Complementary Therapies in Medicine (2008) 16, 131138

available at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/ctim

An experimental study on the effectiveness of

massage with aromatic ginger and orange essential
oil for moderate-to-severe knee pain among the
elderly in Hong Kong
Yin Bing Yip a,, Ada Chung Ying Tam b

a
33A Holt Street, North Ryde, Sydney, NSW 2113, Australia
b
Hong Kong, PR China
Available online 4 March 2008

KEYWORDS Summary
Massage; Objectives: To assess the efcacy of an aromatic essential oil (1% Zingiber ofcinale and 0.5%
Knee pain; Citrus sinesis) massage among the elderly with moderate-to-severe knee pain.
Essential oil; Method: Fifty-nine older persons were enrolled in a double-blind, placebo-controlled experi-
Experimental mental study group from the Community Centre for Senior Citizens, Hong Kong. The intervention
was six massage sessions with ginger and orange oil over a 3-week period. The placebo control
group received the same massage intervention with olive oil only and the control group received
no massage. Assessment was done at baseline, post 1-week and post 4 weeks after treatment.
Changes from baseline to the end of treatment were assessed on knee pain intensity, stiffness
level and physical functioning (by Western Ontario and McMaster Universities Osteoarthritis
index) and quality of life (by SF-36).
Results: There were signicant mean changes between the three time-points within the inter-
vention group on three of the outcome measures: knee pain intensity (p = 0.02); stiffness level
(p = 0.03); and enhancing physical function (p = 0.04) but these were not apparent with the
between-groups comparison (p = 0.48, 0.14 and 0.45 respectively) 4 weeks after the massage.
The improvement of physical function and pain were superior in the intervention group com-
pared with both the placebo and the control group at post 1-week time (both p = 0.03) but not
sustained at post 4 weeks (p = 0.45 and 0.29). The changes in quality of life were not statistically
signicant for all three groups.
Conclusion: The aroma-massage therapy seems to have potential as an alternative method for
short-term knee pain relief.
2008 Elsevier Ltd. All rights reserved.

Introduction

Corresponding author. Osteoarthritis (OA), a degenerative disease, affects nearly

E-mail address: yipvera@gmail.com (Y.B. Yip). 3 out of 4 older adults.1 The knee is the most commonly

