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Contents lists available at ScienceDirect

Pain Management Nursing

journal homepage: www.painmanagementnursing.org

Original Article

Effect of Persian acupressure (Ghamz) on Patients with Knee

Osteoarthritis: A Single-Blinded Parallel Clinical Trial ✩
Maryam Alinaghizadeh, M.D. ∗, Jessie Hawkins, Ph.D. †, Alireza Abbassian, M.D., Ph.D ∗,#,
Tohid Seif barghi, M.D. ‡, Mohammad Hossein Ayati, M.D., Ph.D ∗, Mahdi Alizadeh
vaghasloo, M.D., Ph.D ∗
∗
Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
†
Integrative Health, Franklin School of Integrative Health Sciences, Franklin, Tennessee
‡
Department of Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Background: Many patients choose complementary and alternative medicine (CAM) to treat various con-
Received 27 August 2020 ditions. Among osteoarthritis patients, acupressure is a popular CAM treatment. In Iran, Ghamz (a Persian
Received in revised form 16 May 2021
acupressure technique) uses for musculoskeletal ailments like knee pain.
Accepted 3 June 2021
Aims: To examine the potential efficacy of Ghamz on osteoarthritis outcomes.
Available online xxx
Design: Clinical Trial.
Settings: Randomized, single-blind, sham-controlled clinical trial.
Participants/Subjects: Eighty patients with diagnosed knee osteoarthritis, age over 35 years old.
Methods: Eighty adult patients with confirmed knee osteoarthritis from three outpatient clinics were
recruited. Participants were randomly assigned either to intervention or placebo groups using sham acu-
pressure. The primary outcomes included Knee injury and Osteoarthritis Outcome Score (KOOS) parame-
ters and pain scores measured using the visual analog scales (VAS).
Results: Seventy-two individuals completed the trial and were included in the analysis. At baseline, there
was no difference between the mean scores of both outcomes. After the intervention, the group receiv-
ing Ghamz therapy experienced an improvement in KOOS parameters, including symptoms, pain, activity
daily livings, sport, recreation function, and quality of life. The mean pain score in the intervention group
was significantly decreased from 5.89 at the beginning study to 4.11 at the end of the study, while the
pain score did not change substantially in the sham group. These findings remained consistent after ad-
justing for covariates of age, weight, and pre-treatment.
Conclusions: This study supports evidence that Ghamz therapy provides an effective option for short-
term knee pain relief in patients with knee osteoarthritis. Additional studies are recommended to confirm
these findings.
© 2021 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Osteoarthritis is the most common joint disorder and is one osteoarthritis are known to be increasing, in part due to increased
of the leading causes of disability around the world (Hunter & life expectancy, which produces a larger aging population, but also
Bierma-Zeinstra, 2019). The effects of osteoarthritis on global and due to increased obesity, sedentary behavior, and poor quality of
public health extend beyond loss of productivity and affect socioe- diet (Hunter & Bierma-Zeinstra, 2019; Hunter, et al., 2014). The part
conomic status (Hunter et al., 2014). Incidence and prevalence of of the body most commonly affected by osteoarthritis is the knee
joint; knee osteoarthritis (KOA) is responsible for 86.8% of the over-
all osteoarthritis burden (G.B.D. 2016). KOA affects over 250 million
✩
The Tehran University of Medical Science [grant number people with a prevalence of is 3.8%, and it is more common among
IR.TUMS.VCR.REC.1397.388] supported this work. The funder had no role in females than males (Cross, et al., 2014). The primary symptoms of
the trial design and will not influence data collection, analysis, or reporting. KOA are pain, stiffness, and function limitation (Castell et al., 2015;
#
Address correspondence to Alireza Abbassian, M.D., Ph.D., Department of Tradi- Loeser, 2010). These result in a significant reduction of quality of
tional Medicine, School of Persian Medicine, Tehran University of Medical Sciences,
life, interaction with daily activities, and sleep quality (Farr Ii et al.,
P. O. Box: 1416643139, Tehran, Iran.
E-mail address: abbasian@sina.tums.ac.ir (A. Abbassian). 2013; Ferrell, 1991).

