EFFECT OF PARTIAL MASSAGE USING CHAMOMILE AND

LEMONGRASS OIL ON PAIN MANAGEMENT IN OSTEOARTHRITIS

OF KNEES.

ABSTRACT

Background: Knee osteoarthritis is one of the most common musculoskeletal conditions,

causing joint degeneration and, as a result, difficulty in daily activities. This study aims to assess

the benefits of partial massage with coconut oil (carrier oil), essential oils of lemongrass, and

chamomile on patients with knee osteoarthritis.

Methods: The study was non-randomized clinical trial with the convenience selection method.

From the GYNMC Out-Patient department, 50 patients were chosen. The Western Ontario and

McMaster Universities Osteoarthritis Index (WOMAC) and the Visual Analog Scale (VAS)

Scale were used to measure the patients' activities and pain intensity of daily living at baseline

and 10 days following the intervention.

Results: Result showed a significant reduction in mean scores for VAS ,WOMAC pain,

stiffness and functional state were significantly decreased at the end of 10 days were

significantly lower than the baseline scores (P value < .001)

Conclusion: A Partial massage using chamomile (essential oil), lemongrass (essential oil), and

coconut oil (carrier oil) enhances a patient's everyday activities and lessens pain in Osteoarthritis.

However, further studies are required in larger sample size in order to confirm findings of this

study.

Keywords: Osteoarthritis, Pain, knees, Massage, Lemongrass oil, Chamomile oil, VAS,

WOMAC.
1
 Introduction

Osteoarthritis is the most prevalent form of arthritis, with an associated risk of mobility

disability. It is a multifactorial process in which mechanical factors have a central role and is

characterised by changes in structure and function of the synovial joint[1] . This degenerative

and progressive joint disease affects around 250 million people worldwide. Elderly

(approximately 35% of patients over 65 years old) females, patients with obesity and African

Americans are the population with the highest risk of developing OA [2].Knee symptoms can

vary depending on the cause of the problem. The most common symptom of knee OA is pain

around the knee joint. Pain can be dull, sharp, constant, or intermittent (off and on). Pain can

vary from mild to agonizing. Range of motion can be decreased. The practitioner may hear

grinding or popping sounds and may report muscle weakness. Swelling, locking, and giving way

of the knee are common problematic symptoms. These disabilities, mainly related to pain, are

usually manifested by difficulty in walking, climbing stairs, performing household chores, and

sitting upright and have a negative psychological impact, all of which can lead to a decreased

quality of life. OA results from a multifactorial, complex interplay of constitutional and

mechanical factors, including joint integrity, genetic predisposition, local inflammation,

mechanical forces, and cellular and biochemical processes. Knee OA is closely associated with

age, as radiographic evidence of OA occurs in most people by age 65 years and in more than

75% of people older than age 75 years. Although there are many associations and mechanisms

that are not well understood, it has been reported that there is a higher prevalence of OA among

elderly women. Excess weight on the knee can adversely affect the functional capacity of the

knee joint. An association between obesity (body mass index) and the prevalence and incidence

2
of knee OA has been consistently demonstrated in several cross-sectional and longitudinal

studies. Although excess weight increases joint loading, resulting in deleterious effects on

weight-bearing joints, this is not the only factor involved in the relationship between OA and

obesity. Obesity increases the risk of knee OA by multiple mechanisms: Increased joint loading;

changes in body composition, with negative effects related to inflammation; and behavioral

factors, such as diminished physical activity and subsequent loss of protective muscle strength.

An evaluation of the body weight, joint range of motion, discomfort location, muscular strength,

and ligament stability should all be included of a physical examination. Plain radiographs can

show osteophytes, a narrowing of the joint space, and possibly alterations in the subchondral

bone when the disease is progressed. The diagnosis of various knee pain conditions that may be

mistaken for knee osteoarthritis, such as osteochondritis dissecans and avascular necrosis, may

be aided by the use of magnetic resonance imaging. Whenever an effusion is evident and a

disease other than osteoarthritis (such as septic arthritis, gout, or pseudogout) is suspected, you

might want to think about aspirating a joint. Joints with altered synovial fluid have non

inflammatory synovial fluid (leucocyte count 2000/mm3, transparent, viscous).The pain

experience of knee osteoarthritis is apparently due to activation of sensory pain fibers in the

arthritic joint and to weakening of the surrounding muscles. The following are the management's

objectives: Informing patients about the condition and its treatment Controlling pain, enhancing

function, and changing the course of the disease and its effects. The toxicity and adverse event

profiles of the most popular current treatments (such NSAIDs, COX-2 inhibitors, and total joint

replacement) are unfavorable when compared to conservative therapy like exercise, weight loss,

braces, and orthotics. Multiple site pain typically has a negative effect on mental health . The

usual course of treatment for knee OA comprises medication, joint injections, physical therapy,

3
use of aids and exercise, weight control, and joint replacement surgery for end-stage illness.

Although though each of these therapy has some advantages, many OA patients still have pain,

functional restrictions, and other symptoms, including a reduced quality of life.Massage is an

intervention with a high safety and low adverse event profile when administered by trained

massage therapists.Aromatherapy refers to the medicinal or therapeutic use of essential oils

absorbed through the skin. Essential oils, which are derived from plants, are used to treat illness

as well as to enhance physical and psychological well-being.When applied topically, the oil is

usually added to carrier oil and used for massage[3] . Chamomile is one of the most ancient

medicinal herbs known to mankind.Chamomile preparations are commonly used for many

human ailments such as hay fever, inflammation, muscle spasms, menstrual disorders, insomnia,

ulcers, wounds, gastrointestinal disorders, rheumatic pain, and hemorrhoids. Essential oils of

chamomile are used extensively in cosmetics and aromatherapy[4]. It was found that chamomile

oil caused increase in the analgesic activity patients with knee osteoarthritis[5] .The anti-

inflammatory activity was confirmed by a reduced production of TNF-α seen in mice treated

with APG following LPS treatment [6]. Cymbopogon citratus, Stapf (Lemon grass) is a widely

used herb in tropical countries, especially in Southeast Asia. The essential oil of the plant is used

in aromatherapy. The compounds identified in Cymbopogon citratus are mainly terpenes,

alcohols, ketones, aldehyde and esters. Some of the reported phytoconstituents are essential oils

that contain Citral α, Citral β, Nerol Geraniol, Citronellal, Terpinolene, Geranyl acetate,

Myrecene and Terpinol Methylheptenone. The plant also contains reported phytoconstituents

such as flavonoids and phenolic compounds, which consist of luteolin, isoorientin 2’-O-

rhamnoside, quercetin, kaempferol and apiginin. Studies indicate that Cymbopogon citratus

possesses various pharmacological activities such as anti-amoebic, antibacterial, antidiarrheal,

4
antifilarial, antifungal and anti-inflammatory properties [7].Multiple site pain typically has a

negative effect on mental health . The usual course of treatment for knee OA comprises

medication, joint injections, physical therapy, use of aids and exercise, weight control, and joint

replacement surgery for end-stage illness.Although though each of these therapy has some

advantages, many OA patients still have pain, functional restrictions, and other symptoms,

including a reduced quality of life.Massage is an intervention with a high safety and low adverse

event profile when administered by trained massage therapists. It is acceptable to patients,

reduces stress, anxiety, and pain . The biological mechanisms of massage therapy are not fully

elucidated. Relaxation effects may be modulated through reduction of cortisol and

norephinephrine .Other mechanisms may include increased tissue revascularization by

upregulating vascular endothelial growth factor (VEGF), a signal protein that stimulates

angiogenesis and vasculogenesis. Other possible mechanisms include modulating stem cell

activity and inflammation [8]. Knee osteoarthritis is reputedly the most common joint disease in

the elderly and the largest cause of functional disability with some 80% of people over 65 years

of age showing radiological symptoms of osteoarthritis [9]. According to a study by Qin s et.al,

patients with knee osteoarthritis are more prone than healthy individuals to experience worry,

depression, and restless nights in addition to joint pain. Therefore, it is essential to develop

therapies that effectively improve patients' quality of life while also reducing their medical costs.

