골절 재생을 촉진하는 방법들에 대한 논문(자극, 영양, 흡연, 알콜 등) 정리 끝.

[문형철]

가장 중요한 것은 calories, 다음으로 중요한 것은 new protein

적당한 blood supply는 fracture healing에 필수. 그래서 blood flow를 줄이는 흡연, poor circulation은 healing process를 늦추는 중요한 요인

- 골절이 발생하면 large amount of inflammatory prostaglandis 분비. 이 과정은 fracture healing에 중요한 역할을 하기 때문에 NSAIDs는 통증을 줄이기 위해 추천되지 않음. 

-  aspirin, ibuprofen, indomethacin, etodolac (Lodine), meloxicam (Mobic), nabumetone (Relafen), and naproxen (Anaprox, Naprosyn)을 피해야 함. 

- 이 이야기를 어떻게 받아들여야 할까? 의철학적 문제군...

How to Speed Fracture Healing.pdf

How to Speed Fracture Healing

Dr. Susan E. Brown, PhD

Physiology of fracture healing

Fracture healing involves complex processes of cell and tissue proliferation and differentiation. Many players are involved, including growth factors, inflammatory cytokines, antioxidants, bone breakdown (osteoclast) and bone‐building (osteoblast) cells, hormones, amino acids, and uncounted nutrients.

- fracture healing은 cel과 tissue의 복잡한 proliferation and differention이 관여하는 과정

- growth factor,  inflammatory cytokines, antioxidants, bone breakdown (osteoclast) and bone‐building (osteoblast) cells, hormones, amino acids, and uncounted nutrients등이 관여함. 

Fracture healing can be divided into three phases. The inflammation phase is the first stage of healing. Immediately upon fracture, a blood clot forms, allowing the influx of inflammatory, clean‐up cells to the wound area. This is followed by a cytokine cascade that brings the repair cells into the fracture gap. These cells immediately begin to differentiate into specialized cells that build new bone tissue (osteoblasts) and new cartilage (chondroblasts). Over the next few months, these cells begin the repair process, laying down new bone matrix and cartilage. At this initial stage, osteoclast cells dissolve and recycle bone debris.

fracture healing은 세단계를 거침

1) inflammation phase

- 골절 부위에 blood clot form, influx of inflammatory, clean-up cell

- fracture gap에 회복을 위한 cytokine이 모임

- specialized cell로 분화하여 osteoblast에 의해 new bone cell을 만들고, chondroblast에 의해 new cartilage를 만듬

- 몇개월이 지나면 repair process를 거쳐 new bone matrix와 cartilage를 만듬. 

- 이 시기에는 osteoclast cell이 bone debris를 dissolve and recycle함.

The second, reparative stage begins about two weeks after the fracture occurs. In this stage, proteins produced by the osteoblasts and chondroblasts begin to consolidate into what is known as a soft callus. This soft, new bone substance eventually hardens into a hard callus as the bone weaves together over a 6‐ to 12‐week time period.

2) reparative stage

- 골절 2주후 일어나는 회복과정

- osteoblasts and chondroblasts에 의해서 단백질이 생성되어 굳어지기 시작. 이를 soft callus formation

- soft callus, new bone substance는 단단해져 hard callus가 되어 6~12주가 지나면 단단한 bone조직으로 됨.

The final step of fracture repair is known as the remodeling phase. At this stage the callus begins to mature and remodel itself. Woven bone is remodeled into stronger lamellar bone by the orchestrated action of both osteoblast bone formation cells and osteoclast bone resorption cells.1

3) remodeling phase

- final step of fracture repair

- 이 시기에 callus는 mature and remodel itself

- osteoblat bone formation cell과 osteoclast bone resorption cell의 협동작용에 의해 woven bone은 재생되어 강한 lamellar bon이 됨.  