0965-2299/$ see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ctim.2007.12.003
132
Figure 1 Participants and study ow. Note: a = 1, began physiotherapy; b = 1, walking difculty & 1, reported massage causing
more pain; c = 1, reported massage was ineffective; d = 1, admitted to hospital.
affected joint in the lower limb among Hong Kong Chinese.
Recently, a local survey reported that among people aged
50 and over, 13% of women and 7% of men were diagnosed
with osteoarthritis of the knee and that 24% of women and
17% of men had persistent knee pain.2 OA is often associated
with pain, functional impairment,1,3 and reducing quality of
life.4,5
Present-day therapy for OA of the knee is directed at
symptoms, since there is no established disease-modifying
therapy.6 Many older people have turned to alternative ther-
apies such as herbal6 and massage treatment7 for relief.
Ginger is one of the most popular herbal remedies and
has a long tradition of medicinal use. Ginger (Zingiber
ofcinales) belongs to the family of Zingiberaceae. It con-
tains a number of different pungent and active ingredients
of sesquiterpene hydrocardons predominantly zingiberene,8
gingerols, pinene, cineole, capsaicin, beta-carotene, caf-
feic acid, and curcumin.9,10 Gingerols can convert into
6-paradol, 6-gingerol and 6-shogaol. These compounds have
Y.B. Yip, A.C.Y. Tam
antipyretic and analgesic effects.8 Ginger has been used as
an anti-inammatory and anti-rheumatic for musculoskele-
tal disorders in Ayurvedic and Chinese medicine for more
than 2500 years.6,9,11 Three clinical trials reported the short-
term benecial effects of Ginger extract taken orally in knee
pain reduction.6,8,12 However, oral ginger extract has a pun-
gent taste, and can causes mild gastrointestinal (GI) adverse
events like nausea, dyspepsia and eructation.6,11 Aromatic
ginger essential oil used with massage therapy, can be a safe
alternative, avoiding these GI adverse events.
Massage therapy has long history and has been shown to
have positive effects on musculoskeletal pain1315 or chronic
pain16 and is most popularly used with pain syndromes.
Field et al.17 proposed that massage leads to increased
serotonin (by urinary 5HIAA levels) and dopamine (by urine
assays) and closes the gate to the pain stimulus. As well,
massage can increase endorphin levels and enhance local
blood ow which could increase the clearance of local pain
mediators.18 Massage therapy has been shown to be an effec-
Effectiveness of massage with aromatic ginger and orange essential oil
tive treatment in some areas of musculoskeletal problems
like low back pain,15 neck pain,13 or chronic pain.16 How-
ever, Ernst18 performed a systematic review evaluating the
effectiveness of massage therapy for pain relief and found
that there was no fully convincing evidence that massage-
controlled musculoskeletal pain. Osborn et al.19 suggested
that an essential oil might prolong the effects of massage.
Two clinical trials have reported benecial effects from
aroma-massage in relieving physical symptoms among can-
cer patients in a palliative care setting.20,21
Unfortunately, there is limited evidence either for or
against the efcacy of aroma-massage with ginger essential
oil for arthritic pain. The aim of this study was to assess the
efcacy of massage with aromatic Ginger essential oil (Zin-
giber ofcinales) in relieving knee pain and stiffness, and
enhancing physical functionality and quality of life among
older persons. The participants satisfaction as well as any
adverse events from this add-on treatment was noted.
Methods
Study design and participants
This was a double-blind, placebo-controlled group exper-
imental study design. The research was carried out on a
voluntary basis among members of the Community Cen-
tre for Senior Citizens, Hong Kong. The participants were
recruited via notices on bulletin boards.
A power calculation was rst performed for the over-
all test of efcacy. According to the table of Portney and
Watkins,22 a sample size for each group of N = 18 can detect a
medium effect size (f = 0.5) with a power of 90% at = 0.05.
Therefore, the expected total number of participants was
54.
The inclusion criteria were those (1) having knee joint
pain that scored 4cm or above on a 10cm visual analog scale
over the past week; (2) aged 60 years or above; (3) who were
able to understand the explanation of the study, complete
the interview and comprehend the instructions. The partic-
ipants were excluded if they (1) had knee joint surgery in
the past 3 months; (2) were undergoing physiotherapy for
the knee joint pain; (3) had an allergic reaction towards
natural essential oils; (4) had cancer and/or blood clotting
diseases such as hemophilia; (5) were undergoing steroid
injection treatment; (6) had a large wound over knee joint
area; or (7) had acute inammatory signs over the knee joint
area.
Participants who were eligible and willing to participate
in the study were requested to sign a consent form before
undergoing treatment. Participants were allocated to one of
three groups by them randomly drawing an envelope. There
were three letters on the envelopes, i.e. letters AC. The
participants were allocated on the basis of the letter on the
envelope into either an intervention group (IG), a placebo
control group (PG) or a control group (CG).
Ginger massage treatment protocols
Participants in the intervention and placebo groups received
a session of 3035 min of aroma massage on both lower limbs
six times within 23 weeks. The intervention group received
133
massage with ginger essential oil (1% ginger and 0.5% orange
oil in olive oil as the base lubricant) and conventional
treatment. 0.5% orange essential oil (Citrus Aurantium) was
added to give a more acceptable odor since some partici-
pants would nd the pungent odor of ginger oil disturbing.
The orange essential oil was about 90% limonene.23 Both
essential oils were from Absolute Aromas Ltd. Olive oil
was selected as the base because it was relatively less
costly, and safe for dry and delicate skins compared to
other carrier oils. The placebo control group received the
massage with olive oil only as well as conventional treat-
ment, while the control group received no massage but
conventional treatment during study. However, an equiva-
lent massage session was given to the control group after
study as a service. The same supply of oils and dilutions
were used throughout the study. Efeurage and petrissage
were applied over the back and the front of both legs of the
participants. Various muscles on the thigh and leg were mas-
saged: Quadriceps femoris, Gracillis, Biceps femoris on the
thigh and Fibularis Longus, Gastrocnemius, Tibialis anterior
on the leg. Tendons in the lower limbs were massaged as
well: the tendon of Quadriceps femoris, Patellar ligament,
tendon of Gastrocnemius and Calcaneal tendon.24 The mas-
sage treatment was given by a nurse with training in leg
aroma-massage. Her skill was assessed and evaluated by
an experienced masseur. Safety was evaluated on the basis
of physical examination and the subjects self-reporting of
study events.
Data collection procedures
Questionnaires and health assessments were performed by
year four nursing students using face-to-face interviews.
In this study, the data collector and all participants were
blinded to the group allocation. Besides, the nurse who gave
the massage therapy was not involved in the data collec-
tion of outcome measurements except the general feedback
toward the massage process. Data were collected at three
time points (1) before the intervention (baseline assess-
ment), (2) 1 week after the completion of treatment (post
1-week assessment) and (3) 4 weeks after the completion of
treatment (post 4-week assessment).
Outcome measures
Demographic information including age, gender, educa-
tion occupation and medical history and knee pain related
information (e.g. knee pain nature, duration of knee pain
and treatment for the current knee pain condition) were
recorded.
The primary outcome was the knee joint pain intensity.
It was measured by the Western Ontario and McMaster Uni-
versities Osteoarthritis Index (WOMAC).25 A standard 10-cm
horizontal Visual Analogue Scale (VAS) was used. Participants
were asked to place their ngers at the point on a line rep-
resenting their level of pain with the anchor points of 0 = no
pain and 10 = pain as bad as it could be. Information on
the duration of current knee joint pain episode was also
obtained.
The secondary outcomes were knee joint stiffness inten-
sity, physical functioning and quality of life. Both knee
134 Y.B. Yip, A.C.Y. Tam

