Ethnobotany and phytochemistry of plants used to treat musculoskeletal disorders among Skaw Karen, Thailand

Abstract

Context

Musculoskeletal system disorders (MSD) are prevalent around the world affecting the health of people, especially farmers who work hard in the field. Karen farmers use many medicinal plants to treat MSD.

Objective

This study collects traditional plant-based remedies used by the Skaw Karen to treat MSD and evaluates their active phytochemical compounds.

Materials and methods

The ethnobotanical study was conducted in six Karen villages in Chiang Mai province using semi-structured interviews were of 120 informants. The data were analyzed using ethnobotanical indices including use values (UV), choice value (CV), and informant consensus factor (ICF). Consequently, the 20 most important species, according to the indices, were selected for phytochemical analysis using LC–MS/MS.

Results

A total of 3731 use reports were obtained for 139 species used in MSD treatment. The most common ailments treated with those plants were muscular pain. A total of 172 high-potential active compounds for MSD treatment were identified. Most of them were flavonoids, terpenoids, alkaloids, and steroids. The prevalent phytochemical compounds related to treat MSD were 9-hydroxycalabaxanthone, dihydrovaltrate, morroniside, isoacteoside, lithocholic acid, pomiferin, cucurbitacin E, leonuriside A, liriodendrin, and physalin E. Sambucus javanica Reinw. ex Blume (Adoxaceae), Betula alnoides Buch.-Ham. ex D.Don (Betulaceae), Blumea balsamifera (L.) DC. (Asteraceae), Plantago major L. (Plantaginaceae) and Flacourtia jangomas (Lour.) Raeusch. (Salicaceae) all had high ethnobotanical index values and many active compounds.

Discussion and conclusions

This study provides valuable information, demonstrating low-cost medicine plants that are locally available. It is a choice of treatment for people living in remote areas.

Keywords:

• Anti-inflammatory
• ethnobotanical indices
• LC–MS/ms

Introduction

Thailand is blessed with a rich biodiversity. More than 30% of the country or about 16 million hectares are covered by natural forests (Royal Forest Department [RFD] 2022). These forests are a source of countless plants, many of which are used by ethnic people of Thailand. The knowledge about plant usage is passed from generation to generation and has developed into unique traditional knowledge of each ethnic group (Bruchac 2014). Traditional medicine has played an important role for the subsistence and health of ethnic people, especially for those who live in remote areas (Cadena-González et al. 2013; Junsongduang et al. 2020). In Thailand, ethnic people have used medicinal plants for treating many disorders including digestive system disorders, infections/infestations, nutritional disorders, and musculoskeletal system disorders (Pongamornkul 2017; Phumthum et al. 2018; Kantasrila et al. 2020). There are more than 2000 species of vascular plants used to treat ailments in daily life of ethnic people (Phumthum et al. 2018). More than 30% of these species were reported to be related to musculoskeletal system disorders (MSD) (Phumthum et al. 2018).

MSD are non-communicable diseases causing short-term and long-term pains (Woolf and Pfleger 2003; Collins and O’Sullivan 2010). Approximately 2 billion people around the world suffer from MSD, such as sprains, strains, back pain, carpal tunnel syndrome, osteoarthritis, lower back pain, upper limb disorders, sprains, fractures, dislocations, and connective tissue disease (Cieza et al. 2020). MSD are a main problem leading to disability and death (Hignett and Fray 2010). MSD are influenced by many factors, such as age, lifestyle, physical activity, and career (Hignett and Fray 2010; Sombatsawat et al. 2019; World Health Organization [WHO] 2019). In this context, agriculture is a risk occupation, which is one of the most important causes of MSD due to the hard work, lifting, and carrying heavy loads, working with farm vehicles, and a high risk of accidents (Kang et al. 2016; Sombatsawat et al. 2019). Farmers from various countries, such as India (Gupta and Tarique 2013), Iran (Omran et al. 2015), Thailand (Puntumetakul et al. 2011; Sombatsawat et al. 2019), Pakistan (Saeed et al. 2021) and Korea (Kang et al. 2016) suffer from MSD. The most prevalent symptoms, which occur among these farmers are pain in various body parts, especially in the lower back, neck, and shoulders. These problems have limited the working ability, causing decrease of farm income (Oh et al. 2011; Hartvigsen et al. 2018). Farmers, which are a majority occupation in Thailand, are affected by MSD like the farmers around the world (Puntumetakul et al. 2011; Sombatsawat et al. 2019; Kantasrila et al. 2020). People around the world have used both traditional medicine and modern medicine to cure MSD. Traditional medicine has experienced growing popularity (Sheng-Ji 2001), especially for treating muscular pain, rheumatism, fractured bones, etc. Many active phytochemical compounds such as flavonoids, terpenoids, alkaloids in medicinal plants possess the potentiality to prevent the generation of free radicals and inflammation, which are two highly important causes of MSD (Kanadaswami et al. 2005; Fusco et al. 2007; Barros et al. 2011; Carocho and Ferreira 2013). Medicinal plants are one of the best alternative therapies for treating MSD in communities of tribes and other parts of the world (Cameron and Chrubasik 2013).

Thailand has a high diversity of ethnic groups such as Karen, Kui, Mon, Hmong, Lahu, Akha, etc. (Schliesinger 2000). There are more than thirty ethnic groups and together they count about 1.1 million people who live along the borders of Thailand (Department of Social Development and Welfare [DSDW] 2016). Sgaw Karen is the largest of the ethnic groups in Thailand with more than 500,000 people in Tak, Mae Hong Son, Chiang Mai, Ratchaburi, and Kanchanaburi provinces (DSDW 2016). Their subsistence mostly depends on traditional agriculture, especially rice cultivation in swidden fallows (Schliesinger 2000; Santasombat 2004). Their agricultural work relies primarily on manual labor because of lack of agricultural machines. This causes various health problems associated with uncomfortable postures such as bending, twining, lifting, and carrying heavy loads (Luangwilai et al. 2014; Sombatsawat et al. 2019). These activities are the causes of MSD. Many medicinal plants are used to treat MSD among the Karen people because healthcare centers are limited and often located far away. Moreover, modern medicine, which are used to treat MSD, are costly and have a lot of side effects. Even if medicinal plants are very important to Karen people for treating MSD, studies of such medicinal plants are limited (Kantasrila et al. 2020). The study about medicinal plants involves alternative therapies, which are one of the good choices to treat MSD among Karen communities due to medicinal plants being available and easy to get. Therefore, in this study, we aimed to answer the following questions: 1) What were the most prevalent phytochemical compounds in medicinal plants related to treatment of MSD? 2) Which species had the highest number of phytochemical compounds related to MSD determined using LC-MS/MS method? 3) Can these ethnomedicinal species with high ethnobotanical index scores be scientifically validated based on the results of phytochemical analysis? This study is a comprehensive review survey of phytochemical constituents of medicinal plants to screen important medicinal plant species for further drug development and produce new product of medicine form plants. In addition, this study highlights the importance of the usage medicinal plants to treat MSD among ethnic groups and provides significant information to preserve traditional knowledge about medicinal plants usage for future generations.

Materials and methods

Study site

The ethnobotanical study was conducted in Chiang Mai Province, northern Thailand, which is covered by high mountains and forested area (Asavachichan 2010). Chiang Mai is one of the provinces with large Skaw Karen population (DSDW 2016). There are more than 33,000 households, and approximately 30% of Skaw Karen population in Thailand, live in Chiang Mai (DSDW 2016). Field investigations were conducted in six Karen villages from five districts in Chiang Mai province, Thailand (Figure 1). Basic information of the villages is shown in Table 1.

Figure 1. Locations of the five sub-districts in Chiang Mai province where ethnobotanical knowledge was studied in six villages.

Table 1. Basic information of the six studied Karen villages in Chiang Mai, Thailand.