The nutritional demands of healing

Each stage of the fracture healing process brings with it increased nutritional demands. For starters, the whole process requires a great deal of energy—which is generally supplied through the intake of calories in food. Next, healing requires the synthesis of new proteins, which is dependent upon an ample supply of amino acids derived from dietary proteins. An adequate blood supply is also mandatory for fracture healing, so anything that diminishes blood flow (such as smoking or poor circulation) slows the healing process. Also, the trauma of the fracture itself creates a biochemical burst of pro‐oxidants (free radicals), causing oxidative stress that can overwhelm the body’s antioxidant reserves.

골절 치유 bone healing에 관여하는 영양물질

- 가장 중요한 것은 음식으로 섭취되는 calories

- 다음으로 중요한 것은 new protein

- 적당한 blood supply는 fracture healing에 필수. 그래서 blood flow를 줄이는 흡연, poor circulation은 healing process를 늦추는 중요한 요인 

Nutritional steps to accelerate fracture healing

People who have had a fracture aren’t often told that they can do anything to make their bones heal faster – at most, they’re told to limit the use of the injured bone or limb (not easy to do if the fracture is in your spine!). But there are a number of methods you can employ to reduce your healing time:

Provide the body with adequate energy. 

Fracture healing requires more energy than you might expect. Thus, it’s appropriate to increase your caloric intake to promote healing. In traumatic fractures of the long bones, for example, there is an immediate increase in metabolic demands that can translate into a caloric demand three times that of normal. While a normally active adult may require 2,500 calories a day, a bedridden, injured patient with multiple fractures may need 6,000 calories per day!2 If this demand is not met, the healing process is compromised.3

- fracture healing에 가장 중요한 요인은 에너지(칼로리)

- 정상 성인이 하루 2500칼로리 필요, 복합골절의 경우 하루에 6000칼로리 필요함. 

Check your protein intake. 

Bone can be imagined as being somewhat like a sponge made of living protein upon which mineral crystals are embedded. By volume, roughly half of bone is comprised of protein. When a fracture occurs, the body is called upon to gather protein building blocks together to synthesize a new structural bone protein matrix. 

- volume관점에서 볼때 뼈의 절반은 단백질

- 골절이 되면 인체는 단백질은 모아 합성하여 새로운structural protein matrix를 합성. 

In addition, protein supplementation increases growth factors like insulin‐like growth factor‐1 (IGF‐1), a polypeptide that exerts a positive effect on skeletal integrity, muscle strength, immune response, and bone renewal.4 Protein malnutrition or under‐nutrition leads to a “rubbery” callus, compared to the rigid calluses of those with adequate or high protein intake. 

- 단백질 공급은 lGF-1과 같은 성장인자를 증가시키고, 폴리펩타이드는 Skeletal integrity, 근력, 면역력, bone renewal에 긍정적인 효과

- 단백질이 부족해지면 고무같은 callus를 만들어 ...

Numerous studies document the acceleration of fracture healing with even a modest 10‐ to 20‐gram increase in protein intake. The benefits of supplemental protein are important to everyone and especially important to those with malnutrition or low baseline protein intake. In fact, among elderly hip fracture patients, poor protein status at the time of fracture predicts fracture outcome. Those with low protein status take longer to heal, and have more complications, including death.5

- 많은 연구에서 적당한 10-20 그램의 단백질 섭취가 fracture healing를 촉진한다고 보고.

- 단백질 보충의 이점은 malnutrition환자나 단백질 섭취가 부족한 환자에게 특히 중요함.

- 노인 골절의 경우 단백질이 부족한면 healing이 늦어지고, 합병증이 생기고, 죽음에 이르기도..

Specific amino acids of special importance include lysine, arginine, proline, glycine, cystine, and glutamine. Lysine, for example, is known to enhance calcium absorption, increase the amount of calcium absorbed into the bone matrix, and aid in the regeneration of tissue.

- 라이신, 아르기닌, 프로린, 글라이신, 치스테인, 글루타민을 포함한 아미노산을 포함. 

- 라이신은 calcium absorption을 증가시키고, ...

Increase anti-inflammatory nutrients. 

