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Effectiveness of Rosmarinus officinalis essential oil as antihypotensive
agent in primary hypotensive patients and its influence
on health-related quality of life
L.F. Fernández
a
, O.M. Palomino
a
, G. Frutos
b,
n
a
Department of Pharmacology, Faculty of Pharmacy, Universidad Complutense de Madrid, Avda. Complutense s/n, 28040 Madrid, Spain
b
Department of Statistics and Operational Research, Faculty of Pharmacy, Universidad Complutense de Madrid, Avda. Complutense s/n, 28040 Madrid, Spain
article info
Article history:
Received 1 July 2013
Received in revised form
31 October 2013
Accepted 2 November 2013
Available online 20 November 2013
Keywords:
Rosmarinus officinalis
Essential oil
Hypotension
HRQOL
Statistical evaluation
abstract
Ethnopharmacological relevance: To study Rosmarinus officinalis (Rosemary) essential oil effect on
primary hypotension and its influence on both physical and psychological aspects responsible for
health-related quality of life (HRQOL) of patients.
Methodology: Thirty-two patients with diagnosed hypotension were recruited between March 2007 and
September 2008 for a prospective study for 72 weeks in a Spanish pharmacy. Clinical evaluation was
carried out through the control of systolic and diastolic blood pressure levels (SBP and DBP, respectively)
according to the International Standards from the American Society of Hypertension. HRQOL data were
recorded within the SF-36 Health Survey
s
questionnaire throughout the study. Statistical methods were
used as the essential tools to evaluate the effectiveness of Rosemary essential oil and to assess the
relationship between the two quantitative variables (SBP and DBP) and scores from physical and mental
summary components (PSC and MSC) obtained from the SF-36 Health Survey.
Results: Both blood pressure variables of SBP and DBP reflect the clinically significant antihypotensive
effect of Rosemary essential oil that was maintained throughout the treatment period. After validation of
the use of the questionnaire (Cronbach's alpha coefficient40.82), statistically significant differences
have been found between pre-treatment and post-treatment values of PSC and MSC, which indicate an
improvement in these parameters that is directly related to the variation in blood pressure values.
Conclusions: The increase achieved in blood pressure values after administration of Rosemary essential
oil is clinically significant. The results obtained from this prospective clinical trial prove the effectiveness
of statistical methodology as a new approach to explain the antihypotensive effect of rosemary essential
oil and its relationship with the improvement in patients' quality of life.
&2013 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Low levels in blood pressure are not considered a major disease
as they do not imply a risk for patient's life. Nonetheless, people
suffering from hypotension, mainly chronic or constitutive hypo-
tension, suffer from physical and psychological symptoms such as
temporary fatigue and sensation of weakness that usually affect
their daily life and health-related quality of life (Mann, 1992;
Pilgrim et al., 1992;Tonkin, 2004). Several herbal remedies have
been traditionally used to treat hypotension, such as those plants
rich in purine bases (i.e. caffeine, theobromine) like coffee (Coffea
arabica), tea (Camellia sinensis) or cola (Cola nitida or Cola acumi-
nata), or different essential oil-containing plants.
Rosemary (Rosmarinus officinalis L.) is a spontaneous shrub
growing in the Mediterranean area. It belongs to the Lamiaceae
family and has been used because of its medicinal properties since
earliest times. First references cited the traditional use of rosemary
oil as tonic for asthenia relief, for blood circulation and nervous
system, for chronic weakness, asthenia and peripheral vascular
disorders. In the middle ages, Rosemary oil was distilled for
medical purposes and was used as a tonic, stimulant, and carmi-
native for dyspepsia, headache and nervous tension, as described
in the Dioscorides Materia Medica in 1555 (Laguna, 1968;Puerto,
2005); as bath additive, it has been traditionally used in conditions
of exhaustion and for stimulation of circulation (Morton, 1977).
In Indian Materia Medica Nadkarni K.M. (1999), described it as
Contents lists available at ScienceDirect
journal homepage: www.elsevier.com/locate/jep
Journal of Ethnopharmacology
0378-8741/$ - see front matter &2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jep.2013.11.006
Abbreviations: BMI, Body Mass Index; HRQOL, Health Related Quality of Life; SBP,
Systolic Blood Pressure; DBP, Diastolic Blood Pressure; PSC, Physical Summary
Component; MSC, Mental Summary Component; SF-36, 36-item Short Form Health
Survey Questionnaire; FDA, Food and Drug Administration; WHO, World Health
Organization; AST, Aspartate Aminotransferase; CREA, Creatinine; ANOM, Analysis
of means; PF, Physical Function; PR, Physical Role; CP, Corporal Pain; GH, General
Health; V, Vitality; SF, Social Function; ER, Emotional Role; MH, Mental Health
n
Corresponding author. Tel.: þ34 913941722; fax: þ34 913941726.
E-mail address: gloriafr@ucm.es (G. Frutos).
