Volume 8, Number 3 | Fall 2013

Kampo Medicine - Current Research
Kampo Medicine and Concept of Weak Constitution– Frailty, Locomotive Syndrome, and Sarcopenia
Kazunari Ozaki1)2)3)
1) Department of Clinical Gene Therapy,
Osaka University Graduate School of Medicine,
Osaka, Japan
2) Department of Geriatric Medicine and Nephrology,
Osaka University Graduate School of Medicine,
Osaka, Japan
3) Department of Geriatric Medicine, Itami City Hospital,
Itami, Hyogo, Japan

Key words: weak constitution, frailty, locomotive
syndrome,
sarcopenia,
asthenic,
traditional
medicine, Kampo medicine, Arthralgia Due toStagnation of Blood and Consumptive Diseases (Xue
Bi Xu Lao, 血痺虚労), Quantification in traditional
medicine, globalization of traditional medicine,International Organization for Standard (ISO)Introduction
In recent years, terms such as frailty, locomotive
syndrome, and sarcopenia have been proposed toembody the concept of “weak constitution.” Theauthor has long been occupied with the question: “Isthere any concept equivalent to frailty, locomotive
syndrome, or sarcopenia in traditional medicine,
particularly in Kampo medicine?” In practice,concepts quite akin to these terms have been used in
Kampo medicine, and treatments for such conditions
are also found in Kampo medicine. In this paper,
frailty, locomotive syndrome, and sarcopenia will
first be briefly described. The Kampo medicine terms(or candidate terms) corresponding to these concepts
will then be introduced and compared. We will thus
discuss correlations and differences between Kampo
medicine and Western medicine. Due to limited
space, only representative examples will be cited.
After these discussions, the author will point out
unaddressed issues associated with Kampo medicine
research in order to provide hints that may stimulate
future advances in Kampo medicine research. At theunaddressed issues related to Kampo medicine
research, we will first discuss issues related to8quantification in traditional medicine and thenconsider issues related to the globalization of
traditional medicine.
1. Summarization of the terms frailty, locomotive
syndrome, and sarcopenia
The concepts of frailty, locomotive syndrome, andsarcopenia will first be briefly described. The term“frailty” is used in the field of geriatric medicine.
This term indicates weak constitution, senile decay,
and weakening or vulnerability. In short, it is used
to describe aging-associated irreversible weakness.
Frailty may also be used to describe the state in thesenile period (a period of discrepancy between
healthy life expectancy and mean life expectancy),
which is characterized by reduced physiologicalreserve resulting in the outcomes such as
vulnerability to stress, disturbance in activities ofdaily living, requirement of assistance with dailyliving, and likelihood of death.
The term “locomotive syndrome” is used in thefield of orthopedics. Unlike the term “frailty,” which
is a broad concept encompassing physical,
mental/psychological, and social aspects, the term
“locomotive syndrome” is a narrower term confinedto the fields of orthopedics and rehabilitation. It is
used to indicate “a condition of restricted daily living
due to reduction in mobility (walking, standing andsitting, etc.) arising from locomotor organ
dysfunction, leading to need or imminent need ofassistance with daily living.” Locomotive syndrome
was proposed as a new concept at the meeting of theJapanese Orthopaedic Association in 20071). Since
this condition may show recovery in response toappropriate treatment, early diagnosis is considered
to be of high value.
Moreover, the concept of “sarcopenia” was recently
proposed to indicate aging-associated reduction in
muscular mass and muscular strength2). Sarcopenia is
one of underlying diseases of locomotive syndrome,
focusing on reduction in muscular mass and muscularstrength. The term was coined based on the Greek
words sarx (flesh) and penia (loss). Disturbed