Antioxidants repair oxidative damage. When a bone fracture occurs, a remarkable yield of free radicals is generated by the damaged tissues. In particular, this damage occurs as the tightly bound collagen strands running through the mineral phase of bone are forcefully broken. These ruptured collagen strands interact with oxygen‐yielding oxygen radical metabolites.6 These free radicals are associated with inflammation, further breakdown of bone collagen, and excessive bone turnover. In fracture healing, increased free‐radical production can overwhelm the natural anti‐oxidant defense mechanisms. In such cases, antioxidants — including vitamins E and C, lycopene, and alpha‐lipoic acid — have been suggested to be beneficial in suppressing the destructive effect of oxidant free radicals on whole body systems and improving fracture healing in animal models and cultured human cell lines.6

- 골절이 되면 free radical이 손상된 조직에서 만들어지고 

- 프리 라디칼은 염증반응과 연관되고, bone collagen 파괴, 과도한 excessive bone turnover와 연관됨. 

- 골절되어 발생한 프리 라디칼 증가는 자연스러운 anti-oxidant 방어기전을 넘어서서 문제를 발생시킴. 

- 항산화제인 vitamins E and C, lycopene, and alpha‐lipoic acid는 oxidant free radical의 파괴적 효과를 억제하여 골치유를 증진시킴. 

Inflammation is an essential component of the healing process in bone. Although painful, it is an important part of the cleaning‐up and rebuilding process. This inflammatory process involves the cyclooxygenase (COX) enzymes COX‐1 and COX‐2. Many of our standard non‐steroidal anti‐inflammatory drugs act by inhibiting the COX‐1 and COX‐2 enzymes—which relieves the pain, but also delays healing. On the other hand, nourishing the body to reduce inflammation naturally speeds healing. Vitamin C, bioflavonoids and flavonols such as quercitin and proanthrocydins, and omega‐3 fatty acids naturally soothe the inflammatory process and speed healing.

- 염증은 bone healing process에 중요한 역할. 비록 염증반응으로 아프지만 bone debris를 제거하고, rebuilding process에 중요한 역할. 이러한 염증반응은 COX효소, COX-1효소, COX-2효소가 중요한 역할. NSAIDS는 이러한 염증과정에 관여하여 통증을 줄여주지만 과도한 억제는 Healing속도를 늦춤. 

- 영양공급을 제대로 하면 염증을 줄이고 자연스럽게 healing speed를 높임.

- Vitamin C, bioflavonoids and flavonols such as quercitin and proanthrocydins, and omega‐3 fatty acids는 염증반응을 적절히 조절하여 healing을 촉진함. 

Boost your mineral intake. 

By weight, bone is roughly 70% minerals (calcium, phosphorus, magnesium, silicon, zinc, etc.) and fracture healing requires available minerals. Most of us under‐consume minerals on an everyday basis, so drawing minerals to the healing site can often involve a process of “stealing from Peter to pay Paul.” (See our 20 key bone nutrients for details on average mineral intake.) Specific key minerals for fracture healing include the following:

- 뼈는 대략 70% 미네랄로 구성됨.  calcium, phosphorus, magnesium, silicon, zinc

- 그래서 fracture healing과정에서 이러한 미네랄은 필수.

1) ZINC(아연) 

Some 200 enzymes require zinc for their functioning. Many of these functions involve cell proliferation. Zinc supplementation aids in callus formation, enhances bone protein production, and thus stimulates fracture healing.7

- 아연은 callus formation을 돕고, bone protein production을 증진시키고, fracture healing을 자극

2) COPPER(구리)

Copper aids in the formation of bone collagen and is important to the healing process. The body’s demand for both copper and zinc rises according to the severity of the trauma.8

- 구리는 bone collagen formation을 돕고, healing process를 촉진하는 효과. 

3) CALCIUM AND PHOSPHORUS. 

The main minerals in bone are calcium and phosphorus, in the form of calcium hydroxyapatite crystals. This hydroxyapatite compound plays an important role in regulating the elastic stiffness and tensile strength of bone.9 The building and rebuilding of bone tissue requires adequate supplies of both calcium and phosphorus, which can be supplied from diet and bone reserves. 

- 뼈의 주요 미네랄은 calcium hydroxyapatite crystal 형태의 칼슘과 인. 

