Clinical criteria for the diagnosis of carpal tunnel syndrome in diabetes patients.
\r\n\tIn this book the authors will provide complete introduction of Polymers chemistry. The book is mainly divided into three parts. The readers will learn about the basic introduction of general polymer chemistry in the first part of the book.
\r\n\tThe second part of the book starts with a chapter which includes kinetics of polymerization. Polymer weight determination, molecular weight distribution curve and determination of glass transition temperature. The final part of the book deals polymer degradation which includes types of degradation. The chapters of the present book consist of both tutorial and highly advanced material.
Entrapment neuropathies are more prevalent among patients with DM, and carpal tunnel syndrome (CTS) can guide a better understanding of the pathophysiology of entrapment neuropathies in this patient population. CTS is the most commonly studied entrapment syndrome and changes in the small arteries, such as vascular hypertrophy and intimal thickening, and noninflammatory fibroses of connective tissue are key pathologic features as discussed earlier in this book. In patients with DM, the reasons for the higher susceptibility to entrapment neuropathies are likely the combination of increased vulnerability of the nerves to compression arising from underlying diffuse DM-related nerve fiber injury and the presence of altered connective tissue structures within the carpal tunnel causing additional compression [1]. These two mechanisms are most likely relevant to all entrapment neuropathies in DM. Axonal, metabolic, and structural changes in DM that can lead to higher susceptibility to external injury are well-known. Less information on altered connective tissue structure in areas of nerve compression is available in this patient population. Deger et al. found a statistically significant increase in neoangiogenesis in subsynovial connective tissue in DM CTS cases, correlating with greater expression of vascular endothelial growth factor (VEGF), in subsynovial connective tissue in DM than what is present in CTS in patients without DM [2, 3]. These findings are consistent with the findings of Tekin et al., showing DM CTS patients, when compared with non-DM CTS patients, have higher rates of synovial edema and vascular proliferation and increased vascular wall thickness [4]. Thus the increased neovascularization, arising from a proposed ischemia-reperfusion mechanism, and more apparent in patients with DM, impinges the tissue compartment space within the carpal tunnel. In their recently published review, Sharma and Jaggi summarize the current knowledge regarding the role of transforming growth factor (TGF-β), VEGF, and interleukins in the subsynovial connective tissue in CTS patients, with and without diabetes [5].
The high prevalence of DM among patients with clinical CTS was first noted in 1962 by Blodgett et al. who reported DM in 59/915 or 6.4% of consecutive patients diagnosed with CTS [6]. A higher prevalence of DM among patients with CTS was described in 1972 by Phalen, who reported DM in 14.6% or in 56/384 consecutive patients diagnosed with CTS [7]. Subsequent studies demonstrated a similar prevalence with the calculated odds ratio (OR) of 3.02 for CTS in DM [8, 9]. The risk of CTS is further increased in DM patients with neuropathic symptoms, as shown by Perkins et al., who found a similar frequency of clinical CTS in 14% of nonneuropathic DM subjects, increasing to 30% in those with diabetic sensorimotor polyneuropathy (DSP) of varying severity [10]. This prospective cohort study evaluated clinical CTS, defined rigorously, across a broad spectrum of DSP patients (Table 1). Pourmemari and Shiri performed a meta-analysis including over 90,000 subjects and examined DM as a risk factor for CTS. They found the association to be more modest with an unadjusted OR estimate of about 2 and less when controlling for potential confounding factors with a pooled estimate OR was 1.59 [11, 12]. This outcome may be related to varying definitions of CTS within different studies included in the meta-analysis.
Paresthesiae in hands or marked preponderance of sensory symptoms in the hands |
Nocturnal hand symptoms awakening the patient |
Symptoms precipitated by activities such as holding a newspaper or driving a car and relieved by hand shaking |
Predilection for radial digits |
Weak thenar muscles |
Upper limb sensory loss solely within the distribution of the median nerve |
Comi et al. examined the prevalence of median neuropathy in patients with DM using electrophysiological studies, but not symptoms and signs of CTS. 11.2% showed electrophysiology indicating focal median neuropathy. The prevalence was higher (16.1%) among patients with DSP [13]. Other studies have shown even higher rates, up to 23%, of asymptomatic median compressive neuropathy at the wrist in patients with DM [14]. The issue with this approach is that CTS is a clinical diagnosis, and the Perkins study showed that electrophysiological changes at the carpal tunnel are related to DSP and not indicative of the presence of CTS [10]. All of these studies indicate that although median neuropathy at the wrist is relatively common in patients with DM when tested by nerve conduction studies, clinical CTS is not found in a similar proportion. Symptomatic CTS was described in 9% of DM subjects in an early study [15], and the lifetime risk of symptomatic CTS in type 1 diabetes was calculated more recently to be as high as 85% by Singh et al. [16].
DSP symptoms might mimic those of CTS in clinical practice. Nonetheless, clear symptoms for a diagnosis of CTS can be established even in those with advanced DSP [10]. Establishing the diagnosis of CTS based solely on electrophysiological diagnostic criteria is unreliable in DM patients, since the changes in electrophysiological parameters are due to DSP rather than CTS [10]. Various electrophysiological parameters are thought to distinguish CTS from DSP in subjects with DM, but none were found to be different in those with and without CTS in a population of subjects with DM [10]. Parameters such as median nerve distal motor or sensory latency, comparison of ratios of median (ulnar latencies or amplitudes or sensory conduction velocities), and others failed to differentiate those patients who had clinical CTS from those who did not in subjects with DM [10]. Consequently, in subjects with DM, it is prudent to be cautious in attributing changes in electrophysiological parameters to CTS rather than DM with or without DSP.