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013

walking/balance associated with sarcopenia can lead to
aggravation of frailty.
Now that the differences among frailty,
locomotive syndrome, and sarcopenia have beenbriefly described, we will begin a more detailed
discussion of frailty, locomotive syndrome, andsarcopenia. According to Fried et al., frailty isdefined as “A physiologic syndrome characterized bydecreased reserve and resistance to stressors,
resulting from cumulative decline across multiple
physiologic systems, and causing vulnerability toadverse outcomes”3). The concept of “frailty” is easy
to understand for clinical practitioners, but isdifficult to define strictly. For this reason, the fivephenotypes of frailty proposed by Fried in 2001 seemto be used frequently during clinical practice. The
five phenotypes comprise (1) weight loss, (2) fatigue(subjective sensation of fatigue), (3) low energy
expenditure (reduction in activity of daily living), (4)slow gait (weakening of physical capability [walking
speed]), and (5) weak grip (reduction in muscularstrength [grip strength]). Patients with at least threeof these phenotypes are considered to have “frailty”
and those with one or two phenotypes are considered“intermediate” or “pre-frail”4). Frailty is in essence areversible condition in which normalcy may berestored if the appropriate intervention is used. For
this reason, early detection of frailty in elderly
individuals
andsubsequent
appropriate
intervention is expected to enable the maintenanceand improvement of functions of daily living.
Although the Japanese term “Kyojaku (虚弱) or weak
constitution” may be used as a translation for“frailty,” it cannot sufficiently express the diverse
elements of frailty (i.e., weakness in the physical,
mental/psychological, and social aspects). The Japan
Geriatrics Society is thus exploring a more
appropriate Japanese term as a translation forfrailty to lead to widespread recognition of frailty
and dissemination of the importance of its
prevention. “Frailty” may be caused by a variety offactors, including not only locomotor organ disease
and aging, but also disturbed cognitive function,
nutrition, mental state, and socioenvironmental

factors. Epidemiological studies have demonstrated
a close association between frailty and cognitive
dysfunction. Although the exact mechanism is
unknown, it has been epidemiologically shown thatearly detection of cognitive dysfunction is importantto prevent frailty. In order to avoid frailty, maintainand improve functions of daily living, appropriate
interventions
based
on
more
accurate
epidemiological data are desirable. An important
issue for the future is the execution of appropriate
screening tests at early stages of the condition.
Frailty is a broad concept encompassing physical,
mental/psychological, and social aspects. Locomotive
syndrome, on the other hand, is a concept used inorthopedics and indicates a condition of restricteddaily living due to reduction in mobility (walking,standing and sitting, etc.) arising from locomotororgans dysfunction, leading to need or imminent
need of assistance with daily living. Since thiscondition may show recovery in response totreatment, early diagnosis is considered to be of highvalue.
Sarcopenia is attributable to reduction in
muscular mass, muscular strength, and physicalcapabilities, and is a condition that may underlie
locomotive syndrome. It is a term that has beencoined relatively recently by Rosenberg andindicates the “aging-associated reduction in
muscularstrengthorsenescence-associateddecrease in muscular mass”5). The decrease inskeletal muscle mass is assessed using the skeletal
muscle index (SMI), which is calculated by dividing
the limb skeletal muscle mass (kg) by the square ofheight (m), i.e., limb fat-free soft tissue quantity(kg)/height (m2). A SMI of 2 standard deviations(SDs) below the mean SMI of healthy individuals
aged 18-40 years is often considered to reflectsignificant decreases in skeletal muscle mass6). In
2010, the European Union Geriatric Medicine
Society and 4 European and international societies
related to nutrition jointly established the European
Working Group on Sarcopenia in Older People(EWGSOP), which proposed a definition forsarcopenia7). Based on this definition, a diagnosis of

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9Volume 8, Number 3 | Fall 2013