Table 1 Demographic characteristics of intervention, placebo control and control groups at baseline

Socio-demographic data Intervention Placebo control Control group p-Valuea

group (N = 19) group (N = 17) (N = 17)
frequency (%) frequency (%) frequency (%)

Gender
Male 3 (15.8) 5 (29.4) 3 (17.6)
Female 16 (84.2) 12 (70.6) 14 (82.4) 0.56
Occupation
Housewife 7 (36.8) 6 (35.3) 9 (52.9)
White collar 0 (0.0) 1 (5.9) 0 (0.0) 0.54
Services 1 (5.3) 1 (5.9) 1 (5.9)
Labour/worker 11 (57.9) 9 (52.9) 7 (41.2)
Highest education attainment
Primary or below 16 (84.2) 16 (94.1) 16 (94.1)
Junior secondary 1 (5.3) 1 (5.9) 0 (0.0) 0.59
Senior secondary or above 2 (10.5) 0 (0.0) 1 (5.9)
Treatment in the past month
On analgesics 8 (42.1) 4 (23.5) 6 (35.3) 0.50
On NSAIDs 7 (36.8) 5 (29.4) 8 (47.1) 0.57
Knee pain site
Unilateral knee 1 (6.30) 2 (6.20) 1 (5.90)
Bilateral knee 18 (94.70) 15 (93.80) 16 (94.1) 0.99

Socio-demographic data Intervention Placebo control Control group p-Valuea

group (N = 19) group (N = 17) (N = 17)
(mean S.D.) (mean S.D.) (mean S.D.)

Age (years) 73.39 5.24 72.99 6.29 74.43 4.89 0.66

Arthritis history 8.71 7.25 8.22 6.04 12.25 7.40 0.31
Note: S.D., standard deviation.
a For continuous data, p-value is calculated by Kruskal Wallis test; for categorical data, p-value is calculated by Chi-squared test.