There have been attempts to establish electrodiagnostic methods that might distinguish CTS from DSP but doubt about the results which arise from the Perkins study [10]. For example, the median nerve distal motor latency or the median nerve sensory distal onset latency when stimulating at the palm or at the wrist crease has been reported to show differences between DM patients with CTS and idiopathic CTS in a small study [17], but those same parameters were not reliable in larger studies [10, 18]. Additional studies have reported other parameters that may be useful in diagnosis such as the median-radial sensory latency difference from the thumb, which showed 94% sensitivity in one study [19], and for a cutoff of 0.55, 82% sensitivity and 80% specificity in another study [18]. As the ulnar nerve is also susceptible to entrapment, a comparison of median nerve parameters to radial nerve parameters was thought to be preferable. Other studies have suggested using the median-ulnar sensory latency difference measured from the ring finger with 86% sensitivity in one study [19], and for a cutoff of 0.35, 90% sensitivity and 85% specificity in another study [18], although this sensory latency difference could not identify those with CTS in a larger study [10]. The lumbrical-interosseous latency difference was significantly different between CTS patients with and without DM, with sensitivity of up to 88.4% in two studies [17, 20], and for a cutoff of 1 ms had 78% sensitivity in another study [21].
Small studies have examined the feasibility of using ultrasonography to distinguish CTS with DM cases from DSP alone. Kim et al. found that all the cross-sectional areas (CSA) of the median nerve were larger in DSP patients compared with healthy controls, and the CSA of the median nerve at the wrist revealed no significant differences among DSP patients with and without CTS; however, patients with CTS (with and without DM) had larger CSAs at the wrist and a higher wrist/forearm ratio compared with DSP patients. The cutoff value for the CSA at the wrist that yielded the highest sensitivity and specificity was 11.6 mm [22]. A smaller study found no ultrasound measurement (distal median CSA, wrist-forearm ratio, wrist-forearm difference) reached significance to detect CTS in patients with DSP [17].
The outcome of open decompression of the median nerve by sectioning the carpal transverse ligament in DM patients has been evaluated in many studies. Several studies, with a post-procedure follow-up of up to 2 years, showed similar beneficial outcomes, in nerve conduction studies and symptoms, for patients with and without DM [23, 24, 25, 26, 27, 28, 29]. Some studies found that electrodiagnostic findings and assessment of symptoms and clinical signs improved significantly in both DM patients and in non-DM patients but that the improvement was less in the diabetic group [30, 31, 32, 33]. Zhang et al. demonstrated an association of DM with an increased risk for secondary surgery following carpal tunnel decompression. They tested a total of 904 patients with and without DM, for a median follow-up length of less than a year [34]. Gulabi et al. compared the symptomatic outcome at 6 months and 10 years after decompression of 27 patients with DM and 42 patients with idiopathic CTS. They found that at 6 months, the outcomes were similar for the DM and non-DM groups, but at 10 years the DM group had poor outcomes possibly due to progression of DSP in the DM group [35]. Recently published results of a randomized controlled prospective study comparing the outcome of endoscopic carpal tunnel release versus open carpal tunnel release in DM patients suggest that the endoscopic approach is more beneficial for patients with diabetes. In this study, the patients who underwent endoscopic carpal tunnel release had better relief of symptoms and better function scores, less pillar pain and tenderness at 12 weeks after surgery, faster regain of grip and pinching functions, significantly faster return to work and significant improvement in wound healing, as well as reduction in wound infection and complications [36].
The evidence to date indicates that surgery in DM patients with CTS leads to an improvement in symptoms and signs of CTS that is very similar to non-DM patients with CTS. Given this background, it is reasonable to offer surgical therapy to DM patients with CTS when conservative treatments have failed, as is the case for idiopathic CTS, i.e., in those without DM.
There is controversy over whether or not cubital tunnel syndrome is more common in those with DM. Stamboulis et al. found 12.2% of patients with cubital tunnel syndrome had DM [37]. In other studies, the prevalence of DM was the same in patients with cubital tunnel syndrome as in the general population, i.e., 6% in both groups, when the diagnosis of cubital tunnel syndrome was established on the combination of symptoms, objective clinical findings, and electrodiagnostic tests [38], and the severity of symptoms was also similar between those with and without DM [39]. In a case-control study, including only patients who had undergone ulnar nerve decompression, DM was not found to be a risk factor for ulnar neuropathy at the elbow [40]. The question of whether DM is a risk factor for cubital tunnel syndrome remains uncertain.
Rota et al. tested DM patients for ulnar neuropathy at the elbow irrespective of clinical symptoms and found that 34% had electrodiagnostic features of ulnar dysfunction due to chronic compression at the elbow. Most of the patients with neurophysiological abnormalities were asymptomatic, and only 6% had sensory symptoms and showed clinical signs of cubital tunnel syndrome [41].