https://doi.org/10.1016/j.pmn.2021.06.002
1524-9042/© 2021 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Please cite this article as: M. Alinaghizadeh, J. Hawkins, A. Abbassian et al., Effect of Persian acupressure (Ghamz) on Patients with Knee
Osteoarthritis: A Single-Blinded Parallel Clinical Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2021.06.002
JID: YJPMN
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2 M. Alinaghizadeh, J. Hawkins, A. Abbassian et al. / Pain Management Nursing xxx (xxxx) xxx
Clinical management of osteoarthritis prioritizes pain relief
and improvement in joint function (Jordan et al., 2003; Oteo-
Alvaro et al., 2012). To control pain, both non-pharmacologic
and pharmacologic treatments are used (W. Zhang et al.,
2008). The most common medications used in osteoarthritis
treatment include paracetamol, non-steroidal anti-inflammatory
drugs (NSAIDs), opioids, topical analgesics, and corticosteroids
(McAlindon et al., 2014; Steinmeyer et al., 2018). Because of the
side effects of these medications and non-response to conventional
therapies, many osteoarthritis patients turn to alternative ap-
proaches such as complementary and alternative medicine (CAM)
(Phang et al., 2018; Steinmeyer et al., 2018).
CAM is widely used as a treatment for osteoarthritis with ap-
proximately 40%, 45%, and 65% of patients using different modal-
ities of CAM in Australia, Pakistan, and Morocco, respectively
(Ayaz et al., 2016; Azzouzi et al., 2016; Zochling et al., 2004). CAM
refers to a variety of modalities, including the use of herbal prod-
ucts, dietary supplements, homeopathy, acupuncture, massage, and
acupressure, each of which has been used to improve symptoms of
osteoarthritis (Phang et al., 2018; Zochling et al., 2004).
Massage is a leading CAM approach for osteoarthritis, with
approximately 15.4 million American osteoarthritis patients us-
ing it therapeutically in 2012 (Clarke et al., 2015). Massage ap-
pears to be a safe treatment with few side effects (Posadzki &
Ernst, 2013), which has been shown to decrease stress, anxiety,
and pain (Fiechtner & Brodeur, 2002). Evaluating the efficacy of
massage therapy is complex due to the dramatic variation in treat-
ment techniques (De Luigi, 2012). Some studies have shown that
Swedish and Chinese massage reduces pain and improves function
in patients with KOA (Perlman et al., 2019; Zhu et al., 2016).
Acupressure is another type of CAM that has similarities to both
massage and acupuncture. Like acupuncture, acupressure targets
specific acupoints, but acupressure uses fingers to press acupoints
rather than needles (Zhang, et al., 2012a). An evidence-based re-
view has confirmed the efficacy of acupuncture, a traditional Chi-
nese medicine, on pain reduction in KOA (Manheimer et al., 2007;
White et al., 2007). Few studies, however, have evaluated the ben-
efits of acupressure on knee pain (Tse & Au, 2010).
Ghamz is an ancient traditional Persian medicine acupressure
technique that utilizes the application of pressure with fingertips
on specific points of the body to relieve pain and discomfort asso-
ciated with musculoskeletal disorders such as the neck, lower back,
and knee pain. Ghamz can be self-administered or administered by
a trained acupressurist. The technique can also be used in preg-
nancy and pediatric populations for pain reduction, in athletes for
fatigue, and in the elderly for gastrointestinal diseases (Liu et al.,
2015; Parvizi et al., 2018). Multiple studies have found that Ghamz
therapy improves pain, range of motion, and quality of life in pa-
tients who experience neck and low back pain (Khorsand et al.,
2019; Mohammadi-Kenari et al., 2021). According to ancient Per-
sian medicine texts, renowned physicians such as Avicenna and
Razi used the technique for a wide variety of purposes, ranging
from diagnosis, prevention, treatment, and rehabilitation.
Ghamz therapy is believed to be beneficial for musculoskele-
tal improvement, but this notion is not supported by sufficient
evidence-based literature. The purpose of this clinical trial was to
examine the efficacy of Ghamz therapy on patients with KOA.
Methods
Study Design and Participants
This trial is a randomized, single-blind, sham-controlled clinical
trial. Patients with knee problems referred to three outpatient clin-
ics affiliated with Tehran University of Medical Sciences were se-
Please cite this article as: M. Alinaghizadeh, J. Hawkins, A. Abbassian et al., Effect of Persian acupressure (Ghamz) on Patients with Knee
Osteoarthritis: A Single-Blinded Parallel Clinical Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2021.06.002
[mNS;July 11, 2021;10:35]
lected. Eligibility included: diagnosed knee osteoarthritis using the
diagnostic criteria of the American College of Rheumatology (ACR)
(Altman et al., 1986), age over 35 years old, ability to comprehend
the protocol of the study, and the ability to complete the inter-
view and understand the instructions. Exclusion criteria included:
clinical neuropathy, wound over the acupoints, use of CAM within
the previous three months, use of opioids or analgesics. Addition-
ally, participants were not included if they: (1) had a significant in-
jury in the past 6 months; (2) had an open wound over the knee;
(3) used oral corticosteroids within the previous five weeks, intra-
articular knee depo-corticosteroids in the past three months, or
intra-articular hyaluronate during past six months; (4) had chronic
diseases such as rheumatoid arthritis, fibromyalgia, cancer, kid-
ney and liver failure, asthma treated with corticosteroids; (5) knee
arthroscopy during past a year. Participants were removed from
the trial if they discontinued treatment, reacted to the treatment,
or failed to adhere to the protocol during the intervention.
Before providing consent, each participant was advised of the
study’s aim, method, advantages, and disadvantages, including
their right to leave the study at any stage. Written consent was ob-
tained from participants before enrollment. The Review Board and
the Ethical Committee of Tehran University of Medical Sciences
(TUMS) approved the study protocol and all recruitment materi-
als (number: IR.TUMS.VCR.REC.1397.388). This study was registered
with the IRRC20181130041802N1 code at the Clinical Trial Regis-
tration Center of Iran.
Sample Size Estimation
The sample size was calculated to detect a mean difference