- hydorxyapatite는 뼈의 인장강도와 elastic stiffness를 조절하는데 중요한 역할.

참고) hydorxyapatite 다른 논문 

Early research suggested that fractures can heal normally independent of dietary calcium and indeed it has been found that during the first few weeks of healing, calcium is drawn from the skeleton for fracture healing. After that, the diet provides the calcium necessary for fracture repair.10 

- 연구에 의하면 dietary calcium은 골절 치유의 처음 몇주에서 중요한 역할. 이후 칼슘은 fracture repair에 중요한 역할

Calcium adequacy at the RDA level is important, but unusually high intakes do not appear to speed fracture healing. As calcium absorption is dependent on vitamin D, these nutrients work synergistically. Human studies, in fact, suggest that for best fracture healing both calcium and vitamin D should be obtained in optimum daily levels.11 Most of us consume plenty of phosphorus and often too much if the diet is high in processed foods and colas. However, the elderly, dieters, and those on low protein diets often do not consume enough phosphorus to meet the needs of new bone formation.12

- 칼슘 흡수는 비타민 D에 의존적이기 때문에 함께 사용해야

- 인은 일반적으로 음식에서 흔히 많이 섭취됨. 하지만 노인의 경우나 Low protein diet의 경우는 bone formation에 충분치 않으므로 주의해서 섭취해야

4) SILICON(규소)

It has long been known that bioactive silicon (silica) plays an important role in bone collagen synthesis. A 2005 human study found bioactive silicon to enhance the effects of calcium and vitamin D3 on new bone formation.13

- 규소는 bone collagen합성에 중요한 역할. 연구에 의하면 bioactive silicon은 칼슘과 비타민 D3의 new bone formation에 중요한 역할.

Enhance vitamin intake. 

While protein and minerals may be the building blocks, vitamins are the catalysts for many biochemical reactions and are equally important. In fracture healing, we can clearly identify the vital roles of several vitamins including vitamin C, vitamin D, and vitamin K as well as the energy‐producing B vitamins, which should all be taken in therapeutic doses:

1) VITAMIN C is essential for proper synthesis of the bone collagen protein matrix. It is also one of the most important antioxidants and anti‐inflammatory nutrients. In severe vitamin C deficiency, collagen becomes too unstable to function properly, which results in skin lesions and fragile blood vessels with eventual bleeding from all mucous membranes. A tendency to black and blue without reason is most often a sign of sub‐clinical vitamin C deficiency. Because of its essential role in bone collagen formation, adequate vitamin C is required for fracture healing. Several animal studies document this fact. For example, a small Turkish rat study showed that vitamin C supplementation accelerated the fracture healing process.14 A similar, yet larger, Spanish study also documented that rats with higher vitamin C blood levels developed a stronger fracture callus than did those with low blood levels.15

- 비타민 C는 bone collagen protein matrix의 합성에 중요한 역할. 항산화제와 항염증 영양분으로 중요한 역할. 

- 심각한 비타민 C부족은 skin lesion, blood vessel의 약해짐 등으로 출혈

2) VITAMIN D is the primary regulator of calcium absorption and without adequate vitamin D calcium blood level drops making less calcium available for fracture healing. Studies as early as 1945 documented that low vitamin D levels led to suboptimal fracture healing and the administration of vitamin D accelerated initial fracture callus mineralization.16 Further, we now know that vitamin D, in conjunction with vitamin K, stimulates the transformation of fracture site stem cells to bone building osteoblasts.17 Overall, vitamin D is central to fracture healing and vitamin D status has been shown to be an independent predicator of functional recovery after hip fracture.18

- 비타민 D는 칼슘 흡수 조절자. 

- 비타민 D는 비타민 K와 함께 osteoblast를 자극하여 골절치유를 촉진.