Journal of Ethnopharmacology 151 (2014) 509–516
having carminative and stimulant actions. The British Herbal
Pharmacopoeia (1983) lists the specific indications of “Depressive
states with general debility and indications of cardio-vascular
weakness”for Rosemary oil. Nowadays, rosemary essential oil is
used as brain and nerve tonic, and as a remedy for mental fatigue
(Laybourne et al., 2003). Several other activities are reported in the
literature: antiseptic, diuretic, antidepressant and anstispasmodic;
it is also used to treat cold, influenza and rheumatic pain
(Chandler, 1985;Erenmemisoglu et al., 1997) and has proved to
enhance the performance for overall quality of memory and
secondary memory factors (Moss et al., 2003).
Rosemary leaves contain no less than 12 ml/kg of essential oil
whose composition may vary according to the plant chemotype or
other factors such as climatic conditions, geographic origin or time
of collection (Angioni et al., 2004;Lakusićet al., 2013;Palomino
et al., 2010;Varela et al., 2009). The structure of the carbon
skeleton of the main constituents of the essential oil indicates the
existence of three biogenetic types: the eucalyptol type (Italy,
Morocco and Tunisia), the camphor-borneol type (Spain) and the
α-pinene–verbenone type (France, Corsica). 1,8-Cineol (20–50%), α-
pinene (15–26%), camphor (10–25%), bornyl acetate (1–5%), bor-
neol (1–6%), camphene (5–10%) and α-terpineol (12–24%) are the
main components. Lower quantities of limonene, β-pinene,
β-caryophyllene and myrcene can also be found (ESCOP, 1997).
The International Standard Limits on Oil of Rosemary states the
exact oil composition for quality purposes (ISO, 2000).
The inclusion of the Health Related Quality of Life (HRQOL)
through different questionnaires is used with the aim of assessing
people's health status related to the treatment received. The 36-
item Short Form Health Survey (SF-36) questionnaire is the most
commonly used and has been translated into many languages and
its use as a tool for clinical validation is based on the position held
by health administrations such as the Food and Drugs Adminis-
tration (FDA) in the United States of America and the European
Medicines Agency (EMA) (Ware et al., 1998;Madrigal de Torres
and Velandrino Nicolás, 2007). This study was carried out accord-
ing to the legal Spanish framework for pharmaceutical care as
well as the recommended guidelines on structure and working
methodology.
The aim of this work is to study Rosmarinus officinalis essential
oil effect on primary hypotension and so, its positive effect on the
HRQOL of patients. Statistical methods were used as an important
tool to evaluate the effectiveness of Rosemary essential oil and to
know the relationship between the two types of variables in the
study, quantitative variables (SBP and DBP), and scores from
physical and mental summary measures obtained from the SF-36
Health Survey.
2. Material and methods
2.1. Patients
Patients were recruited between March 2007 and September
2008 and were randomly chosen among the customers from one
Spanish pharmacy. Inclusion criteria were as follows: patients with
diagnosed primary hypotension (by a general practitioner or
cardiologist), according to the corresponding group of sex or age
(Master et al., 1950) no matter the sex, educational degree,
physical capacity; age superior to 18 years. Exclusion criteria
were the existence of any hypertensive treatment or the use of
other drugs that could induce hypertension as a secondary
pharmacodynamic effect; alcohol or drugs abuse; mental imbal-
ance; being involved in other clinical trial; renal or hepatic
insufficiency; pregnancy; allergy to Rosemary essential oil or any
of its components.
2.2. Treatment regime
The Rosemary essential oil posology of 1 ml every 8 h was
stated according the German Commission E monograph on
Rosemary essential oil, together with the safety profile derived
from its clinical and traditional use (Blumenthal et al., 2000).
Rosemary essential oil samples were purchased by Metapharma-
ceutical (Barcelona, Spain). The main components were 1,8-cineol
(47.6%), camphor (13.8%) and α-pinene (11.7%), corresponding to a
Morocco-type Rosemary oil. Minor components were of β-pinene,
camphene, borneol, limonene, α-terpineol, p-cymene, β-myrcene,
bornyl acetate and verbenone.
Rosemary essential oil and placebo were provided in 30 ml
volume bottles made of topaz coloured glass with a dropper.
Patients have the corresponding dose by dropping 1 ml on a sugar
lump to avoid unpleasant flavour.
2.3. Experimental design
It is a prospective study based on the therapeutic interest and
safety of Rosemary essential oil, according to the International
Guidelines for Methodologies on Research and Evaluation of
Traditional Medicine Guidelines (WHO, 2000) and the Spanish
framework for Pharmaceutical care and working methodology
(Spanish Ministry of Health, 1980,1999,2002,2006,2008).
The study was structured within three stages: the first one was
a pre-treatment period that lasted twelve weeks; patients received
1 ml placebo (olive oil, 0.41with similar organoleptic character-
istics than Rosemary essential oil) every 8 h and attended 10 visits
(V1–V10). The second stage (treatment period) lasted 44 weeks
(13–60); during this period, patients received 1 ml rosemary
essential oil every 8 h and attended 24 visits (V11–V34). During
the third stage (post-treatment period), that lasted another 12
weeks, patients received 1 ml placebo every 8 h and attended
other 6 visits (V35–V40).
