Herbal compresses or “Luk Prakob” in Thai have been used in Thailand for hundreds of years in conjunction with traditional massage or as a stand-alone therapy [
The ingredients of Thai herbal compress vary widely and depend on the availability of herbs in different local areas and the unique formula of individual recipe [
Thai herbal compress has been selected in 2013 as one of the five champion herbal products that have been widely used and generated income to the country [
This systematic review was conducted according to the Cochrane Collaboration framework guidelines [
The following databases were used to search for original research articles from inception to September 2014: AMED, CINAHL, Cochrane Central Register of clinical trial, EMBASE, Health Science Journals in Thailand, PubMed, Thai Index Medicus, Thai Library Integrated System, Thai Medical Index, Thai Thesis Database, WHO registry, and
Research articles were included if they met the following inclusion criteria: (1) conducted in human; (2) evaluated clinical effects of Thai herbal compress; and (3) had control group. TD scanned all the titles and abstracts to determine whether the studies assessed the effects of herbal compress. Full-text articles of the potential studies were subsequently assessed by TD and CK. When disagreements and uncertainties regarding eligibility occurred, they were resolved by discussions with NC.
Data extraction was undertaken by TD and CK using a data extraction form in accordance with the CONSORT statement for reporting herbal medicinal interventions [
Data from all studies were pooled in a meta-analysis to determine the overall effect size with 95% confidence interval. Studies that employed other procedures/medications in addition to herbal compress in the intervention arm or used different measures were excluded from meta-analyses. Pooled effects were calculated and stratified according to indications of herbal compress and its comparators. In addition to the pooled effects of individual comparators (such as NSAIDs, knee exercise, and hot compress) a collection of all comparators was formulated for each treatment indication and called a “combined comparator.” The combined comparator analyses were undertaken to examine the overall impact of herbal compress for each outcome regardless of comparative treatments. To avoid duplication of studies with more than one comparator arms, only one comparator was selected from each study to be included in a combined comparators analysis. The following are order of preferences used to choose the best comparator for each indication: (a) OA: NSAIDs (nonsteroidal anti-inflammatory drugs), knee exercise, and hot compress [
Mean changes of the outcome variables for each treatment arm were calculated by subtracting the baseline mean with the mean of the postintervention. Pooled standard deviations (
Statistical heterogeneity between studies was assessed using the chi-squared test and
Of the 363 articles extracted from the various databases searched and 3 articles identified through other sources, 277 articles were eligible for screening after duplication removal. Based on title and abstract screened, 27 articles were selected for full text review. A total of 14 papers were excluded after full text review as 10 studies did not use Thai herbal compress recipe, 2 studies were thesis/report which were also published in peer-reviewed journals, and the remaining 2 studies were not clinical studies and did not study the effect of herbal compress. Eventually, 13 studies [
Flow diagram of selected articles.
The indications of herbal compress used in these studies were pain reduction [
Characteristics of the included studies.
Study | Study type | Participants characteristics | Sample size | Male, % | Age, †years | Herbal compress ingredients | Characteristics of herbal compress intervention | Control | ||
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Detail of intervention | Number of sessions (duration) | Practitioner | ||||||||
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Artkarn, 2006 [ |
QE | Have recently been developed symptoms of back pain and knee pain with no prior history of using NSAIDs in the past 7 days | 40 | 30.0 | NR, range 25–55 | The Institute of Thai Traditional Medicines Recipe |
Steamed for 10 minutes then compressed after a 40-minute massage for 30 minutes on days 1, 3, and 5 with concomitant use of oral diclofenac 25 mg tid every day | 5 (5 days) | A Thai traditional massage practitioner who has 5-year experience in using herbal compress | Oral diclofenac 25 mg tid every day |
Chiranthanut et al., |
RCT | Have been diagnosed with knee OA according to the American College of Rheumatology for >3 months and had the VAS of pain in the range of 175–375 out of 500 | 60 | 27.0 | NR, Int. 63.7 ± 6.1; Ctrl1 65.4 ± 9.8; Ctrl2 62.2 ± 9.5 | The 225 g herbal balls contained dried herbs of |