(MD) of 1.6 on the pain outcome measured with the VAS, using
Khorsand et al. as a reference. To achieve 80% statistical power, α
of .05, and a large effect size (d = 0.74) (Khorsand et al., 2019), and
2 (Z1−α /2 +Z1−β )2
with the following formula: n = , a total of 30 indi-
(ES )2
viduals are required in each group of acupressure and sham. To
account for potential dropouts, an additional 10 participants were
added to each group. A total of 80 individuals referred to three
outpatients’ clinics of TPM met the inclusion criteria and entered
the trial.
Randomization and Allocation Concealment
All participants were randomly assigned to either the acupres-
sure or the sham acupressure group, with a 1:1 ratio. A computer-
based blocked randomization method was used to assign patients.
Due to the nature of acupressure, blinding the acupressurist poses
a challenge. The participants, study nurse, and biostatistician, how-
ever, were all blinded to group assignment.
Ghamz Therapy Protocol and Intervention
For this trial, Ghamz was self-administered using a Persian acu-
pressure protocol extracted from traditional Persian medicine lit-
erature such as Canon and reviewed by three ITM practitioners.
The term Ghamz is a specific term that translates to "pressing with
fingers." This approach uses fingers to firmly press different body
parts in a transverse direction designed to achieve individual ther-
apeutic goals. Ghamz therapy is a frequently used CAM that has
gained popularity due to its ability to provide immediate pain re-
duction. Ghamz can be performed using different methods. Twelve
Points Ghamz is the method that is utilized to improve KOA. With
this method, 12 specific acupoints (shown in Fig. 1) are pressed
for 30 seconds. Ghamz therapy is explained in the supplementary
video.
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Figure 1. Acupressure points
Each patient began by receiving an in-person training course.
An expert acupressurist with several years of experience provided
individual patient training teaching the step-by-step process of the
method. Patients were taught the exact location of these acupoints
and how to apply the Ghamz technique. The acupressurist then
monitored their use of the technique, offering correction if re-
quired. Once patients had mastered the technique, they received
a brochure of reminders on the process of self-administration of
Ghamz, complete with images.
Additionally, they were provided contact information for the
acupressurist if they had any questions during the trial. To ensure
compliance, members of the research team called patients daily
to remind them to perform the Ghamz treatment. Patients in the
sham acupressure group experienced the same process. However,
they were instructed with a sham method that involved pressing
non-therapeutic points, along with lighter pressure and a reverse
direction. All patients performed this technique twice daily for five
days (10 sessions). Patients were also free to take up to two tablets
of 50 mg diclofenac per day.
Outcome Measures
Demographic data collected includes age, height, weight, body
mass index (BMI), sex, marital status, educational attainment, oc-
cupation, medical history, and medication intake. These variables
were collected through a face-to-face interview. Primary outcomes
were measured using two instruments: the Visual Analogue Scale
(VAS) and the KOOS (Knee injury and Osteoarthritis Outcome
Score) questionnaire. These questionnaires were administered at
the commencement and end of the study through an in-person in-
terview, and participants rated the VAS scale at the end of the first
and fifth days on their own. The validity and reliability of Persian-
version of these questionnaires had previously been established in
Iranian populations (Alghadir et al., 2018; Salavat, et al., 2008).
Internal consistency (Cronbach’s α ) for subscales of KOOS were:
Pain 0.88, Symptoms 0.25, ADL 0.94, Sport/Rec 0.89, and QoL 0.64.
Please cite this article as: M. Alinaghizadeh, J. Hawkins, A. Abbassian et al., Effect of Persian acupressure (Ghamz) on Patients with Knee
Osteoarthritis: A Single-Blinded Parallel Clinical Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2021.06.002
[mNS;July 11, 2021;10:35]
3
In this study, Cronbach’s α value of KOOS subscales varied from
0.74 to 0.95, which was satisfactory level of internal consistency.
A member of the research team measured anthropometric indices
and trained the patients on how to complete questionnaires cor-
rectly. This person was blinded and was not involved in other as-
pects of the trial.
The KOOS questionnaire measures outcomes related to knee
conditions. KOOS is a self-administered questionnaire with a 5-part
Likert scale ranging from zero, indicating no problem to four, in-
dicating extreme problems. The measure includes five constructs:
pain (nine items), symptoms (seven items), activities of daily living
(17 items), sport and recreation function (five items), and quality
of life (four items). Scores of each subscale are converted to a 0 to
100 scale with this formula: 100 − [(actual raw score × 100)/possi-
ble raw score range]. Lower scores represent severe knee problems
and higher scores represent the absence of knee problems.
Pain intensity was measured using the VAS scale. Patients select
a spot on the 0 to 10 cm VAS scale, which indicates their level of
pain. This scale has been used in epidemiologic and clinical inves-
tigations to evaluate the intensity or frequency of different symp-
toms. Scores range from 0 to 10, with 0 representing no pain and
10 representing severe pain.
To evaluate medication intake, the number of analgesic tablets
at the start and the end of the study were recorded. Participants
were permitted to take up to two 50 mg tablets of Diclofenac per
day during the trial.
Statistical Analysis
To evaluate group assignment, an independent t-test was used
to assess continuous variables and chi-square tests were used to
evaluate categorical variables between the acupressure and sham
groups. Additionally, an analysis of covariance (ANCOVA) was used,
allowing age, weight, pre-treatment measures to be used as covari-
ates. Repeated measure ANCOVA was used to evaluate the differ-
ence in pain intensity scores between the groups and shown as a
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4 M. Alinaghizadeh, J. Hawkins, A. Abbassian et al. / Pain Management Nursing xxx (xxxx) xxx

