Indian Journal of Rheumatology 2006 June

Original Article
Volume 1, Number 1; pp. 37

Effects of ginger on primary knee osteoarthritis

Anousheh Haghighi1, Nazfar Tavalaei1, Mohammad Bagher Owlia2

ABSTRACT

Introduction: Nonsteroidal anti-inflammatory drugs are effective in relieving osteoarthritis pain, but because of
their side effects, search continues for agents that might provide improvement in symptoms with minimal addition-
al risk. Evidence from previous studies suggests that ginger can reduce osteoarthritis pain. The aim of this study
is to compare the effects of indomethacin and ginger on relieving osteoarthritis pain.
Materials and Methods: A double blind, parallel group clinical trial was designed to evaluate the response of 52
patients with knee osteoarthritis to ginger and indomethacin.
Results: Analysis of the mean for pain on standing (based on 100 mm visual analogue scale) showed improve-
ment in both groups (22.5 mm in indomethacin group and 23 mm in ginger group, P value = 0.1). Results of
improvement in pain after walking 50 feet were similar in both groups (23.5 mm in indomethacin group and 21.4
mm in ginger group, P value = 0.34). Changes in total Western Ontario and MacMaster Universities Osteoarthritis
Index score were significant in both groups (4.62 in indomethacin group and 3.39 in ginger group, P value = 0.65).
Conclusion: Ginger is as effective as indomethacin in relieving symptoms of osteoarthritis with negligible side
effects. Therefore in patients with intolerance to indomethacin, ginger may be substituted.
Keywords: Alternative medicine, ginger (Zingiber officinale), osteoarthritis, pain.

INTRODUCTION increased substantially in the last decade, it is imperative

Treatment of osteoarthritis today is only palliative and is
aimed at relieving pain and improving mobility. Treatment
programmes involve a combination of non-pharmacologi-
cal and pharmacological measures, utilising a combination
of analgesics, anti-inflammatory agents and intra-articular
injections. If these are unsuccessful, a variety of surgical
interventions are to be considered. None of the medical
approaches consistently provide adequate relief from pain,
yet they have attendant risk. The search continues for
agents that might bring about improvement in symptoms
with minimal risk. While scientists have turned to the
investigation of newly discovered pharmaceuticals, many
patients have turned to herbal and other remedies that have
not been adequately studied. Since herbal medication has
that good scientific evidence be presented to health care
professionals and consumers to provide a basis for making
informed decisions. Ginger is a very popular spice and the
world production is estimated at 100,000 tons annually, of
which 80% is grown in China.1 Its principal uses
include treatment of motion sickness and disorders of the
gastrointestinal tract. It has also been used as an anti-
inflammatory agent for musculoskeletal diseases, includ-
ing rheumatism, in Ayurvedic and Chinese medicine for
more than 2500 years.2, 3 The mechanisms of action of gin-
ger are not clear, but there is limited evidence of inhibition
of inflammation in experimental animals, and of inhibition
of the synthesis of prostaglandins and leukotrienes.4
Evidence from previous studies suggests that ginger can
reduce osteoarthritis pain.5, 6 We designed a double blind