2.4. Clinical evaluation
The clinical part of the study was conducted in a Spanish
pharmacy, that is the usual environment in which patient–phar-
macist relationship takes place by using Pharmaceutical Care's
interview techniques and therefore, such skills, together with all
kind of technical resources, must be properly known and applied
by pharmacists to improve their patients' quality of life (Basheti
et al., 2005;Mangiapane et al., 2005).
Clinical evaluation was carried out through the control of blood
pressure levels (systolic and diastolic) measured by the pharma-
cist, according to International Standards from the American
Society of Hypertension, and comparison with population trends
using an arenoid sphyngomanometer (Corysan, Barcelona, Spain).
Arterial pressure measures were always recorded using the right
arm of the patient during the morning sessions of Pharmaceutical
care.
In order to obtain reproducible and comparable results, the
procedure for the measurement of blood pressure was the follow-
ing: patient must be sitting on a chair and rest for 5 min before the
first measurement. It is not permitted to drink alcoholic or
stimulating drinks during the 30 min prior to the measurement.
The right arm is always chosen for every patient and blood
pressure is measured three times with a 2 min period between
two measurements. The average value for the last two measure-
ments is taken as the final value.
Age interval was classified according to Master et al. (1950).
HRQOL data were recorded within the SF-36 Health Survey
s
questionnaire (Alonso et al., 1995) throughout the study, the
L.F. Fernández et al. / Journal of Ethnopharmacology 151 (2014) 509–516510
obtained values being compared to reference values (Alonso
Caballero, 2000;Alonso et al., 1998).
Controls took place during the follow-up visits after two weeks.
Prior to initiating the study, the patient form was filled by
answering several questions and then informed consent was
signed and blood pressure was measured. In order to obtain
reproducible and comparable results, the procedure for the mea-
surement of blood pressure was the following: patient must be
sitting on a chair and rest for 5 min before the first measurement.
It is not permitted to drink alcoholic or stimulating drinks during
the 30 min prior to the measurement. The right arm is always
chosen for every patient and blood pressure is measured three
times with a 2 min period between two measurements. The
average value for the last two measurements is taken as the final
value. Patients received the information needed to follow the
study as well as the product to be taken. During the following 72
weeks period, patients attended several visits each two weeks;
during each visit, blood pressure was measured, and the observed
adverse events were noted. HRQOL values were also taken at the
beginning and the end of pre-treatment period, at the middle and
the end of the treatment and at the end of the post-treatment
period (V2, V10, V22, V34 and V40). All data for each patient were
recorded in the Patient's Data Sheet. As a measure of safety on the
adverse effects of treatment, aspartate aminotransferase (AST) and
creatinine (CREA) values were controlled during the same visits as
HRQOL as data from literature indicate that those parameters may
be affected (Agraz and Fernández 1999;Blumenthal et al., 2000).
2.5. Statistical methodology for Blood pressure variables
The experimental data matrices for SBP and DBP variables were
obtained according to a randomized block design where rows
(patients) are the blocks and columns (weeks) are the treatments.
The blocks are formed with paired samples or repeated measures.
The statistical software IBM SPSS Statistics 19.0
s
was used to
describe, numerical and graphically, the variables included in the
study at different intervals: pre-treatment, treatment and post-
treatment. The comparison of two samples taken at different
weeks is held by the Student t-test for paired samples, provided
that the parametric conditions are fulfilled. If there's non com-
pliance, the rank contrast with Wilcoxon sign is used.
Comparisons of more than two samples are performed using
the non parametric hypotheses test of Friedman, with a confidence
level of 95%
H
0
:SBP
1
¼SBP
2
¼⋯¼SBP
k
1=2
H
1
:not all SBP
i
values are equal
where, SBP
k
is mean blood pressure for the k-th week, and kis
the number of samples being compared. Analogously for mean
values of DBP
Likewise, pairwise comparisons are made by distance network
graph. This graph shows the numerical results for all pairwise
comparisons, and distances between network nodes correspond to
differences between samples. This graph is a representation of the
comparison in which the distances between network nodes
correspond to differences between samples. Grey lines corres-
pond to statistically significant differences, whereas the black lines
correspond to non-significant differences.