graph. A chi-square test was performed to assess analgesic intake
between groups. All data analysis was performed using SPSS ver-
sion 18 (SPSS Inc, Chicago, IL, USA) with p < .05 considered statis-
tically significant.
Results
The demographic characteristics of the patients are shown in
Table 1. Of the 80 patients recruited for this trial, 72 (90%) indi-
viduals were included in the analyses. Four patients were excluded
from each group due to a lack of adherence to the study proto-
col (Fig. 2). The majority of the participants were women (80%),
with a mean age of 59.75 years old (SD = 9.92 years) and a range
from 36 to 83 years old. The mean height, weight, and BMI of par-
ticipants were 162.76 cm, 76.72 kg, and 28.92 kg/m2 , respectively.
There was a statistically significant difference in age and weight
between groups, with increased mean age and weight among par-
ticipants in the sham group (p < .05). There was no significant dif-
ference between groups for other demographic variables, including
height, BMI, gender, marital status, educational attainment, and oc-
cupation status.
There was no significant difference between patients’ mean
KOOS scores in the acupressure and sham groups at baseline
(p > .12). All constructs measured by the KOOS, including pain
(p = .026), symptoms (p < .001), activity in daily living (p < .001),
function in sport (p = .004), and quality of life (p = .010), were
found to be significantly improved in the intervention group as
compared with the sham group. The difference between the in-
tervention and sham groups at the end of the study remained
significant after adjusting for pre-treatment, age, and weight
(Table 2).
The reduction in pain intensity as measured through the VAS
by time for both acupressure and sham groups is demonstrated in
Fig. 3. At the start of the study, no significant difference between
the acupressure and sham groups was identified. Patients expe-
riencing the Ghamz therapy had significantly lower pain scores

