KONSEP KEPERAWATAN KOMUNITAS

CRITICAL APPRAISAL TERAPI KOMPLEMENTER PADA KEPERAWTAN

KOMUNITAS
Disusun guna memenuhi tugas mata kuliah Konsep Keperawatan Komunitas dengan dosen
pengampu Ns. Niken Asih Laras Ati, M. Kep.

oleh :
AKHMAD RAMDHANI
222310101071
A / 2022

KEMENTERIAN PENDIDIKAN, KEBUDAYAAN, RISET, DAN TEKNOLOGI

FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
OKTOBER, 2023
 FORMAT RANCANGAN CRITICAL APPRAISAL ARTIKEL

GUIDE TO AN OVERALL CRITIQUE OF A QUANTITATIVE RESEARCH REPORT

ASPECT OF CRITIQUING QUESTIONS RESULTS
THE REPORT
Title Is the title a good one, succinctly suggesting key Iya, judul dari artikelnya sesuai dengan keyword yang ingin
variables and the study population? saya cari yaitu “contemporary therapy” dan “aromatherapy”
Is the problem stated unambiguously, and is it easy to Iya, permasalahan dalam artikel sudah jelas, tidak ambigu,
identify? dan mudah untuk diidentifikasi.
Iya, karena peneliti merumuskan argument mereka dengan
sangat baik, menunjukkan apa urgensi dari penelitian yang
Does the problem statement build a cogent and mereka lakukan, dan melakukan penelitian yang belum pernah
persuasive argument for the new study? dilakukan sebelumnya yaitu aromaterapi dengan
Statement of the menggunakan campuran habatussauda, jahe, dan minyak
problem rosemary (black seed, ginger and rosemary oils)
Iya, perawat dapat melakukan terapi komplementer kepada
pasien untuk meningkatkan status kesehatan dari pasien, salah
satu terapi komplementer adalah Aromaterapi. Adanya
Does the problem have significance for nursing?
penelitian ini adalah untuk mengetahui efek pijat aromaterapi
untuk rasa sakit, status fungsional dan kualitas hidup pada
pasien usia lanjut dengan osteoartritis.
 Iya, karena untuk membuktikan keilmiahan dari aromaterapi
Is there a good match between the research problem and
dan massage ini, harus dilakukan uji coba kuantitatif dengan
the paradigm and methods used? Is a quantitative
metode eksperimen secara langsung terhadap beberapa
approach appropriate?
partisipan.
Are research questions and/or hypotheses explicitly Tidak, hipotetis dari peneliti langsung dituliskan dalam artikel
stated? If not, is their absence justified? penelitiannya.
Are questions and hypotheses appropriately worded, Iya, hipotesis yang dituliskan peneliti beberapa sesuai dengan
Hypotheses or with clear specification of key variables and the study variabel kunci dan populasi dari penelitian ini yaitu
research population? aromatherapy, massage, pain, and quality of life.
questions Iya, hipotesis yang dituliskan peneliti konsisten dan sesuai
Are the questions/hypotheses consistent with the dengan tinjauan literatur yang menjelaskan mengenai pijat
literature review and the conceptual framework? aromaterapi hingga efek yang ditimbulkan dari pijat
aromaterapi.
Tidak, banyak sumber – sumber yang tidak up-to-date, namun
Is the literature review up-to-date and based mainly on
sumber yang digunakan dapat dipercaya karena berasal dari
primary sources?
buku dan jurnal.
Iya, karena pada artikel juga mencantumkan penelitian –
Literature review Does the review provide a state-of-the-art synthesis of
penelitian yang pernah dilakukan oleh peneliti yang lain untuk
evidence on the research problem?
membuktikan efek dari aromaterapi.
Does the literature review provide a solid basis for the Iya, karena peneliti mengangkat metode baru dalam terapi
new study? aromaterapi yaitu dengan menggunakan bahan campuran
 habatussauda, jahe, dan minyak rosemary (black seed, ginger
and rosemary oils)
Iya, karena setiap konsep kucinya di jelaskan secara terperinci
mulai dari apa itu pijat aroma terapi sampai manfaat dari
Are key concepts adequately defined conceptually?
terapi tersebut hingga penelitian sebelumnya mengenai
Conceptual/ aromaterapi ini.
theoretical Tidak ada, mungkin bisa dibenarkan, karena penelitian ini
framework Is there a conceptual/theoretical framework, rationale, tidak berfokus tentang bagaimana mekanisme aromaterapi
and/or map, and (if so) is it appropriate? If not, is the terhadap osteoarthritis kaki, melainkan perbandingan tentang
absence of one justified? keefektifan pijat aromaterapi dengan perawatan rutin terhadap
fungsi tubuh dan kualitas hidup pasien osteoarthritis kaki.
Method
Iya, peneliti memberitahu tentang tujuan dari penelitian ini,
dan mereka dijamin kerahasiaannya dan anonimitas. Para
Were appropriate procedures used to safeguard the rights
lansia juga diyakinkan hak mereka untuk menarik diri dari
of study participants?
Protection of penelitian ini jika tidak bersedia dan bahwa semua informasi
participants’ yang diperoleh hanya akan digunakan untuk tujuan penelitian.
rights Iya, karena untuk melakukan penelitian ini, peneliti meminta
Was the study subject to external review by an
izin tertulis dan diperoleh dari lembaga dengan persetujuan
IRB/ethics review board?
etis dari komite etika
Was the study designed to minimize risks and maximize Iya, meskipun tujuan dari penelitian adalah untuk mengetahui
 benefits to participants? perbandingan pijat aromaterapi dengan pijat biasa, namun
koresponden tetap menerima manfaat dari penelitian ini yaitu
terapi pijat aromaterapi dan perawatan rutin itu.
Research design Was the most rigorous possible design used, given the Penelitian menggunakan desain acak, terkontrol, dan
purpose of the research? eksperimental untuk menguji efek pijat aromaterapi pada
lansia dengan osteoartritis lutut
Were appropriate comparisons made to enhance Penelitian ini membandingkan efek pijat aromaterapi dengan
interpretability of the findings? kelompok kontrol yang hanya menerima perawatan rutin.
Perbandingan ini sesuai dan meningkatkan interpretabilitas
temuan dengan menunjukkan manfaat tambahan dari pijat
aromaterapi dibandingkan perawatan rutin.
Was the number of data collection points appropriate? Pada penelitian ini mengumpulkan data pada tiga poin yaitu
kondisi umum, efek segera setelah intervensi, dan efek setelah
8 minggu setelah intervensi. Hal ini umumnya sesuai untuk
melihat efek langsung dan jangka pendek dari intervensi
aromaterapi ini.
Did the design minimize biases and threats to the internal Bisa iya bisa tidak, desain penelitian memiliki beberapa
construct, and external validity of the study (e.g., was langkah untuk meminimalkan bias dan ancaman terhadap
validitas internal dan eksternal, tetapi ada juga beberapa
blinding used, was attrition minimized)?
keterbatasan dengan tidak menggunakan blinding, atritition,
dan external validity karena ukuran sampel penelitianya kecil.
Penelitian ini memiliki kekuatan dan masih kekurangan.