Numerous studies have reported that aromatherapy massage is a helpful non-pharmacological

approach in complementary therapy for patients with knee OA. These studies were conducted

with various compounds of EOs in certain countries on different age groups and genders.

Therefore, because of the high prevalence of knee OA, especially in older people, and

complications of pharmacological and surgical treatments in these patients, as well as safety,

5
convenience, non-invasiveness and cost-effectiveness of complementary therapies, the present

study aimed to determine the effects of aromatherapy massage with lemon grass, Chamomile EO

as an intervention for improving pain and functional state of subjects. There are few studies

documented on aromatherapy for pain management in osteoarthritis of knees.Though studies

provide such information there is no specific study based on partial massage using chamomile

oil and lemongrass oil for pain management in Osteoarthritis of knees.

6
LITERATURE REVIEW

Osteoarthritis a critical review

Osteoarthritis is the most prevalent form of arthritis, with an associated risk of mobility disability

(defined as needing help walking or climbing stairs) for those with affected knees being greater

than that due to any other medical condition in people aged ≥ 65. The societal burden (both in

terms of personal suffering and use of health resources) is expected to increase with the

increasing prevalence of obesity and the ageing of the community. Osteoarthritis is a

multifactorial process in which mechanical factors have a central role and is characterized by

changes in structure and function of the whole joint. There is no cure, and current therapeutic

strategies are primarily aimed at reducing pain and improving joint function. We searched

Medline for relevant articles (1966 to January 2006) and the Cochrane library (to first quarter of

2006) and consulted experts in rheumatology to produce a narrative review with an update on

management for primary care doctors. We concentrated on osteoarthritis of the knee as this is

associated with the greatest public health burden.

7
What is osteoarthritis?

Osteoarthritis is the clinical and

pathological outcome of a range of

disorders that results in structural and

functional failure of synovial joints. The

current concept holds that osteoarthritis

involves the entire joint organ,

including the subchondralbone, menisci,

ligaments, periarticular muscle, capsule,

and synovium (fig 1).

Epidemiology of osteoarthritis

The reported prevalence of osteoarthritis varies according to the method used to evaluate it. In

most epidemiological studies it is commonly assessed by radiography. Marked osteoarthritic

damage must be present, however, to detect characteristic changes with plain radiographs, and

they are therefore not sensitive diagnostic tests. About 6% of adult’s age ≥ 30 have frequent knee

pain and radiographic osteoarthritis. Osteoarthritis is caused by aberrant local mechanical factors

acting within the context of systemic susceptibility. Systemic factors that increase the

vulnerability of the joint to osteoarthritis include increasing age, female sex, and possibly

nutritional deficiencies. While epidemiological studies have shown a major genetic component to

risk that is probably polygenic, the genes responsible have not yet been identified. Local

mechanical factors such as misalignment, muscle weakness, or alterations in the structural

integrity of the joint environment (such as meniscal damage) facilitate the progression of the

8
disease. Loading can also be affected by obesity and joint injury, both of which can increase the

likelihood of developing osteoarthritis or experiencing its progression.

Diagnosis and investigation

The diagnosis of osteoarthritis can usually be made clinically and then confirmed by

radiography. The main features that suggest the diagnosis include pain, stiffness, reduced

movement, swelling, crepitus, and increased age (unusual before age 40) in the absence of

systemic features (such as fever).

Many of the remainder also probably have disease as yet undetectable on plain radiography or

another source of knee pain such as anserine bursitis or iliotibial band syndrome. The joint pain

of osteoarthritis is typically described as exacerbated by activity and relieved by rest. In more

advanced disease it is painful at rest and at night. The source of pain is not particularly well

understood and is best framed in a biopsychosocialIn contrast, the subchondral bone, periosteum,

synovium, and joint capsule are all richly innervated and could be the source of

nociceptivestimuli in osteoarthritis.

9
Clinical investigation

Physical examination should include an

assessment of body weight, range of motion

in the joint, the location of tenderness,

muscle strength, and ligament stability.

Osteoarthritis can occur in any synovial

joint in the body but is most common in the

hands, knees, and hips. Diagnosis usually

involves assessment of the range of

presenting clinical features, including

imaging. When disease is advanced, it is

visible on plain radiographs, which show

narrowing of joint space, osteophytes, and

sometimes changes in the subchondral bone (fig 2).

Magnetic resonance imaging may be used to facilitate the diagnosis of other causes of knee pain

that can be confused with knee osteoarthritis (such as osteochondritis dissecans and avascular

necrosis). Nearly all people with knee osteoarthritis have meniscal tears, and these are not

necessarily a cause of increased

Because of the high prevalence of laboratory abnormalities in elderly people, such as a raised

erythrocyte sedimentation rate and anemia, however, these will commonly be detected and may

prompt an unnecessary investigation. Consider obtaining a blood count, creatinine concentration,

and liver function tests before starting the patient on non-steroidal anti-inflammatory drugs

(NSAIDS), especially for elderly people or in those with other chronic illnesses.

10
Consider aspirating a joint if an effusion is present and a diagnosis other than osteoarthritis (such

as septic arthritis, gout, pseudogout) is suspected. Synovial fluid from affected joints is non-

inflammatory (leucocyte count < 2000/mm3, clear, viscous).

Treatment

The aims of management are:

 To educate patients about the disease and its

 To control pain

 To alter the disease process and its consequences.

11
Osteoarthritis should be managed on an individual basis and will probably consist of a

combination of treatment options. Treatment should be modified according to the response

obtained. Unfortunately, nearly all treatments tested and used are drugs or surgery, or both. For

example, in a recent meta-analysis, 60% of trials assessed the effect of drug treatment and 26%

evaluated surgical procedures. The lack of studies evaluating rehabilitation techniques, including

bracing and other self-management techniques, has been labelled “research agenda bias”8 and is,

in part, a consequence of lucrative opportunities for drug development. The toxicity and adverse

event profile of the most commonly used existing treatments (such as NSAIDs, cyclo-

oxygenase-2 (COX 2) inhibitors, and total joint replacement) is un favorable compared with

conservative interventions such as exercise, weight loss, braces, and orthotics. Some

management guidelines are based on evidence from trials and expert consensus (additional

educational resources). Clinical features of osteoarthritis

• Joint pain with activity

• Transient stiffness in the morning or after rest

• Reduced range of motion

• Joint crepitus or periarticular tenderness, or both

• Bony swelling

The non-pharmacological approach includes:

Education—Encourage patients to participate in self-management programs (such as those

conducted by the Arthritis Foundation in the United States and Arthritis Care in the United

Kingdom), and provide resources for social support and instruction on coping

12
Weight loss—Encourage overweight patients with osteoarthritis of the hip and knee to lose

weight through a combination of diet and exercise. Exercise increases aerobic capacity, muscle

strength, and endurance and also facilitates weight loss. All people capable of exercise should be

encouraged to take part in a low impact aerobic exercise program (walking, cycling, or

swimming or other aquatic exercise). Exercises to strengthen the quadriceps lead to reductions in

pain and improvements in function.