Table 1
Demographics Characteristics of Participants at the Baseline of Study

Variables Total (n = 72) Acupressure Group (n = 36) Sham Group (n = 36) p

Age (year) 59.75 ± 9.92 55.58 ± 11.14 63.91 ± 6.33 <.001a

Height (cm) 162.76 ± 6.56 161.69 ± 6.40 163.83 ± 9.59 .168
Weight (kg) 76.72 ± 11.02 74.03 ± 11.81 79.41 ± 9.59 .027
BMI (kg/m2 ) 28.92 ± 3.59 28.16 ± 4.19 29.55 ± 2.83 .103
Sex 1.00b
Male 14 (19.4%) 7 (19.4%) 7 (19.4%)
Female 58 (80.6%) 29 (80.6%) 29 (80.6%)
Marriage status .15
Single 2 (2.8%) 0 (0.0%) 2 (5.6%)
Married 70 (97.2%) 36 (100%) 34 (94.4%)
Education .14
Lower diploma 32 (44.4%) 15 (41.7%) 17 (47.3%)
Diploma 22 (30.6%) 11 (30.6%) 11 (30.6%)
Upper diploma 18 (25%) 10 (27.8%) 8 (22.2%)
occupation .09
Wife 40 (55.6%) 20 (55.6%) 20 (55.6%)
Employee 20 (27.8%) 13 (36.1%) 7 (19.4%)
retired 12 (16.7%) 3 (8.3%) 9 (25%)

Values are presented as mean ± SD for quantitative variables and n (%) for qualitative variables.
a
p is calculated by the independent t-test.
b
p is calculated by and chi-square test.

Figure 2. Flowchart of the study according to the CONSORT (Consolidated Standards of Reporting Trials) flow diagram.

Please cite this article as: M. Alinaghizadeh, J. Hawkins, A. Abbassian et al., Effect of Persian acupressure (Ghamz) on Patients with Knee
Osteoarthritis: A Single-Blinded Parallel Clinical Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2021.06.002
JID: YJPMN
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M. Alinaghizadeh, J. Hawkins, A. Abbassian et al. / Pain Management Nursing xxx (xxxx) xxx 5

Table 2
Results of the KOOS Subscales Between Acupressure and Sham Groups

Variables Acupressure Group (n = 36) Sham Group (n = 36) Statistic

Mean ± SD Mean ± SD

Symptoms
Pre-treatment 50.00 ± 13.14 51.09 ± 12.99 F = 2.59, p =.112b
Post-treatment 59.72 ± 11.69 51.19 ± 13.66 F = 31.83, p < .001c
Pain
Pre-treatment 42.13 ± 16.69 36.26 ± 15.67 F = 0.19, p = .658
Post-treatment 45.91 ± 18.70 36.03 ± 15.51 F = 5.18, p = .026
ADL
Pre-treatment 47.96 ± 17.61 46.04 ± 11.92 F = 1.38, p = .243
Post-treatment 53.59 ± 16.22 46.45 ± 11.30 F = 23.77, p < .001
Sport/rec
Pre-treatment 27.95 ± 20.19 21.67 ± 12.19 F = 0.07, p = .936
Post-treatment 29.86 ± 20.72 21.25 ± 12.44 F = 8.73, p = .004
QoL
Pre-treatment 22.57 ± 13.55 19.10 ± 10.59 F = 0.52, p = .470
Post-treatment 28.12 ± 17.13 19.61 ± 10.79 F = 7.11, p = .010
a
p is calculated by the ANCOVA.
b
Adjusted to age and weight.
c
Adjusted to age, weight, and pre-treatment.ADL = activities of daily livings; KOOS = Knee Injury
and Osteoarthritis Outcome Score; QoL = quality of life; sport/rec = sports and recreational activities;
SD = standard deviation.