Was the population identified and described? Was the kelamin, dan karakteristik penyakit mereka. Namun,
sample described in sufficient detail?
Was the best possible sampling design used to enhance
the sample’s representativeness? Were sample biases
Population and minimized?
sample
Was the sample size adequate? Was a power analysis
used to estimate sample size needs?
Iya, responden penelitian diidentifikasi sebagai lansia dengan
osteoarthritis lutut. Sampel dijelaskan dalam hal usia, jenis
penelitian ini tidak memberikan informasi rinci tentang etnis
peserta, status sosial ekonomi, atau karakteristik lain yang
mungkin relevan.
Penelitian ini menggunakan desain uji coba terkontrol secara
acak, yang merupakan desain yang kuat untuk menguji efek
intervensi. Namun, keterwakilan sampel dan minimalisisr bias
dapat ditingkatkan dengan meningkatkan sampel penelitian,
mengidentifikasi informasi rinci dari responden, dan
menggunakan design multi-center supaya mengurangi bias.
Tidak, penelitian ini melibatkan total 90 peserta, yang
merupakan ukuran sampel yang relatif kecil. Meskipun
mungkin cukup untuk mendeteksi efek besar, namun dapat
membatasi kekuatan statistik dan ketepatan penelitian untuk
mendeteksi efek yang lebih kecil atau untuk melakukan
analisis subkelompok terperinci. Pada penelitian ini tidak
menyebutkan penggunaan analisis daya untuk memperkirakan
ukuran sampel yang diperlukan.
 Iya, penelitian ini memberikan definisi operasional yang jelas
Are the operational and conceptual definitions untuk konsep dan variabel utama, termasuk osteoartritis lutut,
congruent? pijat aromaterapi, dan ukuran hasil seperti nyeri, keadaan
fungsional, dan kualitas hidup.
Iya, karena peneliti menggunakan beberapa metode untuk
Were key variables operationalized using the best
menjelaskan variabel kunci seperti observasi catatan medis
possible method (e.g., interviews, observations, and so
dari responden, wawancara dengan responden, dan melihat
on) and with adequate justification?
penelitian yang pernah dilakukan sebelumnya
Data collection Are the specific instruments adequately described and Iya, peneliti menggunakan instrumen seperti Visual Analog
and measurement were they good choices, given the study purpose and Scale (VAS), Western Ontario and McMaster Universities
study population? Osteoarthritis Index, dan Short Form Health Survey (SF-36).
Tidak, penelitian ini tidak menyebutkan penggunaan uji
reliabilitas atau validitas apa pun untuk instrumen atau data.
Does the report provide evidence that the data collection Penelitian ini juga tidak membahas potensi sumber kesalahan
methods yielded data that were high on reliability and atau bias dalam proses pengumpulan data. Penelitian ini juga
validity? tidak memberikan informasi rinci tentang bagaimana data
dikumpulkan, dinilai, dan dianalisis, yang dapat membatasi
transparansi dan replikabilitas penelitian.
If there was an intervention, is it adequately described, Iya dan tidak, intervensi pada penelitian ini adalah pijat
Procedures
and was it properly implemented? Did most participants aromaterapi, yang dijelaskan sebagai sesi pijat 30 menit
allocated to the intervention group actually receive the dengan minyak lavender essential, namun peneliti tidak
 intervention? Was there evidence of intervention menjelaskan bagaimana teknik dan prosedur untuk melakukan
fidelity? terapinya.
Peneliti juga melaporkan bahwa semua peserta yang
dialokasikan untuk kelompok intervensi menerima intervensi
seperti yang direncanakan.
Kepercayaan terhadap intervensi mengacu pada sejauh mana
intervensi disampaikan sebagaimana dimaksud. Penelitian ini
tidak memberikan bukti kepercayaan dari responden terhadap
intervensi, seperti pemeriksaan pemberian terapi misalnya
apakah pijat dilakukan dengan benar atau tanda terima terapi
misalnya, apakah peserta memahami dan terlibat dengan
perawatan.
Tidak, penelitian ini tidak memberikan informasi rinci tentang
bagaimana data dikumpulkan atau apakah staf yang
Were data collected in a manner that minimized bias?
mengumpulkan data dilatih dengan tepat. Namun, dalam
Were the staff who collected data appropriately trained?
penelitian bisa dilihat bahwa peneliti menggunakan instrumen
yang terstandarisasi.
Results
Data analysis Were analyses undertaken to address each research Pertanyaan utama dari penelitian ini adalah apakah pijat
question or test each hypothesis? aromaterapi dapat meningkatkan rasa sakit, keadaan
fungsional, dan kualitas hidup pada orang tua dengan
 osteoarthritis lutut. Penelitian ini menggunakan tes statistik
yang tepat untuk membandingkan hasil antara kelompok
intervensi yang menerima pijat aromaterapi dan kelompok
kontrol yang menerima perawatan rutin.
Were appropriate statistical methods used, given the Penelitian ini menggunakan metode statistik yang tepat untuk
level of measurement of the variables, number of groups analisisnya. Mengingat bahwa variabel yang digunakan
being compared, and so on? (nyeri, keadaan fungsional, dan kualitas hidup) kontinu dan
perbandingannya antara dua kelompok (intervensi vs kontrol),
metode seperti uji-t atau analisis varians (ANOVA) akan
sesuai. Metode ini biasanya digunakan dalam penelitian klinis
