Introduction
Osteoarthritis is one of the most common chronic diseases and one of the main causes of disability and pain in old age. Osteoarthritis puts a heavy economic and social burden on the elderly and the healthcare system [3, 4, 8]. Among the large joints of the body, the knee joint is one of the most common areas affected by osteoarthritis, which causes more disability and clinical symptoms than other joints [5]. There are various methods to reduce the pain in older patients with knee osteoarthritis (KO). One of the safe methods is the use of topical ointments, especially those made by medicinal plants, which the elderly are more intended to use due to their availability and cheapness. This study aims to compare the effect of rosemary ointment and ginger ointment on pain and physical performance of elderly people with KO.

Methods
This is an open-label randomized controlled clinical trial that was conducted on 111 elderly patients with KO referred to the orthopedic clinic affiliated to Lorestan University of Medical Sciences. The samples were diagnosed with grade 1 to 2 osteoarthritis and were selected based on the inclusion and exclusion criteria. Participants, after signing the informed consent form, were evaluated by using a demographic form, the WOMAC scale, and the VAS scale. By block randomization method, the samples were divided into two intervention groups of ginger (n=37), and rosemary (n=37) and one control group (n=37). The intervention groups were asked to use the ointments twice a day, morning and evening, while the control group used an ibuprofen 400 mg tablet once a day. The questionnaires were completed before and 14 days after the intervention, and the obtained data were analyzed in Stata software, version 17. To describe the data, central tendency and dispersion measures were calculated. To compare the pain intensity score and physical performance score between the three groups, analysis of covariance (ANCOVA) was used followed by Tukey’s test for pairwise comparison.

Results
Of 111 participants, 56 were female (50.45%) and 55(49.55%) were male. There were 37(33.33%) older people with grade 1 osteoarthritis and 74(66.67%) with grade 2 osteoarthritis. According to ANOVA results, there was no significant difference in age (P=0.78) between the study groups, but the difference in BMI was significant (P=0.005). Based on the results, there were significant differences in physical performance and pain before and after the intervention in the ginger and rosemary groups (P<0.001) and in the control group (P<0.001). The results showed that by controlling the confounding effect of BMI, the differences in physical performance and pain after the intervention in the study groups were significant (P<0.001). Tukey’s test was performed to compare the two groups. It was found that there was a significant difference between the ginger and control groups (P<0.001), and between the rosemary and control groups (P<0.001) in physical performance, but there was no significant difference between the ginger and rosemary groups (P=0.22). Also, the results of Tukey’s test showed a significant difference in pain intensity after the intervention between the ginger and control groups (P<0.001), and between the rosemary and control groups (P<0.001), but there was no significant difference between the ginger and rosemary groups (P=0.10).

Conclusion
The results of the present study showed that rosemary ointment and ginger ointment reduced the pain intensity of the elderly people with KO. These effects have been observed in some other studies. One of the mechanisms of ginger ointment’s analgesic effect is the inhibition of arachidonic acid metabolism through inhibition of cyclooxygenase and lipoxygenase pathways, similar to the mechanism of action of non-steroidal anti-inflammatory drugs. The simultaneous inhibition of these two enzymes may increase the anti-inflammatory effect and reduce the side effects of ginger ointment [15]. Also, researchers have attributed the analgesic effects of rosemary ointment to the anti-inflammatory effect of rosemary [31]. Our results also showed that rosemary and ginger ointment improved the physical performance of the elderly with KO. Both rosemary and ginger ointments had the same efficacy as ibuprofen. Therefore, using local treatments using rosemary and ginger ointments can be useful to reduce pain and improve physical performance of the elderly with KO.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethics Committee of Lorestan University of Medical Sciences (Code: IR.LUMS.REC.1400.002) and was registered by the Iranian Registry of Clinical Trials (IRCT) (ID: IRCT20210521051354N1).

Funding
This study was extracted from the master’s thesis of Ehsan Asadi, approved by School of Nursing and Midwifery, Lorestan University of Medical Sciences.

Authors' contributions
Conceptualization: Ehsan Asadi, Afsaneh Biranvand, Mohammad Gholami, and Razieh Shirzadegan; Data analysis: Yaser Mokhayeri, Afsaneh Biranvand and Mohammad Gholami; Writing: All authors.

Conflicts of interest
The authors declared no conflict of interest. 


 

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