sv-lncs RUHUNA JOURNAL OF SCIENCE Vol 9(2): 140-149, December 2018 eISSN: 2536-8400  Faculty of Science http://doi.org/10.4038/rjs.v9i2.42 University of Ruhuna  Faculty of Science, University of Ruhuna 140 Short Paper Study on effectiveness and user satisfaction of anti- inflammatory ointment of Curcuma albiflora Thw. in Bentota divisional secretariat, Southern Sri Lanka H.M.I.C. Herath1, T.D.C.M.K. Wijayasiriwardene 2*, G.A.S. Premakumara2 1Faculty of Graduate Studies, University of Colombo, Colombo, Sri Lanka 2Industrial Technology Institute, Bauddaloka Mawatha, Colombo, Sri Lanka *Correspondence: drchandima@iti.lk; ORCID: 0000-0002-8308-6748 Received: 6th March 2018, Revised: 31st August 2018, Accepted: 27th November 2018 Abstract. Under the same Sinhalese vernacular name, three plants (Curcuma albiflora Thw., Curcuma zedoaria Rosc., and Zingiber zerumbet Smith) are being reported. Amongst them, C. albiflora is an endangered and less explored plant. The current study was conducted to study the anti-inflammatory activity of the ointment produced using C. albiflora. Clinical trial was conducted using 175 participants in community based centers (n=2) in Grama Niladari divisions of Bentota Divisional Secretariat, Southern Province, Sri Lanka. Participants treated with the ointment (98 patients) or the placebos (77 patients) were asked to complete the structured questionnaire. Treatment was applied for two weeks and the results were monitored by two Ayurvedic doctors who were involved in the study. Comparisons by chi square test showed that TM users differed from non-users in terms of previous side effects and current inflammatory conditions (P<0.05). By binary logistic regression analysis, treatment group satisfaction was found to be about 31 times the chance of the placebo group. The models indicated that the patients above 60 years of age, female, previous traditional medicine users, duration of current anti-inflammatory condition (≥ 1 year) were more likely to effectively respond to the treatment. Ointment of C. albiflora Thw. showed moderate anti- inflammatory activity. Keywords. Binary logistic regression, Curcuma albiflora, Survey. 1 Introduction Arthritis is a major common health problem in the world, while Osteoarthritis (3.8%) and Rheumatoid arthritis (0.24%) of people are reported globally (Richette and Bardin 2010). According to survey results of the Department of H.M.I.C. Herath et al. Effectiveness and user satisfaction of Curcuma ointment Ruhuna Journal of Science 141 Vol 9(2): 140-149, December 2018 Census and Statistics on Sri Lankan people, nearly 11.4% were reported to have arthritis. Moreover, the prevalence rate of arthritis reported is 1.25% and 2.8% among the males and females respectively (DCS 2014). To date, chemoprevention is a major strategy in controlling inflammatory diseases (Gustin et al. 2002). Non-steroidal anti-inflammatory drugs (NSAIDs) were originally used to alleviate pain and for the treatment of arthritis. NSAIDs lead to a number of side effects in the patients such as pain, gastro-intestinal tract issues, and leading to problems such as high blood pressure (O’Leary 2014). Therefore, day by day herbal medicine becomes popular throughout the world. But, some of the constraints exist in herbal medicine are adulteration of authentic plant materials with other similar looking plant materials (e.g. Curcuma species), legal barriers on cultivation (e.g. Kansa- Canabis sativa) and restrictions to harvest from forests (e.g. Venivel- Coscinium fenestratum, Kotala himbutu- Salasia reticulate, Bimkohomba- Munronia pinnata, Sudu handun- Santalum album and Rath handun- Pterocarpus santalinus) (Kankanamalage et al. 2014). ‘Harankaha’ is a medicinal plant used in Traditional Medicine in Sri Lanka. But, under the same common trivial name Harankaha, three species are reported; Curcuma