untuk membandingkan rata-rata variabel kontinu antara dua
atau lebih kelompok.
Was the most powerful analytic method used? (e.g., did Tidak, pada artikel tidak diberikan informasi rinci tentang
the analysis help to control for confounding variables)? metode statistik spesifik yang digunakan untuk analisis.
Meskipun tampaknya penelitian ini menggunakan metode
seperti uji-t atau analisis varians (ANOVA) untuk
membandingkan hasil antara kelompok intervensi dan kontrol,
metode ini tidak mengontrol variabel perancu, oleh karena itu
belum bisa dikatakan metodenya tidak kuat.
Were Type I and Type II errors avoided or minimized? Pada penelitian ini tidak dituliskan bagaimana peneliti
menghindari atau meminimalisir kesalahan tipe I dan tipe II.
 Was information about statistical significance presented? Iya, pada artikel dituliskan signifikansi statistik, ukuran efek
Was information about effect size and precision of dan ketepatan perkiraan (interval kepercayaan).
estimates (confidence intervals) presented?
Iya, temuan dari peneliti di konklusikan dan disimpulkan
Are the findings adequately summarized, with good use
Findings secara baik, namun tidak di tampilkan dengan tabel dan
of tables and figures?
gambar yang baik.
Are findings reported in a manner that facilitates a meta- Iya, karena untuk dilakukannya meta-analisis, artikel yang di
analysis, and with sufficient information needed for analisis harus ada informasi mengenai signifikansi statistik,
EBP? ukuran efek dan ketepatan perkiraan (interval kepercayaan).
Discussion
Bisa iya, karena untuk interpretasi dan diskusi yang
komprehensif tentang temuan, penelitian ini perlu
Are all major findings interpreted and discussed within
membandingkan hasilnya dengan penelitian sebelumnya,
the context of prior research and/or the study’s
mendiskusikan persamaan atau perbedaan, dan
conceptual framework? Were causal inferences, if any,
menjelaskannya berdasarkan teori atau hipotesis yang ada di
Interpretation of justified?
lapangan. Pada penelitian terdapat beberapa perbandingan
the findings
dengan penelitian sebelumnya.
Iya, karena adanya batasan ini, penulis menyarankan beberapa
Are the interpretations consistent with the results and arah untuk penelitian di masa depan, seperti menggunakan
with the study’s limitations? berbagai jenis dan dosis minyak esensial, membandingkan
aromaterapi dengan metode non-farmakologis lainnya, dan
 melakukan studi jangka panjang dengan sampel yang lebih
besar.
Tidak, penelitian ini tidak membahas masalah generalisasi
Does the report address the issue of the generalizability
temuan, karena tidak ada tulisan yang membahas akan hal itu
of the findings?
di dalam artikel.
Tidak, peneliti tidak membahas implikasi penelitian untuk
Do the researchers discuss the implications of the study praktik klinis atau penelitian lebih lanjut. Penelitian ini tidak
Implications/
for clinical practice or further research—and are those memberikan rekomendasi untuk bagaimana temuan dapat
recommendations
implications reasonable and complete? diterapkan dalam pengaturan klinis atau menyarankan arah
penelitian masa depan berdasarkan hasil.
Global Issues
Iya, karena artikel ini dituliskan dengan struktur yang baik
Is the report well written, well organized, and dan benar, metode yang digunakan dijelaskan secara
sufficiently detailed for critical analysis? terperinci, hasil dituliskan dalam tabel, dan menggunakan
sitasi yang baik dan benar.
Tidak, Pada artikel ini hanya menjelaskan desain dan sampel
Presentation In intervention studies, was a CONSORT flow chart
penelitian dengan kata-kata, tetapi tidak disajikan representasi
provided to show the flow of participants in the study?
visual dari aliran peserta (flow of participant).
Iya, karena penggunaan judul dan kata kunci dalam artikel ini
Was the report written in a manner that makes the
sangat berkorelasi dengan praktik keperawatan terutama pada
findings accessible to practicing nurses?
praktik terapi komplementer.
 Iya, karena peneliti merupakan peneliti yang terkualifikasi
Do the researchers’ clinical, substantive, or
Researcher dari universitas di turki dan berpengalaman di bidang
methodologic qualifications and experience enhance
credibility keperawatan dan juga peneliti menggunakan instrumen yang
confidence in the findings and their interpretation?
terpercaya dan valid dalam penelitian ini.
Iya, meskipun banyaknya limitasi yang ada pada penelitian
Despite any identified limitations, do the study findings
ini, namun peneliti dapat menyampaikannya dengan baik dan
appear to be valid—do you have confidence in the truth
memberikan rekomendasi untuk penelitian kedepannya
value of the results?
Summary supaya terhindar dari limitasi yang dialami pada penelitian ini.
assessment Iya, penelitian ini dapat berpengaruh terhadap praktik
Does the study contribute any meaningful evidence that
keperawatan terutama di bidang terapi komplementer. Dengan
can be used in nursing practice or that is useful to the
adanya penelitian ini, dapat menguatkan keilmiahan dan
nursing discipline?
pembuktian efek positif dari aromaterapi ini
Received: 19 April 2018 Revised: 29 November 2018 Accepted: 20 December 2018
DOI: 10.1111/jjns.12254