Information/Village	Khun Tuen Noi	Mae Lan Kam	Pakanok	Khuntae	Huai I Khang	Huay Poo Ling
District	Omkoi	Samoeng	Samoeng	Chom Thong	Mae Wang	Chom Thong
Sub-District	Mae Tuen	Samoeng Tai	Samoeng Tai	Doi Kaeo	Mae Win	Ban Luang
Coordinates	17.316403N 104.334493E	18.463726N 98.415544E	18.391561N 98.659843E	18.391561N 98.506530E	18.732856N 98.555927E	18.263520N 98.315330E
Altitude (m.a.s.l.)	1200	692	863	1228	947	1084
Religion	Animism, Christianity	Buddhism	Buddhism	Buddhism	Buddhism	Animism, Christianity, Buddhism
Population	182	490	278	807	504	206
Households	37	157	67	229	108	28
Age of settlement (years)	>130	>50	>50	>50	>50	>50
Major economic crops	rice, coffee	rice	rice, corn	rice, ornamental plants, coffee	rice, ornamental plants, onion, coffee	rice, onion, peanut
Presence of school	No	Yes	Yes	Yes	No	Yes
Presence of public health center	No	Yes	No	Yes	No	No
Route to the village	dirt road	dirt road	dirt road	paved road	paved road	dirt road
Distance from nearest urban center (km)	107	14	17	26	14	25

Ethnobotanical study

The field research was conducted from 2017–2020. Initially, the chief of each village was contacted and informed about the aims of the study. Then, the key informants, including folk healers and those who were experienced in using traditional medicine in each village, were selected by snowball sampling (Espinosa et al. 2012). Each key informant was interviewed about medicinal plants that they used for treating musculoskeletal disorders (MSD) using semi-structured interviews (Ethical approval: the Research Ethics Committee of Chiang Mai University, protocol code CMUREC 63/029 9 July 2020). The key questions included local name, plant part used, mode of preparation, mode of administration, frequency of usage, dosage of medication, plant habitats, illnesses treated with their symptomatology and contraindications to medicinal plants usage. The surveys were conducted in home gardens, agricultural areas, and forests around the villages.

Plant samples were collected for identification, at least three specimens were collected from each plant mentioned by the key informants for identification. Plant materials were dried and identified to their species name using Flora of Thailand and related literature. The current scientific names and family names were verified based on The Plant List (www.theplantlist.org). Voucher specimens were deposited at the QBG herbarium.

Quantitative ethnobotanical surveys were conducted in each village with 20 informants, including equal number of men and women, with ages ranging from 20–70 years, who were selected by snowball sampling. Each informant was independently interviewed about plants used to treat MSD by showing photos and plant samples covering parts used, methods of preparation, and route of administration. The interviews were done in local language with a local interpreter.

Ethnobotanical data analysis

The medicinal plants were classified to groups by plant part used (roots, leaves, stems, etc.), mode of preparation (decoction, burned, ground, etc.), and route of administration (oral ingestion, liniment, etc.). The illnesses were grouped into categories of MSD following the International Classification of Primary Care, Second edition (ICPC-2) (Wonca International Classification Committee [WICC] 2005).

The information of medicinal plants was transcribed into use-reports (UR) following illnesses of the MSD. Each “use-report” refers to the use of a particular species to treat a specific ailment in an MSD category in a Karen village. The use-reports were the basis for calculating ethnobotanical indices including Use Value (UV), Choice Values (CV) and Informant Consensus Factor (ICF).

Use value (UV)

UV was proposed by Prance et al. (1987) to evaluate the importance of plant species. $$\mathrm{UV}\mathrm{ }=\mathrm{ }\left(\mathrm{\Sigma }\mathrm{Ui}\right)/\mathrm{N}$$ where Ui represents the number of use reports for each species, which is cited by informants and N is the total number of informants. The UVs are high for plants with many use-reports indicating that the plant is important and useful (Khuankaew et al. 2014; Samoisy and Mahomoodally 2016).

Choice values (CV)

CV was proposed by Kremen et al. (1998) to define the most preferred species in each use category. In this study, CV was used to measure the relative preference for treatment of MSD. It was calculated as: $$\mathrm{CV}\mathrm{ }=\text{ Pcs }/\mathrm{Sc}$$ where Pcs is percentage of informants who cite certain species for MSD.

Sc is total number of species mentioned for treatment of MSD by all informants.

CV ranges from 0 to 100, with a higher value indicating these species were strongly preferred by the informants.

Informant consensus factor (ICF)

ICF was used to test the degree of homogeneity among informants for medicinal plants used in each category (Trotter and Logan 1986). $$\text{ICF\hspace{0.17em}}=\left(\text{Nur}-\text{Nt}\right)/\left(\text{Nur}-1\right)$$ where Nur refers to the number of use-reports for a particular ailment category and Nt refers to the number of plants species recorded in that same category. ICF ranges from zero to one. When it is low (near 0), it implies that most informants report different plants for a particular ailment category. Therefore, the informants had completely different knowledge to treat specific illness, and there has been no exchange of medicinal plants knowledge among informants. On the other hand, the ICF value is high (approaching 1) when there are a few plants used in a particular ailment category and it implies that the knowledge has been exchanged among the informants (Heinrich et al. 1998).

Phytochemical analysis

Plant materials and extraction

Twenty medicinal plants that had high ethnobotanical index scores and were present in most studied villages were selected for further phytochemical analysis. Only the parts of the plants mentioned by the key informants were harvested. The samples were cleaned with tap water and dried in a hot air oven at 60 °C for 24 h. Then, the dried samples were ground by electric blender into powder. Dried sample (5 g) was extracted with 8 mL of distilled water using sonication for 30 min. The solution was filtered through 0.45 µm diameter, 25 mm Nylon membrane syringe filters and kept in amber glass bottles at −20 °C.

Phytochemical study; Liquid Chromatography with Tandem Mass Spectrometry (LC–MS/MS)

The methods and condition of LC-MS/MS (Liquid Chromatography-Tandem Mass Spectrometry) in this study follow Panya et al. (2020). Each sample solution was dissolved in DMSO in the concentration of 5000 ppm for further analysis with LC-MS/MS (Agilent 6545 LC/Q-TOF, Agilent, CA, USA) using Porshell 120 EC-C18, 2.7 µm, 2.1 × 100 mm C18 column, with gradient system of two mobile phases. The mobile phase A comprised of water and 0.1% acetic acid and mobile phase B comprised of acetonitrile (CAN) and 0.1% acetic acid for 60 min. The gradient elution program was set as follows: 100% A (0–30 min), 50% A (30–40 min), 0% A (40–51 min), 50% A (51–60 min). This was followed by a 10 min equilibrium period to the injection of the next sample. The injection volume of each sample was 3 µL, flow rate 0.2 mL/min. The UV spectra were recorded between 210 and 400 nm. The MS analysis condition of each HPLC peak included in the MS positive mode, Dual AJS ESI ion source, with the following operating parameters: sheath gas temperature 350 °C, sheath gas flow 11 L/min, gas temperature 320 °C, drying gas 8 L/min, nebulizer pressure 35 psi. The identified phytochemical compounds from LC-MS/MS methods were searched for their pharmaceutical activities from previous publications focused on anti-inflammatory, antioxidative and analgesic properties related to MSD. The selected compounds with MSD properties were further analyzed for the most prevalent compounds appearing in most medicinal plants.

Results

Diversity of medicinal plants used to treat MSD

From the ethnobotanical study, a total of 3731 use reports from 139 species (117 genera, 62 families) were recorded for treating MSD by the Karen people (Table 2). Most of them (135 species) were angiosperm. The most dominant families of MSD medicinal plants were Fabaceae (10 species, 233 use reports), Asteraceae (8 species, 457 use reports), Zingiberaceae (8 species, 231 use reports), Poaceae (6 species, 164 use reports), and Rubiaceae (6 species, 19 use reports), respectively (Table 3).

Table 2. Medicinal plants used to treat musculoskeletal system disorders (MSD) in the six Karen villages in Chiang Mai, Thailand.