It has been demonstrated in large cohorts that sensory nerve conduction velocity and amplitudes of sensory nerve action potentials are markedly lower in DM patients than in healthy controls, even more so in DM patients with known DSP [38, 42, 43, 44, 45]. As asymptomatic ulnar nerve entrapment at the elbow (UNE) is relatively common among patients with DM, possibly due to the underlying DSP similar to CTS, when the diagnosis of cubital tunnel syndrome in patients with DM with or without DSP is in question, we rely mainly on changes in the motor conduction electrophysiologic parameters. Schady et al. studied 20 DM patients with cubital tunnel syndrome, demonstrated by hand wasting and weakness. All patients also had signs of DSP in the lower limbs. The nerve conduction studies in this cohort showed markedly reduced ulnar nerve compound muscle action potential (CMAP) amplitudes with a mean value of 1.2 versus 7.4 mV in controls and also reduced ulnar/median CMAP amplitude ratios. Less sensitive than the CMAP amplitudes was the ulnar nerve motor conduction velocity. This was disproportionately slowed across the elbow segment in only 8 of 34 affected ulnar nerves [43].
Only two studies have used ultrasonography for the diagnosis of ulnar compressive neuropathy at the elbow in patients with DM. Kang et al. had demonstrated that the cross-sectional area (CSA) of the ulnar nerve at the cubital tunnel outlet was significantly greater in patients with DSP than in healthy controls, with no correlation to nerve conduction study results [46]. It is possible that the larger CSA is a marker of DM and not specific for DSP or of ulnar compressive neuropathy at the elbow in patients with DM, as might be inferred from the second study. Chen et al. tested DM patients with and without confirmed DSP. They found that CSA of the ulnar nerve at the cubital tunnel outlet was greater in DM patients than that in the healthy control group, yet no difference was detected in the CSA of the ulnar nerve between DM patient with and without DSP [47]. These studies found no correlation between the cubital tunnel syndrome and the CSA or even between asymptomatic UNE and the CSA.
A recent US national database review of more than 15,000 patients who underwent ulnar nerve decompression at the cubital tunnel found a low incidence of failure of cubital tunnel release requiring ipsilateral revision, but the presence of DM was an independent risk factor for revision with an adjusted odds ratio of 1.27 [48]. The presence of DM did not increase the risk for infection following cubital tunnel release [49]. Other smaller studies have found that DM is not associated with a poor surgical result, either clinically or electrophysiologically [50], or with a greater likelihood of revision surgery [51, 52, 53]. When satisfaction with treatment was assessed, having DM was not associated with a higher likelihood of dissatisfaction with treatment [54].
Ulnar entrapment at the wrist is far less common, and thus less studied, than ulnar nerve entrapment at the elbow. The prevalence of DM among patients with ulnar tunnel syndrome at the wrist is yet to be determined, as no large-scale study has assessed the presence of this potential entrapment. In fact, the only relevant data comes from a single retrospective study of 31 patients who had an ulnar nerve palsy treated by ulnar tunnel (Guyon’s canal) release, and 6 patients or 19% had DM [55].
The diagnosis of ulnar tunnel syndrome at the wrist is routinely based on the motor nerve conduction study parameters. Rota et al. tested DM patients for ulnar neuropathy at the wrist, and their electrodiagnostic study demonstrated relevant neurophysiological abnormalities in 11% of the patients, all of whom had DSP as well. The paper does not state how many of the patients presenting with these electrophysiological abnormalities were symptomatic [41].
There is a single paper regarding the use of ultrasonography for the diagnosis of ulnar compressive neuropathy at the wrist in patients with DM. Chen et al., who tested DM patients with and without confirmed DSP, showed that the CSA of the ulnar nerve at Guyon’s canal was greater in DM patients than in the healthy control group, yet no difference was detected in the CSA of ulnar nerves between DM patients with and without DSP. No potential relationship to clinical signs or symptoms of ulnar tunnel syndrome was examined in this study [47].
Upper limb mononeuropathies are common in patients with DM with the most common being CTS. The diagnosis of CTS in DM is a clinical diagnosis as the electrophysiologic and ultrasonographic parameters do not reliably distinguish between CTS and DSP. Treatment can be highly effective in CTS patients with DM whether or not DSP is present. Asymptomatic ulnar nerve electrophysiological abnormalities are common in DM, but it is unclear if clinical entrapment syndromes at the elbow are more common or not. The success of surgical decompression of the ulnar nerve at the elbow in those with DM is similar to that in non-DM patients. Ulnar nerve entrapment at the wrist is infrequent, and data on diagnosis and treatment is limited or unavailable.
No funding was received for preparation of this manuscript.
All authors declare that they have no conflict of interest pertinent to this work.
The use of plant and plant-derived natural products for medicinal, religious, and cosmetic purposes has a history dating back to the emergence of humanity. Exploring natural plant products as an option to find new chemical entities as leads is one of the fastest growing areas of research. Medicinal plants are rich sources of bioactive phytochemicals and/or bionutrients, which have shown important role in preventing chronic diseases like cancers, diabetes, and coronary heart diseases [1]. It is well documented that plants produce these chemicals to protect themselves, but they also protect plants from diseases and damages and contribute to the plant’s color, aroma, and flavor [2]. The pharmaceutical properties of aromatic plants are partially attributed to essential oils (EOs), which can also be seen as an important group of plant secondary metabolites. Although the use of EOs has been primarily related to food flavorings, cosmetics, and perfumes due to their aroma, research demonstrates the high potential of the use of volatile monoterpene constituents to cure and prevent human diseases [3, 4]. During the recent years, plant EOs have come more into the focus of phytomedicine and aromatherapy; hence their widespread use has raised more interest to scientists in basic research, especially their antimicrobial, antioxidant, and anticancer activities. In general, EOs consist of chemical mixtures involving from several tens to hundreds of different types of molecules, most of them being complex natural mixture of terpene and phenylpropanoids (benzene derivatives) which are responsible for their biological activities [5, 6]. At the first glance, terpenes and EOs can seem alike; both can come from plants and are aromatic; for many they are used for the same purpose. These similarities have led to a wide misconception that they are same, but this is not necessary the case [7].