albiflora Thw., Curucma zedoaria Rosc., and Zingiber zerumbet Smith (Dassanayaka 1983). Among these three species, C. albiflora is an endangered and poorly explored endemic plant (MOE 2012). However, C. zedoaria is one of the most extensively studied species of Curcuma due to their high commercial value. Proteins of C. zedoaria have shown a significant anti-inflammatory activity (i.e. 77% inhibition after 5h) in the carrageenan induced rat paw oedema model system (Angel et al. 2013). According to Ullah et al. (2014), ethanol extract of C. zedoaria (500 mg/kg) has shown maximum activity (94.67% inhibition) after 3h on carrageenan induced paw oedema test. Moreover, its ethanol extract (500 mg/ml) has significantly inhibited protein denaturation by 77.15%. Makabe et al. (2006) reported that furanodiene and furanodienone isolated from C. zedoaria using ethyl acetate (in hexane) showed 75% and 53% inhibitory effect on TPA (12- O-tetradecanoylphorbol13-acetate) induced edema of mouse ear test respectively. Further, Kaushik and Jalalpure (2011a) has studied histamine induced rat paw edema test on various extracts of C. zedoaria (root) and have shown a significant inhibition. Petroleum ether and chloroform extracts have shown 46.3% and 51.85% inhibition at 200 mg/kg dose after 6h respectively. Further, Kaushik and Jalalpure (2011a) found that petroleum ether and chloroform extracts of C. zedoaria have shown 55.81% and 51.16% inhibition at the dose of 200 mg/kg respectively (on carrageenan induced paw oedema model). But standard group (Indomethacin) has shown 53.49% inhibition after 6h. The petroleum ether extract of C. zedoaria reduced edema 56.70% in the carrageenan induced paw oedema test on oral administration 200 mg/kg when compared to control group (Kaushik and Jalalpure (2011b). However, C. albiflora has not studied to that extent, yet investigation of anti- H.M.I.C. Herath et al. Effectiveness and user satisfaction of Curcuma ointment Ruhuna Journal of Science 142 Vol 9(2): 140-149, December 2018 inflammatory action of C. albiflora is important for Traditional Medicine in Sri Lanka. C. albiflora hydro-ethanolic extract significantly impaired the paw oedema, at 1h (by 61%) by 200 mg/kg on carrageenan induced paw oedema model (Herath et al. 2017). Moreover, the drug group (400 mg/kg) significantly (P<0.05) reduced the paw oedema from the day 5 to 7, when compared with the control (water) on Formaldehyde induced paw oedema model. Although in vivo and in vitro assays are used to predict human response to drugs (or other chemicals), it is an argumentative issue (Shanks et al. 2009). Hence, the current study was conducted to study the anti-inflammatory activity of ointment which was produced from C. albiflora using the modified method of Liu et al. (2012) and Anand and Bansal (2016). The ointment was tested through a clinical trial using 175 people, who were selected from community based centers (n=2) in Grama Niladari divisions of Bentota Divisional Secretariat, Southern Province, Sri Lanka. 2 Materials and Methods 2.1 Ethical clearance Ethical clearance was obtained from the Department of Ayurveda in Sri Lanka to conduct the clinical trial. 2.2 Collection of plants and preparation of the extract Plants were collected from 2016 to early 2017 in Sabaragamuwa province (Erathna: N 6o 50' 07'', E 80o 24' 41'', Kitulgala: N 6° 59' 41'', E 80° 24' 20'' and Bopathella: N 6o 48' 07'', E 80o 22' 12''). Voucher specimens (No. 02, 03, 04) of the plants were authenticated from National Herbarium, Peradeniya, Sri Lanka. 2.3 Preparation of C. albiflora (CA) ointment Decoction, sesame oil (2.5 L) as solvent, soft paraffin (5 L), bee-wax were used to prepare CA ointment (n = 100). 