ANOM analysis (Analysis of Means) in software Statgraphics
Centurion XVI is used. The ANOM procedure allows to determine
which set of groups, if any, has significantly different mean of the
overall average of all groups combined. Instead of searching for the
lower and upper confidence interval, it is as to studied which of
the group means are not contained in a range consisting of a lower
decision line and a top of the line decision obtained by the
expression:
UDL ¼
X
þh
c;n
j
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
S
2
p
ðc1Þ
n
sand LDL ¼
X
h
c;n
j
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
S
2
p
ðc1Þ
n
s
where
cis the number of groups in the study; n
j
is the sample size for
the group j(j¼1,…,c)
n¼total lumber of observations,
X
¼ðX
1
þX
2
þ⋯þX
c
Þ=c¼
global media or grand mean;S
2
P
¼ðS
2
1
þS
2
2
⋯þS
2
c
=cÞ¼weighed
variance and h
c;n
j
¼critical value of statistical hof Nelson with c
groups and n
j
observations
2.6. Statistical methodology for scores from the SF-36 health survey
The Spanish official version of the SF-36 questionnaire was
used to assess the HRQOL scores. The questionnaire measures
eight major health concepts included in the Medical Outcomes
Study and other widely used health survey; each one includes a
different number of items (expressed between brackets) with a
total of 36 items registered for each patient and visit: physical
function (10), social function (2), physical role (4), emotional role
(3), mental health (5), vitality (4), corporal ache—intensity—effect
on daily work (2), general health (6). The options in each answer
create scales that evaluate intensity or frequency. The question-
naire was applied to patients five times over a period of 18 months
(V2, V10, V22, V34 and V40), thus obtaining different ratings for
the same parameter throughout the study.
After the validation process, the steps to obtain interpretable
and comparable results were: (a) data extraction: getting pre-
coded values directly from the patient's responses to the different
items of the questionnaire;(b) decoding data: decoding data from
pre-coded values, (c) parameter generation: grouping the decod-
ing data, according to established rules, to obtain real raw scores
and (d) reparametrization: transformation of real raw scores on
the transformed scale scores according to established rules.
The transformed scale scores are then aggregated and standar-
dized using the mean and standard deviation values of Spanish
population. Finally, the Physical Summary Component (PSC) and
the Mental Summary Component (MSC) are obtained (Alonso
et al., 1998).
Similar analysis for blood pressure variables were applied to
PSC and MSC.
3. Results and discussion
A clinical study has been designed and conducted to assess the
use of Rosemary essential oil on primary hypotension. The SF-36
Health Survey
s
questionnaire was used to assess the patients'
health-related quality of life due to its reliability and parametric
strength, together with its easy application that allows minimising
those errors derived from the instrument use.
The anthropometric distribution of the sample (sample
size¼30) is shown in Table 1. All the patients were Caucasian
(C); all women except 4 were fertile. Mean age was 44.53 years
(44.3 years for women and 43.5 years for men), with no statisti-
cally significant difference between groups (p¼0.81). Mean
weight was 73.84 kg (70.8 Kg for women and 78.4 Kg for men),
with a statistically significant difference between groups (p¼
0.047), while mean height was 166.26 cm and mean Body Mass
Index (NMI) was 26.77.
Arterial pressure values were then measured as described in
Materials and Methods Section.
All the patients included in the study fulfilled the protocol with
respect to visits and questionnaire answers. Although Rosemary
oil preparations can be considered safe and devoid of toxic effects
L.F. Fernández et al. / Journal of Ethnopharmacology 151 (2014) 509–516 511
if taken in recommended doses, its use is not recommended
during pregnancy due to the toxic effects of some components
(McGuffin et al., 1997) and is contraindicated in cases of obstruc-
tion of the bile duct, cholangitis, liver disease, gallstones and any
other biliary disorders that require medical supervision and
advice. In our study, the following adverse events were recorded:
acute gastroenteritis (n¼17), acute respiratory tract infections
(n¼16), flu(m¼8), conjunctivitis (n¼3), herpes (n¼3), mycosis
(n¼1) and lower back pain (n¼3). None of them were considered
as related to treatment.
3.1. Statistical analysis of blood pressure variables
3.1.1. Individual evolution of SBP and DBP
An individual study was performed for each patient for both,
SBD and DBP variables. Each column in Table 2 includes two
values, the first one corresponding SBD and the second one, DBP.
This table shows the average in the different periods of the assay
as well as the percentage difference between the three periods
(Phase 1–Phase 2; Phase 2–Phase 3; Phase 1–Phase 3, respec-
tively). Maximum increase of 21.76% was found between pre-
treatment and treatment periods, for patient 15; 15.30% increase
between post-treatment and treatment also for patient 15; and
3.7% difference between pre-treatment and post-treatment for
patient 2. The number of visits corresponding to the first max-
imum peak for each patient is also included in the table, these data
providing information on the individual period of induction.
When analysing the blood pressure evolution for each patient,
an increase in SBP values is observed during the first stage which
is maintained during treatment with Rosemary essential oil.
Nonetheless, after treatment period, patients experienced a rapid
decrease in SBP values, up to hypotensive range again. DBP values
behaviour is similar, although individual values show a wider
variability than SBP values (patient 8 during several visits and
patient 28 on week 20).
In summary, both blood pressure variables of SBP and DBP
reflect the antihypotensive effect of Rosemary essential oil
although with a different profile: induction period exists for both
variables with a slower increase and lower mean values for DBP;
once the maximum effect is achieved, blood pressure values are
maintained although more irregularly for DBP values; post-
treatment values are similar to those obtained for the pre-
treatment period with a similar behaviour for both variables and
reversible antihypotensive effect after ending Rosemary essential
oil administration.
The observed increase in Blood pressure levels was not accom-
panied by a statistically significant increase in heart rate.