\nA plethora of practical definitions of the term essential or volatile oils exist. Essential oils are concentrated aromatic hydrophobic oily volatile liquids characterized by a strong odor and produced by different plant materials such as flowers, peels, rhizomes, buds, seeds, leaves, twigs, bark, herbs or grass, wood, fruits, roots, and whole plant from one single botanic species [7, 8, 9]. However, EOs with a specific characteristic (including chemical properties and biological activities) are generally obtained from a single botanical source when the age of the plant, the climate, and the edaphic and harvest period are relatively identical [10]. They are called “essential oils” because they contain the “essence” of the plant material. A few are produced by animals and microorganisms [11]. Mosses, liverworts, seaweeds, and fungi have also been shown to contain EOs. EOs are limpid, rarely colored, and soluble in nonpolar or weakly polar organic solvents and of lower density (lighter) than water, with very few exceptions [12]. They are usually colorless particularly when fresh, but few may also be pale yellow (yellow mandarin), blue (
The quality and the quantity of EOs in plant material depends on the climate, the soil type, the age and vegetable cycle stage, the preparation method, chemotypes, as well as the plant organ [8]. An estimated 3000 EOs, from about 2000 plants, are of great value and are used in a very large variety of fields [15, 16]. All plants possess principally the ability to produce volatile compounds, quite often, however, only in traces. Those plants that can produce an EO of commercial interest are called essential oils plants [17]. EOs occur specially in higher plants (with about 17,500 known species) but are distributed in good amount in a limited number of families including Myrtaceae, Myristicaceae, Oleaceae, Rosaceae, Acoraceae, Cupressaceae, Lauraceae, Compositae, Rutaceae, Lamiaceae, Asteraceae, Umbelliferae, Apiaceae, Poaceae, Zingiberaceae, etc. [18, 19, 20, 21].
\nIn most cases, the biological function of EOs remains obscure. They are nowadays subject of intensive scientific research and also attract attention of diverse industries due to their potentials as active pharmacological compounds or natural preservatives [22]. Their ecological role is however well studied and described. The most known are plant interactions (allelopathic agents, germination inhibitors) and plant–animal interactions for protection against predators (insects, fungi, herbivores) and attraction of pollinating insect to their host [23]. Industries have always had special interest on the microbial safety of cosmetics, as microbial spoilage can lead to product degradation and cause a risk for customers’ health. EOs and drugs containing them are of great importance in pharmacy, perfumery (heal, perfume, incense, household cleaning products), food technology (favor for food, drinks, spices, preservative), agriculture (insecticide), and aromatherapy. Their importance is nowadays known and appreciated in plant chemotaxonomy [24, 25].
\nThe world production and consumption of EOs and perfumes are increasing very fast. Production technology of EOs is an essential element to improve their overall yield. They are obtained from raw material by several extraction techniques such as water or steam distillation, solvent extraction, expression under pressure, microwave-assisted extraction, supercritical fluid, or subcritical water extractions [22, 26, 27, 28]. The best extraction method to use depends on the ease of evaporating (volatility) and the hydrophilicity or hydrophobicity (polarity) of the desired components. The extraction method chosen greatly affects the chemical composition of EOs.
\nThey are the most frequently used method for the extraction of EOs from plants.
\nIt is the oldest and easiest conventional method of extraction of EOs [11, 29, 30, 31]. The principle is based on the isotropic distillation. The plant material soaks up water during the boiling process, and the oil contained in the oil cells diffuses through the cell walls by means of osmosis. The distillation time depends on the plants material being processed (Figure 1).
\nDiagrammatic illustration of hydrodistillation (HD) method [
The principle of this technique is that the combined vapor pressure equals the ambient pressure at about 100°C so that the volatile components with the boiling points ranging from 150 to 300°C can be evaporated at a temperature close to that of water. The steam distillation takes advantage of the volatility of a compound to evaporate when heated with steam and the hydrophobicity of the compound to separate into an oil phase during the condensation process (Figure 2) [33].
\nDiagrammatic illustration of steam distillation method [
Also known as liquid–liquid partitioning, its principle is based on the solubility in an organic solvent non-mixable to water. This technique is used on delicate plants to produce higher amounts of EOs at a lower cost. The method is limited by the compound solubility in the specific solvent used, long extraction time, relatively high solvent consumption and often unsatisfactory reproducibility and purity (Figure 3) [33].
\nIllustration of liquid–liquid extraction method.
Typically, it is a solid–liquid extraction used when the desired compound has a limited solubility in a solvent and the impurity is insoluble in that solvent. There are several advantages of using this technique. These advantages include:
Low solvent consumption for a larger amount of raw material,
Repeatedly brought into contact with fresh portions of the solvent, this prevents the possibility of the solvent to become saturated with extractable material and enhances the removal of analyte from the matrix. Moreover, the temperature of the system is close to the boiling point of the solvent. This helps to increase the extraction kinetic of the system.
As disadvantages, it requires several hours or days to be performed; moreover, the sample is diluted in a large volume of solvent.
\nDue to heating, the thermal degradation and volatilization of components have been observed, and hydrolysis of esters to yield alcohols and carboxylic acids can occur (Figure 4) [34].