2.4 Participants and Settings A descriptive survey design was used to collect data through a questionnaire about CA ointment. Data were collected from the people gathered at the community based centers (n= 2) in Dedduwa and Mahawila Grama Niladhari H.M.I.C. Herath et al. Effectiveness and user satisfaction of Curcuma ointment Ruhuna Journal of Science 143 Vol 9(2): 140-149, December 2018 dividions in Benthota, Galle district, Southern province on 22/12/2017 and 14/01/2018. 2.5 Questionnaire In the present study, a modified version of the questionnaire developed by Swisher was used (Swisher et al. 2002). A draft questionnaire was prepared, and it was reviewed by Ayurvedic doctors (n=2). Then a pilot test was performed in two community groups as mentioned in 2.4. The questionnaire used to collect data was attached and it consisted of three parts; the first part on the demographic information of participants (age, gender, educational level, marital status and religions), the second part on participants' clinical condition, use of traditional medicine (TM) (activity of daily life, methods of obtaining information about TM), and the third part on the satisfaction or dissatisfaction on Curcuma albiflora (CA) ointment after applying it for two weeks. They were advised to use ointment without using any anti- inflammatory drug during these two weeks. TM users were defined as patients who had used TM at least once before the use of CA ointment. 2.6 Statistical analysis of the survey data Differences in demographic and clinical characteristics between TM users and non-users were assessed using test. Factors associated with TM use were identified via binary logistic regression analysis. The analysis provided an odds ratio and a 95% CI for each variable while simultaneously controlling for the effects of other variables. Data were analyzed with Minitab 17 software. Logistic regression is applicable when the response is binary and uses a transformation or link function to convert the binomial data into continuous variable using formula Logit(p) = ln( ). The regression output provides the predicted logit value for each observation, which transform to a binary percentage (Peng 2002). The event probability (E) is the estimated event probability value for that observation. E = where logit(p) = constant+α1x1+α2x2…+αnxn 3 Results and Discussion The survey conducted in the community based centers (Dedduwa and Mahawila) in Benthota division, Galle district, Southern province noted mean H.M.I.C. Herath et al. Effectiveness and user satisfaction of Curcuma ointment Ruhuna Journal of Science 144 Vol 9(2): 140-149, December 2018 ages as 62 and 58 for two populations (SD 13). Required total sample size was obtained as 166. Total of 175 participants attended the survey from the community based centers (n=2) in Dedduwa and Mahawila Grama Niladhari, in Benthota division (Plate 1). Plate 1. Survey on two community based centres (A: Dedduwa Grama Niladhari, Benthota division, Galle district, Southern province B: Mahawila-West Grama Niladhari, Benthota division, Galle district, Southern province, Sri Lanka). Table 1: Demographic and clinical characteristics of the participants. Variable Category TM Users % TM Non users % Total % Chi square value P value Age >60 32.6 40 72.6 0.72 Ref: 3.84 0.39 <= 60 14.3 13.1 27.4 Education Illiterate 4 4.6 8.6 2.75 Ref: 7.82 0.43 Primary 21.1 25.7 46.9 OL 17.1 14.3 31.4 > OL 4.6 8.6 13.1 Marital status Married 27.4 33.7 61.1 0.44 Ref: 5.99 0.80 Never 4 4 8 Widowed 15.4 15.4 30.9 Sex Male 10.9 15.4 26.3 0.77 Ref: 3.84 0.37 Female 36 37.7 73.7 Previous Side effects Free 41.7 53.1 94.8 10.76 Ref: 3.84 < 0.001* Simple 5.1 0 5.1 Food type Vegetarian 14.3 17.1 31.4 0.06 Ref: 3.84 0.80 Mix 32.6 36 68.6 Current inflammatory condition Never 0 4 4 6.42 Ref: 5.99 0.01* Slight 46.3 49.1 95.4 Duration of current inflammatory condition <1 year 21.7 29.1 50.9 1.75 Ref: 5.99 0.41 1-5 years 19.4 20 39.4 >5 years 5.7 4 9.7 A B H.M.I.C. Herath et al. Effectiveness and user