These results agree with previous pharmacological studies demon-
strating that rosemary oil and isolated 1,8-cineole and bornyl
acetate depress contractility of the cardiac muscle and inhibit
acetylcholine-induced contractions of guinea pig ileum (Hof and
Ammon, 1989). So the observed antihypotensive effect of Rosem-
ary oil seems to be mainly at vascular level.
A recent study shows that rosemary oil stimulated blood
pressure levels and breathing rates after inhalation (Sayorwan
et al., 2013); at the same time, they were more attentive and alert,
probably due to stimulatory effects on the autonomic nervous
system by 1,8-cineole and α-pinene. Both of them have stimulating
effects on the nervous system through sympathetic activity (Albert
and Steven, 1996;Hongratanaworakit, 2004,2009). 1,8-cineol
also increased respiratory rate (Heuberger et al., 2008), while
1,8-cineole and α-pinene moderately inhibited acetylcholinester-
ase (Orhan et al., 2008), an acetylcholine degradation enzyme
which results in prolonged muscle contraction.
3.1.2. Sample evolution of SBP and DBP
The overall evolution of the means of blood pressure was
analysed by the following three statistical procedures: (a) graphi-
cal evolution of means, (b) analysis of means (ANOM) and (c) non-
parametric tests.
Evolution graphical means.Fig. 1 shows the evolution of the SBP
and DBP means for each week throughout the study. A first phase
occurs with a small slope that results in a very similar set of values
that corresponds to the pre-treatment period; a baseline value is
then identified from which the antihypotensive effect of Rosemary
essential oil is calculated. In a second phase, after a brief period of
high slope in which the values of systolic blood pressure increase
very significantly, there is a "plateau" in which the blood pressure
values are kept in a band within a small range, indicating that a
balance is established between the drug dosage and its metabo-
lization. Finally, a third phase occurs with a sharp decline in
values, corresponding to the period in which the drug levels
decrease due to the elimination of the drug; the tendency is
stabilized at levels similar to those in the pre-treatment period.
The recorded arterial pressure values allow one to conclude
that during the pre-treatment period, no placebo effect was
detected (no mean value statistically different from the global
mean value). During the treatment period, arterial pressure
showed a two-phase evolution: the first one shows an increasing
tendency with a high slope whcih means a rapid antihypotensive
effect during the first week; the second phase is characterised by
the maintenance of the antihypotensive effect without statistically
significant differences between the weeks within this period. The
plateau value reached during this period corresponds to SBP and
DBP values higher than those recorded at the initial phase, with
a statistically significant difference. During post-treatment phase,
arterial pressure shows a decreasing exponential tendency;
the obtained data allow the detection of a statistically significant
Table 1
Anthropometric data for patients included in the study.
Patient Sex Age
(years)
Race Weight
(kg)
Height
(cm)
BMI State fertile
(women only)
1 Woman 45.5 C 65 164 24.2 Yes
2 Woman 52 C 81 160 31.6 No
3 Man 21.5 C 76 171 26.0 –
4 Man 53 C 76 168 26.9 –
5 Woman 47 C 55 156 22.6 Yes
6 Man 45 C 78 174 25.8 –
7 Woman 45.5 C 68.9 157 28.0 Yes
8 Man 61.5 C 87 190 24.1 –
9 Woman 46.5 C 61.9 155 25.8 Yes
10 Woman 51 C 84.4 170 29.2 No
11 Man 43 C 89 180 27.5 –
12 Woman 46.5 C 62.7 164 23.3 Yes
13 Woman 42 C 64.9 152 28.1 Yes
14 Man 36.5 C 83.8 168 29.7 –
15 Woman 41 C 84.2 156 34.6 Yes
16 Woman 37.5 C 62 166 22.5 Yes
17 Man 32 C 65 168 23.0 –
18 Woman 37.5 C 69.5 168 24.6 Yes
19 Man 56.5 C 69 171 23.6 –
20 Woman 27.5 C 72.4 165 26.6 Yes
21 Man 31.5 C 87 193 23.4 –
22 Woman 32 C 60.1 160 23.5 Yes
23 Woman 46.5 C 78.1 156 32.1 Yes
24 Woman 47 C 88.9 161 34.3 No
25 Woman 52.5 C 86.6 158 34.7 No
26 Man 48 C 78.7 184 23.2 –
27 Woman 53.5 C 59.1 156 24.3 No
28 Woman 46.5 C 69.3 164 25.8 Yes
29 Man 47.5 C 64.4 158 25.8
30 Man 46 C 87.4 175 28.5
L.F. Fernández et al. / Journal of Ethnopharmacology 151 (2014) 509–516512
difference between the first two weeks of this period and the
other weeks until the end of the study.