Physical therapy consists of several strategies to facilitate resolution of symptoms and improve

functional deficits, including range of motion exercise, muscle strengthening, muscle stretching,

and soft tissue mobilization. Knee braces and orthotics - For those with instability of the knee

and varus misalignment, valgus bracing and orthotics shift the load away from the medial

compartment and, in doing so, may provide relief of pain and improvement in function has

shown that heel wedges can reduce medial compartment loads, there is no evidence that, used

alone, and they improve knee symptoms. Appropriate supportive footwear should be worn by

people who have osteoarthritis of the knee and hip .Pharmacological approach Analgesics

Paracetamol (up to 4 g/day) is the oral analgesic of choice for mild to moderate pain in

osteoarthritis. NSAIDs should be added or substituted in patients who respond inadequately and

are sometimes the first choice because of greater efficacy and patients’ preference. There are,

however, certain disadvantages of routinely using NSAIDs—for example, all NSAIDs (non-

selective and COX 2 selective) are associated with potential toxicity, particularly in elderly

people. COX 2 selective inhibitors have also been associated with an increased risk for

cardiovascular disease. Rofecoxib, a COX 2 selective inhibitor, was recently withdrawn because

of such concerns. In people with an increased gastrointestinal risk, nonselective NSAIDs plus a

gastro protective agent or a selective COX 2 inhibitor should be used.

13
Opioid analgesics are useful alternatives in patients in whom NSAIDs are contraindicated,

ineffective, or poorly tolerated. Topical formulations of NSAIDs and capsaicin may be helpful.

Glucosamine compounds, in particular, have attracted a great deal of attention, mostly in the lay

press. Possibly as a function of this publicity, osteoarthritis is the leading medical condition for

which people use alternative therapies.w6 Glucosamine and chondroitin seem to have the same

benefit as placebo, and there is controversy over whether they also have structure modifying

benefits.

Intra-articular steroids

In patients who present with acute exacerbations of pain and signs of local inflammation with

joint effusion, analysis of synovial fluid is warranted to look for gout or pseudogout crystals and

evidence of an inflammatory arthritis, such as rheumatoid arthritis. When not otherwise

contraindicated, intra-articular corticosteroids are of short term benefit (one week) for pain and

function.

Intra-articular hyaluronan

Though the meta-analyses reviewing the efficacy of intra-articular hyaluronan are not in

complete agreement, mainly because of variation in study methods, most suggest that the effect

size is relatively small and the placebo response is significant.

Surgery

Surgery should be resisted when symptoms can be managed by other treatment modalities. The

typical indications for surgery are debilitating pain and major limitation of functions such as

walking and daily activities or impaired ability to sleep or work.

14
Arthroscopic debridement and lavage

The role of arthroscopic debridement of the knee is controversial. In a well-designed placebo

surgery trial, improvement in symptoms could be attributed to a placebo effect. For a subgroup

of knees with loose bodies or flaps of meniscus or cartilage that are causing mechanical

symptoms, especially locking or catching

Non-pharmacological management

 Education, exercise,

 weight loss,

 appropriate footwear

 Mild Severity of symptoms Severe

 Non-pharmacological

 management

 Physiotherapy, braces, and begin

 Pharmacological treatment with simple analgesics (such as paracetamol)

 Pharmacological management

 NSAIDs, opioids (if effusion is present, aspirate and inject)

 Surgery

 Osteotomy,

 Total joint replacement

15
Osteotomy

A recent systematic review of studies comparing different types of osteotomy showed

improvements in pain and function.w8 Recovery is typically prolonged, but osteotomy may

delay the need for total joint replacement for 5-10 years.18 Currently there is debate as to the

relative merits of osteotomy versus uni-compartmental knee replacement; this warrants further

investigation in well-designed clinical trials.

Joint replacement

Development of modern total hip arthroplasty in the1960s by John Charnley, a British surgeon,

represents a milestone in orthopaedic surgery. Currently the most common indication for knee

and hip replacement (about 85% of all cases) is osteoarthritis. Joint replacement is an irreversible

intervention used in those for whom other treatments have failed. Based on a survey of

orthopaedic surgeons, indications for the procedure were severe daily pain and x ray evidence of

narrowing of the joint space.19 With proper selection of patients, good to excellent results can be

expected in 95%, and the survival rate of the implant is expected to be 95% at 15 years.20 When

overall health improvement is used to assess the cost effectiveness of total joint arthroplasty, hip

and knee arthroplasty have similar results.w10 Costs associated with long term medication,

assistive care, and decreased work productivity may exceed the cost of arthroplasty. Total joint

replacement has been shown to be cost effective compared with non-surgical treatments

including NSAIDs. Joint replacement was more cost effective in patients who had the most to

gain (those with lower preoperative function). If left until functional status has declined,

however, the postoperative functional status does not improve to the level achieved by those with

higher preoperative function.

16
We anticipate, that with the current major research initiatives driving a better understanding of

the course of symptomatic and structural change in the disease, that new treatments to retard the

progress of osteoarthritis will be developed in the medium term. At present clinicians should

manage patients with osteoarthritis with a combination of methods. Contributors: DJH performed

the literature search, wrote the manuscript, and is guarantor. [10]

Osteoarthritis: New Insight on Its Pathophysiology

Understanding of the basis of osteoarthritis (OA) has seen some interesting advancements in

recent years. It has been observed that cartilage degeneration is preceded by sub-chondral bone

lesions, suggesting a key role of this mechanism within the pathogenesis and progression of OA

as well as the formation of ectopic bone and osteophytes. Moreover, low-grade, chronic

inflammation of the synovial lining has gained a central role in the definition of OA

physiopathology and central immunological mechanisms, innate but also adaptive, are now

considered crucial in driving inflammation and tissue destruction. In addition, the role of neuro-

inflammation and central sensitization mechanisms as underlying causes of pain chronicity has

been characterized. This has led to a renewed definition of OA, which is now intended as a

complex multifactorial joint pathology caused by inflammatory and metabolic factors underlying

joint damage. Since this evidence can directly affect the definition of the correct therapeutic

approach to OA, an improved understanding of these pathophysiological mechanisms is

fundamental. Osteoarthritis (OA) is the most common chronic articular disease with an

increasing prevalence due to population aging and obesity. Osteoarthritis is characterized by

articular cartilage degeneration and persistent pain, causing disability, loss of function, decreased

quality of life (QoL), and economic burden The global incidence of OA has been estimated at

about 20% .However, according to recent assessments, regional and individual country

17
differences exist Indeed, OA incidence has been estimated at 10–17% in Europe, 12–21% in

North America, 2–4% in South America, 16–29% in Asia, Africa, and Middle-Eastern countries .

Considering that OA

Susceptibility is strongly affected by genetic and environmental risk factors, the assessment of

OA epidemiology in different populations can contribute to the understanding of the worldwide

burden of the disease and may also shed light on the underlying mechanisms of the disease.

Osteoarthritis has long been considered a degenerative cartilage disease, characterized by a

progressive loss of functionality due to different factors, such as excessive body weight,

advanced age, surgical joint treatments, repeated joint injuries, and genetic predisposition.

Nevertheless, the understanding of the basis of OA has seen some interesting advancements in

recent years Indeed, modern imaging approaches have shown that OA pathogenesis involves the

breakdown of cartilage and structural changes in the whole joint. In particular, it has been

observed that cartilage degeneration is preceded by subchondral bone lesions, suggesting a key

role of this mechanism within the pathogenesis and progression of OA, as well as the formation

of ectopic bone and osteophytes Moreover, low-grade, chronic inflammation of the synovial

lining now plays a central role in defining OA pathophysiology, and innate but adaptive central

immunological mechanisms are now considered crucial in driving inflammation and tissue

destruction. Lastly, the role of neuro- inflammation and central sensitization mechanisms as

underlying causes of pain chronicity has been characterized. This evidence has led to a renewed

definition of OA, which is now intended as a complex multifactorial joint pathology caused by

inflammatory and metabolic factors underlying joint damage. This new perspective directly

impacts the definition of the correct therapeutic approach to OA. Therefore, an improved

understanding of these pathophysiological mechanisms is crucial. This narrative review provides

18
an overview of the most updated evidence on OA pathogenesis. It presents the latest insight on