Species	Family	UV	CV	Part Used	Preparation	Application	Disorder treated	Symptom/complaint	Villages	Voucher specimen number
Acanthus montanu (Nees) T.Anderson	Acanthaceae	0.08	0.04	leaves, roots	Burning, Decoction, Grind and burning	Bath, Oral ingestion, Poultices	back pain, fracture, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Muscle pain	HIK, HPL, MLK	Kantasrila MSD105
Acmella uliginosa (Sw.) Cass	Asteraceae	0.15	0.05	leaves, inflorescences, roots, whole plants	Alcoholic infusion, Cook, None, Decoction, None, Steam	Eaten, Oral ingestion, Steaming	back pain, knee pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Knee symptom/complaint, Muscle pain	HPL, MLK, PN	Kantasrila MSD001
Ageratina adenophora (Spreng.) R.M.King & H.Rob.	Asteraceae	0.28	0.12	aerial parts, leaves, inflorescences, roots, whole plants	Burning, Grind and burning, Decoction	Compress, Poultices, Oral ingestion, Poultices	arthralgia, back pain, fracture, knee pain, lumbago, muscle pain, sprain of hand/finger, sprain of joint, sprain of joint/ligament, sprain of knee	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain, Sprain/strain of joint NOS, Sprain/strain of knee	HIK, MLK, KTN, PN	Kantasrila MSD002
Ageratum conyzoides L.	Asteraceae	0.13	0.06	leaves, roots, whole plants	Decoction, Grind and burning	Oral ingestion, Poultices	arthralgia, back pain, knee pain, lumbago, muscle pain, sprain of joint	Back symptom/complaint, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HPL, MLK, PN	Kantasrila MSD003
Alpinia galanga (L.) Willd.	Zingiberaceae	0.28	0.1	rhizomes, roots	Cook, Grind, Grind and burning, Grind and steam	Eaten, Poultices	arthralgia, back pain, effusion of joint, fracture, Knee pain, leg pain/thigh pain, lumbago, muscle pain, sprain of arm, sprain of leg, sprain of joint/ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HIK, PN, MLK	Kantasrila MSD004
Alpinia roxburghii Sweet	Zingiberaceae	0.32	0.13	rhizomes, inflorescences, roots, stems	Cook, Decoction, Grind and burning, None	Compress, Poultices, Eaten, Oral ingestion,	arthralgia, arthritis, osteoarthrosis, rheumatoid, back pain, effusion of joint, fracture, knee pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain, Osteoarthrosis other	HIK, PN, KTN, MLK	Kantasrila MSD005
Alstonia macrophylla Wall. ex G.Don	Apocynaceae	0.53	0.21	bark, exudates, roots	Decoction, Water infusion, None	Eaten, Oral ingestion	arm pain, arthralgia, back pain, effusion of joint, fracture, knee pain, leg pain/thigh pain, lumbago, muscle pain, sprain of joint/ligament, tendinitis	Arm symptom/complaint, Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HIK, HPL, KTN, MLK, PN, KT	Kantasrila MSD006
Alstonia rostrata C.E.C.Fisch.	Apocynaceae	0.33	0.14	exudates, bark, leaves, roots	Decoction, water infusion, None	Eaten, Oral ingestion, Poultices	arm pain, arthralgia, back pain, knee pain, leg pain/thigh pain, lumbago, muscle pain, tendinitis	Arm symptom/complaint, Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Knee symptom/complaint, Knee symptom/complaint, Leg/thigh symptom/complaint, Leg/thigh symptom/complaint, Muscle pain	HIK, HPL, MLK, PN, KTN, KT	Kantasrila MSD007
Anredera cordifolia (Ten.) Steenis	Basellaceae	0.03	0.01	leaves, whole plants	Cook	Eaten	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HPL	Kantasrila MSD008
Antidesma bunius (L.) Spreng.	Euphorbiaceae	0.02	0.01	stems	Decoction	Oral ingestion	back pain, lumbago	Back symptom/complaint, Flank/axilla symptom/complaint	MLK	Kantasrila MSD106
Asparagus filicinus Buch.-Ham. ex D.Don	Asparagaceae	0.15	0.07	roots, whole plants	Decoction	Oral ingestion	arthralgia, back pain, knee pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain	HPL, KT, PN	Kantasrila MSD009
Baccaurea ramiflora Lour.	Euphorbiaceae	0.08	0.02	bark, infructescences, stems	Decoction, None	Eaten, Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	MLK, PN	Kantasrila MSD010
Betula alnoides Buch.-Ham. ex D.Don	Betulaceae	1.15	0.51	bark, roots, leaves, whole plants	Alcoholic infusion, Decoction	Oral ingestion	arthralgia, back pain, bone pain, knee pain, leg pain/thigh pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Osteoarthrosis other	HIK, HPL, KTN, KT, MLK, PN	Kantasrila MSD011
Biancaea sappan (L.) Tod.	Fabaceae	0.31	0.14	bark, infructescences, stems, whole plants	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, HPL, MLK, PN, KT	Kantasrila MSD012
Blumea balsamifera (L.) DC.	Asteraceae	1.13	0.48	leaves, roots, stems, whole plants	Burning, Decoction, Grind and burning, None, Steam	Bath, Compress, Poultices, Eaten, Oral ingestion, Steaming	ankle pain, arm pain, arthralgia, back pain, calf pain, fracture, knee pain, leg pain/thigh pain, lumbago, muscle pain, neck pain, sprain of ankle, sprain of joint/ligament, sprain of leg, tendinitis	Ankle symptom/complaint, Arm symptom/complaint, Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Neck symptom/complain, Sprain/strain of ankle, Sprain/strain of joint NOS	HIK, HPL, KTN, KT, MLK, PN	Kantasrila MSD013
Boehmeria glomerulifera Miq.	Urticaceae	0.02	0.01	leaves	Burning	Poultices	sprain of joint/ligament	Sprain/strain of joint NOS	HPL	Kantasrila MSD107
Brachypterum scandens (Roxb.) Miq.	Fabaceae	0.02	0.01	whole plants	Decoction	Oral ingestion	muscle pain	Muscle pain	KTN	Kantasrila MSD108
Buddleja asiatica Lour.	Scrophulariaceae	0.11	0.04	leaves, roots, whole plants	Burning, Decoction, Grind	Compress, Oral ingestion, Poultices	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, MLK, HPL	Kantasrila MSD014
Canscora andrographioides Griff. ex C.B.Clarke	Gentianaceae	0.05	0.04	whole plants	Decoction	Oral ingestion	lumbago, muscle pain	Flank/axilla symptom/complaint, Muscle pain	HIK, KTN	Kantasrila MSD015
Celastrus paniculatus Willd.	Celastraceae	0.18	0.08	leaves, stems, roots, whole plants	Decoction, Dried and decoction	Bath, Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, HPL, KT, MLK	Kantasrila MSD016
Centella asiatica (L.) Urb.	Apiaceae	0.63	0.34	leaves, roots, whole plants	Alcoholic infusion, Cook, Decoction, Grind and water infusion, None	Eaten, Oral ingestion	back pain, leg pain/thigh pain, lumbago, muscle pain, sprain of ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HIK, HPL, KTN, KT, MLK, PN	Kantasrila MSD017
Cheilocostus speciosus (J.Koenig) C.D.Specht	Costaceae	0.3	0.13	bark, roots, rhizomes, stems, whole plants	Decoction, Grind and burning, None	Eaten, Oral ingestion, Poultices	arthralgia, back pain, fracture, knee pain, leg pain/thigh pain, lumbago, muscle pain, sprain of joint/ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HIK, HPL, PN	Kantasrila MSD018
Chloranthus elatior Link	Chloranthaceae	0.07	0.03	leaves, roots	Alcoholic infusion, Decoction, Burning and grind	Oral ingestion, Poultices	back pain, fracture, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Muscle pain, Sprain/strain of joint NOS	HIK, HPL, MLK	Kantasrila MSD019
Chromolaena odorata (L.) R.M.King & H.Rob.	Asteraceae	0.59	0.28	leaves, aerial parts, roots	Burning, Grind, Grind and burning, Decoction,	Oral ingestion, Poultices	back pain, effusion of joint, fracture, knee pain, leg pain/thigh pain, lumbago, muscle pain, sprain of joint/ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HIK, HPL, KTN, KT, MLK, PN	Kantasrila MSD020
Citrus medica L.	Rubiaceae	0.02	0.01	infructescences, roots	Crush, Decoction	Oral ingestion	muscle pain	Muscle pain	HPL	Kantasrila MSD109
Clausena excavata Burm.f.	Rutaceae	0.01	0.01	leaves	Burning	Poultices	Knee pain	Knee symptom/complaint	HIK	Kantasrila MSD021
Clematis smilacifolia Wall.	Ranunculaceae	0.01	0.01	roots	Decoction	Oral ingestion	muscle pain	Muscle pain	HIK	Kantasrila MSD110
Clerodendrum petasites (Lour.) S.Moore	Lamiaceae	0.02	0.01	roots	Decoction	Oral ingestion	lumbago	Flank/axilla symptom/complaint	HIK	Kantasrila MSD111
Cnestis palala (Lour.) Merr.	Connaraceae	0.02	0.01	leaves, stems	Burning, Decoction, Dried and decoction	Oral ingestion, Poultices	muscle pain, sprain of joint/ligament	Muscle pain, Sprain/strain of joint NOS	HPL, KT	Kantasrila MSD022
Coix lachryma-jobi L. var. monilifer Watt	Poaceae	0.12	0.05	infructescences, roots	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, HPL, MLK, KTN	Kantasrila MSD112
Crinum asiaticum L.	Amaryllidaceae	1.02	0.4	bulbs, leaves, whole plants	Burning, Burning and grind, Decoction	Compress, Oral ingestion, Poultices	ankle pain, arthralgia, back pain, bone pain, effusion of joint, fracture, knee pain, leg pain/thigh pain, lumbago, muscle pain, sprain of joint, sprain of joint/ligament, sprain of ligament, tendinitis	Ankle symptom/complaint, Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Osteoarthrosis other, Sprain/strain of joint NOS	HIK, HPL, KT, MLK, PN, KTN	Kantasrila MSD023
Croton kongensis Gagnep.	Euphorbiaceae	0.35	0.13	bark, stems, leaves, roots	Burning, steam, Decoction, Grind, Grind and burning, Steam	Bath, Oral ingestion, Poultices, Steaming	arthralgia, back pain, bone pain, fracture, knee pain, leg pain/thigh pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Osteoarthrosis other	HIK, HPL, MLK, PN	Kantasrila MSD024