ORIGINAL ARTICLE

Effects of aromatherapy massage on pain, functional state, and

quality of life in an elderly individual with knee osteoarthritis

Seda Pehlivan1 | Ayfer Karadakovan2

1
Health Science Faculty, Department of
Nursing, Bursa Uludag University, Bursa,
Turkey
2
Nursing Faculty, Nursing of Internal
_
Medicine, Ege University, lzmir, Turkey
Correspondence
Seda Pehlivan, Health Science Faculty,
Department of Nursing, Bursa Uludag
University, Bursa, TR-16059, Turkey.
Email: pehlivan_seda@hotmail.com
Funding information
The authors declared that this study received
no financial support. This study is funded by
the authors themselves.
Abstract
Aim: To investigate the effects of aromatherapy massage on pain, functional state
and life quality of elderly individuals with knee osteoarthritis.
Methods: This controlled and experimental study was conducted in two nursing
homes. In this study, 90 elderly individuals with knee osteoarthritis were random-
ized as aromatherapy, massage and control groups. Data were collected in weeks
0, 4, and 8 using Patient Information Form, Western Ontario and McMaster Uni-
versities Osteoarthritis Index (WOMAC) Knee Osteoarthritis Evaluation Scale,
OsteoArthritis Knee and Hip Quality of Life Scale (OAKHQoL). Aromatherapy
and massage groups received a total of 15–20 min total classic leg massage twice
weekly for 3 weeks. In the aromatherapy group, two essential oils (ginger and rose-
mary) were added to the black seed oil.
Results: In the aromatherapy group, WOMAC (pain and functional state) scores
were lower and quality of life scores were higher than the massage and control
groups in week 4, and these differences were statistically significant (p < .001).
These significant differences were present in the massage group when compared
with the control (p < .001). These significant differences in the aromatherapy
group were also sustained decreasingly in week 8 (p < .001), while the means were
not different from baseline in the massage group (p > .05).
Conclusions: Aromatherapy massage performed in elderly patients with knee oste-
oarthritis reduced pain and improved functional status and quality of life. The week
8 findings showed that aromatherapy has more favorable and longer sustained
effects than the massage.

KEYWORDS
aromatherapy, knee osteoarthritis, massage, nursing, pain, quality of life

1 | INTRODUCTION most commonly observed joint disease in the world and is

Osteoarthritis is defined as a progressive and irreversible
degenerative joint disease which affects joint cartilage and
causes joint pain and functional loss (Glass, 2006; Ste-
mberger & Kerschan-Schindl, 2013). Osteoarthritis is the
also the most common cause of loss of function and disability
in adults (Atkins & Eichler, 2013; Conaghan, Dickson, &
Grant, 2008). Osteoarthritis, which is encountered in 75% of
the elderly population has unfavorable effects on the func-
tional state and quality of life of patients due to pain and