joint stiffness and physical functioning were assessed by
WOMAC. It consisted of 24 questions, assessed on a 10-
cm visual analog scale, analyzed as 3 subscales with the
average score of 5 questions on pain, 2 questions on stiff-
ness, and 17 questions on physical function. Overall quality
of life was measured by the Short Form 36 item general
health questionnaire (SF-36).26 It included eight multi-item
scales containing 210 items each plus a single item to
assess health transition. The scales covered the dimen-
sions of physical functioning, physical role, bodily pain,
social functioning, emotional role, vitality, mental health
and general health. The scores ranged from 0 (maximal
symptoms/maximal limitation/poor health) to 100 (no
symptoms/no limitations/excellent health). At the end of
the sixth session, participants were asked about their accep-
tance of the intervention. Adverse events, i.e. the onset,
duration and intensity (mild, moderate, or severe) were
noted.
A panel of ve experts including one doctor, two physio-
therapists and two nurses with at least 2 years experience
in the orthopaedic area were invited to verify the content
validity of the outcome measures. The validity was cal-
culated by a content validity index (CVI). The overall CVI
was 0.77, the 1-week testretest reliability ranged from
0.94 to 1, and the inter-rater reliability ranged from 0.97
to 1.
Data analysis
Normality checking of the outcome data was examined
by the KolmogorovSmirnov test, with p < 0.05 indicat-
ing that the data were not normally distributed and that
non-parametric statistics should be performed. We then
compared the baseline characteristics of participants from
the control, placebo control and intervention groups using
Kruskal Wallis test or Chi-square tests according to the
type of variables. To determine whether groups of partici-
pants improved in outcome measures, we calculated a mean
change by the following formula: mean change = X2 X0
and X1 X0 , where X2 was the mean score at post 4
weeks, X1 was the mean score at post 1-week and X0
was the mean score at baseline. The Friedman test was
used to compare the outcome measures over the base-
line and the two follow-ups within the groups since most
of outcome data were not normally distributed. The level
of signicance was 0.05 (one-tailed) for all tests. All of
the analyses were completed using the Statistical Pack-
Effectiveness of massage with aromatic ginger and orange essential oil 135

Table 2 Comparison on the mean change in the WOMAC subscales among intervention, placebo and control groups from post
1-week follow-up and post 4-week follow-up to baseline

Baseline Post 1-week Post 4-week Post 1-week Post 4-week Within group
(mean S.D.) (mean S.D.) (mean S.D.) to baseline to baseline p-valuea
(mean S.D.) (mean S.D.)

WOMAC
Painb (020, worse)
IG 5.74 2.40 4.26 2.26 3.95 1.93 1.47 2.27 1.79 2.49 0.02
PG 4.53 2.21 3.94 2.11 2.88 1.50 0.69 2.75 1.65 2.29 0.11
CG 6.35 2.37 5.24 2.33 5.64 2.55 1.12 2.06 0.71 3.22 0.06
Between-groups p-valuec 0.59 0.48
Stiffness (08, worse)
IG 2.74 2.31 1.21 1.23 1.58 1.46 1.53 2.29 1.16 2.27 0.03
PG 1.71 1.69 1.44 1.50 1.01 1.03 0.31 1.62 0.65 1.32 0.29
CG 2.29 1.40 1.59 1.62 2.59 2.24 0.71 1.69 0.29 2.05 0.04
Between-groups p-valuec 0.26 0.14
Function (068, worse)
IG 14.19 9.79 10.13 6.45 10.54 7.89 4.07 5.21 3.65 6.67 0.04
PG 11.07 6.49 10.13 5.23 10.61 5.97 1.08 3.81 0.47 5.80 0.35
CG 15.53 5.56 16.14 5.90 14.64 4.88 0.61 5.99 0.89 5.50 0.29
Between-groups p-valuec 0.03 0.45
CG, control group; IG, intervention group; PG, placebo control group; S.D., standard deviation; WOMAC, Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC) consists of 24 questions, assessed on 10-cm visual analog scale, analyzed in 3 subscales as
the average score for 5 questions on pain, 2 questions on stiffness, and 17 questions on function.
a p-Value is calculated by Friedman test for within group comparison.
b In baseline between-groups comparison on pain level by Kruskal Wallis test, p-value = 0.01.
c p-Value is calculated by Kruskal Wallis test for between-groups comparison.