1
Hormozgan University of Medical Sciences and Health Services, Bandar Abbas, 2 Shahid Sadoughi University of Medical Sciences and Health
Services, Yazd, Iran.
Correspondence: Dr. MB Owlia, email: mbowlia2@yahoo.com
4 Indian Journal of Rheumatology 2006 June; Vol. 1, No. 1
parallel group trial to compare the effects of ginger and
indomethacin on relieving osteoarthritis pain.
MATERIALS AND METHODS
To compare the effects of ginger and indomethacin on
relieving symptoms of primary knee osteoarthritis a 6-
week, double blind, parallel group trial was performed at
the rheumatology clinic of Shahid Mohammadi Hospital in
Bandar Abbas, Iran. All consecutive outpatients diagnosed
as having idiopathic knee osteoarthritis that attended the
outpatient clinic of rheumatology from June 2003 to
February 2004, were included in the study. Diagnosis of
osteoarthritis of the knee was made using the clinical cate-
gory of American College of Rheumatology criteria.7 All
patients had knee pain which was more than 40 mm on a
100 mm visual analogue scale (VAS) on 5-minute standing
during the preceding 24 hours. None of the patients had
any other underlying diseases, signs or history of liver or
kidney failure, gallstone, peptic ulcer disease, bleeding
tendency, treatment with oral corticosteroids within the
prior 4 weeks, intra-articular injection within the last 3
months, and history of intolerance to nonsteroidal anti-
inflammatory drugs (NSAIDs). All patients were informed
about the study and provided with a questionnaire inquir-
ing about demographic characteristics, duration of disease,
intensity of symptoms based on VAS (consists of pain on
5-minute standing and pain after walking 50 feet) and
Western Ontario and MacMaster Universities
Osteoarthritis Index (WOMAC) and radiographic grading
based on Kellgren and Lawrence criteria. All patients were
randomised to receive ginger or indomethacin, and both,
the investigator and the patients were blinded to treatment
assignment. During the 6-week treatment period, patients
in ginger group ingested one capsule four times a day.
Each capsule contained 250 mg of ginger powder (Goldaru
Company, Iran). All patients in indomethacin group ingest-
ed one capsule similar to ginger capsules three times a day.
Each capsule contained 25 mg of indomethacin (Loghman
Company, Iran). All patients were evaluated again after 6
weeks of drug consumption. The ethical committee of
Hormozgan University of Medical Sciences and Health
Services approved the study.
Minitab 11.2 statistical software was used for statisti-
cal analysis, and chi-square and t-test were used to com-
pare the groups. P value was considered significant at less
than 0.05.
Haghighi et al.
RESULTS
To compare the effects of ginger and indomethacin on
symptoms of knee osteoarthritis, 57 patients were includ-
ed in the study. Of these, five patients (2 of indomethacin
group and 3 of ginger group) discontinued the trial before
completing any evaluation of efficacy. A total of 52
patients completed the study, 27 patients in indomethacin
group and 25 patients in ginger group. Demographic char-
acteristics of patients are shown in Table 1. There was no
statistically significant difference in the demographics
between the two treatment groups. The patients were pre-
dominantly women. Patients in both study groups were
generally overweight, since the mean ( SD) body mass
index (BMI) was 27.18 4.31 kg/m2, 27.40 4.16 kg/m2
in the indomethacin group and 26.92 4.57 kg/m2 in gin-
ger group (P value = 0.7). The mean ( SD) duration of
disease was 50.42 ( 10.58) months. Disease severity
based on radiographic findings was similar in both groups
with no statistically significant difference in both groups
(P value = 0.32; Table 1). Because none of our patients had
past history of peptic ulcer disease or NSAIDs intolerance,
there was only one report of indomethacin intolerance due
to gastrointestinal side effects. One of the patients in gin-
ger group discontinued ginger because of increased vagi-
nal bleeding during menstruation. She restarted it after ter-
mination of the menstrual cycle. The analysis of mean for
pain on standing showed improvement in both treatment
groups. Improvement was 22.5 mm in indomethacin group
and 23 mm in ginger group. There were no statistically sig-
nificant differences in relieving pain between the two
groups (P value = 0.1; Table 2). Results of improvement in
pain after walking 50 feet too were similar in both treat-
ment groups. There were 23.5 mm and 21.4 mm improve-
ment in indomethacin and ginger group, respectively
(P value = 0.34; Table 2). The changes in total WOMAC
score were significant in both treatment groups (P < 0.05).
It was 4.62 in indomethacin group and 3.39 in ginger
group. There were no statistically significant differences
between the two groups (Tables 2 and 3). The effects of
indomethacin and ginger on relieving pain, both on stand-
ing and after walking are shown in Figures 14.
DISCUSSION
This study was planned to compare the effects of ginger
and indomethacin on symptoms of primary knee
osteoarthritis. According to the results of the study, there
Ginger in osteoarthritis Original Article 5

Table 1 Demographic characteristics of study population

Variable Randomised (n = 52) Indomethacin (n = 27) Ginger (n = 25)
Age (Mean SD; years) 50.42 10.58 50.61 8.06 50.20 13.01
Sex: number of women (%) 49 (94.23) 25 (92.59) 24 (96)
BMI (Mean SD; kg/m2) 27.18 4.31 27.40 4.16 26.92 4.57
Diagnosed OA (Mean SD; months) 35.05 45.23 33.10 44.86 35.8 31.3
Radiographic classification* ( %)
Stage 1 2.22 0 2.22
Stage 2 51.11 26.67 24.44
Stage 3 44.44 31.11 13.33
Stage 4 2.22 0 2.22