Croton persimilis Müll.Arg.	Euphorbiaceae	0.33	0.13	roots, leaves, bark, stems	Burning, Burning and grind, Decoction, Steam	Oral ingestion, Poultices, Steaming	arthralgia, back pain, bone pain, calf pain, fracture, knee pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Osteoarthrosis other	HIK, MLK, HPL	Kantasrila MSD025
Curcuma longa L.	Zingiberaceae	0.7	0.3	leaves, rhizomes	Grind, Grind and burning	Poultices	fracture, leg fracture, muscle pain	Fracture: femur, Fracture: other, Fracture: tibia/fibula, Muscle pain	HIK	Kantasrila MSD113
Curcuma zedoaria (Christm.) Roscoe	Zingiberaceae	0.26	0.08	inflorescences, rhizomes, whole plants, leaves	Decoction, Dried, pounding and honey infusion, Grind, Grind and burning, None	Compress, Poultices, Eaten, Oral ingestion	arthralgia, arthritis, osteoarthrosis, back pain, bone pain, fracture, knee pain, leg fracture, leg pain/thigh pain, lumbago, muscle pain, rheumatoid, sprain of joint, sprain of joint/ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: femur, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Osteoarthrosis other, Rheumatoid/seropositive arthritis, Sprain/strain of joint NOS	HIK, HPL, KT, MLK, PN, KTN	Kantasrila MSD114
Curcuma elata Roxb.	Zingiberaceae	0.05	0.02	leaves, whole plants, rhizomes	Decoction, Grind and burning, Grind	Oral ingestion, Poultices	arthralgia, arthritis, osteoarthrosis, bone pain, fracture, leg fracture, muscle pain, rheumatoid, sprain of joint/ligament	Fracture: femur, Fracture: other, Fracture: tibia/fibula, Muscle pain, Joint symptom/complaint NOS, Osteoarthrosis other, Rheumatoid/seropositive arthritis, Sprain/strain of joint NOS	HIK, HPL	Kantasrila MSD026
Cuscuta chinensis Lam.	Convolvulaceae	0.08	0.05	whole plants	Alcoholic infusion, Decoction, Dried and decoction	Oral ingestion	lumbago, muscle pain	Flank/axilla symptom/complaint, Muscle pain	HIK, KTN, KT	Kantasrila MSD027
Cymbopogon citratus (DC.) Stapf	Poaceae	0.86	0.29	aerial parts, roots, leaves, whole plants, rhizomes	Burning and water infusion, Cook, Decoction, Grind and burning, Grind and steam, Grind and decoction	Poultices, Eaten, Oral ingestion	arm fracture, arthralgia, arthritis, osteoarthrosis, back pain, bone pain, fracture, knee pain, leg fracture, leg pain/thigh pain, lumbago, muscle pain, rheumatoid, sprain of joint, sprain of joint/ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: femur, Fracture: other, Fracture: radius/ulna, Fracture: tibia/fibula, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Osteoarthrosis other, Rheumatoid/seropositive arthritis, Sprain/strain of joint NOS	HIK, KTN, KT, PN, HPL, MLK	Kantasrila MSD028
Dendrocalamus brandisii (Munro) Kurz	Poaceae	0.01	0.01	stems	Decoction	Oral ingestion	chest pain	Chest symptom/complaint	MLK	Kantasrila MSD029
Dendrophthoe pentandra (L.) Miq.	Loranthaceae	0.32	0.16	leaves, whole plants, roots, stems	Decoction, Steam	Oral ingestion, Steaming	arthralgia, back pain, fracture, knee pain, lumbago, muscle pain, sprain of joint/ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HIK, HPL, MLK, PN, KT	Kantasrila MSD030
Desmodium renifolium (L.) Schindl.	Fabaceae	0.49	0.19	roots, stems, whole plants	Alcoholic infusion, Decoction	Oral ingestion	back pain, leg pain/thigh pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Leg/thigh symptom/complaint, Muscle pain	HIK, HPL, KT, MLK, KTN, PN	Kantasrila MSD031
Desmos macrocarpus Bân	Annonaceae	0.06	0.04	roots, whole plants	Decoction, Dried and decoction	Oral ingestion	arthralgia, muscle pain	Joint symptom/complaint NOS, Muscle pain	KTN	Kantasrila MSD115
Diplazium esculentum (Retz.) Sw.	Athyriaceae	0.01	0.01	rhizomes	Grind	Poultices	fracture	Fracture: other	KTN	Kantasrila MSD032
Dischidia nummularia R.Br.	Apocynaceae	0.18	0.07	leaves, whole plants	Decoction, None	Chewing with Areca catechu, Eaten, Oral ingestion	back pain, leg pain/thigh pain, lumbago	Back symptom/complaint, Flank/axilla symptom/complaint, Leg/thigh symptom/complaint, Muscle pain	HIK, PN, KT	Kantasrila MSD033
Duabanga grandiflora (DC.) Walp.	Lythraceae	0.17	0.08	bark, infructescences, stems, whole plants	Decoction, Grind, Grind and burning, Steam	Oral ingestion, Poultices, Steaming	arthralgia, back pain, bone pain, effusion of joint, fracture, knee pain, lumbago, muscle pain, tensinitis	Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain, Osteoarthrosis other	HIK, KTN, MLK, PN	Kantasrila MSD034
Dufrenoya sessilis (Craib) Stauffer	Santalaceae	0.44	0.11	roots, stems, whole plants, leaves	Boil, Burning, Grind, Grind and burning, Decoction, Dried and decoction	Oral ingestion, Poultices	arm fracture, arthralgia, effusion of joint, fracture, leg fracture, leg pain/thigh pain, lumbago, muscle pain, sprain of joint/ligament, sprain of leg, tendinitis	Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Fracture: femur, Fracture: other, Fracture: radius/ulna, Fracture: tibia/fibula, Joint symptom/complaint NOS, Leg/thigh symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HIK, KTN, MLK	Kantasrila MSD035
Duhaldea cappa (Buch.-Ham. ex D.Don) Pruski & Anderb.	Asteraceae	0.79	0.31	leaves, inflorescences, roots, stems, whole plants	Burning, Grind and burning, Decoction, Steam	Compress, Poultices, Oral ingestion, Steaming	arthralgia, back pain, calf pain, fracture, knee pain, lumbago, muscle pain, sprain of joint/ligament, sprained ankle	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Sprain/strain of ankle, Sprain/strain of joint NOS	HIK, HPL, KT, MLK, KTN, PN	Kantasrila MSD036
Elephantopus scaber L.	Asteraceae	0.69	0.31	roots, whole plants	Decoction, Dried and decoction	Oral ingestion	arthralgia, back pain, leg pain/thigh pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Leg/thigh symptom/complaint, Muscle pain	HPL, KTN, MLK, PN, HIK	Kantasrila MSD037
Eleutherine bulbosa (Mill.) Urb.	Iridaceae	0.02	0.01	bulbs, rhizomes	Decoction, Pounding and water infusion	Compress, Liniment, Oral ingestion	lumbago, muscle pain	Flank/axilla symptom/complaint, Muscle pain	MLK	Kantasrila MSD038
Embelia ribes Burm.f.	Primulaceae	0.1	0.05	bark, stems, roots	Crush, Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, HPL, KTN, MLK	Kantasrila MSD039
Engelhardtia spicata Lechen ex Blume	Juglandaceae	0.18	0.07	bark	Decoction	Oral ingestion	back pain, leg pain/thigh pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Leg/thigh symptom/complaint, Muscle pain	HPL, MLK, PN	Kantasrila MSD040
Ensete glaucum (Roxb.) Cheesman	Musaceae	0.2	0.07	bark, stems, exudates, infructescences	Crush, Decoction	Bath, Compress, Liniment, Oral ingestion	arthralgia, back pain, knee pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain	HPL, KT, MLK	Kantasrila MSD116
Erythrina subumbrans (Hassk.) Merr.	Fabaceae	0.02	0.01	bark	Grind	Poultices	fracture, muscle pain	Fracture: other, Muscle pain	KTN	Kantasrila MSD041
Eurycoma longifolia Jack	Simaroubaceae	0.4	0.22	leaves, roots	Decoction	Oral ingestion	arthralgia, back pain, knee pain, lumbago, muscle pain, tendinitis	Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain	HIK, MLK, PN	Kantasrila MSD042
Flacourtia jangomas (Lour.) Raeusch.	Salicaceae	0.96	0.4	roots, whole plants, bark	Decoction, Dried and decoction, Grind, None, Steam	Eaten, Oral ingestion, Steaming	back pain, bone pain, knee pain, leg pain/thigh pain, lumbago, muscle pain, tendinitis	Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Osteoarthrosis other	HIK, HPL, KT, MLK, PN	Kantasrila MSD043
Flemingia strobilifera (L.) W.T.Aiton	Fabaceae	0.23	0.09	roots, whole plants	Decoction	Oral ingestion	back pain, leg pain/thigh pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Leg/thigh symptom/complaint, Muscle pain	HPL, MLK, PN	Kantasrila MSD044
Flueggea leucopyrus Willd.	Phyllanthaceae	0.03	0.02	roots	Decoction	Oral ingestion	muscle pain	Muscle pain	KTN	Kantasrila MSD045
Gmelina arborea Roxb.	Lamiaceae	0.68	0.29	bark, roots, stems	Grind, Grind and burning, Decoction, Steam, Water infusion	Bath, Soak, Compress, Oral ingestion, Poultices, Steaming	arthralgia, back pain, bone pain, calf pain, fracture, knee pain, lumbago, muscle pain, leg pain/thigh pain, metatarsalgia, sprain of joint/ligament, tendinitis	Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Foot/toe symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Osteoarthrosis other, Sprain/strain of joint NOS	HIK, HPL, MLK, PN, KT	Kantasrila MSD046
Grewia nervosa (Lour.) Panigrahi	Malvaceae	0.03	0.02	bark	Decoction	Oral ingestion	muscle pain	Muscle pain	KT	Kantasrila MSD047
Gynostemma pentaphyllum (Thunb.) Makino	Cucurbitaceae	0.07	0.05	roots, whole plants	Decoction, Dried and decoction	Oral ingestion	arthralgia, muscle pain	Joint symptom/complaint NOS, Muscle pain	HPL, KT, MLK	Kantasrila MSD048
Heliciopsis terminalis (Kurz) Sleumer	Proteaceae	0.02	0.01	bark	Decoction	Oral ingestion	back pain, lumbago	Back symptom/complaint, Flank/axilla symptom/complaint	MLK	Kantasrila MSD117