Analysis of means (ANOM). The ANOM procedure plots the
sample means on a chart designed to determine which means
are significantly different than the grand mean of all groups
combined. If a point falls outside the boundaries of decision can
conclude that there is a statistically significant difference between
groups. In Fig. 2, the ANOM analysis is shown for a set of values of
the variable SBP, particularly relevant in the study. This figure
shows the difference between the values obtained in the periods
before and after treatment compared to the values obtained in the
treatment period. According to the mean graph ANOM, the points
V2, V10 and V40 corresponding to the beginning and the end of
the study (weeks 1, 13 and 72, repectively) are statistically equal to
each other. There is also no statistically significant difference
between the mean values obtained within V22 and V34 (weeks
36 and 60, repectively). Moreover, the difference between these
two groups is so great that both are out of the zone of confidence
of the grand mean of the study.
Non-parametric tests. The inferential analysis results from Fried-
man nonparametric test allow us to accept the alternative
hypotheses (asymptotic significance less than 0.0001)
Table 2
Individual statistical study for blood pressure variables.
Patient Mean phase 1 Mean phase 2 Mean phase 3 Phase 1–2 Phase 2–3 Phase 1–3
SBP DBP SBP DBP SBP DBP SBP (%)DBP (%) SBP (%) DBP (%) SBP (%) DBP (%)
1 98.17 59.99 108.46 61.16 98.31 59.66 10.49 1.95 9.36 2.45 0.15 0.54
2 99.77 56.79 115.52 61.49 103.53 58.32 15.79 8.27 10.38 5.15 3.76 2.69
3 92.60 51.39 111.52 56.64 93.66 51.32 20.43 10.21 16.02 9.38 1.15 0.13
4 99.19 57.99 108.82 66.06 99.64 57.99 9.71 13.92 8.44 12.21 0.46 0.00
5 95.18 60.39 109.37 67.73 96.31 59.99 14.90 12.17 11.94 11.44 1.18 0.66
6 96.99 53.79 106.40 62.57 97.99 53.99 9.70 16.32 7.90 13.71 1.03 0.37
7 94.79 50.39 110.09 53.99 95.62 50.99 16.14 7.14 13.14 5.56 0.87 1.18
8 93.19 53.59 101.81 57.57 94.99 54.33 9.25 7.43 6.70 5.64 1.93 1.37
9 93.99 54.99 109.90 58.97 93.99 55.66 16.93 7.23 14.48 5.61 0.00 1.22
10 97.38 59.19 111.19 64.41 96.32 58.98 14.18 8.81 13.37 8.42 1.09 0.36
11 98.80 54.69 107.72 60.57 98.99 56.32 9.04 10.75 8.11 7.03 0.20 2.97
12 98.98 59.39 113.96 62.48 98.98 55.66 15.13 5.21 13.14 10.91 0.0 0 6.27
13 94.19 59.19 110.28 64.31 95.32 58.99 17.08 8.65 13.56 8.27 1.20 0.34
14 99.99 56.39 110.32 61.99 100.32 56.33 10.33 9.93 9.07 9.14 0.33 0.12%
15 92.99 56.79 113.23 63.07 95.93 57.65 21.76 11.06 15.28 8.60 3.16 1.51
16 99.39 54.59 113.60 62.06 102.22 55.63 14.30 13.68 10.01 10.37 2.85 1.89
17 100.39 54.59 112.65 62.98 101.31 55.31 12.21 15.37 10.07 12.18 0.91 1.32
18 93.39 56.39 105.16 64.64 94.65 57.65 12.60 14.62 10.00 10.82 1.35 2.23%
19 105.59 55.19 115.16 63.48 105.33 56.62 9.06 15.02 8.53 10.80 0.25 2.60
20 96.99 52.58 114.04 61.16 97.33 52.25 17.59 16.32 14.66 14.56 0.35 0.61
21 99.59 57.78 113.80 66.99 100.98 61.23 14.27 15.93 11.27 8.60 1.39 5.96
22 92.60 51.78 105.80 57.40 93.66 51.65 14.26 10.85 11.48 10.02 1.15 0.26
23 99.18 54.99 113.45 62.32 99.64 54.66 14.39 13.32 12.17 12.29 0.46 0.60
24 97.39 55.99 113.52 64.41 98.92 56.31 16.56 15.05 12.87 12.58 1.57 0.57
25 98.38 58.79 114.03 66.14 98.31 59.29 15.91 12.51 13.79 10.36 0.07 0.85
26 103.79 56.59 113.73 66.64 104.32 56.65 9.58 17.76 8.28 15.00 0.50 0.10
27 98.39 56.99 111.87 66.63 96.99 56.98 13.70 16.91 13.30 14.48 1.42 0.02
28 92.79 56.39 105.11 64.40 94.65 56.66 13.27 14.20 9.96 12.03 2.00 0.47
29 101.99 57.99 114.24 65.82 104.32 58.65 12.01 13.49 8.68 10.89 2.28 1.13
30 101.00 54.59 115.82 65.15 102.59 54.66 14.68 19.34 11.42 16.11 1.58 0.12
Mean sample values 97.57 56.01 111.02 62.77 98.50 56.35 0.14 0.12 0.11 0.10 0.01 0.01
Fig. 1. Graphical evolution of the SBD and DBP mean values and their corresponding 95% confidence intervals, for the three periods of the study.