Steamed for 20 minutes and compressed for 1 hour (changed the steamed herbal ball when the current one was slightly lukewarm) three times a week | 9 (3 weeks) | A health professional practitioner who is trained in Suandok-style Thai massage | Ctrl1: massage for 1 hour three times a week; Ctrl2: oral ibuprofen 400 mg tid every day |
Iampornchai et al., |
QE | Postpartum mothers who had back pain for both after labor and 24 hr after labor | 100 | 0 | NR, Int. 26.5 (23.0–33.0)‡; Ctrl 26.0 (21.7–30.0)‡ | NR | Compressed after the court type Thai traditional massage for the total of 60 minutes | Once | Five trained Thai traditional medicine practitioners | Usual labor care including medication and exercise |
Intarasukum and Kerdcharoen, |
QE | Primigravida mothers with singleton term who had labor pain | 100 | 0 | NR, Int. 22.6 ± 4.1; Ctrl 21.7 ± 4.8 |
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Start compressed on pelvis, coccyx, and waist when the cervix dilated for 4-5 cm, compress for 30 minutes and pause for 10–15 minutes then recompress for 30 minutes. Perform this cycle (compress and pause) until the cervix dilated for 8-9 cm, and then perform the final compress for 30 minutes | One course | The investigator (nurse) | Usual labor care |
Lekutai et al., |
QE | Had been diagnosed with subacute knee OA with no plan for surgical treatment | 89 | NR | NR, range 51–55 | Damnoen Saduak Hospital Recipe ( |
Compressed for 30 minutes (changed the steamed herbal ball every 5 minutes) once a day | 5 (5 days) | NR | Ctrl1: compressed with hot compress for 30 minutes once a day; Ctrl2: isometric exercise for 30 minutes once a day |
Phromjuang, |
QE | Elderly (age 60–80 years) who had knee OA pain ≥6 months | 40 | NR | NR, range 60–80 |
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Steamed for 10 minutes and then compressed for 30 minutes (changed the steamed herbal ball every 5 minutes) twice a week | 8 (4 weeks) | NR | Usual care including oil massage and OA modern medicines |
Puengsuwan et al., |
CT | Had been diagnosed with nonspecific low back pain | 24 | 37.5 | 41 ± 8 | Fresh herbs contain |
Steamed for 30 minutes then compressed for 20 minutes | Once | A Thai traditional massage practitioner | Compressed with hot compress for 20 minutes |
Sathianrat et al., |
QE | Had myofascial pain syndrome with pain around neck, shoulder, and upper back for 2 days to 2 weeks | 90 | 27.8 | NR, range 20–69 | The Institute of Thai Traditional Medicines Recipe |
Compressed for 30 minutes on days 1, 3, and 5 | 3 (5 days) | A health professional practitioner who has 2-year experience in using herbal compress | Ctrl1: compressed with hot compress for 30 minutes on days 1, 3, and 5; Ctrl2: applied diclofenac gel at 7 am, 1 pm, and 9 pm everyday |
Sukonthasarn, |
QE | Elderly (age >60 years) who had knee pain >1 year with no sign of inflammation at knee | 75 | NR | NR | NR | Compressed everyday | 14 (2 weeks) | Village health volunteers who were trained in the use of herbal ball | Ctrl1: knee exercise 3 times a day; Ctrl2: knee exercise 3 times a day plus herbal compress once a day |
Suwan, 2000 [ |
QE | Had been diagnosed with knee OA with no plan for surgical treatment | 30 | 20.0 | NR, range 40–79 |
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Compressed everyday | 7 (7 days) | The investigator (nurse) | Compressed with hot compress once a day |
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Listisit and Pakdeechot, |
QE | Postcesarean mothers who had no milk production within 2 hours postpartum | 100 | 0 | NR, Int. 32.0 ± 4.1; Ctrl 27.5 ± 5.6 | NR | Compressed within 24 hours postcesarean | Once | The investigator (nurse) | Routine increasing milk production program (baby holding and breast feeding promotion every 2-3 hours) |
Pakdeechot et al., |
QE | Postpartum mothers who had no milk production within 2 hours postpartum | 100 | 0 | NR, Int. 27.1 ± 5.6; Ctrl 26.8 ± 5.1 | NR | Compressed within 24 hours postpartum | Once | NR | Routine increasing milk production program (baby holding and breast feeding promotion every 2-3 hours) |
Trainapakul et al., |
QE | Mothers who had no milk production within 48 hours postpartum | 46 | 0 | NR, Int. 29.1 ± 6.4; Ctrl 27.7 ± 5.5 |
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Steamed for 10 minutes and then compressed after a 10-minute breast massage for 20 minutes each breast | Once | A Thai traditional massage practitioner | Compressed after a 5-minute breast massage with mini hot bag for 5 minutes each breast |
The ingredients of Thai herbal compress were reported in 9 studies [
Comparators that were most used among studies in patients with knee OA and muscle pain were hot compress (4 studies) [
All three studies investigating the effects of herbal compress on improving lactation assessed the outcome after a single course treatment [
The majority of included studies, 10 out of 13 [
Methodological quality assessment of the included studies.