\nSoxhlet equipment [
Also kwon as scarification method, this is one of the best methods to extract EOs. The term cool pressed theoretically means that the oil is expeller-pressed at low temperature and pressure. This process insures that the resulting oil is 100% pure and retains all the properties of the plant. Here the heat is reduced and minimized throughout the batching of the raw material. EOs are then separated from the material by centrifugation [36].
\nSince economy, competitiveness, eco-friendly, sustainability, operation costs, high efficiency, and good quality become keywords of the modern industrial production, the development of EO extraction techniques has never been interrupted. The most relevant disadvantage of conventional techniques are time and solvent consumption and also related to the thermolability of EOs components which undergo chemical alteration (hydrolyze, isomerization, oxidation) due to the high applied temperatures [37]. The quality of the obtained oil is damaged, particularly if the extraction time is long. It is important that the extraction method maintain the chemical composition and the natural proportion at its original state. Strictly speaking, conventional methods are not the only way for the removal of EOs. Novel techniques known as innovative have been developed for this purpose but may not necessarily be widely used for commercial production due to the high cost of production of oils without any alteration of their thermosensitive components (Figure 5).
\nCold pressing apparatus and procedure distillation method [
It is a process of separating one component (the extractant) from another (the matrix) using supercritical fluids as the extracting solvent. In practice, more than 90% of all analytical supercritical fluid extraction (SFE) is performed with carbon dioxide (CO2) as the most used fluid. The CO2 is chosen for several reasons including the following: relatively low critical pressure (74 bars) and temperature (32°C), inertness, non-toxic, nonflammable, high soluble, non-corrosive, safe, available in high purity at relatively low cost, perfect conditions for thermosensitive compounds extraction, selectivity for desired compounds, and easy removal from the extract. At lower temperatures, to avoid potential damage of desired components of EOs, supercritical CO2 extraction technique is highly recommended [39, 40]. Extraction of EOs by SFs, particularly with CO2, provides products free of toxic waste, having a higher quality (especially it reserves the thermal instability of compounds) than EOs obtained by conventional methods (Figure 6) [40, 41, 42].
\nFlow diagram of SC-CO2 extraction [
SFEAP is a novel technique of extraction recently developed by Johner and collaborators [43]. It integrated both the cold-pressed extraction method and the SFE technique. Here, the solid raw material is loaded inside the extraction vessel, and a cold pressing is provided by contracting an under pressure piston with the raw material. SFEAP has been shown to offer faster extraction rate at 333 K and 40 MPa with the best yield [44]. Its advantages include gain of extraction time and solvent consumption. This technique has been used to extract EOs from
Schematic diagram of SFEAP apparatus [
The principle of the microwave-assisted hydrodistillation (MAHD) is based upon its direct impact with polar materials/solvents and is governed by two phenomena: ionic conduction and dipole rotation, which in most cases occurs simultaneously [46]. MAHD has been shown to reduce both extraction time and volume of solvent required, minimizing environmental impact by emitting less CO2 in atmosphere [47, 48, 49]. Some recently reported studies have successfully utilized a microwave oven for the extraction of volatile active components from plants [50]. It has been regarded as an important alternative in conventional extraction techniques because of its advantages which mainly are a reduction of extraction time, solvents, selectivity, volumetric heating, and controllable heating process (Figure 8) [51].
\nSchematic and picture of MAHD apparatus [
The basic principle of ultrasound-assisted extraction (UAE) to extract EOs from plant raw material consist of generating sound waves (ultrasound frequency about 20 KHz), which create cavitation bubbles in the solution and produce enough energy to break the structure containing the oil in order to release it. Moreover, UAE can act as an emulsifier dispersing lipophilic molecules in water, this facilitating the subsequent separation and purification of EOs [54, 55]. This technique was developed in 1950 [56]. It has been used to extract many EOs especially from flowers, leaves, or seeds [32, 55]. As known disadvantages, it requires filtration steps, and possible degradation of compounds at high frequencies occurs (Figure 9) [57].
\nUltrasound-assisted extraction (UAE): from laboratory (a) to pilot scale (b) [
Microwave-assisted extraction (MAE) is a process of using microwave energy to heat the solvent in contact with a sample in order to partition analytes from the sample into the solvent. The ability to rapidly heat the sample solvent mixture is inherent to MAE and is the main advantage of this technique [59]. It is a recent green technology broadly used to extract various EOs from plant. It has been established as an alternative method to conventional heating because it allows gain of time, volume of solvent used, and amount of biomass needed while increasing the extraction yield [28]. In most cases, recoveries of analytes and reproducibility are improved compared to conventional techniques (Figure 10) [59].
\nPicture and schematic diagram of the microwave oven adaptation to perform MAE [
Solvent-free microwave extraction (SFME) is proposed as a method for “green” extraction of edible EOs from fresh plant material, at atmospheric pressure without addition of water or organic solvent [61]. The SFME apparatus (Figure 3) is an original combination of microwave heating and dry distillation at atmospheric pressure. Based on a relatively simple principle, this method involves placing the plant material in a microwave reactor, without adding any solvent or water. The internal heating of the in situ water within the fresh plant material distends the plant cells and leads to the rupture of the glands and oleiferous receptacles. This process thus free EO which is evaporated by in situ water of the plant material. A cooling system outside the microwave oven condensed the distillate continuously. The excess of water is refluxed to the extraction vessel in order to restore in situ water to the plant material. At the end, EO is removed from the aqueous extract by simple decantation. SFME is neither a modified microwave-assisted extraction (MAE) which uses organic solvents nor a modified hydrodistillation process which uses a large amount of water; it can be consider as a dry distillation process, with water coming from the fresh plant material [62, 63, 64]. As advantages, the SFME method increases the EO yield, ameliorate the EO composition, eliminate the waste of water treatment, and also contributes to limited time, and lower an energy consumption (Figure 11) [62].