sarcopenia can be made if there is decreased skeletal
muscle mass (essential) and either reduction in
muscular strength or locomotor function, or both, arepresent. The parameters assessed to diagnose frailty
include attenuation of physical function andreduction in muscular strength. This indicates thatsarcopenia is closely associated with frailty. The
presence of sarcopenia is associated with dizziness,
fall/fracture, and frailty in elderly individuals, andcorrelates closely with physical dysfunction andconditions requiring assistance with daily living8).
2. The term “asthenic” was seemingly used in theearly 20th century.
Concepts such as frailty, locomotive syndrome,and sarcopenia, which correspond to the Japaneseterm “Kyojaku” or “weak constitution” were alreadyin use at the beginning of the 20th century in Westerncountries. In 1908, a publication in the journal
Lancet used the term “asthenic constitution” toindicate the group of diseases causing “atonic habitof body” in the broader sense of the term. These
conditions included floating kidney, gastroptosis,
enteroptosis, nervous dyspepsia, and neurasthenia9).
The term “asthenic” seems to have been a word thatwas prevalent in those days. This term was also usedin the famous paper on body build and physicalconstitution typing by Kretschmer. Kretschmer
described three types of body build: pyknic (stocky
and rounded), athletic (with strong development ofmuscles and bones), and asthenic or leptosomatic(lean and narrow)10).
3. What is the traditional medicine term
corresponding to frailty, locomotive syndrome, andsarcopenia?
Before discussing Kampo medicine terms
corresponding to frailty, locomotive syndrome, andsarcopenia, we will focus only on the physical aspectsoffrailty
without
consideringthemental/psychological and social aspects mentioned
in its definition to simplify the discussion. We willthus treat locomotive syndrome and frailty as the10same concept and explore Kampo medicine terms
corresponding to this concept.
The Kampo medicine or traditional Chinese
medicine terms corresponding to locomotive
syndrome and frailty seem to be “legweakening/adynamia” and “weakening/adynamia,”
which were used in “Dokkatsukiseito, or PubescentAngelica and Taxillus Decoction (Du Huo Ji Sheng
Tang, 獨活寄生湯)” in the monograph “Important
Formulas Worth a Thousand Gold Pieces (Bei Ji
Qian Jin Yao Fang, 備急千金要方)”11). “PubescentAngelica and Taxillus Decoction” is an EightTreasure Decoction (Ba Zhen Tang, 八珍湯) made ofa Four-Substance Decoction (Si Wu Tang, 四君子湯)with blood-replenishing activity and a FourGentlemen Decoction (Si Jun Zi Tang) with Qireplenishing ( 補 気 ) activity. This herbal mix has
been used to treat (1) conditions characterized byphysical senescence (kidney deficiency according totraditional Chinese medicine); and (2) thosecondition involving shortages of Qi and bloodaccompanied by cold sensation and pain in the lower
back and knees due to moisture or water retention,and by fear of coldness, pleasure with warmness,
weak/powerless legs, and paralysis/neuralgia/swelling
attributable to external factors (invasion by
disturbing factors, such as wind, coldness, andmoisture). In Japan, Pubescent Angelica andTaxillus Decoction is often replaced with an herbal
extract called “Relax the Channels and Invigorate
the Blood Decoction (Hu Jing Huo Xue Tang, 疎経活血 湯 ),” which is covered by the national healthinsurance system.
The term corresponding to sarcopenia seems to be“Arthralgia Due to Stagnation of Blood andConsumptive Diseases (Xue Bi Xu Lao, 血痺虚労),”which is found in the Astragalus Decoction toConstruct the Middle (Ogikenchuto, Huang Qi Jian
Zhong Tang, 黄耆建中湯) or Minor Construct the
Middle Decoction (Shokenchuto, Xiao Jian Zhong
Tang, 小建中湯) in the monograph “Kinkiyoryaku(Essential Prescriptions from the Golden Cabinet,
Jin Gui Yao Lue, 金匱要略)”12). This expression isfound in the chapter “On Pulse, Symptom Complex

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Volume 8, Number 3 | Fall 2013

and Treatment of Arthralgia Due to Stagnation of
Blood and Consumptive Diseases (血痺虚労病脈証幷
治)” in the same monograph. Both the Astragalus
Decoction to Construct the Middle and the Minor
Construct the Middle Decoction are herbal
preparations used to treat consumptive disease (虚労 ). In traditional Chinese medicine, they areclassified as Onrikyokanzai (agents used to reverse
warmth and control coldness, 温 裏 袪 寒 剤 ). The
concept of “decrease of skeletal muscle mass,” which
is used in the current definition of sarcopenia, wasundoubtedly absent in the age of “Kinkiyoryaku(Essential Prescriptions from the Golden Cabinet).”However, patients with conditions corresponding tosarcopenia, i.e. patients with frailty presenting withdecreased skeletal muscle mass, reduced muscularstrength, or reduced locomotor function, are likely tohave chronic disease or senescence as a background.
The presence of chronic disease or senescence is
probably accompanied by asthenia cold (Yangdeficiency,陽虚). Therefore, the use of Onrikyokanzai(agents used to reverse warmth and control coldness),which is indicated for asthenia cold (Yang deficiency)
is expected to be effective in patients with sarcopenia.