Study | Risk of bias domain | Jadad score | ||||||
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Sequence generation | Allocation concealment | Blinding | Incomplete outcome data | Selective outcome reporting | Other sources of bias | Overall risk of bias | ||
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Artkarn, 2006 [ |
H | H | H | L | L | H | H | 0 |
Chiranthanut et al., |
L | L | H | L | L | L | L | 3 |
Iampornchai et al., |
H | H | H | L | H | L | H | 0 |
Intarasukum and Kerdcharoen, |
L | H | H | L | L | H | H | 2 |
Lekutai et al., |
H | H | H | L | L | H | H | 1 |
Phromjuang, |
H | H | H | L | L | H | H | 1 |
Puengsuwan et al., |
L | H | H | L | L | H | H | 2 |
Sathianrat et al., |
H | H | H | L | L | H | H | 0 |
Sukonthasarn, |
H | H | H | L | L | H | H | 0 |
Suwan 2000 [ |
H | H | H | L | L | H | H | 0 |
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Listisit and Pakdeechot, |
H | H | H | L | L | H | H | 0 |
Pakdeechot et al., |
H | H | H | L | L | H | H | 0 |
Trainapakul et al., |
H | H | H | H | L | H | H | 1 |
H, high risk of bias; L, low risk of bias.
Information extracted from the included studies was generally complied with the requirement in the CONSORT statement for reporting herbal medicinal interventions [
Of the studies that investigated the use of herbal compress in patients with knee OA, all six studies [
Outcomes of the included studies.
Study | Measuring tool | Herbal compress | Control | |||
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Before† | After† | Description | Before† | After† | ||
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Artkarn, 2006 [ |
Average VAS of pain when performing activities (score range 0–10) | 5.5 ± 1.2 | 2.6 ± 1.2 | Oral diclofenac | 4.3 ± 2.0 | 2.8 ± 2.6 |
Chiranthanut et al., |
Total VAS of pain over the last two days when performing 5 daily activities (score range 0–500) | 260.2 ± 68.9 | 61.6 ± 49.4 | Oral ibuprofen | 253.8 ± 63.4 | 69.2 ± 71.0 |
Lekutai et al., |
Average VAS of pain after wakeup, noon, 6 pm, and before going to bed (score range 0–10) | 5.9 ± 2.0 | 2.8 ± 0.3 | Hot compress |
5.4 ± 1.4 |
2.5 ± 0.3 |
Phromjuang, |
VAS of pain when performing activities (score range 0–10) | 4.3 ± 1.8 | 1.7 ± 1.0 | Usual care | 3.9 ± 2.0 | 2.0 ± 1.1 |
Sukonthasarn, |
Average VAS of pain when performing 15 daily activities (0–10) | 4.2 ± 1.0 | 2.8 ± 0.9 | Knee exercise |
4.1 ± 1.3 |
2.7 ± 1.2 |
Suwan, |
Total VAS of pain when performing 13 daily activities (score range 0–130) | 88.0 ± 24.0 | 36.6 ± 19.6 | Hot compress | 88.0 ± 26.2 | 53.2 ± 27.6 |
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Artkarn, 2006 [ |
Average VAS of difficulty in performing selected activities (score range, NR) | 12.2 ± 16.5‡ | Oral diclofenac | 12.5 ± 14.7‡ | ||
Chiranthanut et al., |
Lequesne's functional index (score range 0–24) | 13.2 ± 4.1 | 6.5 ± 3.7 | Oral ibuprofen | 12.7 ± 2.4 | 7.8 ± 3.3 |
Lekutai et al., |
Average VAS of difficulty in performing daily activities, during climbing up and down stairs, and during night time (score range 0–10) | 6.0 ± 2.1 | 3.1 ± 2.6 | Hot compress |
6.1 ± 1.4 |
3.0 ± 1.9 |
Sukonthasarn, |
Average VAS of difficulty in performing 20 daily activities | 3.9 ± 2.7 | 3.2 ± 2.7 | Knee exercise |
4.1 ± 2.5 |
2.8 ± 2.4 |
Suwan, |
Total VAS of difficulty in performing 22 daily activities (score range 0–220) | 144.0 ± 35.9 | 76.2 ± 30.1 | Hot compress | 133.5 ± 30.3 | 86.4 ± 38.6 |
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Artkarn, 2006 [ |
Average VAS of pain when performing activities (score range 0–10) | 6.1 ± 1.3 | 3.48 ± 1.1 | Oral diclofenac | 5.0 ± 1.9 | 2.2 ± 1.8 |
Puengsuwan et al., |
VAS of pain (score range 0–10) | 3.4 ± 2.4 | 2.4 ± 2.4 | Hot compress | 3.7 ± 2.5 | 2.4 ± 2.1 |
Sathianrat et al., |
VAS of pain (score range 0–10) | 5.7 ± 1.5 | 1.7 ± 1.3 | Hot compress |
5.0 ± 1.6 |
2.1 ± 2.1 |
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Iampornchai et al., |
Pain numeric rating scale (score range 0–10) | 5 (5-6) |
4 (3–4.2) |
Usual care | 5 (5-6) |