\nSchematic representation of the solvent-free microwave extraction apparatus [
Microwave hydrodiffusion and gravity (MHG) is a new green extraction technique of EOs developed by Vian and collaborators in 2008. This green extraction technique is an original “upside down” microwave alembic combining microwave heating and earth gravity at atmospheric pressure [65]. MHG has become not only an economic and efficient but also an environmental- and eco-friendly, not require water or solvent and as it does require less energy (Figure 12) [65, 66].
\nSchematic representation of the microwave hydrodiffusion and gravity [
As the consumption of EOs is growing up annually, their world production by different companies to satisfy the market demand has been increasing every year. The quality control of produced EOs has become then necessary to ensure the genuineness of the product, the shelf life, and the storage conditions [67]. The EO composition can sometimes be falsified by adding cheaper oils; it is often necessary to characterize small differences between oils that correspond to variation in geographic or genetic origin of the plant material. EOs analysis can be summarized in few points: the qualitative composition, the quantitative determination (major and/or minor constituents), and the detection of alteration of true EOs. With regard to the quality aspect of the EO, the identity and the purity are always investigated. Their physical properties are commonly assessed by specific gravity, the relative density, the optical rotation, the refractive index, etc.
\nMost of the methods applied in the analysis of EOs rely on chromatographic procedures, which enable component separation and identification. These include gas chromatography–mass spectrometry (GC–MS), liquid chromatography-mass spectrometry (LC–MS), gas chromatography-Fourier transform infrared spectrometry (GC-FT-IR), gas chromatography-Fourier transform infrared spectrometry-mass spectrometry (GC-FT-IR-MS), gas chromatography-atomic emission detector (GC-AED), gas chromatography-isotope ratio mass spectrometry (GC-IR-MS), on-line coupled liquid chromatography-gas chromatography (LC-GC), and multidimensional gas chromatography (MDGC) [68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78].
\nA considerable large number of studies on EOs to evaluate their pharmacological properties and toxicity in order to find possible alternative medicine have become active in recent years [79]. EOs are known to exhibit a large range of biological activities.
\nIt is one of the most intensively studied properties of EOs. This could be explained by the damages of various biological substances by oxidation which subsequently causes many degenerative and/or metabolic diseases such as cancer, diabetes, arthritis, inflammation, and Parkinson’s and Alzheimer’s disease just to name a few [80, 81, 82, 83, 84]. EOs are known as rich sources of potential antioxidants that can be investigated to prevent oxidative damage [85]. Antioxidants comprise substances that, in low concentrations, significantly delay or inhibit the oxidation of the substrate [86]. Volatile compounds in EO, beside their protective antioxidant activity, can also act as prooxidant, by affecting the cellular redox status and damage cellular biomolecules, in the first instance proteins and DNA [15]. All these must be taken into account when antioxidant properties of EOs are considered.
\nAlthough phenolic compounds are recognized as being responsible for the antioxidant ability, recent studies showed that volatile components could also individually and/or in mixture (essential oil) contribute to the whole antioxidant ability. EO of lemon balm (
Cancer is a worldwide public health concern with 18.1 million people been diagnosed with the disease annually. It is the second largest single leading cause of death claiming in excess of 9.6 million lives in the world in 2018, with approximately 70% of deaths occurring in low- and middle-income countries [88]. Current valuable drugs used in the treatment include vinblastine, vincristine, camptothecin, and Taxol [89]. Many studies pointed out the anticancer properties of plants. Over 500 research papers are published on the anticancer activity of EOs [90, 91, 92, 93], even though, till date, there are no scientific studies showing that aromatherapy can cure or prevent cancer. Most promising research results obtained from in vitro studies revealed that EOs were found to affect cancer cell lines in petri dishes. EOs are well known for their anti-inflammatory activity; hence it appeared that EOs could also have anticancer effects as there is a relationship between the production of reactive oxygen species to the origin of oxidation and inflammation that can lead to cancer. More than 100 EOs from more than 20 families of plants have been tested on more than 20 different types of cancers in the past 10 years [94]. Bourgou and collaborators showed that the EO from seeds of black cumin (
EOs are well-kwon as antimicrobial agents and are well documented in numerous research works. Their antimicrobial activity depends not only on the presence of the main active compounds but also on the interaction between different components which can have synergistic or antagonistic actions. It also depends on the content, concentration, interaction between main active components, and susceptibility of microorganisms [97, 98]. The inactive compounds might influence resorption, the rate of the reactions, as well as biological activities of active compounds. The combination of both major and minor components can thus modify the activity to exert significant synergistic or antagonistic effect [99, 100]. EOs extracted from cinnamon, oregano, and thyme showed significant antibacterial activities against
In general, EOs in decreasing order of antimicrobial activities are reportedly as follows: oregano (
Antibiotic resistance is one of the most serious health burdens worldwide due to the continuous appearance of antibiotic-resistant bacterial strains. The bacteria that cause the most major clinical problems are
New agents that are effective against common pathogens are needed particularly for those resistant to conventional antiviral agents. The ability of viruses to persist in fresh products, as well as their low infectious dose, could lead to serious foodborne problems [111]. Plants and plant-derived natural products provide unlimited opportunities for new antiviral drugs. Many EOs have been investigated in recent years toward their antiviral activity. As conclusion of their work, Reichling and collaborators reported that particular free viruses are very sensitive to EOs [112].