Jpn J Nurs Sci. 2019;1–9. wileyonlinelibrary.com/journal/jjns © 2019 Japan Academy of Nursing Science 1
2 PEHLIVAN AND KARADAKOVAN
limitation of movement (Alkan, Fidan, Tosun, & Ardıçoglu,
2014; Conaghan et al., 2008). The treatment of osteoarthritis
aims to increase patients’ quality of life by approaches
directed to decrease symptoms such as pain and disability
(Atkins & Eichler, 2013).
Pain is the most common symptom in elderly patients with
osteoarthritis. The gradually increasing severity of pain as the
disease progresses is determinative of the negative relation-
ship between quality of life and osteoarthritis (Laslett et al.,
2012). Non-pharmacological approaches play an important
role in symptom management and disability prevention in
osteoarthritis treatment, which includes methods, such as
physical treatment (e.g. heat, light), exercise, training, hot-
cold application, health spas, massage and tissue manipulation
(Davis & MacKay, 2013; Glass, 2006). Previous studies con-
ducted on osteoarthritis have shown the positive effects of
non-pharmacological methods (e.g. balneotherapy, acupunc-
ture, yoga) on pain and quality of life (Evcik, Kavuncu,
Yeter, & Yigit, 2007; Fouladbakhsh, 2012; Mavrommatis,
Argyra, Vadalouka, & Vasilakos, 2012). Nursing practices in
a patient with osteoarthritis should be focused on performing
regular follow up, training, and determining the most effective
symptom management methods (Kee, Harris, Booth,
Rouser, & McCoy, 1998). Aromatherapy and massage are
among the non-pharmacological methods which nurses may
directly and independently use to control pain (Apay, Arslan,
Akpinar, & Celebioglu, 2012; Lai et al., 2011).
Aromatherapy is one of the complementary treatment
methods and is frequently used in nursing care in some coun-
tries (Glass, 2006; Lai et al., 2011). Aromatherapy is a safe
and supportive treatment method, in which essential oils and
essential oil-containing herbs (aromatic herbs) are used for
the treatment (Apay et al., 2012; Battaglia, 2003). Increasing
knowledge and experience is very important in aromatherapy
and nurses have contributed to this field by investigating the
potential effects of aromatherapy and essential fats in several
areas, such as gestation, maternal and fetal health, dysmenor-
rhea, pain, intensive care, cancer, gastrointestinal, nervous,
respiratory diseases and mental health (Cho, Min, Hug, &
Lee, 2013; Kim, Nam, & Paik, 2005; Maddocks-Jennings &
Wilkinson, 2004). There are studies that have shown that aro-
matherapy decreases pain, fatigue, anxiety and sleep disorders
(Cho et al., 2013; Kabiri, HasanPour-Dehkordi, & Deris,
2018; Kim et al., 2005; Lee, Choia, Posadzki, & Ernst, 2012).
Studies conducted on elderly individuals have shown that aro-
matherapy could be applied effectively and safely. Different
studies revealed that aromatherapy had beneficial effects on
pain, psychological stress, anxiety, depression, cognitive
functions and sleep in the elderly (Johannessen, 2013; Tang &
Tse, 2014). In one study a total of eight sessions of aromatic
hand massage (with lavender) was performed over 4 weeks
on elderly individuals who had lived for long periods of time
in nursing homes and had chronic pain. The findings showed
that chronic pain decreased in the aromatic massage group
and could be used effectively and safely in the elderly with
pain (Cino, 2014).
Aromatherapy may also be used to relieve symptoms,
such as pain and limitation of movement in osteoarthritis
(e.g. Efe Arslan, Kutlutürkan, & Korkmaz, 2018; Kim &
Kim, 2009; Kim et al., 2005; Nasiri & Mahmodi, 2018;
Nasiri, Mahmodi, & Nobakht, 2016; Therkleson, 2014;
Yip & Tam, 2008). In this studies, lavender, eucalyptus,
chamomile, or ginger oils were used as essential oils in aro-
matherapy. There is no study that a mixture of black seed,
ginger and rosemary oils were used in aromatherapy. In
addition, previous studies were based on pre- and post-test
assessments. There are only two study follow-ups to evalu-
ate the long-term effectiveness of aromatherapy massage
(Nasiri & Mahmodi, 2018; Nasiri et al., 2016). After an
independent electronic search, we have found a few studies
performed to evaluate the efficacy of aromatherapy massage
among elderly subjects with knee osteoarthritis (Choi, 2006;
Won & Chae, 2011; Yip & Tam, 2008), which show there is
an urgent need to conduct studies in the nursing literature on
the effects of aromatherapy massage for pain, functional sta-
tus and quality of life in elderly patients with osteoarthritis.
Hence, conducting research in this area is significant. Nurses
may be able to apply aromatherapy to decrease pain, facili-
tate daily activities and increase the quality of life of their
patients with osteoarthritis. Therefore, we conducted the pre-
sent study to determine the effects of aromatherapy (black
seed, ginger and rosemary oils) and massage on pain, func-
tional state, and quality of life of elderly individuals with
knee osteoarthritis.
Our hypotheses are as follows.
1. Participants who received aromatherapy massage would
have less pain than the patients in the massage and con-
trol groups.
2. Participants who received aromatherapy massage would
have better functional state than the patients in the mas-
sage and control groups.
3. Participants who received aromatherapy massage would
have a higher quality of life than the patients in the mas-
sage and control groups.
2 | METHODS
2.1 | Design and sample
The present study was designed as a randomized, pre-test
and post-test controlled experimental study. Participants
were selected after interviews with 169 elderly residents of
PEHLIVAN AND KARADAKOVAN
two nursing homes between April and November 2014 in
Bursa, Turkey.
In this study, the inclusion criteria were being diagnosed
with osteoarthritis according to the 1987 American College
of Rheumatology criteria at least 6 months ago, being at or
over 65 years of age and having pain severity intensity at or
above four points according to a visual analog scale (VAS).
The exclusion criteria were communication and cognitive
problems, acute inflammation at the application site, knee
joint surgery or drug (steroid, chloramine, hyaluronic acid)
treatment in the last 6 months, a known allergy against aro-
matic fatty acids, and having cancer, bleeding diathesis or
circulation problems.
The sample size was determined according to the power
analysis performed by taking means of scales used in previ-
ous studies which were conducted on individuals with knee
osteoarthritis. The confidence interval was calculated as
29.05 if α was 0.05, and 1-β was 0.80. According to this
result, a total of 90 elderly individuals with knee osteoarthri-
tis were included in this study so that each group consisted
of 30 participants. Participants were allocated into three
groups (aromatherapy, massage, and control) using a ran-
dom table of numbers.
2.2 | Procedures
Each elderly individual in the aromatherapy and massage
groups received a total of six massage sessions; that is, twice
a week for 3 weeks. In the aromatherapy group was per-
formed the massage using aromatic oils, whereas in the mas-
sage group sunflower oil was used. The participants in the
control group received no aromatherapy or massage. All
groups were provided with routine, conventional treatment
and care. Evaluation forms were completed for each partici-
pant at previously defined timelines (weeks 0, 4, and 8;
Figure S1).
Aromatherapy: The main oil used was black seed oil
which is known to have analgesic and anti-inflammatory
effects. Ten drops each of ginger (2.5%) and rosemary
(2.5%) as essential oils (total 5%), which have analgesic and
circulation increasing effects, were added to 20 mL of black
seed oil (Keville & Green, 2008; Lai et al., 2011;
Murugananthan, Sudheer Kumar, Sathya Chethan, &
Mohan, 2013). All of the oils were bought from a firm that
has ICEA (Institute Ethical and Environmental Certification)
“Master Certificate”. Oils to be used during aromatherapy
were prepared weekly in airtight and blackout bottles. The
aromatherapy oils were applied for testing purposes to the
inner surfaces of the forearms of participants in the aroma-
therapy group. None of the participants developed an aller-
gic reaction after a 24 hr follow up period.
3
2.2.1 | Massage application
The massage application was performed in a private room
that is allocated in the two nursing homes. All of the mas-
sages of the elderly patients (aromatherapy and message)
were performed in the same massage room. The elderly
patients took a semi-Fowler’s position. For each patient, bed
protectors were only for single usage. The confidentiality of
the patients was ensured. Close attention was paid to the
hand temperature of the practitioner and the room. It is nota-
ble that during the massage, there was a good communica-
tion with the patients, thus, there was an embracing milieu in
which patients expressed themselves.
Massage was performed, including effleurage and
petrissage techniques that were applied to the total leg
(mainly on the knee joint) in the direction of lymph drainage
for 15–20 min (Jain, 2002). Lower extremity massage, which
was applied in the beginning of this research, was started
with general effleurage. The patting started when the patients
were standing and continued toward the thigh. Superficial
effleurage was applied downward until when the upper part
of the thigh was reached. This application was repeated three
times. Then, massage was performed to the lower leg, knee
and thigh. To all parts, first effleurage was applied
deeply and superficially three times. Then, petrissage was
applied and this application was repeated three times. After
the petrissage, localized effleurage massage and localized
massage were applied. All these interventions were made for
the anterior, outside, posterior and inside. After the localized
massages ended, deep and superficial effleurage was per-
formed three times again to all of the extremities. The mas-
sage application was performed on both legs.
2.3 | Data collection
2.3.1 | Patient information form
This form contained a total of 20 questions. Seven of them
were about the participants’ socio-demographic characteris-
tics, five of the questions were about daily activities, and
eight of the questions were about their disease and its treat-
ment. The 10 cm VAS (0: none, 10: very much) was used
for pain evaluation.
2.3.2 | WOMAC knee osteoarthritis
evaluation scale
Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC) Knee Osteoarthritis Evaluation Scale was
developed by Bellamy et al. (Bellamy, 2002; Bellamy,
Buchanan, Goldsmith, Campbell, & Stitt, 1998). The Turk-
ish validation and reliability study was performed by Tüzün,
Eker, Aytar, Daşkapan, and Bayramoglu (2005). This scale,
4 PEHLIVAN AND KARADAKOVAN