3) VITAMIN K is an essential part of the biochemical processes that bind calcium to bone and it is required for proper formation of the osteocalcin bone protein. In addition, vitamin K helps conserve calcium by reducing the loss of calcium in the urine.19 Since 1960 it has been noted that vitamin K has a beneficial effect on fracture healing and has a real effect on all collagen tissues, especially bone tissue.20 Researchers have found that vitamin K is sequestered to the site of fracture resulting in markedly depressed circulating levels of vitamin K in fracture patients. The time taken for the vitamin K blood level to return to normal appears to be influenced by the severity of the fracture.21

- 비타민 K는 뼈에 칼슘을 붙이고, Osteocalcin bone protein의 적절한 형성에 필수. 

- 비타민 K는 소변으로 칼슘이 빠져나가는 것을 줄여서 칼슘을 보존. 또한 fracture healing에 도움이 되고, 특히 collagen tissue의 치유에 더욱 효과적.

4) VITAMIN B6 is one of the B vitamins that has been linked to fracture healing. Animals deficient in this vitamin fracture more frequently and experience reduced fracture healing. It appears that vitamin B6 modulates the effects of vitamin K on bone through complex biochemical pathways.22

- 비타민 B6는 골절 치유속도에 중요한 역할. 특히 비타민 k를 조절하여 ....

Anti-inflammatory nutrients help reduce pain. 

Where there is pain, there is inflammation — a product of the body’s action to tear down, recycle, and repair damaged tissues. For fracture healing, it is ideal to use nutrients that are both anti‐inflammatory and nourishing to new bone growth. Useful anti‐inflammatory nutrients include vitamin C, quercitin and other flavonoids, omega‐3 fatty acids, and proteolytic enzymes such as bromalain and trypsin.

- 유용한 항염증 영양물질은 비타민 c, quercitin, flavonoid, 오메가 3, bormalain and trypsin 등.

Multi-nutrient therapy is the likely best approach

Bone is complex tissue that requires many nutrients. Given this fact, supplementation with a wide range of key bone nutrients is likely to provide more effective fracture healing than individual nutrient supplementation. At the Center for Better Bones, we always recommend therapeutic doses of all the 20 key bone‐building nutrients for optimum fracture healing. 

- 20가지 뼈재생 영양물질.

While no scientist has yet conducted a clinical trial using all 20 key nutrients for fracture healing, several studies have found multi‐nutrient therapy to reduce complication and accelerate fracture healing. A 2006 Swedish hip fracture study found fracture patients given complex multi‐nutrient supplementation containing protein, carbohydrates, amino acids, sodium, potassium, calcium, magnesium, chloride, trace minerals, and fat soluble vitamins, had only a 15% rate of complications as compared to a 70% complications rate among the non‐supplemented group.23 Also impressive is a Swedish meta‐analysis of 17 such clinical hip fracture trials which reported that oral multi‐nutrient supplementation (including nutrients such as carbohydrates, protein, arginine, zinc, and antioxidants) reduced deaths and complications from hip fracture by nearly 50%.24

참고) Nutritional supplementation decreases hip fracture-related complications.

Eneroth M, Olsson UB, Thorngren KG.

Source

Department of Orthopaedics, Lund University Hospital, Lund, Sweden. magnus.eneroth@med.lu.se

Nutritional Supplementation Decreases Hip fracture-related .pdf

Abstract

Protein energy malnutrition is an important determinant of clinical outcome in older patients after hip fracture, but the effectiveness of nutritional support programs in routine clinical practice is controversial. We performed a prospective, randomized, controlled clinical trial to determine if nutritional supplementation decreased fracture-related complications in a selection of otherwise healthy patients with hip fractures. Patients were randomized to intervention or control groups. The control group (n = 40) was given ordinary hospital food and beverage. The intervention group (n = 40) also was administered a 1000 kcal daily intravenous supplement for 3 days, followed by a 400 kcal oral nutritional supplement for 7 days. We recorded daily fluid and energy intake during the first 10 days of hospitalization and fracture-related complications up to 4 months. The total fluid and energy intake in the intervention group neared optimal levels. The control group received 54% and 64% of optimal energy and fluid intake, respectively. The risk of fracture- related complications was greater in the control group (70%) than in the intervention group (15%). Four patients in the control group died within 120 days postoperatively. The comprehensive balanced nutrition supplement resulted in lower complication rates and mortality at 120 days postoperatively.

