Dang gui (Angelica sinensis, (Oliv.) Diels, Umbelliferae)
has been found to have a hematopoietic effect on
blood cells (hematopoietic stem cells are the blood cells
The Register of Chinese Herbal Medicine Journal
involved in the formation of blood cellular components)
which could be consistent with providing the joint blood
and fluid. (Gao QT, 2008)
Ren shen (Panax Ginseng C.A. Mey.) has ginsenosides
Rd and Rb3 which suppress MMP3 secretion (See Du
Zhong above). Ginsenosides Rd and Rb3 are the major
elements involved in the suppression of MMP3. The
suppression of MMP3 occurs via the inhibition of
phospho-p38 activation which may exert a protective
effect against cartilage degradation. (Joon-Shik Shina,
2009) It is also suggested that ginsenosides inhibit
matrix metalloproteinase-13 expression in articular
chondrocytes which prevent cartilage degradation. (Je
Hyeong Leea, 2013) Ren shen also modulates the levels
of MMP3 in S12 murine articular cartilage cell line
which may exert a protective effect against cartilage
degradation. (Joon-Shik Shina, 2009) There was also
a protective effect of ginsenoside Rb1 on hydrogen
peroxide-induced oxidative stress in rat articular
chondrocytes where inflammatory genes related to
chondrocytes were reduced by approximately 50%.
(Sokho Kim, 2012) Chondrocyte apoptosis has been
recognized as an important factor in the pathogenesis of
OA of which the anti-apoptotic activity of ginsenoside
Rb1 in hydrogen peroxide-treated chondrocytes results
in less cell damage around the joint. (Ji-Young Na, 2012)
This has been confirmed by research in human trials.
(Wendan Cheng, 2013)
as randomization, control, quality of life (QOL), patient
reported outcomes (PROs) and biomarkers, quality
control, safety evaluation, sample size and bias have
been noticeable in the clinic papers search. TCM has
struggled in the past fitting to the RCT model because its
diagnostic model is variable and dependant on the skill
of the clinician with a number of approaches available.
TCM pattern classification needs to be incorporated
into research design, producing value-added clinical
evidence to test the efficacy of TCM diagnostic and
treatment principles. (Miao Jiang, 2010) This was
attempted in (Hua, 2011) which used multiple clinicians
to blindly diagnose patients then formulate an aggregate
pattern diagnosis. Clinician sizes were too small and
further research needs to be done on this method.
Conclusion
Classification issues around the aetiology and
pathophysiology in western medicine hamper the overall
treatment of OA. In TCM, research is commencing to
evaluate the benefits of particular formulas and herbs.
DHJS is the most researched and widely understood
formula and as a result is the most assessed. The
formula’s main herb du huo is one of the least researched
for OA yet nui xi and ren shen are shown to be the most
efficacious because of the volume of positive research
findings. More research needs to done on the individual
formula components and the interactions of the mixed
herbs acting synergistically.
Quality and relevance of papers
More research is required on classifying OA outcomes
and clinical results, in particular with long term follow
Issues around the conduct of clinical trials in CHM, such up studies. Further research also needs to be done in the