which evaluated osteoarthritis-related disability in the hip
and/or knee osteoarthritis, is also very sensitive to the
changes in health states (Bellamy et al., 1998). The scale
contains a total of 24 items and three dimensions. The scores
obtained from the scale differ, with pain (5 items) having
0–20 points, stiffness (2 items) 0–8 points, and difficulties in
daily activities (17 items) 0–68 points. As scores increase in
all dimensions, the intensity and severity of the complaint
also increase (Bellamy, 2002). In the Turkish validation and
reliability study, the Cronbach alpha value was determined
to be 0.70 (Tüzün et al., 2005).
2.3.3 | Osteoarthritis knee and hip quality of
life (OAKHQoL)
The OAKHQoL scale developed by Rat et al. is made up of
43 items, and it contains five sub-dimensions as follows:
physical activity, mental health, pain, social support and
social functionality. The scale is calculated using 40 items,
and questions in the pain section are included in the calcula-
tion of the sub-dimension of physical activity. Each item is
evaluated between 0–10 in the scale, which consists of
Likert-type responses. As the total score increases, the qual-
ity of life also increases (Rat et al., 2005; Rat et al., 2006).
The validity and reliability study for Turkey was performed
by Duruöz et al., and the Cronbach alpha value was deter-
mined to be 0.80, 0.51, 0.87, 0.77, and 0.31 for each sub-
dimension respectively (Duruöz, Duruöz, Uçar, & Topçu,
2013). In this study, the Cronbach alpha value was deter-
mined to be 0.82, 0.76, 0.80, 0.64, 0.20 for each sub-
dimension respectively and 0.78 for total items.
2.4 | Ethical considerations
To conduct this study, written permission was obtained from
the institution with the ethical consent form ethics committee
(dated: 04.03.2014 and numbered 2014/22). Before this
study started, permission was received for the use of scales
in this study and at the nursing homes where this study was
conducted. Written informed consent was obtained from the
elderly individuals. All the individuals were informed about
the aim of this study, and they were assured of confidentiality
and anonymity. The elderly individuals were also assured of
their right to withdraw from this study and that all the infor-
mation obtained would be used only for research aims.
2.5 | Data analysis
Data analysis was performed using the SPSS 22.0 program
(IBM, Armonk, NY, USA). The cases distribution was eval-
uated by Kolmogorov-Smirnov test, and according to the
results of this test, there was normal distribution. For that
reason, we have used parametric tests for statistical evalua-
tions to compare means. Chi-square, multiple variance anal-
ysis (ANOVA), and the significance of differences between
two pairs (paired t-test) were used for the analysis, The
Tukey Honestly Significant Difference test analysis was per-
formed for advanced analysis. p values of less than .05 were
defined as statistically significant.
3 | RESULTS
3.1 | Characteristics of the patients
The distributions of the characteristics of the elderly individ-
uals enrolled in this study are shown in Table 1. There was
no difference in age, means of age, gender, education level,
body mass index (BMI) and disease duration between the
groups (p < .05).
The distribution of previous treatments among elderly
individuals with osteoarthritis was determined as 78.9%
pharmacological treatment, and 40% of these individuals

TABLE 1 Distribution of characteristics of the elderly according to groups

Aromatherapy Massage Control p value

Age (mean, years) 78.30 ± 7.82 76.00 ± 6.69 75.63 ± 6.89 .280
Gender (n / %)
Female 18 60.0 18 60.0 17 56.7 .955
Male 12 40.0 12 40.0 13 43.3
Education level (n / %)
Literate 8 26.7 11 36.7 14 46.7 .272
Primary school 13 43.3 13 35.1 11 36.7
Secondary school 6 20.0 3 10.0 3 10.0
High school - 3 10.0 2 6.7
BMI (mean, kg/m2) 27.00 ± 4.52 29.44 ± 10.02 28.32 ± 4.31 .388
Disease duration (mean, years) 11.67 ± 11.55 8.10 ± 8.70 11.10 ± 8.36 .311

BMI, body mass index.

PEHLIVAN AND KARADAKOVAN 5

had used nonsteroidal anti-inflammatory (NSAI) gel, and
60% of them had used NSAI drugs. While 23.3% of the
elderly reported they had previously had injections in their
joints, 36.7% reported they had had physical treatment. Of
the participants, 21.1% reported they had asked for an alter-
native treatment for osteoarthritis.
3.2 | Results of the groups’ pain and
functional states
The distributions of mean scores of WOMAC pain, stiffness
and functional state by groups are shown according to
groups in Table 2. While the mean scores for WOMAC pain,
stiffness and functional state were significantly decreased at
the end of week 4 in the aromatherapy group, at week
8, these scores were significantly lower than the baseline
scores (p < .001).
While the mean scores for WOMAC pain and stiffness
were significantly decreased at the end of week 4 in the mas-
sage group (p < .001), they were re-elevated in week 8 and
these scores were not different from baseline
scores (p > .05).
When mean differences at baseline and week 4 scores
were compared, there were significant differences in
WOMAC pain and functional state in the aromatherapy
group when compared with the massage and control groups,
while significant differences were present in the massage
group when compared with the control group (p < .001).
When the mean differences between at baseline and week
8 scores were compared, significant differences were present
in WOMAC pain, stiffness, functional state of the aroma-
therapy group compared with the massage and control
groups (p < .001). When the mean differences between the
week 4 and week 8 scores were evaluated, the mean pain
scores within the WOMAC pain sub-dimension had
increased in aromatherapy and massage groups, and the
change was different from the control group (p < .001).
3.3 | Results of the groups’ quality of life
The distributions of the mean scores for quality of life are
shown by group in Table 3. Our findings showed that in
week 4 in the aromatherapy group the mean scores in the
sub-dimensions of quality of life (expect social functional-
ity) significantly increased, and that they decreased again in
week 8, and the same scores were determined to be signifi-
cantly higher than the mean scores baseline (p < .001).
Social support, which was a sub-dimension of quality of life,