OA pathophysiology, describing the interplay between immunological and biochemical

mechanisms proposed to drive inflammation and tissue destruction. Changes in the

Osteochondral Unit during Osteoarthritis: The Role of the Subchondral Bone Increasing

evidence suggests that OA is a whole-joint disease in which all the joint components (cartilage,

synovium, subchondral bone, and associated muscles) are affected Articular cartilage covers the

ends of bones in the diarthrodial joint and absorbs shock from joint movement. It has an aneural,

avascular, and lymphatic structure composed of 65–80% water, 20–40% extracellular matrix

(ECM), and 1–5% chondrocytes The subchondral bone is the bony layer below the hyaline

cartilage and can be divided into the subchondral bone plate (SBP) and subchondral bone

trabeculae (SBT). The SBPis a compact, porous, calcified plate traversed by nerve fibers and

vessels. The SBTs are cancellous bony structures that undergo continuous bone

remodeling .Articular cartilage, calcified cartilage, SBP, and SBTs form the osteochondral unit,

which transfers load during joint movement Subchondral bone provides both nutritional and

mechanical support for cartilage within the osteochondral unit, indicating that changes in the

subchondral bone microenvironment can affect cartilage metabolism Subchondral bone marrow

lesions (SBMLs), reported by abnormal MRI signals below the calcified cartilage, have affected

more than half of asymptomatic individuals over 50 years. Their prevalence seems to increase

with age. The SBMLs are due to abnormal and persistent mechanical insults, which lead to

cellular and biomolecular responses to microfractures. Since SBMLs can be observed in the early

stage of OA, and the worsening of SBMLs based on MRI manifestations has been associated

with subsequent radiographic findings and persistent pain, they are thought to be helpful in early

screening The site of an SBML is characterized by a high in situ turnover rate, pain, and

19
activation of pro-inflammatory pathways, finally resulting in increased subchondral sclerosis and

bone mineral density Clinical observations over 24 months suggested a strong relationship

between the increased size of the SBMLs and cartilage volume loss in corresponding regions.

Consequently, subchondral bone remodeling is now considered a key element of OA, which can

disrupt the integrity of the osteochondral unit and lead to increased crosstalk between cartilage

and subchondral A recent study reported the presence of a horizontal fissure at the interface

within the osteochondral unit in obese patients, characterized by irregular cartilage erosion,

fibro-granulation tissue infiltration, presence of free cartilage/bone debris, and rupture of micro

capillaries This can be considered a new type of pathological feature, where neurovascular

invasions have also been identified in degenerative osteochondral tissues . Subchondral bone

marrow lesions (SBMLs), reported by abnormal MRI signals below the calcified cartilage, have

affected more than half of asymptomatic individuals over 50 years. Their prevalence seems to

increase with age The SBMLs are due to abnormal and persistent mechanical insults, which lead

to cellular and biomolecular responses to microfractures. Since SBMLs can be observed in the

early stage of OA, and the worsening of SBMLs based on MRI manifestations has been

associated with subsequent radiographic findings and persistent pain, they are thought to be

helpful in early screening The site of an SBML is characterized by a high in situ turnover rate,

pain, and activation of proinflammatory pathways, finally resulting in increased subchondral

sclerosis and bone mineral density Clinical observations over 24 months suggested a strong

relationship between the increased size of the SBMLs and cartilage volume loss in corresponding

regions Consequently, subchondral bone remodeling is now considered a key element of OA,

which can disrupt the integrity of the osteochondral unit and lead to increased crosstalk between

cartilage and subchondral bone A recent study reported the presence of a horizontal fissure at the

20
interface within the osteochondral unit in obese patients, characterized by irregular cartilage

erosion, fibro-granulation tissue infiltration, presence of free cartilage/bone debris, and rupture of

micro capillaries. This can be considered a new type of pathological feature, where

neurovascular invasions have also been identified in degenerative osteochondral tissues, the

articular cartilage, and the synovial lining of the joint cavity. A thin layer of calcified cartilage is

present underneath the articular cartilage. The subchondral bone beneath the calcified cartilage is

formed from cortical bone that merges into a network of trabecular bone, which is relatively

porous and metabolically active.

Mechanisms Underlying Joint Deterioration - The Interplay between Immunological and

Biochemical Processes Increasing evidence highlights the interplay between mechanical damage

to the osteochondral unit and low-grade chronic inflammation of the synovial membrane

(synovitis) in the OA physiopathology. The involvement of innate and adaptive immune

responses in the initiation and maintenance of inflammation is also described.

Synovitis Most OA patients present with low-grade inflammation, which has thus been crucial

in OA development and progression. Pro-inflammatory mediators, such as cytokines, lipid

mediators, and reactive oxygen species (ROS), which are also produced by chondrocytes,

synoviocytes, and osteoblasts, are responsible for battering anabolism and release of proteolytic

enzymes, degrading the extracellular matrix and mediating cartilage loss Thus, an altered

balance between pro- and anti-inflammatory cytokines, directed toward catabolism, can be

described Several pro-inflammatory cytokines, such as interleukin (IL)-1_, IL-6, IL-15, IL-17,

IL-18, tumor necrosis factor (TNF)-_, and leukemia inhibitory factor (LIF), increased in OA

tissues; at the same time, interferon- (IFN-), IL-6, IL-10, IL-4, and TGF-_ provided anti-

inflammatory activity . Reactive oxygen species and inflammation are interdependent, each

21
being the target of the other. Reactive oxygen species production and oxidative stress were found

elevated in patients with OA, and the concept of chronic or prolonged ROS production is

considered central to the progression of inflammatory disease .Evidence for ROS implication in

cartilage degradation derives from lipid peroxidation products, such as oxidized low-density

lipoprotein, nitrite (NO2􀀀), nitrotyrosine, and nitrated (NO3) products in the biological fluids

and the cartilage of OA patients with and in OA animal models . Otherwise, antioxidant

enzymes, such as superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase

(GPX) were decreased in OA patients, further suggesting a role for the oxidative stress in OA

pathogenesis.

Innate Immune System: It has been observed that damage to cellular and cartilage ECM can

generate damage associated molecular patterns that activate the innate immune system and elicit

a sterile inflammatory response through interaction with particle recognition receptors, such as

Toll like receptors (TLR), on the surface of immune cells, or with particle recognition receptors

in the cell cytoplasm, such as nod-like receptors. TLR-2 and TLR-4 have been found to be

upregulated in the synovial tissue, articular cartilage lesions, and the synovial membranes of

patients with OA, leading to the up regulation of matrix metalloproteases, nitric oxide, and

prostaglandin E2 .Recent reports suggest that among the TLR-induced innate immune responses,

apoptosis is one of the critical events. Apoptosis is particularly important, given that chondrocyte

death is a dominant feature in OA .Once initiated, this inflammatory response leads to up

regulation of catabolic factors, such as proinflammatory cytokines, proteolytic enzymes, and

chemokine’s, and down regulation of anabolic factors, such as anti-inflammatory cytokines and

growth factors, contributing to an ongoing sterile wound- healing “vicious circle” resulting in

joint tissue pathology. The mediators that cause cartilage damage in OA, such as damage-

22
associated molecular patterns and ECM components, can exude into the synovial fluid and

activate synovial macrophages. Activated synovial macrophages further stimulate the release of

proinflammatory

Cytokines, such as IL-1_ and TNF-_ and other catabolic as well as anabolic mediators involved

in OA pathology. Since macrophages are critical mediators for the maintenance of tissue

homeostasis, they are thought to be involved in the pathology and symptomology of OA once

deregulated.

Several studies have been published that further support macrophages as key mediators in OA-

associated inflammation in recent years. Furthermore, it has been shown that modulating these

cells or intervening with factors that modify their phenotypic state may be a promising approach

to slowing down OA development. Lastly, different recent studies suggested the involvement of

mast cells in OA pathology due to the reported presence of these cells and their degranulation

products in OA synovium and synovial fluid .In particular, a central role for IgE-dependent mast

cell activation has been proposed in the pathogenesis of osteoarthritis. Moreover, the high

prevalence of mast cells in the synovial fluid has been associated with structural damage in OA

patients, further suggesting the role of these cells in the disease.