age for Social Sciences, version 9.0 (SPSS Inc., Chicago,
IL).
Results
Participants socio-demographic and knee pain
related characteristics
Of the 59 participants enrolled in this study, 53 (89.8%) par-
ticipants completed both post 1-week and 4-week follow-ups
(Fig. 1.). The majority of the 53 participants were women
(79%) and the mean age was 73.59 years old (S.D. = 5.42
years). Their mean knee joint pain history was 9.71 years
(S.D. = 7.05 years) (Table 1).
The majority of participants (n = 49%, 92.4%) reported
bilateral knee joint pain. About half (50.9%) had regular
medical follow-up on knee joint pain. Eighteen participants
(34.0%) used oral analgesics, while 20 participants (37.7%)
used oral non-steroid anti-inammatory drugs (NSAIDs).
There were no signicant differences between the partici-
pants (n = 53) and those who dropped out (n = 6) with respect
to the socio-demographic characteristics (p = 0.810.95)
and outcome measures (p = 0.080.97), except the educa-
tional level (p = 0.02). The drop-outs were less educated
than the participant group. Among the participants, the
control group suffered greater pain (p = 0.01) and reported
poorer in fullling the physical role (p = 0.02) than placebo
control and intervention groups (refer to Table 2, rst
column). There were no signicant differences among
control, placebo control and intervention groups for use
of oral analgesic, NSAIDs and other outcome measures
(p = 0.070.97).
Effect on knee pain and stiffness relief
Reductions in the current knee pain ratings were similar
among the three groups either at post 1-week (p = 0.59)
and post 4 weeks (p = 0.48) for between-groups compari-
son. However, the intervention group reported a reduction
in knee pain rating (p = 0.02) at the 4-week follow-up period,
but neither the placebo control (p = 0.11) nor control groups
(p = 0.06) demonstrated this for within group repeated mea-
sure analysis.
Intervention group participants did show more stiffness
relief outcomes (p = 0.03) than the placebo group (p = 0.29)
and control group (p = 0.04), as assessed by the WOMAC:
Stiffness for within group repeated measures analysis. How-
ever, there were no signicant differences in mean change
in stiffness intensity for between-group comparison at the
post 1-week follow-up (p = 0.26) or post 4-week follow-up
(p = 0.14).
Improvement in physical functioning
Intervention group participants did show more favourable
physical functioning outcomes than both the placebo con-
136 Y.B. Yip, A.C.Y. Tam

Table 3 Comparison on the mean change in the SF-36 Subscales among intervention, placebo and control groups from post
1-week follow-up and post 4-week follow-up to baseline

Baseline Post 1-week Post 4-week Within group

(mean S.D.) to baseline to baseline p-valuea
(mean S.D.) (mean S.D.)

SF-36
Physical function (0100, better)
IG 57.96 19.57 7.54 13.40 2.33 14.23 0.15
PG 57.51 19.00 3.27 15.82 1.61 13.62 0.62
CG 52.94 17.59 3.53 10.72 6.47 19.35 0.42
Between-groups p-valueb 0.59 0.23
Physical rolec (0100, better)
IG 62.50 27.64 1.18 19.61 2.63 19.36 0.49
PG 65.44 29.07 10.16 23.92 3.31 24.62 0.89
CG 38.60 26.45 5.15 31.35 6.99 31.01 0.95
Between-groups p-valueb 0.26 0.84
Bodily pain (0100, better)
IG 38.21 20.85 9.45 23.73 8.47 16.58 0.16
PG 49.18 14.36 12.50 18.44 7.12 20.09 0.20
CG 37.8 11.84 4.18 17.16 2.29 17.32 0.52
Between-groups p-valueb 0.03 0.29
General health (0100, better)
IG 47.05 20.69 1.27 15.09 1.89 14.40 0.69
PG 51.12 17.80 3.69 17.49 5.18 15.38 0.52
CG 40.76 22.52 1.88 18.15 6.35 16.61 0.14
Between-groups p-valueb 0.75 0.12
Vitality (0100, better)
IG 50.10 22.56 9.82 20.05 4.93 19.50 0.10
PG 51.10 17.71 2.76 17.07 9.19 20.74 0.17
CG 47.43 19.52 4.78 22.91 5.88 16.90 0.17
Between-groups p-valueb 0.73 0.10

Social function (0100, better)