Another innovative placebo controlled, multi‐nutrient study from India administered vitamin C, lysine, proline, and vitamin B6 to tibial fracture patients. In those receiving multi‐nutrient therapy, fracture healing time was reduced by approximately two weeks, with a larger percentage healing in 10 weeks (33%) as compared to the 11% in the placebo group.25

참고) 아래 논문 원문 찾고싶다

Reduction in Tibial Shaft Fracture Healing Time With Essential Nutrient Supplementation Containing Ascorbic Acid, Lysine, and Proline

J.Jamdar, B. Rao, S. Netke, M.W. Roomi, V. Ivanov, A. Niedzwiecki, M. Rath
“Letter to the Editor” (4 pg) by Journal of Alternative and Complementary Medicine 2004, 10 (6): 915-916.

Objective:
Healing of bone fractures is a prolonged process that can be affected by nutrition. Our objective was to critically eval‎uate the effect of supplementation with an essential nutrient complex, containing ascorbic acid, lysine, proline, and vitamin B6 on healing time of tibial fractures.

Design: 
Random double-blind placebo-controlled study

Setting: 
Dr. Jamdar Hospital, Jabalpur, India

Subjects and Intervention: 
113 patients with unilateral displaced closed or grade I open tibial fractures were randomized to receive either standard care with placebo or with supplementation with an essential nutrient complex containing ascorbic acid, lysine, proline, and vitamin B6. Qualifying patients, on admission to the study, were clinically examined, radiographs of the affected limbs taken, fractures reduced under anesthesia, and above knee plaster casts applied. Radiographs were taken at each follow-up visit to confirm‎ reduced alignment of fracture and proper callus formation.

Primary Outcome Measure: 

The primary outcome measure was the number of weeks required for fracture to be healed. Healing was defined as absence of abnormal mobility at fracture site clinically, absence of pain elicited by stressing the fracture or by walking, and radiographic confirmation of callus formation.

Results: 
Data analysis demonstrated reduced fracture-healing time associated with experimental supplementation. For PP analysis group, fracture healing time in 75% of the supplemented group of patients (N=21) was 17 weeks or less and 19 weeks or less in 75% of the placebo group patients (N=36). The percentage of patients with fractures healing in 10 weeks or less was 33.3% for the supplemented group and 11.1% for the placebo group. However, the difference in healing time between the two groups did not reach statistical significance.

Conclusion: 
Results showed encouraging trends that fracture-healing time is reduced by supplementation with an essential nutrient complex containing ascorbic acid, lysine, proline, and vitamin B6. In addition, the nutrient supplemented participants reported improved feeling of well-being with use of the supplement.

An Alkaline for Life™ eating program stimulates bone repair

The Alkaline for Life™ eating program provides a diet rich in minerals, vitamins, and phytonutrients obtained from vegetables, fruits, nuts, and seeds. This life‐supporting eating pattern has been shown to create a health‐promoting internal biochemical environment which, among other things, conserves bone building minerals and proteins. Such a base‐forming eating program also has been shown to increase growth hormones and growth factors such as IGF insulin‐like growth factor.26 These growth hormones are among the most important biochemical forces encouraging fracture repair and new bone formation.27

Herbal fracture healing aids

Throughout history, and even today in much of the world, traditional herbal medicine has been the mainstay of medical practice. This long tradition of herbal wisdom has employed various herbs to speed fracture healing. Among these is cultivated (European) comfrey (Symphytum uplandics x.), which should not be confused with a potentially toxic wild variety (Symphytum officinale), nor with a native herb that is also called “wild comfrey” (Cynoglossum virginianum) that is native to the US. Herbalist Susun Weed recommends cultivated comfrey be used in the form of a strong tea (infusion) as an aid in fracture healing. Details of her recommendation are available at www.susunweed.com/herbal_ezine/June08/wisewoman.htm). 