Figure 3. Mean of VAS score in two groups of intervention and sham

Please cite this article as: M. Alinaghizadeh, J. Hawkins, A. Abbassian et al., Effect of Persian acupressure (Ghamz) on Patients with Knee
Osteoarthritis: A Single-Blinded Parallel Clinical Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2021.06.002
JID: YJPMN
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6 M. Alinaghizadeh, J. Hawkins, A. Abbassian et al. / Pain Management Nursing xxx (xxxx) xxx
Table 3
Comparison of Analgesic Medication Intake Between Acupressure and Sham Groups
1 Analgesic Tablet/day 1 Analgesic Tablet/2 day
Pretreatment
Acupressure group 11 (30.56%) 8 (22.22%)
Sham group 12 (33.33%) 7 (19.44%)
Post-treatment
Acupressure group 11 (30.56%) 7 (19.44%)
Sham group 17 (47.42%) 12 (33.33%)
a
chi-square test.
as compared with those in the sham group at the end of the
first intervention day, end of the study, and 10 days after the
last therapy session (p < .001). The pain score in the treatment
group increased on the 15th day but was not found to be sig-
nificant. The results did not change after controlling for potential
confounders.
Analgesic tablet intake was not significantly different between
groups at the start of the trial (p = .573). Participants in the
acupressure group consumed fewer analgesic tablets as compared
with participants in the sham acupressure group during the study
(p = .009) (Table 3).
Discussion
Identification of a beneficial CAM approach to improve out-
comes in patients with knee osteoarthritis is a priority in the clin-
ical investigation due to the increased prevalence and the adverse
effects of KOA on quality of life. This randomized clinical trial study
was conducted to examine Ghamz therapy’s impact on multiple
outcomes, which play important roles in osteoarthritis patients’
lives. According to our findings, patients with knee osteoarthri-
tis who receive 10 sessions of Ghamz therapy experience a no-
table improvement in overall symptoms, pain intensity, daily ac-
tivity routines, sports and recreation activities, and quality of life.
This study is the first RCT to evaluate the effects of Ghamz therapy
on knee osteoarthritis to the best of our knowledge.
Ghamz is an Iranian acupressure technique derived from Tradi-
tional Persian Medicine (TPM) principles which consist of strong
pressure and movement of the fingertips in a transverse direc-
tion on specific points (Khoramizadeh, Hashem-Dabaghian, & Mo-
hammadikenari, 2019). This therapeutic modality shares features
with specific other CAM methods such as Shiatsu and reflexol-
ogy (Hakimi, Saeedi, & Mokaberinejhad, 2015; Jaladat, Atarzadeh,
& Homayouni, 2013). A trial by Kielar et al. (2017) found that re-
flexology has an analgesic effect and can decrease pain intensity
and medication intake as well as improve functionality and sleep
quality (Kielar, Drzał-Grabiec, Truszczyńska, & Twarowska, 2017).
Similarly, patients with pain and anxiety due to lower back pain
experienced a reduction in both pain and anxiety after four shi-
atsu therapy sessions (Brady, Henry, Luth, & Casper-Bruett, 2001).
The efficacy of acupressure and isometric exercise has been eval-
uated in patients with KOA, and findings revealed that patients in
the isometric exercise group experienced better improvements in
stiffness and physical function, while the acupressure group expe-
rienced lower pain (Sorour et al., 2014).
Our findings support evidence that certain CAM methods, such
as acupressure, provide an effective option in the improvement of
osteoarthritis as an alternative to pharmaceutical medications. In
this study, patients who experienced Ghamz therapy enjoyed lower
pain scores, higher KOOS scores, and lower medication intake, as
compared with patients who were in the sham group. These find-
ings are consistent with a study by Chiranthanut et al. (2014), who
found that Thai massage and oral ibuprofen had similar effects
Please cite this article as: M. Alinaghizadeh, J. Hawkins, A. Abbassian et al., Effect of Persian acupressure (Ghamz) on Patients with Knee
Osteoarthritis: A Single-Blinded Parallel Clinical Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2021.06.002
[mNS;July 11, 2021;10:35]
1 Analgesic Tablet/3-5day Not using Analgesic pa
.573
9 (25.00%) 8 (22.22%)
14 (38.88%) 3 (8.33%)
.009
7 (19.44%) 11 (30.56%)
5 (13.88%) 2 (5.55%)
on symptoms of knee osteoarthritis (Chiranthanut et al., 2014). As
safe, non-invasive therapies, these CAM modalities offer situable