Henslowia collettii Gamble	Santalaceae	0.2	0.08	bark, leaves, whole plants	Decoction, Dried and decoction, Burning, Grind and burning	Oral ingestion, Poultices	arm fracture, back pain, foot pain, fracture, leg fracture, loin pain, leg pain/thigh pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Foot/toe symptom/complaint, Fracture: femur, Fracture: other, Fracture: radius/ulna, Fracture: tibia/fibula, Leg/thigh symptom/complaint, Muscle pain	HIK, HPL, KTN, MLK	Kantasrila MSD049
Hippochaete debilis (Roxb. ex Vaucher) Ching	Equisetaceae	0.26	0.1	whole plants	Decoction, Dried and decoction	Oral ingestion	back pain, knee pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Knee symptom/complaint, Muscle pain	HIK, KTN, MLK, PN, KT	Kantasrila MSD050
Hiptage benghalensis (L.) Kurz subsp. candicans (Hook.f.) Sirirugsa	Malpighiaceae	0.11	0.06	bark, stems, whole plants	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, HPL, KT, MLK	Kantasrila MSD118
Hiptage benghalensis (L.) Kurz	Malpighiaceae	0.07	0.04	bark, roots, stems	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, KT, MLK, PN	Kantasrila MSD119
Hydrocotyle javanica Thunb.	Araliaceae	0.19	0.07	leaves, roots, whole plants	Cook, Decoction, Grind and water infusion, None	Eaten, Oral ingestion	back pain, leg pain/thigh pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Leg/thigh symptom/complaint, Muscle pain	HPL, KT, PN, MLK	Kantasrila MSD051
Illigera trifoliata (Griff.) Dunn	Hernandiaceae	0.02	0.01	bark	Decoction	Oral ingestion	back pain, lumbago	Back symptom/complaint, Flank/axilla symptom/complaint	MLK	Kantasrila MSD052
Imperata cylindrica (L.) Raeusch.	Poaceae	0.22	0.09	roots	Decoction	Oral ingestion	back pain, effusion of joint, fracture, lumbago, muscle pain, sprain of joint/ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Muscle pain, Sprain/strain of joint NOS	HIK, HPL, KTN, MLK, PN	Kantasrila MSD053
Indigofera caloneura Kurz	Fabaceae	0.03	0.01	whole plants	Decoction	Oral ingestion	back pain, lumbago	Back symptom/complaint, Flank/axilla symptom/complaint	KT	Kantasrila MSD120
Ixora henryi H.Lév.	Rubiaceae	0.04	0.02	roots, leaves	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	KTN, MLK	Kantasrila MSD121
Leea indica (Burm.f.) Merr.	Vitaceae	0.19	0.09	bark, whole plants, roots, leaves, stems	Burning, Decoction	Oral ingestion, Poultices	back pain, elbow pain, knee pain, lumbago, muscle pain, tendinitis	Arm symptom/complaint, Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Knee symptom/complaint, Muscle pain	HIK, KTN, MLK, PN	Kantasrila MSD054
Lycopodiella cernua (L.) Pic.Serm.	Lycopodiaceae	0.03	0.01	whole plants	Grind and burning	Poultices	Knee pain, muscle pain, sprain of ankle	Knee symptom/complaint, Muscle pain, Sprain/strain of ankle	HIK	Kantasrila MSD055
Lygodium flexuosum (L.) Sw.	Lygodiaceae	0.18	0.06	leaves, roots, whole plants	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HPL, MLK, PN	Kantasrila MSD056
Macaranga denticulata (Blume) Müll.Arg.	Euphorbiaceae	0.03	0.01	roots	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	MLK	Kantasrila MSD057
Maclura fruticosa (Roxb.) Corner	Moraceae	0.65	0.28	roots, bark, leaves, stems, whole plants	Cook, Decoction, None, steam	Eaten, Oral ingestion, Steaming	back pain, fracture, lumbago, muscle pain, knee pain,	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain	HIK, HPL, KT, MLK, PN	Kantasrila MSD122
Mangifera indica L.	Anacardiaceae	0.02	0.01	bark	Decoction, Grind and burning	Compress, Oral ingestion	heel pain, muscle pain	Foot/toe symptom/complaint, Muscle pain	HIK, KTN	Kantasrila MSD058
Melicope lunu-ankenda (Gaertn.) T.G.Hartley	Rutaceae	0.06	0.02	leaves, roots	Cook, Decoction, None	Eaten, Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HPL, MLK	Kantasrila MSD059
Melicope pteleifolia (Champ. ex Benth.) T.G.Hartley	Rutaceae	0.13	0.08	roots, leaves	Decoction, None	Eaten, Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	MLK, PN	Kantasrila MSD060
Miliusa thorelii Finet & Gagnep.	Annonaceae	0.08	0.03	roots, whole plants	Decoction	Oral ingestion	back pain, lumbago	Back symptom/complaint, Flank/axilla symptom/complaint	KT, MLK	Kantasrila MSD123
Miliusa velutina (Dunal) Hook.f. & Thomson	Annonaceae	0.11	0.04	bark, roots, whole plants	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HPL, KT, MLK	Kantasrila MSD124
Mimosa pudica L.	Fabaceae	0.2	0.08	aerial parts, roots, whole plants	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HPL, PN, MLK	Kantasrila MSD125
Mitragyna rotundifolia (Roxb.) Kuntze	Rubiaceae	0.01	0.01	roots	Burning	Poultices	Tendinitis	Bursitis/tendinitis/synovitis NOS	HPL	Kantasrila MSD126
Momordica charantia L.	Cucurbitaceae	0.03	0.02	leaves, whole plants	Decoction, Grind	Compress, Poultices, Oral ingestion	muscle pain	Muscle pain	HIK	Kantasrila MSD061
Monosis volkameriifolia (DC.) H.Rob. & Skvarla	Asteraceae	0.03	0.02	roots, stems	Decoction, Steam	Oral ingestion, Steaming	muscle pain	Muscle pain	HIK, MLK	Kantasrila MSD127
Mussaenda sanderiana Ridl.	Rubiaceae	0.08	0.03	roots	Decoction	Oral ingestion	arthralgia, back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Muscle pain	MLK, PN	Kantasrila MSD062
Oenanthe javanica (Blume) DC.	Apiaceae	0.02	0.01	leaves	None	Eaten	back pain, lumbago	Back symptom/complaint, Flank/axilla symptom/complaint	HPL	Kantasrila MSD063
Oroxylum indicum (L.) Benth. ex Kurz	Bignoniaceae	0.19	0.1	inflorescences, infructescences, bark, roots, stems	Decoction, Cook, Grind and burning	Eaten, Oral ingestion, Poultices	back pain, fracture, lumbago, muscle pain, tendinitis	Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Fracture: other, Muscle pain	HIK, KTN, MLK, PN	Kantasrila MSD064
Orthosiphon aristatus (Blume) Miq.	Lamiaceae	0.03	0.01	whole plants	Decoction	Oral ingestion	back pain, lumbago	Back symptom/complaint, Flank/axilla symptom/complaint	MLK	Kantasrila MSD065
Osbeckia chinensis L.	Melastomataceae	0.1	0.05	roots	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	KTN, KT, MLK, KT	Kantasrila MSD066
Paris polyphylla Sm.	Melanthiaceae	0.11	0.07	infructescences, rhizomes, roots, whole plants	Alcoholic infusion, Decoction, None	Eaten, Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HPL, MLK, KTN, KT, PN	Kantasrila MSD128
Peliosanthes caesia J.M.H.Shaw	Asparagaceae	0.03	0.01	whole plants	Decoction	Oral ingestion	back pain, lumbago	Back symptom/complaint, Flank/axilla symptom/complaint	KT	Kantasrila MSD067
Phlogacanthus curviflorus Nees	Acanthaceae	0.33	0.13	aerial parts, roots, leaves, whole plants	Burning, Decoction, Steam	Bath, Compress, Oral ingestion, Poultices, Soak, Steaming	arthralgia, back pain, bone pain, knee pain, lumbago, muscle pain, sprain of joint/ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain, Osteoarthrosis other, Sprain/strain of joint NOS	HIK, HPL, MLK, PN, KT	Kantasrila MSD068
Phyllanthus amarus Schumach. & Thonn.	Phyllanthaceae	0.17	0.08	roots, whole plants	Decoction	Bath, Oral ingestion	arm pain, back pain, knee pain, lumbago, muscle pain	Arm symptom/complaint, Back symptom/complaint, Flank/axilla symptom/complaint, Knee symptom/complaint, Muscle pain	HIK, MLK, PN, HPL	Kantasrila MSD069
Phyllanthus emblica L.	Phyllanthaceae	0.05	0.02	bark, infructescences	Decoction, Salt infusion	Eaten, Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	MLK, PN	Kantasrila MSD070
Phyllodium pulchellum (L.) Desv.	Fabaceae	0.24	0.08	leaves, roots, whole plants	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	KT, MLK, PN	Kantasrila MSD129
Picrasma javanica Blume	Simaroubaceae	0.18	0.08	bark, whole plants	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, HPL, MLK	Kantasrila MSD071
Piper ribesioides (Wall.) C.DC	Piperaceae	0.06	0.03	stems, whole plants	Alcoholic infusion, Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HPL, MLK, KT	Kantasrila MSD130
Piper interruptum Opiz	Piperaceae	0.11	0.05	stems	Alcoholic infusion, Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HPL, MLK	Kantasrila MSD072
Plantago major L.	Plantaginaceae	1.1	0.43	leaves, roots, whole plants	Burning, Decoction, Dried and decoction, Dried and grind, Grind, Grind and burning, None	Eaten, Oral ingestion, Poultices	arthralgia, back pain, bone pain, fracture, knee pain, leg pain/thigh pain, lumbago, muscle pain, heel pain, sprain of arm, sprain of joint/ligament, sprained ankle, tendinitis	Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Foot/toe symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Osteoarthrosis other, Sprain/strain of ankle, Sprain/strain of joint NOS,	HIK, HPL, KT, MLK, PN	Kantasrila MSD073
Plumbago indica L.	Plumbaginaceae	0.08	0.03	roots	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, HPL	Kantasrila MSD074
Plumbago zeylanica L.	Plumbaginaceae	0.04	0.02	roots	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK	Kantasrila MSD075
Plumeria rubra L.	Apocynaceae	0.05	0.02	stems	Grind	Poultices	Knee pain	Knee symptom/complaint	MLK	Kantasrila MSD131
Plumeria obtusa L.	Apocynaceae	0.01	0.01	bark, stems	Decoction, Grind	Oral ingestion, Poultices	arthralgia, back pain, knee pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain	MLK	Kantasrila MSD132