- 컴프리 약재

She also reports great success applying a hot, fresh burdock leaf poultice to reduce the swelling induced by a fracture.28 Arnica (Arnica montana) is reportedly another helpful herb, as detailed by herbal researcher Alma Hutchens, but it must be used with caution as large amounts are poisonous. She reports that five drops or fewer of Arnica tincture given every 3 to 4 hours after the initial trauma is said to help recovery from the trauma of fracture.29 Horsetail grass is an herb high in silicon, which can be boiled and made into a tea valuable in the early stages of fracture healing.30 In all cases, however, herbal medicine should be used under the guidance of a qualified herbalist.

- horsetail grass 약재

Traditional Chinese herbal medicine can be an effective way to reduce the swelling, pain, and soreness of fracture. Chinese medicine can also accelerate healing when used under the guidance of an experienced practitioner.31 Finally, the traditional Ayurvedic medicine of India is now becoming known in the West and drawing the attention of scientists and pharmaceutical companies alike. The Indian herb Cissus quadrangularis in particular has been studied for its fracture‐healing benefits.

As we look around the world, we would indeed expect to find traditional herbal approaches to fracture healing and those with access to an expert herbalist can benefit from this traditional wisdom.

Exercise and fracture healing

Exercise is unlikely to pop into your mind as an important way to accelerate fracture healing — yet it is. In general, bone tissue responds to patterns of loading by increasing matrix synthesis, altering composition, organization, and mechanical properties. Evidence indicates that the same holds true for bone under repair. Further, fracture healing requires good circulation and an adequate flow of nutrient‐replenishing blood to the fracture site — both of which are enhanced by exercise. To avoid stress on the broken bone, joint loading, range of motion, and specific tendon‐gliding exercises are employed to accelerate healing and assure return of function post fracture.32 For example, in the case of a broken forearm, exercises would involve movements of the fingers and hand, as well as the elbow and shoulder joints.

Energy medicine for fracture healing

Energy medicine is described in a recent medical journal as, “...a field of complementary therapy based on the interactions of the human energy field with other energy fields (human or other).”33 Interestingly enough, pulsing electromagnetic field therapy is a form of energy medicine that has been used for many years by conventional doctors to heal fractures that have not healed on their own (known as non‐union fractures). 

Approximately 5 – 10% of bone fractures fail to heal normally and result in delayed healing or non‐union. In these situations, the use of electromagnetic bone stimulating devices has proven to speed healing. For a review of the literature see: www.ifess.org/Services/Consumer_Ed/References/bone_healing_references.htm

- 5~10% bone fracture환자에서 delayed healing

-  use of electromagnetic bone stimulating devices has proven to speed healing

Homeopathy, reiki, qi gong, polarity therapy, healing touch, acupuncture, and massage are all non‐conventional energy healing modalities with applications for fracture healing. Common over‐the‐counter homeopathic remedies include arnica as an anti‐trauma remedy for immediately after the fracture (not to be used if the person is unconscious), symphytum (comfrey) for pain relief and the joining of set bones, and Calcarea phosphorica for fractures that are difficult to heal. Low‐potency homeopathic remedies (6x, 6c to 30x, 30c) are often used for self‐help, as detailed in Homeopathic Self‐Care by Robert Ullman and Judyth Reichenberg‐Ullman (Prima Publishing, 1997) and at www.peacehealth.org/kbase/cam/hn‐2201007. Homeopathy is a powerful medicine and when possible the best policy is to seek the advice of a professional homeopath.

- Homeopathy, reiki, qi gong, polarity therapy, healing touch, acupuncture, and massage는  non‐conventional energy healing modalities다. 