脾(気)虚＋血虚?
(Spleen (Qi)deficiency andBlooddeficiency)

The author believes that aging corresponds to“kidney deficiency of both Ying and Yang nature (腎陰陽両虚)” (a concept of traditional Chinese medicine andJapanese Kampo medicine), while long-term
malnutrition corresponds to the concept of “spleen (Qi)deficiency (脾(気)虚)” or “blood deficiency (血虚).” Theauthor has compared these concepts using an
illustration of the vicious cycle of frailty, locomotive
syndrome, and sarcopenia, as proposed in the field of
geriatric medicine in Western medicine13) (Figure).
This illustrative comparison includes some indefinite
points. For example, reduced walking speed is aconcept that began to be used when accurate
measurements of time became possible and was absent
in the age of “Kinkiyoryaku (Essential Prescriptions
from the Golden Cabinet).” However, if “Symptom
Complex of Arthralgia (痺証)” is present, a reduction in
mobility should be present, and a reduction in walking
speed is a plausible consequence. However, the author
cannot rule out the possibility that newliterature/documents will be found later indicatingthat a concept corresponding to reduced walking speed
was used already in those days. This illustration is only
the author’s proposal and may require correction,
improvement, and review in the future.

腎陰陽両虛?
(Kidney deficiency
of both Ying and ≒Yang nature)

脾(気)虚?
(Spleen(Qi)≒
deficiency)≒ 外邪(邪気)?
(External
pathogen)(血痺) 虚労?
(Arthralgia
due to≒Stagnation of
Blood andConsumptive
Diseases)
Locomotive
syndrome≒ 下肢軟弱無力?
and Frailty(Leg weakening/
Adynamia)

Adapted from Linda P. Fried et al. J Gerontol A Biol Sci Med Sci 2001;56:M146-M157

Figure: Cycle of frailty with Kampo terms: Under-nutrition, Aging, andDisease will lead elderly people to sarcopenia. And sarcopenia lead toloss of walking-speed, which is one of the frailty sign.

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Volume 8, Number 3 | Fall 2013

4. Existing issues essential to advancement of

quantitative approach to diagnostic imaging andtraditional medicine researchmolecular biology.
In the future, it would be desirable to conduct

4-1 Quantification in traditional medicine
A striking difference in the diagnostic methods

comparisons and analyses of the correlations

between Kampo medicine and modern medicine is

between quantitative data obtained in traditionalthat Kampo medicine basically attempts diagnosis

medicine and data obtained in modern medicine

andregardingtreatment

throughthecomprehensive

clinicalindicators

andbiochemicalinterpretation of subjective symptoms and objective

markers. It would also be desirable to conduct

findings or through holistic assessment of individual

pharmacological and molecular biological studies topatients. One problem in Kampo medicine researchenable the detailed visualization of biologicalthat arises from this feature is difficulty inactivity and drug delivery at the molecular level sonumerical or quantitative analysis when comparedthat further advances in traditional medicine

to Western medicine. However, quantitative analysis

research can be linked to life science research.

of parameters serving as criteria for diagnosis in

Eventually, the development of diagnosis/treatment

traditional medicine will also be indispensable in themethods through the integration of modern medicine

future. Surprisingly, there was little difference(Westernbetween Kampo medicine and Western medicine in(Kampo medicine) beyond the borders of these two

the level of diagnosis/treatment until about 100

fields may contribute to further advances inyears ago, and the outcome of treatment for Spanish

medicine.

medicine)

andtraditional

medicine

flu was better with Kampo medicine than withFor example, we have introduced "New clinicalWestern medicine. However, due to advances inassessment in diastolic heart failure: The correlation

science during the past 100 years, the predominancebetween a combination of clinical findings andof modern medicine/Western medicine has been

indices with echocardiography"15)16). We studied

established. Following recent advances in technology

more than 30 outpatients at the hemodyalysis unit

used for measurements for medical use and inwithmedicalandechocardiographical indices with echocardiography.

diagnostic imaging data have frequently been used

They measured and compared Kampo-scores andfor diagnosis in modern/Western medicine. In

echo-cardiographical indices by linear regression.