\nMost of EOs have been firstly identified and used for the treatment of inflammatory and oxidative diseases.
The insect repellent activity of EOs is well studied and many research papers have been published. The EOs of
EOs of the leaves of
EOs are generally very complex mixture (60–300) of nonpolar and semipolar lipophilic constituents of low molecular weight, at different concentrations with two or three appearing to be major ones [116, 117]:
Terpenoids
Straight-chain compounds not containing any side chain
Aromatic and phenolic components
Sulfured derivatives
The variation in odor and taste of EO depends on the plants variety, the harvesting seasons, the geographical location, the drying methods, and the extraction techniques [102, 118, 119, 120]. The major volatile constituents may be classified into two main categories: terpenoids and polypropanoids [121, 122, 123]. We will focus our investigation on terpenoids.
\nTerpenes are defined as secondary metabolites with molecular structures containing carbon backbones of isoprene (2-methylbuta-1,3-diene) units [124]. Terpenes are synthetized in the cytoplasm of plant cells through the mevalonic acid pathway. Biochemical modification such as oxidation or rearrangement of terpenes produces the related terpenoids. Terpenoids are then oxygenated derivatives of hydrocarbon terpenes such as aldehydes, ketones, alcohols, acids, ethers, and esters [34]. Terpenoids are the largest classes of plants’ natural products accounting for more than 40,000 individual compounds of both primary and secondary metabolisms been identified; to date, new terpenoids are being discovered every year [12, 124].
\nIn general, terpenoids can be divided into at least four groups of compounds that include true terpenes, steroids, saponins, and cardiac glycosides.
\nThese types of natural lipids can be found in every class of living things, mainly in plants as constituents of EOs, and are therefore considered as the largest and structurally diverse group of natural products [125]. In general, only the hemiterpenoids, the monoterpenoids, and sesquiterpenoids are sufficiently volatile to be components of EOs. As widely acknowledged, the composition of EOs is mainly represented by mono-, sesqui-, and even diterpene hydrocarbons and their respective oxygenated derivatives [30, 126, 127, 128].
\nStructurally, EO constituents typically have low molecular weights, which contribute to their high volatility. Terpenes are the most common constituents found in EOs [128]. They are made from isoprene units (several five carbon base units). Each group of terpenes arises from the head-to-tail condensation of a variable number of isoprene units. Variations in the number of isoprene unit repetitions, cyclisation reactions, and rearrangements are primarily responsible for their chemical and structural diversity. EOs consist of mainly monoterpenes (C10) and sesquiterpenes (C15) but also have diterpenes (C20), triterpenes (C30), and tetraterpenes (C40) at very low concentration with their oxygenated derivatives, respectively (Figure 13) [15, 102, 130].
\nBiosynthesis pathways of monoterpenes, sesquiterpenes, and diterpenes.
Hemiterpenes are part of minor terpenes of EOs. They are usually alcohols, aldehydes, and esters, with a 2-methylbutane skeleton [131]. The number of hemiterpene aglycone is less than 100 [132]. Chlorinated hemiterpenes were recently isolated from the leaves of
Structure of few isolated hemiterpenes and hemiterpenoids.
Regular monoterpenes are made from the combination of two isoprene units (C10) linked by the head-to-tail binding. They are the major molecules consisting of 90% of (some) EOs; thereby, they contribute to the specific smell of plants [134, 135]. Monoterpenes are found in nearly all EOs and usually possess one double bond in their structures. In nature, they are mostly involved in plant–animal and plant–plant interactions such as pollination, seed and fruit dissemination, and allelopathic agents. Monoterpenes occur in more than 30 known skeletons and can be divided into 3 subgroups: acyclic, monocyclic, and bicyclic. A number of monoterpenes are oxygenated (Figure 15).
\nStructures of some monoterpenes and monoterpenoids.
Sesquiterpenes are other major EO components and are less volatile than monoterpenes. They are derived from three isoprene units and exist in a wide variety of forms, including linear, monocyclic, bicyclic, and tricyclic frameworks. Sesquiterpenes are the most diverse group of terpenoids (Figure 16).
\nStructures of some sesquiterpenes and sesquiterpenoids.
They are chemically complex and are usually components of plants resins but are sometimes encountered as by-products in the isolation of EOs. Diterpenes are less volatile because of their high molecular weights and less numerous than the mono- and sesquiterpenes. Consequently, they are difficult to extract by steam distillation and then appear rarely in distilled EOs. When present, they are found in EOs in very low amounts. However, traditional extraction using distillation allows separation and identification of diterpenes present in EOs [136]. Generally, molecules with molecular masses higher than 300 uma can be seen as sign of improper extraction conditions or adulteration. Diterpenes that are usually found in EOs include camphorene, cafestol, kahweol, cambrene, and taxideme (Figure 17).
\nStructures of some diterpenes and diterpenoids.
Some sesquiterpenoids are very toxic, but some are antifungals, carminatives, and insecticides.