IG 72.37 29.92 2.24 23.74 1.97 16.80 1.00
PG 73.53 25.34 4.69 31.91 6.62 30.97 0.75
CG 63.24 26.34 1.47 36.41 7.35 35.65 0.52
Between-groups p-valueb 0.76 0.56
Emotional role (0100, better)
IG 63.16 36.46 2.97 25.32 4.82 23.29 0.32
PG 80.39 22.62 1.57 17.26 1.47 21.50 0.94
CG 63.24 31.88 4.03 31.77 3.92 36.22 0.61
Between-groups p-valueb 0.81 0.52
Mental health (0100, better)
IG 66.58 23.92 3.86 14.32 2.37 14.94 0.39
PG 74.71 21.03 3.94 19.72 2.65 18.04 0.68
CG 67.35 20.40 1.47 19.75 0.00 18.11 0.90
Between-groups p-valueb 0.86 0.92
CG, control group; IG, intervention group; PG, placebo control group; S.D., standard deviation; SF-36, the Short Form 36. It consists of
36 questions and divides into eight categories.
a p-Value is calculated by Friedman test for within group comparison.
b p-Value is calculated by Kruskal Wallis test for between-groups comparison.
c In baseline between-groups comparison on physical role by Kruskal Wallis test, p-value = 0.02.