BMI = body mass index, OA = osteoarthritis, *by Kellgren and Lawrence criteria

Table 2 Results of efficacy variables

Parameter Indomethacin (n = 27) Ginger (n = 25) Between-group P value
Mean SD change Mean SD change difference
Pain on standing
Baseline 70.8 25.4 57.8 23.2
Second visit 48.3 24.6 22.5 34.8 28.4 23 0.5 0.1
Pain after walking 50 ft
Baseline 69.2 24 59.2 24
Second visit 45.7 24.6 23.5 37.8 30.1 21.4 2.1 0.34
WOMAC
Baseline 14.1 2.4 13.43 4.33 0.47
Second visit 9.48 2.61 4.62 10.04 5.47 3.39 1.23 0.65
SD = standard deviation, WOMAC = Western Ontario MacMaster Universities Osteoarthritis Index

Table 3 WOMAC scores in two groups

Points Baseline Second visit
Indomethacin % (n) Ginger % (n) Indomethacin % (n) Ginger
14 0 0 3.45 (1) 14.29 (4)
67 0 14.29 (4) 6.9 (2) 14.29 (4)
810 6.9 (2) 14.29 (4) 58.62 (17) 25 (7)
1113 37.9 (11) 17.8 (5) 17.24 (5) 17.86 (5)
>14 55.1 (16) 53.57 (15) 6.9 (2) 17.86 (5)
Total 100 (29) 100 (28) 100 (29) 100 (28)
WOMAC= Western Ontario MacMaster Universities Osteoarthritis Index
6 Indian Journal of Rheumatology 2006 June; Vol. 1, No. 1
Figure 1 The effect of indomethacin on relieving osteoarthri-
tis pain after 50 feet walking.
Figure 3 The effect of indomethacin on relieving osteoarthri-
tis pain in standing position.
were no significant differences between ginger and
indomethacin in relieving osteoarthritis pain and improv-
ing function. The analysis of mean for pain on standing,
pain after 50 feet walking and WOMAC score showed
improvement in both treatment groups with no statistical-
ly significant differences between them. A possible expla-
nation for it may be the effects of ginger on reducing
prostaglandins and leukotrienes.8 The benefits found in
this trial are consistent with the results described in the few
existing reports. In a large cohort involving 56 patients
with rheumatic disorders, more than 75% experienced
relief from pain and swelling after an average dosage of
3 g raw ginger per day for periods varying between 3
Haghighi et al.
Figure 2 The effect of ginger on relieving osteoarthritis
pain after 50 feet walking.
Figure 4 The effect of ginger on relieving osteoarthritis pain
in standing position.
months and 2 years.9 A randomised clinical trial included
67 patients, of whom 56 were could be evaluated. This was
a 3-way, crossover study comparing ibuprofen, ginger
extract and placebo. The ranking of efficacy was ibuprofen
> ginger extract > placebo for VAS scores on pain and
Lequesne index, but no significant difference was seen
when comparing ginger extract and placebo directly.
Exploratory testing of the first period of treatment (before
crossover) was performed and this showed a better
effect of both ibuprofen and ginger extract compared with
that of placebo (P < 0.05 by chi-square test).6 Altman and
Marcussen evaluated the efficacy and safety of a highly
purified and standardised ginger extract in 2001. They
Ginger in osteoarthritis
found its effect statistically significant on reducing symp-
toms of osteoarthritis of the knee.5 There was a good
safety profile for ginger in that study. There was only one
report of adverse effects of ginger in our study which
may be due to platelet dysfunction as mentioned by
Srivastava.10 So it could be a good substitute for NSAIDs
in patients who cannot tolerate NSAIDs. For understand-
ing of long-term effects further investigations are
required.
CONCLUSION
This study shows that ginger has considerable effect on
reducing symptoms of primary knee osteoarthritis. The
exact mechanism of action and long-term effects of ginger
remain to be carefully studied and documented.
ACKNOWLEDGEMENTS
Authors would like to thank Dr. Zaree for his help with
data analysis of this article. Funding provided by
Hormozgan University of Medical Sciences and Health
Services, Bandar Abbas, is gratefully acknowledged.
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