5 (3.8–5.2) |
Intarasukum and Kerdcharoen, |
VAS of pain in early phase, that is, cervix dilated for 4-5 cm (score range 0–10) | 6.2 | 4.5 | Usual care | 7.8 | 7.5 |
Intarasukum and Kerdcharoen, |
VAS of pain in late phase, that is, cervix dilated for 8-9 cm (score range 0–10) | 6.2 | 6.4 | Usual care | 7.8 | 9.6 |
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Listisit and Pakdeechot, |
Duration from delivery to milk secretion >1-2 drops, minutes | 1,684.8 ± 540.7‡ | Routine increasing milk production program | 2,003.3 ± 575.3‡ | ||
Pakdeechot et al., |
Duration from delivery to milk secretion >1-2 drops, minutes | 1,309.3 ± 535.3‡ | Routine increasing milk production program | 1,837.6 ± 901.1‡ | ||
Trainapakul et al., |
Milk ejection score (score range 0–4) | 51.4& | 54.6& | Breast massage followed by mini hot bag compress | 42.1& | 39.0& |
Variations in measuring level of pain and reporting scale were observed among these studies. Most studies [
Two studies [
The overall effects of herbal compress.
Comparator | Study | Mean difference |
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Heterogeneity test |
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df |
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NSAIDs |
Chiranthanut et al., 2014 [ |
0.222 [−0.400, 0.844] | |||||
NSAIDs | Phromjuang, 2010 [ |
0.483 [−0.146, 1.112] | |||||
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Knee exercise |
Lekutai et al., 2008 [ |
1.430 [0.768–2.092] |
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Knee exercise | Sukonthasarn, 2004 [ |
−0.100 [−0.720, 0.520] | |||||
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Hot compress |
Lekutai et al., 2008 [ |
0.207 [−0.301, 0.714] | |||||
Hot compress | Suwan, 2000 [ |
0.350 [−0.371, 1.072] | |||||
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NSAIDs |
Chiranthanut et al., 2014 [ |
0.544 [−0.088, 1.176] | |||||
Knee exercise |
Lekutai et al., 2008 [ |
0.230 [−0.805, 1.265] |
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Knee exercise | Sukonthasarn, 2004 [ |
−0.450 [−1.893, 0.993] | |||||
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Hot compress | Lekutai, 2008 [ |
−0.059 [−0.565, 0.447] | |||||
Hot compress | Suwan, 2000 [ |
0.610 [−0.123, 1.343] | |||||
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NSAIDs |
Sathianrat et al., 2003 [ |
0.300 [−0.539, 1.139] |
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Hot compress |
Puengsuwan et al., 2009 [ |
−0.280 [−1.613, 1.053] | |||||
Hot compress |
Sathianrat et al., 2003 [ |
1.130 [0.300, 1.960] | |||||
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Routine program |
Listisit and Pakdeechot, 2009 [ |
−318.500 [−501.015, −35.985] | |||||
Routine program |
Pakdeechot et al., 2010 [ |
−528.240 [−903.301, −153.179] | |||||
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For those that evaluated difficulties in performing activities in patients with knee OA, four studies [
The VAS of pain level with the same rating scale, 0 to 10, was used in all studies on muscle pain [
The overall effect of herbal compress on labor pain reduction could not be drawn because the two studies on this indication were not comparable. One study [
Two studies evaluated the effects of herbal compress by measuring the duration from delivery to milk secretion in postcesarean mothers [
Safety outcomes were reported in only three studies [
This systematic review and meta-analysis provided a comprehensive synopsis of the effects of herbal compress in various indications. Despite a lack of statistical significance, current evidence demonstrates a strong trend of better clinical benefits of Thai herbal compress compared with conventional therapies, such as NSAIDs, knee exercise, and hot compress in alleviating pain and improving difficulty to perform activities in patients with knee OA and muscle pain. However, Thai herbal compress was shown to be more effective than routine program in inducing milk production among postpartum mothers.