alternatives to NSAIDs for osteoarthritis treatment, particularly in
patients who experience adverse side effects from NSAIDs.
In this study, Ghamz therapy was first performed on patients
by an expert practitioner who then trained them to self-administer
the treatment. The feasibility of self-administration of acupressure
was assessed by Zhang et al. (2012), who focused on effects on
symptoms of osteoarthritis among postmenopausal women with
knee osteoarthritis. They concluded that self-administered acupres-
sure exercise by individuals is safe and does not pose any addi-
tional risk or disadvantage to the patients (Zhang et al., 2012).
Due to similarities between Ghamz therapy and acupressure, these
findings are generalizable to the concept of training patients to
self-administer Ghamz therapy effectively.
The exact mechanism of pain reduction using Ghamz therapy
has not been established. One proposed mechanism relates to con-
nective pathways (called "Mohazat canal"), which link organs of
the body and transfer substances across the body. According to tra-
ditional Persian medicine, the accumulation of waste products in
the body is a leading cause of disease. Theoretically, Ghamz ther-
apy plays a role in the dilation of these canals, the transition of
substances, diversion of damaging flow, improvement of circula-
tion, and elimination of waste products, all of which result in a
decrease in the severity of diseases and lead to immediate effects
on pain reduction (Hakimi et al., 2015; Jalada, et al., 2013). Like
Persian medicine, traditional Chinese medicine defines connective
pathways that distribute energy in all the body’s organs. One pos-
sible mechanism of the actions of Shiatsu is that the practice im-
proves energy production, as well as consumption and regulation
of energy balance between these pathways (Hakimi et al., 2015).
Limitations
This is the first study to evaluate the effects of Ghamz ther-
apy on knee osteoarthritis using evidence-based protocols and
valid, reliable instruments to assess knee osteoarthritis outcomes.
In addition to these strengths, this study has several limitations.
Most participants were female, limiting generalizability. Addition-
ally, owing to the nature of the intervention, it is difficult to fully
blind the acupressurist, which may lead to bias. There is also a sig-
nificant difference in weight and age between the acupressure and
sham groups, and both of these factors could affect pain intensity
(Neogi, 2013). However, the findings did not change after adjust-
ing for these covariates. Socioeconomic status influences pain per-
ception and was not considered in this analysis (Fitzcharles et al.,
2014). Finally, while the Ghamz therapy produced near-instant pain
relief in this trial, the treatment duration was only five days, and
the overall follow-up was too short of establishing long-term effi-
cacy.
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M. Alinaghizadeh, J. Hawkins, A. Abbassian et al. / Pain Management Nursing xxx (xxxx) xxx
Conclusions
In conclusion, our findings indicate that 10 Ghamz therapy ses-
sions safely result in beneficial effects on pain and stiffness reduc-
tion, as well as improvement of symptoms, daily activities, sport
and recreation function, and quality of life among patients with
knee osteoarthritis. Therefore, Ghamz therapy should be consid-
ered an effective CAM modality servicing as an alternative to con-
ventional medicine to alleviate knee pain in the short-term. How-
ever, further studies with larger samples and longer intervention
periods should be conducted to determine the optimal treatment
protocol, cost-effectiveness, and generalization to other conditions.
Declaration of Competing Interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared to
influence the work reported in this paper.
Acknowledgments
The authors thank all participants for participating in this study.
We thank the outpatients’ clinics including Asra, Ahmadieh, and
Tooba, that collaborated with us and also, Dr. M. Azizkhani for his
kind supports.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.pmn.2021.06.002.
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Please cite this article as: M. Alinaghizadeh, J. Hawkins, A. Abbassian et al., Effect of Persian acupressure (Ghamz) on Patients with Knee
Osteoarthritis: A Single-Blinded Parallel Clinical Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2021.06.002