trol and the control groups, as assessed by the WOMAC for group participants did show more improvement in phys-
between-group comparison at the post 1-week follow-up ical function outcomes (p = 0.04) than the placebo group
(p = 0.04) but this was not sustained at the post 4-week (p = 0.35) and control group (p = 0.29), as assessed by the
follow-up. For within group comparison, the intervention WOMAC: Physical Function.
Effectiveness of massage with aromatic ginger and orange essential oil
Change in quality of life
Table 3 shows the results of quality of life at baseline,
post 1-week and 4-week follow-ups among the three groups.
Intervention group participants did show more favourable
bodily pain outcomes than both the placebo control and
the control groups, as assessed by the SF36 for between-
group comparison at the post 1-week follow-up (p = 0.03)
but this was not sustained at the post 4-week follow-up. No
signicant difference in bodily pain was noted at the three
time slots for within group comparison (p = 0.16, 0.20 and
0.52 respectively). Of the other seven dimensions for over-
all quality of life, there were no signicant differences in
mean change in physical function (p = 0.23), physical role
(p = 0.84), general health (p = 0.12), vitality (p = 0.10), social
function (p = 0.56), emotional role (p = 0.52) and mental
health (p = 0.92) between the baseline and the post 4-week
assessment for all groups.
No major adverse events from the massage intervention
were reported during the study. However, one withdrew
from the placebo control group reporting more pain after
the massage therapy. All intervention and placebo groups
reported that they enjoyed and were satised by either the
aroma or the plain massage.
Discussion
Ginger is one of the most popular herbal remedies and has
traditionally been used as a spice in cooking and is rec-
ommended for rheumatic conditions in Chinese medicine.
Unfortunately, few of the Ginger remedies using aroma-
massage have been tested for efcacy and safety in
well-designed clinical trials despite the widespread use of
ginger throughout the world.
Our ndings using within group analysis demonstrated a
signicant decrease in knee joint pain, stiffness and physical
function at the post 4-week follow-up for the intervention
group, but not for the plain massage or control groups. These
results are consistent with the results of studies of oral gin-
ger extract treatment in relieving knee joint pain, stiffness
and physical function in arthritis participants in the short-
term.6,8,12 This suggests that ginger may possibly be used as
anti-inammatory and analgesic agent to relieve pain and
stiffness for moderate-to-severe knee pain in the elderly.
Thomson and his team suggested that the soothing action
was related to dual inhibition of both the cyclooxygenase
and lipooxygenase pathways (prostaglandin synthetase inhi-
bition) in inammatory processes by the active ingredients
in Ginger, gingerols and shogaol.8 The capsaicin-like effect
of 6-shogaol is possibly the analgesic substance found in
ginger that inhibits the release of the neuro-peptide, sub-
stance P.9 The improvement noted in physical functioning
may be related to a reduction in pain by these pharmacologic
agents.
We found that the action length of pain and stiffness
relief by 1% Ginger essential oil aroma-massage is shorter
by comparison with oral administration of ginger powder.6,12
Although our ginger massage intervention group reported
neither GI adverse events nor allergic episodes, we used
the lower concentration of Ginger essential oil though the
recommended percentage was from 1% to 3%.10 A higher
137
concentration of 2% or 3% is worth trying to assess its rela-
tion with the length of the effect in any future study. Our
study focuses primarily on knee pain in terms of anatom-
ical site and pain level. Though many of our participants
have osteoarthritic causes of knee pain, there is possibil-
ity of rheumatoid arthritic and other active inammatory
causes of knee pain. Thus, we recommend that future
study targeting to one prevalent inammatory group such
as osteoarthritic knee pain will lead to a clearer picture on
doses for pain relief measure.
Our ndings on quality of life outcome measure are con-
sistent with one study of oral ginger extract in that no
essential differences in enhancing quality of life could be
found in the elderly with moderate-to-severe knee pain.6
This might be due to the short period of intervention
(2 weeks) and the follow-up duration (4 weeks). It may
relate to the selection of measurement, Angst, Aeschlimann,
Steiner and Stucki27 stated that the disease-specic WOMAC
was better for measuring functional limitations than the
generic SF-36. It is unclear whether this is because of the
responsiveness of the instruments, or the size of effect of
the ginger aroma-massage intervention, or both.
Application of our research ndings on ginger aroma-
massage to the elderly with moderate-to-severe knee pain
may have important implications for alternative add-on
treatments. These ndings provide evidence for recom-
mending aroma-massage for older persons with knee joint
pain. There were several reasons for choosing ginger aroma-
massage as the therapy in the current study: (1) ginger
aroma-massage is a popular and non-invasive intervention
with lesser GI adverse events; (2) the care-giver or patient
with knee pain could be referred to a trained therapist or
taught to perform self-leg massage; (3) it is feasible for prac-
ticing nurses to undertake. The RCN has recommended the
incorporation of complementary therapies in Project 2000
training.28 Trained nurses can use aroma leg massage to care
for their patients with knee pain. Moreover, leg massage
techniques can be easily taught and learnt by the patient
or their care-giver. However, when suggesting self-leg mas-
sage, the nurse must tell the patient to stop if pain increases
and to avoid massaging a joint that is acutely inamed or
swollen.
The strength of the study is the inclusion of placebo con-
trol group and the blind measure. They help to eliminate the
placebo effects and observation bias in outcome measures.
Despite of the strength, there were potential limitations.
Although the nurse massage therapist was not involved in
data collection, she was not blind to the types of treatment
being given. It was inevitable that the therapists aware-
ness might sensitize the participants on every symptom to
the treatment. Secondly, this study may have increased the
awareness of the participants on the effects of ginger in
the management of knee pain; they may have incorporated
ginger into their daily diet. However, self-medicating oral
ginger powder or tablet supplement among elderly is uncom-
mon in the local context. In this study, the net total number
of participants was 53 and from one source. The sample size
of this study was beneath enough to reect real conditions.
The incompleteness of follow-up is a potential weak-
ness. Furthermore, the functional abilities of participants
may be overstated when assessing the functional status
of daily activities, as discrepancies between self-reports
138
of functional ability and observation assessment were
found.29
In conclusion, the results of our study show that six-
sessions of aroma-massage therapy using ginger and orange
essential oil was effective in relieving moderate-to-severe
knee joint pain, stiffness and daily function in the short-
term but not for improving the quality of life. No adverse
effects were reported. Therefore, aroma-massage therapy
seems to have some potential as an alternative method for
short-term knee pain relief.
Acknowledgements
We would like to acknowledge the partial support of the
SN Departmental Research Committee for this study. The
authors would also like to thank Ms. Chau Yu Moon, Ms.
Ng Yuk Wah and Ms. Tsui Hoi Ying for their contributions to
the data collection and eldwork for this study. The authors
also gratefully acknowledge Dr. Tony Chan for his thought-
ful discussion especially on the analysis and Mr. Ian Dunn
for English proof-reading and suggestions on renement of
the manuscript. Additionally, the study would not have been
possible without the co-operation of the arthritic partici-
pants. I conrm all patient/personal identiers have been
removed or disguised so the patient/person(s) described are
not identiable and cannot be identied through the details
of the story.
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