There are a number of similarities and differences of this systematic review and the previous Cochrane review. First, both reviews found limited number of studies to be included. Pooling results could not be determined in the Cochrane review [
Results from a recent systematic review [
Similar to the effects on osteoarthritis, heat was shown to be effective in treating patients with muscle pain [
In the present review, the pooled effect of herbal compress on labor pain reduction could not be drawn. However, findings from the individual studies indicated that herbal compress significantly reduced labor pain compared with usual care. Heat may be the main mechanism of action of herbal compress in improving labor pain as indicated in other studies [
It appears that the effects of Thai herbal compress were mainly associated with heat and, in some extents, herb component. Effect of heat from applying herbal compress may explain why Thai herbal compress has exerted clinical benefits in two distinct indications, which were pain reduction and induce lactation. To identify additional effects from herbal component in both indications, a direct comparison between Thai herbal compress and hot compress is strongly advocated. However, it should be noted that the herbal compress recipes used among some of the included studies were slightly different and the quality of herbal compress varied as few were produced using good manufacturing practice (GMP) whilst some others were prepared in community with traditional method. A study on quality of herbal compresses produced in the community of eight provinces in the Northern of Thailand showed that the components of volatile oil in each product were different and contaminated with microbial organisms (7 out of 16, 43.8%) and cadmium (1 out of 16, 6.2%) [
Although no adverse events associated with herbal compress were reported in this review, it does not preclude the concern of safety issue over the use of this product. This is because there was a lack of attempt to investigate adverse effects of herbal compress among the majority of included studies as 10 out of 13 studies did not indicate that adverse events were systematically measured and reported. Findings from a report of adverse events of herbal compress revealed that 5 out of 600 patients were shown to have adverse reactions associated with herbal compress, that is, rash and urticaria [
Current evidence suggested that Thai herbal compress might be more efficacious than standard/recommended therapy in patients with osteoarthritis and muscle pain. It could be considered as an alternative option for improving symptoms of these conditions especially when adverse effects from other treatments such as NSAIDs are an issue of concern. Thai herbal compress may also be used as a treatment of choice to induce lactation as the evidence suggested that herbal compress was more effective than usual care in promoting milk production in postpartum mothers who had no milk secretion. However, to consider Thai herbal compress to be incorporated into a practice guideline for each indication, we suggest that a consensus of standard recipe and practice need to be established and evaluated by further well-designed RCTs.
Teerapon Dhippayom (TD), Chuenjid Kongkaew (CK), Nathorn Chaiyakunapruk (NC), Piyameth Dilokthornsakul (PD), Rosarin Sruamsiri (RS), and Surasak Saokaew (SS) declare no financial relationships with any organizations that might have an interest in the submitted work in the previous three years or other relationships or activities that could appear to have influenced the submitted work. Anchalee Chuthaputti (AC) is currently a government official under the Department for Development of Thai Traditional and Alternative Medicine, Ministry of Public Health, Nonthaburi, Thailand.
This systematic review received financial support from the Thai Traditional Medical Knowledge Fund.