satisfaction of Curcuma ointment Ruhuna Journal of Science 145 Vol 9(2): 140-149, December 2018 Out of these 175 people, 98 (56%) were eligible for receiving CA ointment. After screening past diagnosis, current health status of patients were assessed by Ayurvedic doctors (n=2). Participants (who have chronic diseases such as diabetes, kidney diseases etc.) and healthy participants were recommended to obtain placebo. Patients with arthritis and joint disorders have received the CA ointment. Of the 175 surveyed people consisting of 46 (26.3%) males and 129 (73.7%) females completed the survey with a response rate of 100%. Their mean age was 64.6 ± 11.8 years; most participants were married (n = 107; 61.1%) and were widowed (n=54; 30.9%). Demographic and clinical characteristics of participants were summarized in Table 1. Nine patients (5.1%) reported side-effects of the TM drugs such as traditional mixtures called ‘arishta’ and ‘kalka’. These side-effects included gastric upset, stomachache and increase of phlegm, but nobody experienced serious side- effects. 46.9% (n = 82) of the total responders were TM users (patients who had used TM at least once before the use of CA ointment). Comparisons by chi square test showed that TM users differed from non-users in terms of previous side effects and current inflammatory condition (P<0.05). TM users did not differ from non-users in terms of age, education, marital status, sex, food type, and duration of current inflammatory condition (P>0.05). Effect of the CA ointment and placebo were reported in Table 2. Table 2: Effect of treatment from surveyed result of Curcuma albiflora (CA) ointment and placebo. Exposure Outcome Odd ratio Improved No improvement Treatment group (CA ointment) 74 24 31 Placebo group 07 70 Odd ratio equals to 31 indicated the satisfaction of the treatment group who used CA ointment for two weeks is about 31 times that of the placebo group. According to response of the CA ointment users, results were summarized in Table 3. CA ointment was received by 56% (n = 98) of the surveyed group. Comparisons by Chi square test showed that CA satisfied responders did not differ from dissatisfied in terms of age, education, food-type, sex, and the duration of current inflammatory condition (P>0.05). Some of the factors were studied in detail and reported in Table 4. H.M.I.C. Herath et al. Effectiveness and user satisfaction of Curcuma ointment Ruhuna Journal of Science 146 Vol 9(2): 140-149, December 2018 Table 3: Bivariate analysis results by survey on satisfaction/dissatisfaction of Curcuma albiflora ointment. Variable Category Satisfied % Dissatisfied % Total % Chi- square P-value Age < 60y 25.5 5.0 30.6 1.97 0.16 >= 60y 64.3 5.0 69.4 Education < OL 41.8 7.1 49.0 1.96 0.16 >= OL 37.8 13.3 51.0 Sex Male 16.3 8.2 24.5 1.34 0.24 Female 59.2 16.3 75.5 Food type Vegetarian 23.4 6.1 29.6 2.73 0.09 Mix 0.64 6.1 70.4 Duration of current inflammatory condition <1 year or >5 0.32 6.1 37.8 0.18 0.67 1-5 years 0.54 8.2 62.2 Table 4: Factors associated with Curcuma albiflora ointment users in the binary logistic regression. Variable Category Response Test OR Treatment Placebo Age >60 years Improved 50 6 24.5 No improvement 18 53 <60 years Improved 24 1 68 No improvement 6 17 Sex Male Improved 16 3 12.6 No improvement 8 19 Female Improved 58 4 46.2 No improvement 16 51 Previous TM use TM users Improved 35 1 102.1 No improvement 12 35 TM non users Improved 39 6 19.0 No improvement 12 35 Duration of current inflammatory condition <1 year Improved 19 5 12.4 No improvement 8 26 1-5 or >5 years Improved 54 2 69.9 No improvement 17 44 H.M.I.C. Herath et al. Effectiveness and user satisfaction of Curcuma ointment Ruhuna Journal of Science 147 Vol 9(2): 140-149, December 2018 The binary logistic models indicated that above 60 years of age, female, previous traditional medicine