Polygala arillata Buch.-Ham. ex D.Don	Polygalaceae	0.06	0.02	roots	Decoction	Oral ingestion	back pain, lumbago, muscle pain, sprain of ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HPL, KT	Kantasrila MSD076
Polygala chinensis L.	Polygalaceae	0.64	0.29	roots, whole plants	Decoction, Dried and decoction	Oral ingestion	back pain, fracture, knee pain, lumbago, muscle pain, sprain of ligament, tendinitis	Arm symptom/complaint, Back symptom/complaint, Bursitis/tendinitis/synovitis NOS, Flank/axilla symptom/complaint, Fracture: other, Knee symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HIK, HPL, KTN, KT, PN, MLK	Kantasrila MSD077
Pothos chinensis (Raf.) Merr.	Araceae	1.02	0.4	leaves, whole plants, roots, stems	Decoction, Dried and alcohol infusion, Dried and decoction, Steam	Oral ingestion, Steaming	arthralgia, back pain, knee pain, lumbago, muscle pain, shoulder pain	Back symptom/complaint, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain, Shoulder symptom/complaint	HIK, HPL, KT, MLK, PN, KTN	Kantasrila MSD078
Pothos scandens L.	Araceae	0.93	0.35	leaves, whole plants, roots, stems	Decoction, Dried and alcohol infusion, Dried and decoction, Steam	Oral ingestion, Steaming	arthralgia, back pain, fracture, knee pain, leg pain/thigh pain, lumbago, muscle pain, shoulder pain	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Shoulder symptom/complaint	HIK, HPL, KT, MLK, PN, KTN	Kantasrila MSD079
Rhinacanthus nasutus (L.) Kurz	Acanthaceae	0.01	0.01	roots, stems	Decoction	Oral ingestion	muscle pain	Muscle pain	HIK	Kantasrila MSD080
Rotheca serrata Steane & Mabb.	Lamiaceae	0.03	0.02	aerial parts, leaves, roots	Burning, Decoction, Steam	Oral ingestion, Poultices, Steaming	muscle pain	Muscle pain	MLK	Kantasrila MSD081
Rubia cordifolia L.	Rubiaceae	0.01	0.01	roots	Decoction	Oral ingestion	muscle pain	Muscle pain	HPL	Kantasrila MSD082
Saccharum officinarum L.	Poaceae	0.11	0.05	roots, stems	Decoction	Oral ingestion	back pain, leg pain/thigh pain, lumbago, muscle pain, sprain of joint/ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HPL, MLK	Kantasrila MSD083
Salacia verrucosa Wight	Celastraceae	0.03	0.01	roots	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	KTN, MLK	Kantasrila MSD084
Sambucus javanica Reinw. ex Blume	Adoxaceae	1.49	0.56	leaves, aerial parts, roots, whole plants	Boil and crush, Burning, Burning and grind, Decoction, Dried and decoction, Grind, Grind and burning	Bath, Oral ingestion, Compress, Poultices	ankle pain, arthralgia, ankle pain, back pain, bone pain, effusion of joint, fracture, knee pain, leg pain/thigh pain, lumbago, muscle pain, sprain of arm, sprain of hand, sprain of joint/ligament	Ankle symptom/complaint, Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Hand/finger symptom/complaint, Joint symptom/complaint NOS, Knee symptom/complaint, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Osteoarthrosis other, Sprain/strain of joint NOS	HIK, HPL, KTN, KT, MLK, PN	Kantasrila MSD085
Sambucus simpsonii Rehder	Adoxaceae	0.84	0.28	aerial parts, leaves, whole plants, roots	Grind, Burning, Burning and grind, Decoction	Oral ingestion, Compress, Poultices	arthralgia, arthritis, osteoarthrosis, back pain, bone pain, effusion of joint, fracture, knee pain, leg pain/thigh pain, lumbago, muscle pain, rheumatoid, sprain of hand, sprain of joint/ligament	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Leg/thigh symptom/complaint, Muscle pain, Osteoarthrosis other, Rheumatoid/seropositive arthritis, Sprain/strain of joint NOS	HIK, HPL, KTN, KT, MLK, PN	Kantasrila MSD086
Sarcandra glabra (Thunb.) Nakai var. brachystachys (Blume) Verdc.	Chloranthaceae	0.01	0.01	whole plants	Decoction	Soak	Knee pain	Knee symptom/complaint	HIK	Kantasrila MSD087
Schefflera leucantha R.Vig.	Araliaceae	0.28	0.13	bark, leaves, whole plants, roots, stems	Decoction, Dried and decoction, Grind and burning, steam	Oral ingestion, Poultices, Steaming	back pain, bone pain, fracture, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other, Muscle pain, Osteoarthrosis other	HIK, HPL, KT, PN	Kantasrila MSD088
Scleropyrum maingayi Hook.f.	Santalaceae	0.05	0.02	leaves, whole plants, stems	Decoction	Bath, Oral ingestion	back pain, elbow pain, knee pain, lumbago, muscle pain	Arm symptom/complaint, Back symptom/complaint, Flank/axilla symptom/complaint, Knee symptom/complaint, Muscle pain	HIK, HPL	Kantasrila MSD089
Scleropyrum pentandrum (Dennst.) Mabb.	Santalaceae	0.38	0.17	roots, stems, bark, infructescences, whole plants	Burning, Decoction, Steam	Oral ingestion, Poultices, Steaming	arthralgia, back pain, leg pain/thigh pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Joint symptom/complaint NOS, Leg/thigh symptom/complaint, Muscle pain	HIK, MLK, PN, HPL	Kantasrila MSD090
Scoparia dulcis L.	Plantaginaceae	0.18	0.08	roots, whole plants	Decoction, Dried and decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, HPL, KTN, MLK	Kantasrila MSD091
Senna occidentalis (L.) Link	Fabaceae	0.06	0.02	leaves, whole plants, seeds	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HPL, MLK	Kantasrila MSD133
Sida acuta Burm.f.	Malvaceae	0.03	0.02	roots, whole plants	Decoction	Oral ingestion	back pain, fracture, lumbago	Back symptom/complaint, Flank/axilla symptom/complaint, Fracture: other	HPL, KT	Kantasrila MSD092
Sida cordifolia L.	Malvaceae	0.01	0.01	roots	Decoction	Oral ingestion	back pain	Back symptom/complaint	KT	Kantasrila MSD093
Sida rhombifolia L.	Malvaceae	0.01	0.01	roots	Decoction	Oral ingestion	back pain	Back symptom/complaint	KT	Kantasrila MSD094
Smilax corbularia Kunth	Smilacaceae	0.17	0.1	roots	Decoction	Oral ingestion	back pain, knee pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Knee symptom/complaint, Muscle pain	HPL, KTN, MLK, PN	Kantasrila MSD134
Smilax glabra Roxb.	Smilacaceae	0.03	0.02	roots	Decoction	Oral ingestion	muscle pain	Muscle pain	KTN, MLK	Kantasrila MSD095
Smilax luzonensis C.Presl	Smilacaceae	0.23	0.08	inflorescences, roots, stems	Cook, Decoction	Eaten, Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, HPL, MLK, PN	Kantasrila MSD135
Solanum erianthum D.Don	Solanaceae	0.03	0.01	leaves, stems, roots	Decoction, Grind	Oral ingestion, Poultices, liniment	back pain, leg pain/thigh pain, muscle pain	Back symptom/complaint, Leg/thigh symptom/complaint, Muscle pain	MLK	Kantasrila MSD136
Tadehagi triquetrum (L.) H.Ohashi	Fabaceae	0.34	0.15	leaves, roots, stems, whole plants	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HPL, MLK, PN, KT	Kantasrila MSD096
Thunbergia coccinea Wall. ex D.Don	Acanthaceae	0.33	0.17	leaves, roots, stems, whole plants	Decoction, None	Eaten, Oral ingestion	back pain, leg pain/thigh pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Leg/thigh symptom/complaint, Muscle pain	HPL, MLK, PN, KT	Kantasrila MSD097
Thunbergia laurifolia Lindl.	Acanthaceae	0.28	0.13	leaves, roots, stems, whole plants	Decoction, None	Eaten, Oral ingestion	back pain, leg pain/thigh pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Leg/thigh symptom/complaint, Muscle pain	HPL, MLK, PN	Kantasrila MSD098
Thysanolaena latifolia (Roxb. ex Hornem.) Honda	Poaceae	0.06	0.04	roots, leaves, stems	Decoction	Oral ingestion	lumbago, muscle pain	Flank/axilla symptom/complaint, Muscle pain	KTN, PN	Kantasrila MSD099
Tinospora crispa (L.) Hook.f. & Thomson	Menispermaceae	0.27	0.11	stems, whole plants	Alcholic infusion, Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HIK, MLK, PN, KTN	Kantasrila MSD100
Tupistra muricata (Gagnep.) N.Tanaka	Asparagaceae	0.14	0.05	leaves, inflorescences, whole plants, roots	Burning, Grind, Decoction	Oral ingestion, Poultices	fracture, muscle pain, sprain of ligament, tendinitis	Bursitis/tendinitis/synovitis NOS, Fracture: other, Muscle pain, Sprain/strain of joint NOS	KTN	Kantasrila MSD101
Uncaria laevigata Wall. ex G.Don	Rubiaceae	0.01	0.01	stems	Decoction	Oral ingestion	lumbago	Flank/axilla symptom/complaint	MLK	Kantasrila MSD137
Xantolis burmanica (Collett & Hemsl.) P.Royen	Sapotaceae	0.02	0.01	bark	Decoction	Oral ingestion	muscle pain	Muscle pain	PN	Kantasrila MSD102
Zingiber officinale Roscoe	Zingiberaceae	0.04	0.03	rhizomes, roots	Grind, Grind and burning	Poultices	arthralgia, knee pain, muscle pain	Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain	HIK, HPL	Kantasrila MSD138
Zingiber ottensii Valeton	Zingiberaceae	0.13	0.07	leaves, rhizomes	Burning, Decoction, Grind, Grind and burning, Grind and steam	Oral ingestion, Poultices	arthralgia, effusion of joint, fracture, knee pain, muscle pain, sprain of joint/ligament	Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HIK, HPL, KT	Kantasrila MSD139
Zingiber purpureum Roscoe	Zingiberaceae	0.15	0.08	leaves, rhizomes	Burning, Decoction, Grind, Grind and burning, Grind and steam	Oral ingestion, Poultices	arthralgia	Fracture: other, Joint symptom/complaint NOS, Knee symptom/complaint, Muscle pain, Sprain/strain of joint NOS	HIK, HPL, KT	Kantasrila MSD103
Ziziphus cambodianus Pierre	Rhamnaceae	0.09	0.03	bark, stems	Decoction	Oral ingestion	back pain, lumbago, muscle pain	Back symptom/complaint, Flank/axilla symptom/complaint, Muscle pain	HPL, PN	Kantasrila MSD104