Adaptive Immunity: Macrophages can release pro-inflammatory cytokines that increase vascular

permeability and further facilitate CD4+ T-cell infiltration, angiogenesis, and elevated levels of

COX-2 in the OA synovium. CD4+ T cells and macrophages are abundantly present in OA

synovium and can activate each other. In particular, Th1 type T cells can initiate a cascade of

events that activate both innate and adaptive immune responses, propagate synovial

inflammation, and increase cartilage deterioration. T cells are also responsible for activating B

cells, which hamper cartilage integrity by increasing inflammation and producing autoantibodies

23
specific to chondrocytes’ surface proteins, such as collagen and osteopontin. Functional

Outcomes of Osteoarthritis: It has been estimated that OA causes limitations in activity in 7% of

the older adult population; 25% cannot perform major activities of daily living, and about 80% of

OA patients present some movement limitation . Other than activity limitations, the individual

burden of OA includes pain and markedly reduced QoL. Since OA is a chronic disease, the

accompanying chronic pain can be intermittent but generally severe or intense, or persistent

OA is now intended as a multifactorial pathology caused by different biological functional

alterations based on joint damage. A close understanding of the active biological and cellular

processes that contribute to disease pathology at a given stage of OA progression is fundamental

to targeting the individual components of the pathophysiological process with specific

therapeutic agents and detecting them at the earliest stages. In this perspective, the prevention

and the conservative treatment of OA acquire an important role [11].

Knee osteoarthritis pain in the elderly can be reduced by massage therapy,

yoga and tai chi: A review

Massage therapy for knee osteoarthritis Research on the effects of massage therapy on knee

osteo arthriti spain has been limited, although the results have consistently suggested that the

pain from that condition can be reduced by massage therapy. The pain, however, has typically

been self reported on visual analogue pain scales (e.g. happy to sad faces or 0e100 thermometer

scales) and on the Western Ontario and McMaster Universities Arthritis Index (WOMAC with

all the limitations of self-report studies. In this research, more objective observation measures

such as range of motion (ROM)-related pain were not taken. ROM was not measured in two of

the four studies .In the first of these, pain was measured on a 10-point Likert scale, and pain

decreased even though, according to the authors of that study, only the patient's healthy foot,

24
hands and upper parts of the shoulders were massaged “shallowly” for 20 min each day of their

hospitalization .In the other two WOMAC studies, ROM was measured but did not change .In

one of these studies a self-massage protocol was used. This raises the possibility that the pressure

being applied was not sufficient (moderate pressure massage being key to positive effects). This

would be especially true if the participants were not instructed to use moderate pressure and

given that they would not be inclined themselves to apply pressure to the area around the painful

joint. In the second study, pain and stiffness were reduced, and increased function was noted on

the self-report WOMAC scale, but the ROM results were negative .This could be related not

only to the use of low pressure massage but also to the massage not being focused on the affected

leg .Only 50% of the hour-long massages were applied to the affected leg, and the massage

protocol, again, may have lacked sufficient pressure to increase ROM. A comparison between

Thai massage and Swedish massage for a sample of older people with knee osteoarthritis further

supported the need for moderate pressure. In that study, the group who received Thai massage

(which typically involves more pressure than Swedish massage) reported a greater reduction in

pain on the WOMAC than the group who received Swedish massage. Based on these mixed

findings, we recently conducted a knee osteoarthritis massage study in which moderate pressure

massage was applied to the affected leg by massage therapists. Because earlier research was only

focused on the quadriceps muscles, we designed a massage therapy protocol that was focused on

the hamstrings as well as the quadriceps muscles, thinking that both sets of muscles were

involved in ROM (flexion and extension of the knee). And the assessments not only included

self-reported pain, but also ROM and ROM-related pain. Moderate pressure massage therapy

(moving the skin) was used inasmuch as it has been noted to be more effective than light

pressure massage (light stroking) with adults with hand pain, upper arm and shoulder pain and

25
neck arthritis pain. For example, in the study on adults with arthritis in their upper limbs, the

moderate pressure massage group versus the light pressure massage group had less pain and

greater grip strength following the first and last sessions. By the end of the one-month treatment

period the moderate pressure group was reporting and showing less ROM-related pain behavior

(e.g., grimacing), and greater range of motion. Further, the massage in our study was focused on

the quadriceps muscle in as much as researchers have reported a relationship between quadriceps

weakness, increased pain and altered walking patterns But, the hamstrings were also massaged

given that the previous studies failed to find ROM increases when focusing only on the

quadriceps. The results of this study on increased ROM and decreased self-reported pain as well

as decreased ROM-related pain are consistent with those we have previously reported, i.e.

changes in ROM and pain following moderate pressure massage in adults with arthritis of the

upper limbs and in the neck. Other researchers have noted a reduction in knee osteoarthritis pain

following massage, but only by self-report (WOMAC), not by direct observation of ROM-related

pain. In one of the few studies on massage for adults with knee osteoarthritis, for example, pain

and stiffness were reduced and functionality was increased. However, no ROM changes resulted

from this self-massage study, possibly because it was a self-massage study and because it is not

clear that moderate pressure massage was applied. As we have noted in our earlier studies,

moderate pressure is necessary for positive changes to occur. The positive effects in our self-

massage studies may have derived from moderate pressure being applied and/or the combination

of therapist massage (once a week) and the participants' self-massage (once a day) Another

potential interpretation for the inconsistent findings between the increased ROM we noted and

the lack of change in ROM following massage reported by the other group is that their knee self-

massage was focused solely on the quadriceps muscle group. The authors of that self-massage

26
study suggested that despite the earlier research on joint cartilage degeneration as the key factor

in knee arthritis, the more recent research had noted that quadriceps muscle weakness that affects

joint loading and proprioceptive deficits contributed to knee arthritis. Others have also found

relationships between weak quadriceps muscles and increased pain and limited walking. That

was the rationale for their self-massage protocol focusing on the quadriceps muscle. However,

the findings from our study suggest that it may be necessary to massage both the hamstrings and

the quadriceps muscles to achieve increased ROM, especially since the hamstring muscles are

noted to work together to flex the knee. Our results may be inconsistent with those of Perlman et

al. for different reasons. They again found changes on the WOMAC self-report scale on pain, but

no changes in ROM even though their massages were longer (30e60 min), more frequent (two to

three times weekly) and for a longer study period (8 weeks) than ours. As already mentioned,

their Swedish massages may have lacked sufficient pressure, and, as already mentioned, the

lower limbs were only massaged 50% of the sessions. Their results were inconsistent with ours

in that they only observed reduced pain after 5 weeks of 60- minute massages two or three times

weekly (as opposed to their lower dose group receiving only 30- minute massages two or three

times weekly) . One possible explanation for the positive effects following the shorter and less

frequent massages in our study (20 min weekly for 4 weeks) is our use of moderate pressure

massage, although it is not clear what pressure was used in their study. Cross-study comparisons

are difficult because of the different massage protocols and the various outcome measures used,

i.e. self-report pain scales in their study and the more directly observed ROM-related pain

measures in our study. Combining therapist-delivered massage with daily self-massages has been

effective now in at least three studies and suggests that this may be a more cost-effective therapy

for individuals with arthritis pain and one that may have more sustainability . The data from our

27
knee osteoarthritis study also highlight the importance of designing massage therapy protocols

that target muscle groups affected by the joint movements and then assessing those specific

range of motion measures and the ROM-associated pain Potential underlying mechanisms for

massage therapy alleviating knee osteoarthritis pain The underlying mechanism for the relief of

knee osteoarthritis pain and the increase in ROM is not clear. We have reported elsewhere that

moderate pressure massage is accompanied by decreased heart rate, suggesting a relaxed state.