users, duration of current anti-inflammatory condition (≥ 1 y) were more likely to effectively response for CA ointment. According to binary logistic analysis number of satisfied CA ointment users were reported as 74, and dissatisfied as 24. Predictor variable values were summarized in Table 5. Table 5. Predictor variable values of Curcuma albiflora ointment users by Binary logistic regression analysis (TM= Traditional medicine). Predictor variable β S.E. β Wald Z p Exp (β) OR 95% CI for Exp (β) Lower Upper Age -0.02 0.02 -0.81 0.420 0.98 0.93 1.03 Sex 0.44 0.58 0.76 0.445 1.56 0.50 4.92 Marital status 0.09 0.32 0.30 0.762 1.10 0.58 2.10 Edu1tional level -0.57 0.31 -1.84 0.06 0.56 0.31 1.04 Food -0.59 0.60 -0.98 0.32 0.55 0.17 1.81 Previous TM user -0.39 0.53 -0.74 0.46 0.67 0.23 1.93 Diagnosis/months 0.00 0.00 0.75 0.45 1.00 0.99 1.02 Side effects 0.20 1.25 0.16 0.87 1.23 0.11 14.31 Arthritic condition 0.22 1.37 0.17 0.86 1.26 0.08 18.64 Many researches have revealed effectiveness of curcumin incorporated skin formulations. Gonçalves et al. (2014) has assessed topical formulations of curcuminoid extracted from Curcuma longa by quantifying skin retention (using pig ear membrane) and skin permeation (modified Franz diffusion cell system). They have prepared various gel formulations by water and hydroxyethylcellulose (at 70°C); the most stable formulation was β- cyclodextrin containing hydro-ethanolic and dry extract of turmeric. Although skin penetration lowered by curcumin, skin retention promoted. Therefore, curcumin is used in anti-aging formulations. Gonçalves et al. (2014) has reported that, a tonic prepared from the rhizome of C. longa has shown significant reduction in ulcers, cough, and the common cold as well as ointment form increased wound healing. Furthermore, Hamzah (2011) has found that turmeric gel reduced a 30% inhibition in oedema using the carrageenan-induced rat paw edema model. Huang et al. (1997) found that curcumin inhibited induced skin tumor formation by topical application. Lin and Lin (2008) showed that curcumin prevents skin tumors, spots or wrinkles effectively. Kuptniratsaikul et al. (2009) performed a single-blind randomized controlled trial to evaluate the efficacy of C. domestica extracts (2,000 mg/day) compared with ibuprofen (800 mg/day) of in 107 knee OA patients H.M.I.C. Herath et al. Effectiveness and user satisfaction of Curcuma ointment Ruhuna Journal of Science 148 Vol 9(2): 140-149, December 2018 for 6 weeks. Further, to determine the efficacy and safety of C. domestica extracts (1,500 mg/day) in pain reduction and functional improvement compared with ibuprofen (1,200 mg/day); about 96% were satisfied with the treatment while fewer gastrointestinal issues reported in the C. domestica extracts group. Patient’s assessment of satisfaction on C. domestica extract (n=171) at week 4, satisfied and unsatisfied patients were about 97% and 1% respectively (P > 0.05). Fig. 1. Diagnostic plot of delta chi-square versus probability Log-Likelihood and G value were reported as -50.436 and 8.232 respectively. Goodness-of-Fit Tests under the method Pearson was shown higher Chi- Square value (109.854) indicates enough number of data for the analysis. This is supported with the Figure 1. Hydro-ethanolic extract of C. albiflora significantly impaired the paw oedema, at 1h (by 61%) by 200 mg/kg on carrageenan induced paw oedema model as well as from the day 5 to 7 on formaldehyde induced paw oedema model (Herath et al., 2017). From the current study it was revealed that the treatment group satisfaction was about 31 times the chance of the placebo group. Therefore, CA ointment showed moderate anti-inflammatory activity. 