L.F. Fernández et al. / Journal of Ethnopharmacology 151 (2014) 509–516 513
Pairwise comparisons are presented in the graph of network
distances shown in Fig. 3. In this graph, the distance between
network nodes correspond to differences between samples. Grey
lines correspond to statistically significant differences, while black
lines correspond to no significant differences. The inferential
analysis shows the significant differences between the mean
values of SBP in the treatment period and the corresponding mean
values in the pre-treatment period. There is also a statistically
significant difference between treatment and post-treatment;
no statistically significant differences are found between pre-
treatment and post-treatment periods.
The same behaviour is found for DBP: statistically significant
differences are found between mean values in pre-treatment and
treatment periods, as well as between treatment and post-
treatment periods. No statistically significant differences are found
between pre-treatment and post-treatment periods.
As with many other natural products, it is difficult to determine
which one is the active compound responsible for the biological
activity of Rosemary oil. Different pharmacological in vitro studies
have been performed with Rosemary essential oil demonstrating
its spasmolytc activity and the influence of its composition on
this activity; in this sense, pinene exerts a stimulating action
(Taddei et al., 1988). Also the antioxidant activity of the essential
oil depends on the concentration of phenolic diterpenes (Schwarz
et al., 1992); Rosemary oil showed greater antioxidant activity than
three of its main components alone (1,8-cineole, α-pinene, β-
pinene), again demonstrating the influence of the whole composi-
tion of the essential oil on its biological activity (Wang et al., 2012).
3.2. Statistical analysis of health related quality of life variables
3.2.1. Questionnaire validation
Prior to evaluating the effect of treatment, the use of the
questionnaire was validated following three main stages: (a)
checking the score; it is necessary to be sure about the punctua-
tions, as when managing raw data, it is possible to include several
mistakes; (b) consistency study, by comparison of the calculated
results with those obtained manually by two different computer
media (statistical package SPSS Statistics 19.0
s
and Microsoft
Office Excel 2010
©
spreadsheet); and (c) reliability study, for
which two analysis were performed: first of all, correlations
between General health scale and the other seven scales are
performed (Pearson coefficient) in order to verify whether every-
one is positive and substantial in magnitude (Z0.30); results
obtained for this study were always superior to 0.30. Also, as a
second reliability analysis, the Cronbach's alpha coefficient was
used as a measure of internal consistency of the instrument (SF36)
used. Values obtained were always higher than 0.82, so it is
acceptable that the questionnaire works reliably.
3.2.2. Statistical analysis for the scales from SF-36 questionnaire
Table 3 shows the mean, minimum and maximum values of
the sample for each dimension, Physical function (PF), Physical
role (PR), Corporal pain (CP), General health (GH), Vitality (V),
Social function (SF), Emotional role (ER) and Mental Health (MH).
Patients receiving Rosemary essential oil treatment evolved from
disfunctionality towards functionality in several aspects from daily
life. This effect was more marked on the main factors influencing
physical summary such as physical function (30.19% improvement)
and physical role (1900% improvement). On the other hand, those
factors indicating mental summary, such as vitality, emotional
role and mental health, also experienced a high improvement
(40.37%, 95.65% and 33.83%, respectively) although their increase
was slower than the first ones.
Mean DBP (mmHg)
V2 V10 V22 V34 V40
Analysis of Means Plot
With 95% Decision Limits
55
57
59
61
63
65 UDL=60,13
CL=58,79
LDL=57,44
Mean SBP (mmHg)
V2 V10 V22 V34 V40
Analysis of Means Plot
With 95% Decision Limits
97
101
105
109
113 UDL=104.89
CL=103.39
LDL=101.89
Fig. 2. Analysis ANOM of the (a) SBP and (b) DBP values (mmHg) with 95% Decision
Limits, for the entire study; two values corresponding to treatment period are
included.
Fig. 3. Network graph corresponding to the multiple comparisons made for V2, V10, V22 and V40, for (a) SBP and (b) DBP.
L.F. Fernández et al. / Journal of Ethnopharmacology 151 (2014) 509–516514
When analysing the differences between values during pre-
treatment and post-treatment periods, most dimensions show a
slight increase at the end of the study. This small difference
indicates that the patient circumstances at the end of the study
are nearly the same as they were prior to entering it, with the
main difference of the patient's evolution to functionality which is
much higher for both physical (983.4% increase) and emotional
(30.44%) roles.
3.2.3. Obtaining physical and mental summary Components
The eight scales are hypothesised to form two distinct higher-
ordered clusters due to the physical and mental health variance
that they have in common. According to Ware et al. (1998),in
order to obtain physical and mental summary components (PSC
and MSC, respectively) it is preferable to use the algorithms in
each country, although results should also be accepted if standard
scoring algorithms are use, as a high correlation for both physical
and mental components is found (0.980–0.989 and 0.984–0.988
towards 1, respectively). Factor analytic studies have confirmed
physical and mental health factors that account for 80–85% of the
reliable variance in the eight scales in the U.S. general population;
as from 1998, these studies had been replicated in more than a
dozen countries (Ware et al., 1998). Physical and mental summary
components are calculated according to the study protocol in
Materials and Methods section (Alonso et al., 1998).