\nBeing complex mixtures of constituents, overall activities of EOs cannot therefore be attributed only to their major components (terpenoids) [137]. Many aroma components of EOs, such as terpenes and terpenoids, were proposed to contribute to their antioxidant activity; that include
Terpenoids are, by far, the most important group (numerous and structurally diverse) of natural products as far as EOs are concerned. Reports on the level of terpenoids in EOs vary considerably. Many terpenes have biological activities and are used for medical purposes. For example, the antimalarial drug artemisinin and the anticancer drug Taxol (paclitaxel) are two of a few terpenes with established medical applications [26].
\nMonoterpenes are well known as main constituents of EOs, floral, and scents. Monoterpenes and monoterpenoids have antioxidant, anticonvulsant, antiulcer, anti-inflammatory, antiseptic, antitumor, antiviral, analgesic, antihypertensive, antibacterial, and therapeutic antidiabetic properties [26, 138]. The general mechanism of action of monoterpenes, such as their antimicrobial and antitussive activity, is mainly related to their volatility. Their hydrophobicity, as well as the EOs as a whole, determines their effect on bacterial cell structures with a subsequent antimicrobial effect [139].
Some bicyclic monoterpenoids are known to suppress the acetylcholinesterase activity, which is increased in patient with Alzheimer’s disease. In a study of 17 monoterpenes and monoterpenoids, (+)- and (−)-
In recent years, a considerable large number of research studies have been carried out on the chemical constituents of EOs as source of bioactive natural products against cancer. Piaru and collaborators showed that EO of
Many EO components possess enantiomers that can be sometime present in an oil. It is important to note that there is a close relationship between the chirality of organic compounds and their biological properties. For a given optically active substance, the activity is not identical for both enantiomers [153]. Linalool, for example, has two enantiomers: (3
Geraniol, an acyclic aldehyde monoterpene present in various EOs from many aromatic plants, has in vitro and in vivo antitumor activity against several cancer cell lines. In fact, geraniol alters several metabolic pathways of HepG2 cells such as the mevalonate pathway and the phosphatidylcholine biosynthesis, which results in cell growth inhibition, cell cycle arrest occurring at the G0/G1 interphase, and increased apoptosis [155]. Antibacterial and antifungal activities of oils with high levels of sesquiterpenes as cadinene, spathulenol, and selinene were described [156].
\nCristiani and coworkers have reported the antimicrobial activity of four monoterpenes (
Monoterpenes, sesquiterpenes, and oxygenated derivatives extracted from EOs have shown strong inhibitory activities against pathogenic bacteria, hence suggesting their use as flavoring and antioxidant agents [104].
\nAlzheimer’s disease is by far the most prevalent of all known forms of dementia. Wojtunik-Kulesza and collaborators showed that three monocyclic monoterpenes (carvone, pulegone, and γ-terpene) possess acetylcholinesterase (AchE) inhibitory activity. Among the investigated terpenes, the three later were recognized as compounds with promising activities in the development of multi-target directed ligands [160]. The lipophilic character of terpene skeleton combined with the hydrophobic character of the functional group is essential for activity. Thus, a rank of activity has been proposed as follows: aldehydes > ketones > alcohols > esters > hydrocarbons [156].
\nIn 2010, Conti and coworkers measured the insect repellent activity of three EOs. They found that at lowest dose (0.001%), the OE of
In EOs, the components found in higher concentrations and related to antimicrobial activity are phenolic compounds such as linalool, sabinene, menthol, myrcene, and camphene [161].
\nSesquiterpenes have anti-inflammatory and anti-allergic properties. The anti-inflammatory activities of some medicinal plants are due to the presence of one or more sesquiterpene lactones [26]. Above all, terpenes are responsible for the smell and flavor typical of the different varieties of
Terpenes represent one of the largest and most diverse classes of natural products. They have numerous roles ranging from defense repellents against herbivores or pathogens through animal attract hormones to agents designed to help disperse seeds and pollen. Monoterpenoids and sesquiterpenoids are obviously the major constituents of EOs, while in some oils the occurrence of diterpenoids was observed as quite minor constituents when present. In an ecological context, mono- and sesquiterpenes play an important role in the relations between organisms, for example, as attractants of pollinators or deterrents of herbivores. The enormous diversity of terpenoids and wide spectrum of biological activities make them attractive for many industries, and new areas of application still have not been discovered. Despite their rich and complex composition, the use of EOs remains limited to the cosmetics and perfumery domains. It is worthy to develop a better understanding of their chemistry and biological properties as well as that of their individual components for new and valuable applications in human health.
\nDespite their well-recognized bioactivities, EOs have been misused with regard to their level of toxicity. Some EOs or their major constituents have been recorded to be much toxic with bad side effects including convulsions, irritation, and photodermatosis. Literature review of the available data shows that serious accidents, most of which involve young children, are due to a small number of EOs, ingested in large amount. The development and the expansion of therapies using EOs and the evaluation of their acute toxicity have become more important to avoid their abusive use. The most common adverse events are eye, mucous membrane, and skin irritation and sensitization particularly to oils containing aldehydes and phenols. Despite all, no well-defined studies have proved that these EOs are harmful, but this deserves more detailed studies.
\nIntechOpen is the first native scientific publisher of Open Access books, with more than 116,000 authors worldwide, ranging from globally-renowned Nobel Prize winners to up-and-coming researchers at the cutting edge of scientific discovery. Established in Europe with the new headquarters based in London, and with plans for international growth, IntechOpen is the leading publisher of Open Access scientific books. The values of our business are based on the same ones that any scientist applies to their research -- we have created a culture of respect, collegiality and collaboration within an atmosphere that’s relaxed, friendly and progressive.
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