HIK: Huai I Khang; HPL: Huay Poo Ling; KTN: Khun Thun Noi; MLK: Mae Lan Kam; PN: Pakanok; KT: Khuntae.

Table 3. The plant families, number of species, and use reports of the medicinal plants used to treat MSD among the Karen in the six villages in Chiang Mai province, Thailand.

Families	No. of species	No. of use reports
Fabaceae	10	233
Asteraceae	8	457
Zingiberaceae	8	231
Poaceae	6	164
Rubiaceae	6	19
Acanthaceae	5	122
Apocynaceae	5	130
Euphorbiaceae	5	95
Lamiaceae	4	91
Malvaceae	4	9
Santalaceae	4	128
Annonaceae	3	29
Asparagaceae	3	39
Phyllanthaceae	3	30
Rutaceae	3	24
Smilacaceae	3	52
Adoxaceae	2	280
Apiaceae	2	77
Araceae	2	234
Araliaceae	2	56
Celastraceae	2	24
Chloranthaceae	2	9
Cucurbitaceae	2	11
Malpighiaceae	2	21
Piperaceae	2	20
Plantaginaceae	2	153
Plumbaginaceae	2	14
Polygalaceae	2	84
Simaroubaceae	2	70
Amaryllidaceae	1	122
Anacardiaceae	1	2
Athyriaceae	1	1
Basellaceae	1	3
Betulaceae	1	138
Bignoniaceae	1	23
Connaraceae	1	2
Convolvulaceae	1	10
Costaceae	1	36
Equisetaceae	1	31
Gentianaceae	1	6
Hernandiaceae	1	2
Iridaceae	1	2
Juglandaceae	1	22
Loranthaceae	1	38
Lycopodiaceae	1	3
Lygodiaceae	1	21
Lythraceae	1	20
Melanthiaceae	1	13
Melastomataceae	1	12
Menispermaceae	1	32
Moraceae	1	78
Musaceae	1	24
Primulaceae	1	12
Proteaceae	1	2
Ranunculaceae	1	1
Rhamnaceae	1	11
Salicaceae	1	115
Sapotaceae	1	2
Scrophulariaceae	1	13
Solanaceae	1	3
Urticaceae	1	2
Vitaceae	1	23