Finally, the no parametric hypotheses test of Friedman, with a
confidence level of 95% is applied for PSC and MSC variables,
analogous to those performed for SBP and DBP variables, in order
to determine statistically significant differences between test
results throughout the study. For both PCS and MCS, we reject
the null hypothesis of equal means. Pairwise comparisons are
shown in graphic distance network shown in Fig. 4.
No statistically significant differences were found for PSC
between weeks 2 and 10, this period corresponding the pre-
treatment phase where a placebo effect might be observed.
Differences obtained between V2 and V40 and between V10 and
V40 are statistically significant, which means that the post-
treatment PSC is superior to pre-treatment PSC; after finishing
the study, patients do not recover the clinical status shown prior to
entering the study.
Also statistically significant differences were found between
V10 and V22, this reflecting the PSC variation, probably due to the
drug effect. The period between V22 and V34 does not show
significant differences, as the clinical effect of the drug becomes
stable and so, MSC does not reflect any significant variation. Again,
statistically significant differences were found between V34 and
V40 for the PSC, this proving the effect of Rosemary essential oil on
the physical status of the patients.
With respect to MSC, no significant differences were found
between V2 and V40 and V10 and V40, this meaning that once the
treatment has finished, patients recovered a clinical status similar
to the one they had prior to entering the study. Nonetheless,
differences between V10 and V22 are statistically significant, then
reflecting the effect of Rosemary essential oil administration on
patients' mental components. Again, no significant differences
were observed between V22 and V34 this reflecting the stabilisa-
tion in the clinical effect of Rosemary essential oil. Finally, after
cessation of treatment, MSC variation between V34 and V40 was
statistically significant which means that pharmacological effect of
Rosemary essential oil is reversible.
In summary, the study of the evolution of Physical and Mental
Summary Components according to Jacobson and Truax (1991)
Table 3
Descriptive statistics of the sample by dimensions.
Dimension Visit 2 Visit 10 Visit 22 Visit 34 Visit 40
Min Max Mean Min Max Mean Min Max Mean Min Max Mean Min Max Mean
Physical function 35.0 100.0 72.3 35.0 100.0 70.2 75.0 100.0 91.0 75.0 100.0 94.2 60.0 100.0 77.2
Physical role 0.0 100.0 5.0 0.0 100.0 5.0 75.0 100.0 94.2 100.0 100.0 100.0 0.0 100.0 54.2
Corporal pain 32.0 84.0 58.2 32.0 84.0 57.2 51.0 100.0 76.0 62.0 100.0 81.8 41.0 84.0 60.2
General health 20.0 87.0 49.3 25.0 87.0 50.7 50.0 87.0 66.7 57.0 87.0 67.9 40.0 82.0 54.7
Vitality 5.0 70.0 45.8 5.0 65.0 43.0 25.0 85.0 63.5 30.0 85.0 64.3 10.0 65.0 45.0
Social function 50.0 100.0 70.0 50.0 100.0 70.4 75.0 100.0 93.8 75.0 100.0 94.2 50.0 100.0 71.3
Emotional role 0.0 100.0 51.1 0.0 100.0 44.4 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 66.7
Mental health 52.0 84.0 71.7 52.0 80.0 72.4 76.0 96.0 89.9 75.0 96.0 96.0 60.0 84.0 74.9
Fig. 4. Network graph corresponding to the multiple comparisons made for V2, V10, V22 and V40, for (a) PSC and (b) MSC.
L.F. Fernández et al. / Journal of Ethnopharmacology 151 (2014) 509–516 515
shows statistically significant differences between pre-treatment
and post-treatment values which indicate that the clinical situa-
tion of the patient at the end of the study is not the same as it was
at the beginning. For physical component, final values are sig-
nificantly higher than the initial ones; the mental component
significantly varies between the initial values and the maximum
value reached during the treatment period. The improvement in
these parameters is directly related to the variation in blood
pressure values.
4. Conclusions
A prospective clinical trial has been designed that assesses the
antihypotensive effect of Rosemary essential oil on primary
hypotensive patients. The increase shown in blood pressure values
during treatment is clinically significant. Once the treatment
finished, blood pressure values returned to those recorded prior
to initiating the Rosemary essential oil treatment, with no rebound
effect. Moreover, no adverse events related to treatment were
recorded. Clinical status of patients improved throughout the
study with an increased functionality whereas the behaviour of
blood pressure throughout the study is strongly correlated with
the values of Mental Summary Component.
In conclusion, this work shows a prospective clinical trial that
demonstrates the antihypotensive and stimulatory effect of rosem-
ary essential oil and the related improvement in patients' quality
of life. The study has been performed in a Pharmacy and allowed
to assess the treatment efficacy, together with the importance of
Pharmaceutical care in patients' adherence. The finding of this
study can be used as a guide for future research work aimed at
deepening the scientific knowledge of commonly used plants.
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