contrast, in traditional medicine/Kampo medicine,

According to our study, some of the Kampo-scores

the quantitative approach is seldom used, except for(Suitai-score (or water stagnation score)) had strong

some sporadic cases wherein information regarding

positive correlation to E/Ea (or E/e’: transmitral

subjective

interviews,

early diastolic velocity / mitral annular earlyquestionnaires, etc., and physical findings (such as

diastolic velocity ratio), which were suggested tofindings from abdominal investigations) is processed

have strong relation to pulmonary capillary wedge

numerically. The methods used for quantitative

pressure (PCWP). They suggested that Kampo-

analysis vary greatly among the different schools ofscores especially Suitai-score could be used to define

traditional/Kampo medicine. In the latter half of theclinical assessment of congestion in hemodialysis

1980s, Terasawa et al. made several attempts to

outpatients with diastolic heart failure.

imagingtechnology,

symptoms

biochemical

obtainedinquantitatively analyze diagnostic scores for Qi-

simultaneous

Kampo-scoresandIn order to address sarcopenia and the evidence

However,in “Arthralgia Due to Stagnation of Blood andtraditional/Kampo medicine is far behind theConsumptive Diseases” presented in the author’s

advancedprevious and present papers, we plan to collect not

Blood-Fluid14)

12

level

and
of

similarmoderntests.
medicine

inthe

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013

patients

preparations may have to be modified to match thesatisfying the diagnostic criteria for sarcopenia, but

Chinese domestic standards. Needless to say, aalso data on biomarkers (e.g., inflammatory markers

similar influence will also be seen in Korea, the U.S.,

such as tumor necrosis factor-α and interleukin-6)17)

and other countries in addition to Japan. At present,

andtomography,

there is little international understanding of themagnetic resonance imaging, etc.). We will thendifferences between Kampo medicine in Japan andstudy the correlations among these data. In addition,

Chinese medicine. In addition, many individuals intreatment of sarcopenia and “Arthralgia Due toJapan (other than healthcare professionals) believe

Stagnation of Blood and Consumptive Diseases”

that Kampo medicine in Japan is identical tousing modern medicine will be compared to that

Chinese medicine. However, the differences between

using traditional medicine through randomized

Kampo medicine and Chinese medicine are as large

controlled trials (RCTs) if possible, or by means ofas the differences between baseball and softball, andcross-over trials if RCTs are not possible. We believe

it would be impossible to apply the same rules tothatboth these types of medicine. Kampo medicine in

only

traditional

imaging

medicine

findings

medicinefrom(computed

diagnosis/treatment

moderndata

methods(Western

combining

medicine)

withJapan is far behind Chinese medicine in terms of

traditional medicine (Kampo medicine) can be

globalization effort. In addition, the education forestablished through these incessant studies. It is

non-experts in Japan is insufficient.

desirable that such a scientific and objective versionof traditional medicine be established as soon asConclusions
This paper briefly described frailty, locomotive

possible.

syndrome, and sarcopenia, which are important
4-2 Trends of globalization of traditional medicine
Differences in traditional medicine from different

problems in ultra-aging societies. The author thenpresented terms (or candidate terms) in Kampo

countries have been discussed at international

medicine

conferences, such as meeting of the Internationalcorresponding to these concepts. This was followed

Organization for Standardization (ISO; in particular

by a comparison among these concepts and theTC249, which is discussed later) and the World

description of some herbal preparations used for

Health Organization (International Classification of

their treatment. The author also addressed existing

Diseases 11, etc.). However, smooth arguments haveissues essential to the advancement of traditional

been hampered by conflicts of political and economic

medicine research, focusing on the issues ofinterest, honor/prestige of each country, and so on.

quantification in traditional medicine and theandtraditional

Chinesemedicine

In 2009, China submitted an application for the

globalization of traditional medicine. The author

establishment of the organization of an expert

hopes to make some contribution to the stimulationcommittee on traditional Chinese medicine (TC249)

of progress in traditional medicine research in theto the ISO in an attempt to facilitate the adoption of

future.

Chinesepharmacopeia

and

other

domestic

standards directly as global standards. If thestandards proposed by China are adopted as global
standards, Japanese pharmacopeia (now securing
the quality of herbal medicines used in Japan fromthe viewpoint of Western medicine) and otherstandards related to herbal mixtures and Kampo

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Volume 8, Number 3 | Fall 2013

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