Pain relievers and fracture healing

Cells damaged from the trauma of fracture release large amounts of inflammatory prostaglandins at the site of fracture. The ensuing inflammation causes pain and the natural tendency is to want to block this painful reaction. In this case, non‐steroidal anti‐inflammatory drugs (COX‐1 and COX‐2 inhibitors) might be the medication we reach for to relieve the pain. The use of these COX‐1 and COX‐2 inhibitors, however, can delay fracture healing. As it turns out, prostaglandin‐induced inflammation is an essential component of the fracture healing process, and cyclooxygenase enzymes (COX‐1 and COX‐2) play important roles in fracture repair. These inflammatory prostaglandins are a natural and essential part of initial tissue repair and the initial inflammatory immune response is crucial to fracture healing. Because of this, the use of non‐steroidal anti‐inflammatory pain killers (NSAIDs) is not recommended for fracture pain relief. Among the NSAID COX‐1 and COX‐2 inhibitor drugs to be avoided are aspirin, ibuprofen, indomethacin, etodolac (Lodine), meloxicam (Mobic), nabumetone (Relafen), and naproxen (Anaprox, Naprosyn).34

- 골절이 발생하면 large amount of inflammatory prostaglandis 분비. 이 과정은 fracture healing에 중요한 역할을 하기 때문에 NSAIDs는 통증을 줄이기 위해 추천되지 않음. 

-  aspirin, ibuprofen, indomethacin, etodolac (Lodine), meloxicam (Mobic), nabumetone (Relafen), and naproxen (Anaprox, Naprosyn)을 피해야 함. 

Acceptable alternatives to help reduce the pain of fracture include acetaminophen (as in Tylenol). In severe cases, narcotics such as codeine are given along with the acetaminophen. There are also natural pain‐relief alternatives, including several nutrients that have been documented to help reduce the pain of inflammation of fracture while also enhancing the healing process. 

- 받아들일 수 있는 통증 감소약물은 타이레놀(아세트아미노펜). 심한 경우에는 codeine와 같은 마약성진통제를 아세트아미노펜과 함께 사용. 

For example, in a study of 328 wrist fracture patients, modest 500 mg/day supplementation with vitamin C reduced by more than 4‐fold the incidence of post‐fracture complex regional pain syndrome.35 

Can Vitamin C Prevent CRPS in patient with wrist fracture.pdf

In clinical use at the Center for Better Bones, we have found that the well‐studied flavonoid, quercitin, used in doses of 2–3 g per day, has a synergistic effect with vitamin C, amplifying the pain‐relief benefits. These nutrients, as well as omega‐3 fatty acids, reduce inflammation without inhibiting the COX‐1 and COX‐2 enzymes. In addition, European research has shown the value of proteolitic enzymes (protein digesting enzymes) such as bromelain and trypsin for reducing inflammation, edema, and pain in fracture patients.36 One such European proteolytic enzyme combination available in the US is the Wobenzym formula.

Smoking

Numerous studies document that smoking delays the healing process and increases morbidity associated with fracture. For example, the fractured tibias of patients who smoked took 62% longer to heal than non‐smokers.37 Further, postoperative complications such as delayed healing, infection, and fracture non‐healing (non‐union) are much more common among smokers.38

A further example from a study at Johns Hopkins University found that:

􀂙 Current and previous smokers were less likely to achieve union than non‐smokers.

􀂙 Current smokers were more than twice as likely to develop an infection.

􀂙 Previous smokers were 2.8 times more likely to develop osteomyelitis (bone infection).39

Interestingly enough, the impact of smoking appears to be a non‐nicotine effect involving delays in the cartilage‐forming phase of fracture healing.40 All in all, the clear recommendation is that those who fracture cease smoking for the full rehabilitation period.41

Alcohol abuse

Alcohol in excess can be directly toxic to bone and alcohol abuse is associated with increases in both the incidence of fractures and complications of fracture healing, including infection. In a Danish ankle fracture study, for example, alcohol abusers had significantly more early complications, especially infections, from reparative ankle surgery.42 It is highly advisable to eliminate any excessive alcohol intake during fracture healing.

- 술은 골절치유에 directly toxic

Conclusion

Bone is a complex, living tissue which constantly changes and adapts itself to the demands put upon it. A myriad of nutrients, hormones, and other biochemical factors are essential to bone formation and maintenance, so an equal number of factors figure in the bone repair process. While a fracture can be frightening and leave us questioning the strength of our skeleton, such a mishap might well be seen as a “window of opportunity” to make nutritional and lifestyle changes that will strengthen the entire skeleton and improve overall health.

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