T A B L E 2 Distributions of mean scores of Western Ontario and McMaster Universities (WOMAC) pain, stiffness, and difficulties in daily
activities according to the groups

Baseline
- week 4 Baseline
within - week 8 Week
group within 4–8 within
WOMAC Baseline Mean ± SD Week 4 Mean ± SD Week 8 Mean ± SD P value groupp value groupp value
Pain (0–20, " worse)
Aromatherapy 9.72 ± 2.59 5.96 ± 2.70 7.21 ± 3.13 <.001 <.001 <.001
Massage 9.64 ± 2.27 7.64 ± 2.98 9.18 ± 2.67 <.001 >.05 <.001
Control 10.62 ± 2.30 10.80 ± 2.34 10.83 ± 2.28 <.05 >.05 >.05
Between-groups .218 <.001 <.001 <.001 <.001 <.001
p value
Stiffness
Aromatherapy 2.46 ± 1.40 1.25 ± 1.08 1.65 ± 1.25 <.001 <.001 <.05
Massage 2.58 ± 1.58 1.68 ± 1.41 2.34 ± 1.40 <.001 >.05 <.001
Control 2.70 ± 1.41 2.86 ± 1.26 2.82 ± 1.30 <.05 >.05 >.05
Between-groups .819 <.001 .004 <.001 <.001 <.001
p value
Functionality (0–68, " worse)
Aromatherapy 36.22 ± 9.74 29.53 ± 9.50 31.98 ± 9.78 <.001 <.001 <.001
Massage 35.53 ± 10.31 33.58 ± 14.26 35.73 ± 11.00 >.05 >.05 >.05
Control 35.94 ± 8.81 33.14 ± 8.85 37.36 ± 8.54 >.05 >.05 >.05
Between-groups .962 .034 .101 <.001 <.001 .149
p value

Note: Statistically significant values are shown in bold.

6 PEHLIVAN AND KARADAKOVAN

TABLE 3 Distributions of mean scores of life quality according to groups

Baseline
- week 8
Baseline Week 4 Week 8 Baseline - week 4 within group Week 4–8 within
Quality of life Mean ± SD Mean ± SD Mean ± SD within groupp value p value group p value
Physical activity
Aromatherapy 34.86 ± 13.53 40.40 ± 14.16 38.31 ± 14.33 <.001 <.001 <.001
Massage 35.48 ± 12.64 37.93 ± 13.36 35.08 ± 13.56 <.001 >.05 <.001
Control 36.37 ± 15.47 37.28 ± 11.06 37.04 ± 10.85 >.05 >.05 >.05
Between-groups p value .915 .618 .628 .072 .152 .001
Pain
Aromatherapy 54.25 ± 11.65 80.33 ± 12.97 69.83 ± 16.08 <.001 <.001 <.001
Massage 52.66 ± 13.61 67.50 ± 16.60 56.00 ± 17.01 <.001 <.05 <.001
Control 47.58 ± 14.37 46.25 ± 13.59 40.00 ± 39.63 <.05 >.05 >.05
Between-groups p value .133 .000 .000 <.001 .001 .622
Mental health
Aromatherapy 58.05 ± 10.95 62.46 ± 11.34 60.97 ± 11.15 <.001 <.001 <.05
Massage 56.30 ± 11.45 58.48 ± 12.66 56.41 ± 12.75 <.05 >.05 <.05
Control 55.05 ± 12.89 54.00 ± 13.40 54.15 ± 13.00 <.05 >.05 >.05
Between-groups p value .615 .036 .098 <.001 .001 .023
Social support
Aromatherapy 49.50 ± 10.22 51.16 ± 10.84 50.83 ± 10.71 <.05 >.05 >.05
Massage 50.75 ± 15.98 51.75 ± 16.57 51.58 ± 16.40 >.05 >.05 >.05
Control 53.25 ± 17.69 51.33 ± 18.57 53.00 ± 17.91 >.05 >.05 >.05
Between-groups p value .616 .989 .857 .007 .067 .161
Social functionality
Aromatherapy 53.66 ± 10.87 52.55 ± 10.19 53.77 ± 10.16 >.05 >.05 >.05
Massage 49.44 ± 10.90 49.44 ± 9.67 48.66 ± 9.81 >.05 >.05 >.05
Control 47.66 ± 10.76 49.66 ± 7.94 49.77 ± 7.85 >.05 >.05 >.05
Between-groups p value .616 .617 .618 .076 .094 .081

Note: Statistically significant values are shown in bold.