We have also noted that the stimulation of pressure receptors results in increased serotonin (the

body's natural pain suppressor) which may be the primary underlying mechanism for pain relief.

A related possibility is the substance P decreases (substance P causing pain) that we have

documented following massage therapy in fibromyalgia patients when they are experiencing

more deep/restorative sleep following massage. In addition, the moderate pressure massage

protocol needs to be replicated in a more representative sample than the medical school

employees we have assessed. The clinical implications of these data include the effective use of

moderate pressure massage and massaging both the hamstrings and quadriceps to achieve better

knee ROM and the reduction of knee ROM-related pain. The addition of self-massage on the

days between massage-therapy sessions might lead to even greater therapy effects, as has been

noted in our earlier studies on arthritis of other joints [12].

28
The Effect of Aromatherapy Massage on Knee Pain and Functional Status in

Participants with Osteoarthritis.

This study was conducted to evaluate the effect of aromatherapy massage on knee pain and

functional status in subjects with osteoarthritis. The study was designed as a non-randomized

interventional study. The study was carried out on patients who referred to the outpatient clinics

of the Department of Orthopedics, Physiotherapy and Rehabilitation at Bozok University

Research and Application Hospital, and were diagnosed with osteoarthritis. A total number of 95

patients were included in the study, and of those, 33 were allocated to aromatherapy massage

group, 30 were allocated to conventional massage group, and 32 were allocated to the control

group. The study data were collected using the Patient Identification Form, visual analogue scale,

the Western Ontario and McMaster University Osteoarthritis Index. Repeated measures analysis

of variance test was used to analyze the outcomes in the aromatherapy, conventional massage

and control groups, according to the weeks of follow-up. Bonferroni test was used for further

analysis. Baseline mean visual analogue scale score and the Western Ontario and McMaster

University Osteoarthritis Index were not significantly different between the groups (p>.05).

Visual analogue scale (rest-activity) scores and the scores in the Western Ontario and McMaster

University Osteoarthritis Index in the aromatherapy massage group were lower, and the

difference compared to the control group was statistically significant (p<.001). Aromatherapy

29
massage performed in patients with osteoarthritis reduced knee pain scores, decreased morning

stiffness, and improved physical functioning status. Thus, as long as specific training is provided

for aromatherapy massage, aromatherapy can be recommended for routine use in physical

therapy units, hospitals and homes._ 2017 by the American Society for Pain Management

Nursing Pain is the most important symptom of osteoarthritis (OA). Previous studies have

reported that patients with OA experience various levels of pain have reported the percentage of

osteoarthritis patients experiencing pain as 78.5%. Pain in osteoarthritis is induced by

osteophytes irritating the periosteum, pressure in the subchondral bone, capsule distension,

bursitis, tenosynovitis, central neurogenic changes, and muscle spasms around the affected joint.

Patients with knee osteoarthritis experience joint stiffness in the morning when they wake up

and/or after immobilization for a certain period. The stiffness often lasts for less than 30 minutes,

but the pain and stiffness result in decreased physical function reported that shopping (32%) and

getting into transportation vehicles (28.5%) were the major daily activities during which

individuals with OA felt dependent. Pain, stiffness, decreased physical function, sleep

disturbances, anxiety, and depression experienced by patients with knee OA decrease the quality

of life Such problems must be addressed through up to- date treatment approaches and care

practices .Current guidelines for the treatment of knee OA recommend the concomitant use of

pharmacologic and non-pharmacologic methods. Non-opioids (acetaminophen [paracetamol]

combinations), nonsteroidal anti-inflammatory drugs, and opioids are among the available

pharmacologic options. However, patients often experience gastrointestinal problems, sleep

disturbances, sexual dysfunction, and depression associated with the use of multiple drugs for a

long period. They therefore use their medications irregularly and resort to nonpharmacologic

therapies to cope with their. Aromatherapy massage is a nonpharmacologic method used for

30
symptom control. Its main aim is not to cure the disease but to control the symptoms emerging as

a result of the disease .The use of aromatherapy massage in nursing practice is important to

improve overall health and accelerate recovery. Aromatherapy massage is preferred in many

areas because of its efficacy in relieving pain, strengthening the immune system, alleviating

inflammation, and increasing sleep quality and quality of life of the patients. Aromatherapy

massage can also be performed for joint diseases such as knee. Components of the essential oils

used during aromatherapy massage access the circulatory system through the lymph and blood

vessels in the epidermis and act to relieve pain and improve physical function. It has been stated

that certain components with analgesic characteristics in essential oils reduce pain in patients by

influencing the release of neurotransmitters such as dopamine, endorphin, noradrenaline, and

serotonin Various studies have emphasized that eucalyptus oil, lavender oil, and ginger oil can be

applied during massage therapy to control pain and improve the physical function of patients

with joint diseases In OA, ginger oil is preferred for its effect of improving joint function,

lavender oil for its effect of decreasing pain, and eucalyptus oil for its effect of locally decreasing

pain through the neural networks evaluated 40 patients with arthritis and reported decreased pain

and depression levels in the aromatherapy massage group. Hwang et al. dripped 2-3 drops of

lavender oil on a warmed towel and applied it as a compress on the knees of the patients. They

reported a decrease in knee pain and an increase in joint flexibility (using a visual analog scale

[VAS]) in the experimental group (n ¼ 21) compared with the control group (n ¼ 24) (p < .001).

Varghese et al. (2014) found that aromatherapy massage with eucalyptus oil in female patients (n

¼ 60) decreased joint pain and increased quality of life. In a qualitative study performed by

Therkleson (2010) on 10 individuals with OA, ginger oil compresses increased joint stimulation,

decreased pain, and allowed flexibility of joint movements.[13]

31
Aromatherapy massage with lavender essential oil and the prevention of disability in ADL

In-patients with osteoarthritis of the knee: A randomized controlled clinical trial

Osteoarthritis (OA), also known as degenerative arthritis or osteoarthrosis is the most common

Musculo-skeletal disorder that leads to disability in activities of daily living (ADL), particularly

in the elderly. It is already one of the ten most disabling diseases in developed countries as

reported by the WHO. OA can affect any joint, but the knees are among the most vulnerable.

Common risk factors for developing OA include obesity, age increase, race, previous joint

injury, hormonal problems, overuse of the joint, and job. One of the main goals of the

management of patients with OA is to minimize disability in ADL. Treatment strategies for OA

include pharmacological and non-pharmacological treatments as well as surgical interventions as

the last expedient. Pharmacological treatments have side-effects and surgical interventions are of

high economic costs in this line, complementary therapies have taken a step forward towards

self-sufficiency and have attracted the attention of researchers as they both promote health and

reduce complications and costs. One of the complementary therapies is aromatherapy massage,

which uses the essential oil (EO) extracted from various herbs for their medical properties.