Chinese herbal formulae (Chinese name) Ingredients Du-­‐huo-­‐ji-­‐sheng-­‐tang Shu-­‐jiang-­‐hou-­‐xie-­‐tang Dang-­‐gui-­‐nian-­‐tung-­‐tang Liu-­‐wei-­‐di-­‐huang-­‐wan Ji-­‐sheng-­‐shen-­‐qi-­‐wan Chi-­‐po-­‐ti-­‐huang-­‐wan Kou-­‐qi-­‐di-­‐huang-­‐wan Xue-­‐fu-­‐chu-­‐yu-­‐tang Gui-­‐zhi-­‐shuo-­‐yao-­‐zhi-­‐mu-­‐tang Shou-­‐yao-­‐gan-­‐tsao-­‐tang Jia-­‐wei-­‐xiao-­‐yao-­‐san Number of prescriptions (%) Du-­‐huo, Sang-­‐ji-­‐sheng, Ren-­‐sen, Fu-­‐ling, Gan-­‐cao, Dang-­‐guei, Shao-­‐yao, 8,538 (26.6%) Chuan-­‐qiong, Di-­‐huang, Gui-­‐zhi, Du-­‐zhong, Niu-­‐xi, Xi-­‐xin, Fang-­‐feng, Qin-­‐jiao Dang-­‐gue, Gan-­‐cao, Shao-­‐yao, Di-­‐huang , Bai-­‐zhu, Niu-­‐xi, Chen-­‐pi, Tao-­‐ 7,804 (24.3%) ren, Wei-­‐ling-­‐xian, Chuan-­‐qiong, Fang-­‐ji, QGiang-­‐huo, Bai-­‐zhi, ZLhu-­‐ling, ong-­‐dan-­‐cao, Qiang-­‐huo, Yin-­‐chen-­‐hao, Huang-­‐qin, an-­‐cao, Zhi-­‐mu, Ze-­‐xie, 3,560 (11.1%) Fu-­‐ling, Sheng-­‐jiang Fang-­‐feng, Dang-­‐guei, Cang-­‐zhu, Ge-­‐gen, Ren-­‐sen, Ku-­‐sen, Sheng-­‐ma, Bai-­‐zhu Di-­‐huang, San-­‐zhu-­‐yu, Shan-­‐yao, Mu-­‐dan-­‐pi, Ze-­‐xie, Fu-­‐ling 2,779 (8.7%) Di-­‐huang, Shan-­‐yao, San-­‐zhu-­‐yu, Ze-­‐xie, Fu-­‐ling, Mu-­‐dan-­‐pi, Rou-­‐gui, Fu-­‐ 2,126 (6.6%) zi, Niu-­‐xi, Che-­‐qian-­‐zi Zhi-­‐mu, Huang-­‐bo, Di-­‐huang, San-­‐zhu-­‐yu, Shan-­‐yao, Ze-­‐xie, Mu-­‐dan-­‐pi, 2,081 (6.5%) Fu-­‐ling Gou-­‐ci, Ju-­‐hua, Di-­‐huang, San-­‐zhu-­‐yu, Shan-­‐yao, Ze-­‐xie, Mu-­‐dan-­‐pi, 1,904 (5.9%) Fu-­‐ling Dang-­‐guei, Di-­‐huang, Tao-­‐ren, Hong-­‐hua, Zhi-­‐shi, Shao-­‐yao, Chai-­‐hu, 1,702 (5.3%) Gan-­‐cao, Jie-­‐geng, Chuan-­‐qiong, Niu-­‐xi Gui-­‐zhi, Shao-­‐yao, Bai-­‐zhu, Zhi-­‐mu, Ma-­‐huang, Gan-­‐cao, Fang-­‐feng, Sheng-­‐jiang, Fu-­‐zi Shao-­‐yao, Gan-­‐cao 1,532 (4.8%) 1,411 (4.4%) Table 1 The top 10 Chinese herbal
formulae prescribed for OA in Taiwan
during 2002. (Chen, et al., 2014)
Dang-­‐guei, Fu-­‐ling, Zhi-­‐zi, Bo-­‐he, Shao-­‐yao, Chai-­‐hu, Gan-­‐cao, Bai-­‐zhu, 1,249 (3.9%) Mu-­‐dan-­‐pi, Sheng-­‐jiang The Register of Chinese Herbal Medicine Journal
43
Chinese single herb (Chinese name) Generic name Number of prescriptions Percentage Xu-­‐duan Dipsacus asper 4,419 13.8% Du-­‐zhong Niu-­‐xi Mu-­‐gua Dan-­‐sen Ji-­‐xue-­‐teng Yan-­‐hu-­‐suo Wei-­‐ling-­‐xian Ru-­‐xiang Mo-­‐yao Gu-­‐sui-­‐pu Eucommia ulmoides Achyranthes bidentata Chaenomeles lagenaria Salvia miltiorrhiza Spatholobus suberectus Dunn Corydalis yanhusuo Clematis chinensis Osbeck Boswellia carterii Birdw. Commiphoramyrrha Engl. Drynaria fortune (Kunze) J. Sm. 5,005 3,763 11.7% 3,240 10.1% 3,115 9.7% 2,721 8.5% 2,494 7.8% 2,354 7.3% 1,715 5.4% 1,674 5.2% 1,569 About the Author
Chris Wilson has been interested in the Chinese approach to health
and well-being since studying Chinese martial arts in his early teen
years. He recently completed a degree in Acupuncture at Lincoln
University. He currently works as the Sales and Marketing Director
for Back to Health Chiropractors and is in his second year of the MSc
Chinese herbal Medicine at Westminster University
15.6% Table 2 The top 10 individual Chinese
herbs prescribed for OA in Taiwan during
2002)
4.9% Ernst, E., 2006. The ‘Smallwood report’: method or madness?. The british
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Fergusson, C., 1987. The aetiology of osteoarthritis. Postgraduate Medical
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Fransen, M. et al., 2011. The epidemiology of osteoarthritis in Asia.
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