significantly increased in week 4 (p < .05), but it decreased
again in week 8 (p > .05).
In the massage group, mean scores for physical activity
and mental health, which were sub-dimensions of quality of
life, significantly increased in week 4 (p < .05) and they
decreased significantly in week 8 (p < .05), and were not
different from the mean baseline score (p > .05). The mean
score for pain, which was a sub-dimension of quality of life,
increased significantly in week 4 (p < .05). However, we
should note that the mean score significantly decreased in
week 8, and this was not a significant difference from the
baseline score (p > .05).
When the mean differences between baseline and week
4 scores were compared, the findings showed that the mean
scores for pain, mental health and social support, which were
sub-dimensions of quality of life, were significantly different
in the aromatherapy group than in the massage and control
groups (p < .05). When the mean differences between the
baseline and week 8 scores were compared, no difference
was observed in the mean differences in social support
between the groups (p > .05).
4 | DISCUSSION
The outcome of the present study, which was performed to
analyze the effects of aromatherapy massage on pain, func-
tional state and quality of life in elderly individuals with
knee osteoarthritis, revealed the beneficial effects of aroma-
therapy, primarily on pain, and then on stiffness, functional
state and some sub-dimensions of the quality of life.
There are several studies performed about the effects of
aromatherapy on pain and functional status in knee
PEHLIVAN AND KARADAKOVAN
osteoarthritis in the literature (Efe Arslan et al., 2018;
Kim & Kim, 2009; Nasiri & Mahmodi, 2018; Nasiri et al.,
2016; Therkleson, 2014; Yip & Tam, 2008). Therkleson
(2014) performed a topical ginger application for a week
among subjects with knee osteoarthritis and reported signifi-
cant and favorable effects on pain, fatigue, global evaluation,
functional state, and life satisfaction of individuals after the
applications. In the study performed by Nasiri et al. (2016)
and Nasiri and Mahmodi (2018), the findings showed that
pain severity and activities of daily living disability reduced
significantly in patients who had aromatherapy massage
when compared with before the application, and other
groups (placebo massage and control). Efe Arslan et al.’s
(2018) study showed aromatherapy massage performed in
patients with osteoarthritis reduced knee pain scores,
reduced morning stiffness, and improved physical function-
ing status. Significant decreases in pain and improvements
in functional state in the aromatherapy group of the present
study were consistent with this literature information.
Also, pain and stiffness significantly decreased in the
massage group when compared with the control groups in
the present study. The most commonly preferred alternative
treatment method for elderly people with osteoarthritis is
massage, and the beneficial effects of massage are shown in
the studies that were conducted on pain, stiffness and physi-
cal functionality (Dillard, 2011; Fouladbakhsh, 2012; Perl-
man et al., 2012). In the study performed by Atkins and
Eichler (2013), the effects of self-massage in patients with
knee osteoarthritis were investigated. After randomization of
the participants into two groups, individuals in the massage
group were trained to carry out self-massage on their knees
for 20 min twice a week. Both groups were evaluated
4 weeks later. Their findings showed that pain and stiffness
significantly decreased, whereas functional state and joint
movement range increased in the massage group when com-
pared with the control group. However, the use of aromatic
massage was recommended, because some studies showed
that aromatic massage was more beneficial than massage
alone (Jain, 2002; Lai et al., 2011; Nasiri et al., 2016). In our
study also, aromatherapy massage performed more effective
and longer sustained effects than the massage.
When we performed the literature review, surprisingly,
there was only one study that revealed the efficacy of aroma-
therapy massage on quality of life in elderly individuals with
knee osteoarthritis. Yip and Tam (2008) randomized elderly
individuals with knee osteoarthritis into three groups (aro-
matherapy = 19, massage = 17, and control = 17) and
applied a total of six massage sessions. While improvements
in mean scores for WOMAC pain, stiffness and difficulties
in daily activities were found in patients after aromatherapy
massage (using ginger and orange) compared to the other
groups, no difference was present in the quality of life. Our
7
findings relating to significant differences in the WOMAC
sub-dimensions are consistent with these results. However,
significant differences were determined in sub-dimensions
of quality of life in our study. It is believed that this is
because of the use of a quality of life scale that was specific
for osteoarthritis.
Our findings suggest that aromatherapy may be applied
by nurses as a non-pharmacological treatment method for
osteoarthritis. Nursing practices in the care of osteoarthritic
individuals should be focused on pain control, treatment
management, exercise, patient training programs directed to
diet and joint protection, prevention of pain and avoidance
of disability which may cause psychosocial changes. There-
fore, it is the nurse’s responsibility to present individualized
solutions to patients by performing regular patient follow up
and training, and determining effective methods for symp-
tom management (Kee et al., 1998). Aromatherapy can be
performed effectively, safely and independently by the
nurses. Effective symptom management can be provided for
osteoarthritic patients if nurses are informed about this sub-
ject and are trained in how to apply it. In particular, nurses
who work with elderly patients, who have an increased inci-
dence of osteoarthritis, should be more active in using these
treatments.
4.1 | Limitations
The limitation of this study is that the application of massage
and the patients’ interviews were carried out by the same
researcher. Therefore, communication between the
researcher and the participants may have affected the results
of this research. Because the diagnosis of osteoarthritis was
obtained from the elderly patients’ files, we could not
address the grading. We think that the patients in different
grades would have different symptoms and this could influ-
ence the effects of the non-pharmacological methods. Future
research could be conducted through grading. To show the
efficacy of the aromatherapy, it is thought that the study to
be done by using black seed and black seed + essential oil.
5 | CONCLUSIONS
Our findings showed that aromatherapy had positive effects
on the pain, functional state and quality of life in elderly
individuals with knee osteoarthritis. When aromatherapy
was compared with massage, the findings revealed that aro-
matherapy had more beneficial and longer-lasting effects.
Effective symptom management can be provided to individ-
uals with osteoarthritis if nurses are informed about these
findings and are offered related training programs. Nurses
who specifically care for the elderly, who have increased
incidences of osteoarthritis, should receive information
8 PEHLIVAN AND KARADAKOVAN
about non-pharmacological methods, including aromather-
apy, which can be used for osteoarthritis. Nurses should also
find a place for this treatment in their daily practices. More-
over, nursing home management, elder care and healthcare
units should be informed about the findings of the present
study. Hence, awareness of the efficacy of aromatherapy for
elderly patients with knee osteoarthritis could be increased.
For the sustainability of the present study, the aromatherapy
treatment could be planned and conducted on all age groups,
and interventions could be made to increase its efficacy after
the determination of the baseline severity of the disease.
ACKNOWLEDGMENTS
This study was performed as a PhD thesis in the Institute of
Health Sciences at Ege University by Seda Pehlivan in
advising Ayfer Karadakovan. We thank all of the elderly
patients who participated in this study and nursing homes
employees.
C ON F L I C T O F IN T E RE S T S
The authors declare that they have no conflict of interest.
A UT H O R C O NTR I B UT I ON S
All of the authors have agreed on the final version and meet
at least one of the following criteria recommended by the
International Committee of Medical Journal Editors 2013:
substantial contributions to conception and design, acquisi-
tion of data, or analysis and interpretation of data, drafting
this research article or revising it critically for important
intellectual content.
O R C ID
Seda Pehlivan https://orcid.org/0000-0002-1670-0672
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S UP P OR T I N G I NF OR M A T I ON
Additional supporting information may be found online in
the Supporting Information section at the end of this article.
How to cite this article: Pehlivan S,
Karadakovan A. Effects of aromatherapy massage on
pain, functional state, and quality of life in an elderly
individual with knee osteoarthritis. Jpn J Nurs Sci.
2019;1–9. https://doi.org/10.1111/jjns.12254