Aromatherapy massage is the most extensively used complementary therapy. One of the EOs

used in aromatherapy is lavender (scientific name Lavandula angustifolia) which is well known

32
as a powerful aromatic and medicinal herb. Lavender is used in complementary therapy across

the world for its anti-inflammatory and analgesic effects. Yip and Tse found that lavender oil in

complementary therapy enhanced the physical functionality among adults with sub-acute non-

specific neck pain and adults with sub-acute non-specific low back pain.Numerous studies have

reported that aromatherapy massage is a helpful non-pharmacological approach in

complementary therapy for patients with knee OA .These studies were conducted with various

compounds of EOs in certain countries on different age groups and genders. Therefore, because

of the high prevalence of knee OA, especially in older people, and complications of

pharmacological and surgical treatments in these patients, as well as safety, convenience, non-

invasiveness and cost-effectiveness of complementary therapies, the present study aimed to

determine the effects of aromatherapy massage with lavender EO as an intervention for

improving ADL in patients with knee OA Our findings using within group comparison showed

that ability to perform ADL was significantly improved in all three groups. This can be attributed

to the fact that all the participants continued similar conventional drugs prescribed by the

rheumatologist. Patients’ ADL after intervention were significantly improved in the

aromatherapy massage group compared with the sweet almond oil massage and the control

groups. This finding is consistent with that of Choi’s study (2006), which investigated the

effectiveness of aromatherapy massage on physical function in elderly women with OA. In his

study, the patients were divided into three groups: oil group with non-aromatic oil (sweet almond

oil); aromatherapy massage group with EOs of sage, lavender, marjoram, and ginger; and a

control group. The participants received aroma massage nine sessions during three weeks. A

statistically significant difference was found between the three groups in terms of physical

function scores before and after the intervention In another study, Won and Chae (2011) assessed

33
the effects of aromatherapy massage in the elderly with knee osteoarthritis. In that study, the

participants were assigned randomly into an intervention group (n=21) the participants of which

had aromatherapy massage (with a cream containing peppermint, eucalyptus, rosemary) on lower

legs for 20 minutes twice a week for four weeks as well as a control group (n= 21). The results

showed that the experimental group's stride length increased significantly more than those of the

control group (p=0.009). This is also consistent with our findings.

In a randomized controlled trial, Atkins et al. (2012) enquired into the effects of self- massage in

Management of knee osteoarthritis symptoms. Symptoms were measured using the WOMAC.

Our data indicate that 8 weeks of massage provided a statistically and clinically significant

improvement of osteoarthritis symptoms. These results support findings from our earlier pilot

study8 weeks of massage in reducing pain, stiffness, timed 50-ft walk, and improving physical

function, compared to a wait-list control in adults with knee osteoarthritis.19, 22 We extend prior

work by comparing massage to an active control and determining that a biweekly maintenance

dose of massage maintained improvements in osteoarthritis symptoms at 52 weeks. Although

mean group WOMAC for massage maintenance improved and massage followed by usual care

got worse, this difference was not significant at 52 weeks with this sample size. Thus, while

weekly massage provided more immediate clinically significant improvements in osteoarthritis

symptoms at 8 weeks, massage and light-touch with or without biweekly maintenance showed

similar improvements in WOMAC scores by the end of the study. The global WOMAC score

has been validated for clinically significant change from baseline, but to our knowledge, has not

been validated for clinical significance for between-group changes.30 Angst et al. validated a 7-

point or 12% change from baseline on a 0 to 100 global WOMAC scale as clinically

significant.30 If these criteria are applied to the between-group differences at 8 weeks in this

34
study, massage compared to light touch (8.16 points and 17.2% difference) and massage

compared to usual care (9.55 points and 20.9% difference), then the change in the massage group

would be clinically significantly better than light-touch or usual care. This study was designed

with light-touch functioning as an active control for massage, providing relaxation, human touch,

and interaction with a caring person, but no tissue manipulation. Our results suggest that light-

touch may have significant therapeutic effects for individuals with painful knee osteoarthritis;

however, reasons for this improvement are not well-understood. While the underlying

mechanisms of massage-mediated improvements in osteoarthritis are not well-defined,

preliminary studies suggest that massage may improve systemic immune and inflammatory

profiles in healthy individuals. Effect sizes were large in the present study and were comparable

to, or superior to, those seen in other trials conducted using non-pharmacological approaches in

patients with knee osteoarthritis. Massage does not carry the adverse effects of many

pharmacologic and invasive treatments. While osteoarthritis treatment guidelines favor

pharmacotherapy preferred treatments like NSAIDs and acetaminophen are frequently overused,

increasing the risk of adverse effects such as gastrointestinal, cardiac, and renal complications

[14].

35
AIM AND OBJECTIVES:

Aim:

 To evaluate the effect of partial massage using chamomile oil and lemongrass oil on pain

management in Osteoarthritis of knees.

Objectives:

Primary Objective:

 To determine the effect of partial massage using aroma oils to assess pain in osteoarthritis

of knees.

Secondary Objectives:

 To determine the effect of partial massage using aroma oils to assess functional state in

osteoarthritis of knees.

36
RESEARCH QUESTION AND HYPOTHESIS:

Research question:

Does partial massage using aroma oil have effect on pain management in patient with knee

osteoarthritis?

Null hypothesis:

Partial massage using aroma oils may not reduce pain in osteoarthritis of knees

Alternate hypothesis:

Partial massage using aroma oils may reduce pain in osteoarthritis of knees.

37
MATERIALS AND METHODS:

Study design: An Experimental pre-test and post-test study was adopted for this study. All the

subjects fulfilled inclusion and exclusion criteria were included in the study group. Subjects were

received partial massage by using Chamomile and lemongrass oil.

Subjects: 50 Subjects were recruited from Government yoga and naturopathy medical college

and hospital using appropriate sampling techniques.

Inclusion criteria:

 Gender -Both male and female

 Age - 40-60 years

 BMI - 25-39.9kg/ m²

 Subjects having co-morbidities like Diabetes, hypertension.

Exclusion criteria:

 Subjects with systemic and mental illness.

 Not willing to participate in the study

 Subjects with morbid obesity (BMI >40)

 Subjects having neurological disorders.

38
Withdrawal criteria

The study was totally based on subject willingness. Subjects can withdraw from the study at any

point of time with or without any reason.

Ethical Consideration:

Institutional Ethical committee (IEC) clearance will be obtained from Govt. Yoga and

Naturopathy Medical College and Hospital before recruitment of the first subject. Study protocol

will be explained to the subjects and a signed consent was obtained from each subject.

Randomization and Blinding

In this study Randomization and Blinding were not be done.

Intervention

In this study coconut oil was used as carrier oil, chamomile and lemongrass were used as

essential oils. 15 ml of carrier oil was mixed with 3 drops of each essential oils. Using this

combinations partial massage was given to both knees for 8-10 minutes in a day for 10 days.

Massage therapy The partial massage was performed in a OPD treatment room to the OAK

patient on sitting position.The confidentiality of the patients was ensured . The Swedish massage

technique was applied over knees to subject for 8-10 minutes in a day for 10 days.

Procedure The massage was performed using the following steps after informing the

participants and obtaining consent for the procedure

39
 (1) The participant was placed in the sitting -position.

(2) The practitioner’s hands were rubbed together 10–15 times to warm the hands.

The massage technique used such as

1. Touch, 2.Stroking, 3. Friction, 4. Kneading a. Superficial kneading - Falling, b. Deep

kneading Digital and Palmar kneading 5.Joint movements [15].

Data Collection

Patient information form

This form contained demographic details and outcome measures. In outcome measures Visual

Analog scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index

(WOMAC) scale was used for pain evaluation and functional state [16].

Outcome measures:

Primary outcome-measure:

The primary measure is to observe the intensity of pain using VAS pain score. VAS is a

validated, subjective measure for acute and chronic pain. Scores are recorded by making a

handwritten mark on a 10 cm line that represents a continuum between no pain and worse pain.

Secondary outcome-measure:

WOMAC (pain and functional state) scores. The Western Ontario and McMaster Universities

Osteoarthritis Index (WOMAC) was created to assess pain, stiffness, and physical function in

patients with hip and / or knee osteoarthritis (OA). The WOMAC consists of 24 items divided

into 3 subscales: Pain (5 items): Stiffness (2 items): Physical Function (17 items)

40
Result

This study was single group pre-test and post-test experimental study. The subjects are recruited

from the outpatient department of Government Yoga and Naturopathy Medical College and

Hospital using convenient sampling methods. Screening was done on the Outpatient department

based on inclusion and exclusion criteria. A total of 85 patients were screened and only 50

subjects were selected, as they full-filled the inclusion and exclusion criteria of the study. Finally

50 subjects both male and female age limit within 40-60 years, pre diagnosed with osteoarthritis

of knee were selected as a subject for the study .The Assessment such as VAS score and

WOMAC index were done before and after the intervention. The subjects were undergone partial

massage to the knees for a period of 10 days. All the 50 subject successfully completed the study

and no one was dropped out. We have studied Effect of partial massage using chamomile and

lemongrass oil on pain management in OAK patient by using VAS, WOMAC index. Result

showed a significant reduction in mean scores for VAS ,WOMAC pain, stiffness and functional

state were significantly decreased at the end of 10 days were significantly lower than the

baseline scores

(P value < .001). In table 1, baseline and demographic details were mentioned. In table 2, Pre,

Post-test analysis of the Study Group were mentioned.