4 Conclusion From the present findings it can be concluded that Curcuma albiflora ointment possessed a moderate anti-inflammatory activity. Acknowledgment National Science Foundation provided financial support (NSF/SCH/2018/03). Commissioner of Ayurveda, Southern Province, Sri Lanka is acknowledged for Probability D e lt a C h i- S q u a r e 1.00.80.60.40.20.0 25 20 15 10 5 0 Delta Chi-Square versus Probability H.M.I.C. Herath et al. Effectiveness and user satisfaction of Curcuma ointment Ruhuna Journal of Science 149 Vol 9(2): 140-149, December 2018 providing ethical clearance. Comments from two anonymous reviewers were acknowkedged. References Anand A, Bansal G. 2016. Predicting Customer’s Satisfaction (Dissatisfaction) Using Logistic Regression. International Journal of Mathematical, Engineering and Management Sciences 1(2): 77–88. Angel GR, Vimala B, Nambisan B. 2013. Antioxidant and anti-inflammatory activities of proteins isolated from eight Curcuma species. Phytopharmacology 4(1): 96-105. Dassanayaka MD. 1983. Flora of Ceylon, Vol IV. Amerind Publishing Co. Pvt. Ltd, New Delhi 495 – 496, 501-504. DCS. 2014. National Survey on Self-reported Health in Sri Lanka 2014. Department of Census and Statistics. Sri Lanka: Ministry of National Policies and Economic Affairs. Gustin DM, Brenner DE. 2002. Chemoprevention of colon cancer: current status and future prospects. Cancer and Metastasis Reviews 21:323-348. Hamzah MM. 2011. Evaluation of topical preparations containing curcuma, acacia and lupinus extracts as an anti-inflammatory drugs. International Journal of Applied Research in Natural Products 4(2): 19-23. Herath I, Premakumara S, Wijayasiriwardene C. 2017. Anti-inflammatory activity of Curcuma albiflora Thw. grown in Sri Lanka. Journal of Ayurveda Medical Sciences 2(4): 90-93. Huang MT, Yen P, Xie J, Han J, Frenkel J. 1997. Inhibitory effects of topical application of low doses of curcumin on 12-O-tetradecanoylphorbol-13-acetateinduced tumor promotion and oxidized DNA bases in mouse epidermis. Carcinogenesis 18(1): 83-88. Kankanamalage TN, Dharmadasa RM, Abeysinghe DC, Wijesekara RG. 2014. A Survey on Medicinal Materials Used in Traditional Systems of Medicine in Sri Lanka. Journal of Ethnopharmacology 155 (1):679–91. Kaushik ML, Jalalpure SS. 2011. Anti-inflammatory Efficacy of Curcuma Zedoaria Root Extracts. Asian Journal of Pharmaceutical and Clinical Research 4(3):1-5. Kaushik ML, Jalalpure SS. 2011. Effect of Curcuma zedoaria Rosc root extracts on behavioral and radiology changes in arthritic rats. Journal of Advance Pharmaceutical Technology & Reaserch 2(3): 170-176. Kuptniratsaikul V, Thanakhumtorn S, Chinswangwatanakul P, Wattanamongkonsil L, Visanu T. 2009. Efficacy and Safety of Curcuma domestica Extracts in Patients with Knee Osteoarthritis. Journal of Alternative Complementary Medicine 15(8):891-897. Lin CL, Lin JK. 2008. Curcumin: a potential cancer chemopreventive agent through suppressing NF-ıB signaling. Journal of Cancer Molecules 4(1): 11-16. Makabe H, Maru N, Kuwabara A, Kamo T, Hirota M. 2006. Anti-inflammatory sesquiterpenes from Curcuma zedoaria. Natural Product Research 20(7): 680-685. MOE. 2012. The National Red List 2012 of Sri Lanka, Conservation Status of the Fauna and Flora. Sri Lanka: Ministry of Environment, 339p. O’Leary MR. 2014. Dr. Thomas Addison 1795-1860. USA: iUniverse. Peng CYJ. 2002. An Introduction to Logistic Regression Analysis and Reporting. The Journal of Educational Research, 3-14. Richette, P, Bardin T. 2010. Gout. Lancet 375(9711):318. Shanks N, Greek R, Greek J. 2009. Are animals models predictive for humans?. Philosophy, Ethics and Humanities in Medicine 4: 2. Swisher, EM, Cohn DE, Goff BA. 2002. Use of complementary and alternative medicine among women with gynecologic cancers. Gynecologic Oncology 84(3): 363–367. Ullah HMA, Zaman S, Juhara F, et al. 2014. Evaluation of antinociceptive, in-vivo & in-vitro anti-inflammatory activity of ethanolic extract of Curcuma zedoaria rhizome. BMC Complementary Alternative Medicine 14(1): 1-12.