41
Table 1: Baseline and demographic details of the Study Group
Variable Study Group (n=50)

Age (years) 50.10±5.54

Gender Female (n=38), Male (n=12)

Height (meter) 156.06±6.33

Note: All values are in mean ± standard deviation except gender

Table 2: Pre, Post-test analysis of the Study Group

Variables Group (n=50) p value

Baseline Post-test

VAS Score 8.20±1.26 5.00±1.20 <0.001

WOMAC Score 58.15±8.42 46.84±7.49 <0.001

Weight (kg) 72.78±8.52 71.93±8.47 <0.001

Body Mass Index 29.93±3.55 29.58±3.54 <0.001

(kg/m2)

Note: All the values are in Mean ± Standard deviation. VAS-Visual Analog Scale

WOMAC-Western Ontario and McMaster Universities Osteoarthritis Index

42
Discussion:

Result showed a significant reduction in. mean scores for VAS ,WOMAC pain, stiffness and

functional state were significantly decreased at the end of 10 days were significantly lower than

the baseline scores (p < .001). Massage as a complementary and alternative therapy is widely

used to relieve the pain of patients who are diagnosed with KOA due to its features of high

safety, low-cost, and easy access. Previous studies have also confirmed that massage therapy is

useful in improving pain, stiffness, and functional status for patients with KOA. However, at

present, the evidence of massage for KOA lacks comprehensive system evaluation [17].Patients

with osteoarthritis who received aromatherapy massages reported less knee discomfort overall,

less morning stiffness, and increased physical performance [18].Preliminary studies indicate that

massage may improve systemic immunological and inflammatory profiles in healthy individuals,

despite the fact that the underlying mechanisms of massage-mediated benefits in osteoarthritis

are still not fully established. Studies have demonstrated that aromatherapy reduces aches,

fatigue, anxiety, and sleep difficulties [19].Potential underlying mechanisms for massage therapy

alleviating knee osteoarthritis pain, the underlying mechanism for the relief of knee osteoarthritis

pain and the increase in ROM is not clear. Stimulation of pressure receptors results in increased

43
serotonin (the body's natural pain suppressor) which may be the primary underlying mechanism

for pain relief. A related possibility is substance P decreases pain (substance P causing pain)

following massage therapy in fibromyalgia patients when they are experiencing more

deep/restorative sleep following massage [20].As already known, massage relieves pain by

increasing tissue oxygenation and endorphin release. Participants with knee OA have reduced

level of physical functioning because of pain, stiffness, and structural changes in the joints [21] .

Through lowering transudative weight, granuloma development, and serum alkaline phosphatase

activity, coconut oil demonstrated an inhibitory effect on chronic inflammation. Moreover,

coconut oil demonstrated a mild analgesic impact on the acetic acid-induced writhing response

and a counter-pyretic effect on yeast hyperthermia. The results contribute to coconut oil's

potential as an analgesic, antipyretic, and anti-inflammatory substance [22]. Coconut oil

consumption entirely eliminates the anticipated immune factor responses to endotoxin and

reduces the generation of pro inflammatory cytokines in living organisms .Chamomile is one of

the most ancient medicinal herbs known to mankind.. Traditionally, chamomile has been used

for centuries as an anti-inflammatory, antioxidant, mild astringent and healing medicine [20].

Chamomile preparations are commonly used for many human ailments such as hay fever,

inflammation, muscle spasms, menstrual disorders, insomnia, ulcers, wounds, gastrointestinal

disorders, rheumatic pain, and hemorrhoids.. It was found that chamomile oil caused increase in

the analgesic activity patients with knee osteoarthritis.The anti-inflammatory activity was

confirmed by a reduced production of TNF-α seen in mice treated with APG following LPS

treatment [6]. The flowers of chamomile contain 1–2% volatile oils including alpha-bisabolol,

alphabisabolol oxides A & B, and matricin (usually converted to chamazulene and other

flavonoids which possess anti-inflammatory and antiphlogistic properties. A study in human

44
volunteers demonstrated that chamomile flavonoids and essential oils penetrate below the skin

surface into the deeper skin layers [21].This is important for their use as topical antiphlogistic

(anti-inflammatory) agents. One of chamomile’s anti-inflammatory activities involve the

inhibition of LPS-induced prostaglandin E-2 release and attenuation of cyclooxygenase (COX-2)

enzyme activity without affecting the constitutive form, COX-1 [22].Chamomile oil caused

increase in the analgesic activity patients with knee osteoarthritis. In addition, their physical

function can be improved through topical application of this oil [23].The use of chamomile

shows protective effects against mortality in this sample of older adults of Mexican origin for

women. Further research is warranted in other populations to determine if these effects are

consistent [24].Cymbopogon citratus, Stapf (Lemon grass) is a widely used herb in tropical

countries, especially in Southeast Asia. The essential oil of the plant is used in aromatherapy.

The compounds identified in Cymbopogon citratus are mainly terpenes, alcohols, ketones,

aldehyde and esters. Some of the reported phytoconstituents are essential oils that contain Citral

α, Citral β, Nerol Geraniol, Citronellal, Terpinolene, Geranyl acetate, Myrecene and Terpinol

Methylheptenone. The plant also contains reported phytoconstituents such as flavonoids and

phenolic compounds, which consist of luteolin, isoorientin 2’-O-rhamnoside, quercetin,

kaempferol and apiginin. Studies indicate that Cymbopogon citratus possesses various

pharmacological activities such as anti-amoebic, antibacterial, antidiarrheal, antifilarial,

antifungal and anti-inflammatory properties. [7].Massage is an intervention with a high safety

and low adverse event profile when administered by trained massage therapists. It is acceptable

to patients, reduces stress, anxiety, and pain . The biological mechanisms of massage therapy are

not fully elucidated. Relaxation effects may be modulated through reduction of cortisol and

norephinephrine . Other mechanisms may include increased tissue revascularization by

45
upregulating vascular endothelial growth factor (VEGF), a signal protein that stimulates

angiogenesis and vasculogenesis. Other possible mechanisms include modulating stem cell

activity and inflammation [25]. The primary outcome in the clinical trial was change in VAS and

WOMAC global score participants with knee osteoarthritis. Aromatherapy massage performed

for 10 days reduced pain and improved functional status; there was a significant difference

between the baseline and the post assessment (p <0.001). In our study, patient statements tended

to be consistent with their quantitative changes on standard osteoarthritis measures. Patient with

OA found it easier to perform daily tasks including walking up and down stairs, going shopping,

and putting on socks when aromatherapy massage was used, and these outcomes were beneficial.

Strength of the study

This was the first study,that studied the Effect of partial massage using coconut oil, chamomile

and lemongrass oil on pain management in OAK patient. The subjects were under only Partial

massage by using chamomile and lemongrass oil for a period of 10 days.

Limitation of the study

The pain measuring instrument dolorimeter were not used.The patient were not under follow-up.

Future Direction

This can be done with large sample size and dolorimeter. To ascertain the intervention's long-

term efficacy, future research over a period of 6 months or more is advised. The study can be

designed as the randomized trial to compare its effect with other essential oil combination.

46
Conclusion

10 days of Partial massage by using Chamomile and Lemongrass oil intervention with a

monitored protocol showed a beneficial effect in patient with OAK. However further studies are

needed to warrant the effect.

47
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