The 3731 use reports belonged to 23 ailment categories in the ICPC-2 classification (WICC, 2005). The categories with high numbers of use reports included muscle pain (33%), followed by flank/axilla symptom/complaint (23%), and back symptom/complaint (12%) (Table 4). On the other hand, there were many categories, which had small numbers of use report and species, e.g., sprain/strain of knee, chest symptom/complaint, hand/finger symptom/complaint and neck symptom/complain categories. These categories had only one species each for treating MSD. Moreover, there were five species, which were used to treat the same ailment and they were prepared in the same way in all six villages, including Betula alnoides, Blumea balsamifera, Chromolaena odorata (L.) R.M.King & H.Rob. (Asteraceae), Sambucus javanica, and Sambucus simpsonii Rehder (Adoxaceae).

Table 4. The ICF score for each ailment category (ordered by ICF value).

Category	Number of Use-report (Nur)	Number of Species (Nt)	ICF
Sprain/strain of knee (L78)	2	1	1.00
Muscle pain (L18)	1222	119	0.90
Flank/axilla symptom/complaint (L05)	859	105	0.88
Fracture: other (L76)	272	37	0.87
Sprain/strain of joint NOS (L79)	216	30	0.87
Back symptom/complaint (L02)	676	100	0.85
Fracture: radius/ulna (L72)	10	3	0.78
Joint symptom/complaint NOS (L20)	133	42	0.69
Bursitis/tendinitis/synovitis NOS (L87)	43	15	0.67
Shoulder symptom/complaint (L08)	4	2	0.67
Knee symptom/complaint (L15)	126	44	0.66
Fracture: femur (L75)	14	6	0.62
Leg/thigh symptom/complaint (L14)	84	33	0.61
Fracture: tibia/fibula (L73)	10	5	0.56
Osteoarthrosis other (L91)	30	16	0.48
Rheumatoid/seropositive arthritis (L88)	6	4	0.40
Arm symptom/complaint (L09)	10	7	0.33
Ankle symptom/complaint (L16)	4	3	0.33
Foot/toe symptom/complaint (L17)	4	4	0.00
Sprain/strain of ankle (L77)	3	3	0.00
Chest symptom/complaint (L04)	1	1	0.00
Hand/finger symptom/complaint (L12)	1	1	0.00
Neck symptom/complain (L01)	1	1	0.00

Ethnobotanical indices: use values, choice values and informant consensus factor

Use values (UV)

The use value (UV) index was calculated to find the most important medicinal plants, which were used to treat MSD among the Skaw Karen people based on number of use reports. The UV ranged from 0.01–1.49 (Table 2). Ten species with high UV included Sambucus javanica (1.49), Betula alnoides (1.15), Blumea balsamifera (1.13), Plantago major (1.10), Crinum asiaticum L. (Amaryllidaceae) (1.02), Pothos chinensis (Raf.) Merr. (Araceae) (1.02), Flacourtia jangomas (0.96), Pothos scandens L. (Araceae) (0.93), Cymbopogon citratus (DC.) Stapf (Poaceae) (0.86), and Sambucus simpsonii (0.84). There were 12 species with low UV (=0.01) with only a single use report for each of them, e.g., Clausena excavata Burm.f. (Rutaceae), Clematis smilacifolia Wall. (Ranunculaceae), Dendrocalamus brandisii (Munro) Kurz (Poaceae), and Diplazium esculentum (Retz.) Sw. (Athyriaceae).

Choice values (CV)

The Choice value (CV) was used to find the most preferred species for treating MSD based on number of informants. In this study, CV ranged from 0.01–0.56 (Table 2). The species with high CV values were the same as the species with high UV values, e.g., Sambucus javanica (0.56), Betula alnoides (0.51), Blumea balsamifera (0.48), Plantago major (0.43), Crinum asiaticum (0.40), Pothos chinensis (0.40), Flacourtia jangomas (0.40), Pothos scandens (0.35), Centella asiatica (L.) Urb. (Apiaceae) (0.34). On the other hand, there were 33 species, which had low CV values. These species had only one or two informants who mentioned their use.

Informant consensus factor (ICF)

The ICF was calculated to find any agreement between informants concerning plants used in each category. In this study, ICF ranged from 0.00–1.00 (Table 4). The ailment category with the highest ICF values was [sprain/strain of knee (1.00), pain (0.90), followed by flank/axilla symptom/complaint (0.88), back symptom/complaint (0.85), fracture: other (0.87) and sprain/strain of joint NOS (0.87)] category. However, there were five categories with the ICF values equal to zero, including foot/toe symptom/complaint, sprain/strain of ankle, chest symptom/complaint, hand/finger symptom/complaint and neck symptom/complaint.

Phytochemical compounds in important medicinal plants related to MSD

Twenty species, which had high UV and CV values, were selected for phytochemical analysis. Among these, two species including Sambucus javanica and S. simpsonii were first reported for their phytochemical compound and pharmacological activity. The chemical compositions of the methanol extracts of 20 promising plant species were analyzed using LC-MS/MS and 1674 compounds were reported. Among these, 172 compounds have been recorded for their ability to treat MSD and related diseases such as anti-arthritic, analgesic, anti-inflammatory, anesthetic, antinociceptive, and antioxidative properties (Table 5). The main class of secondary metabolites which had high possibility to be active components were flavonoids (45 compounds), terpenoids (42 compounds), alkaloids (29 compounds) and steroids (14 compounds) (Figure 2). The most prevalent active compounds, which have phytochemistry properties related to MSD were 9-hydroxycalabaxanthone, dihydrovaltrate and morroniside (Table 5). These compounds were found in 11 species. 9-Hydroxycalabaxanthone (C₂₄H₂₄O₆) is a member of xanthones, dihydrovaltrate (C₂₂H₃₂O₈) is a member of iridoid monoterpenoids and morroniside (C₁₇H₂₆O₁₁) is a member of iridoid monoterpene glycosides. Other most prevalent compounds were isoacteoside (C₂₉H₃₆O₁₅) and lithocholic acid (C₂₄H₄₀O₃). These active compounds were found in 9 species. Pomiferin (C₂₅H₂₄O₆) was found in 8 species. Cucurbitacin E (C₃₂H₄₄O₈), leonuriside A (C₁₄H₂₀O₉), liriodendrin (C₃₄H₄₆O₁₈), and physalin E (C₂₈H₃₂O₁₁) were found in 7 species. Eurycoma longifolia Jack (Simaroubaceae) and Flacourtia jangomas had the highest number of active compounds (29 compounds) followed by Croton kongensis Gagnep. (Euphorbiaceae) (28 compounds), Plantago major (27 compounds), Blumea balsamifera (27 compounds), Betula alnoides (27 compounds), and Tadehagi triquetrum (L.) H.Ohashi (Fabaceae) (27 compounds) (Figure 3).

Figure 2. The proportion of number of active compounds in each group which related to MSD treatments found in 20 selected medicinal plant species.

Figure 3. The numbers of active compounds related to MSD treatments found in 20 selected medicinal plant species.

Table 5. The 172 active compounds found in the 20 medicinal plant extracts using for MSD treatments in the six Karen villages in Chiang Mai province, Thailand.

Phytochemical compounds	Classifications	Molecular formulas	Pharmacological activities	Species	References
(-)-Epigallocatechin 3-(4-methyl-gallate)	flavonoids	C24H22O11	anti-inflammatory activity, antioxidant activity	Betula alnoides Buch.-Ham. ex D.Don, Croton kongensis Gagnep., Flacourtia jangomas (Lour.) Raeusch., Plantago major L.	(Chiu and Lin 2005; Lotito et al. 2011)
(+)-Gallocatechin	flavonoids	C15H14O7	anti-inflammatory activity	Pothos chinensis (Raf.) Merr., Tadehagi triquetrum (L.) H.Ohashi	(Siebert et al. 2020)
(R)-N-Methylcoclaurine	alkaloids	C18H21NO3	analgesic activity	Croton kongensis Gagnep.	(Beaudoin and Facchini 2014)
(S)-Coclaurine	alkaloids	C17H19NO3	antioxidant activity, anti-inflammatory activity	Croton kongensis Gagnep.	(Marahel and Umesha 2016)
(S)-Edulinine	quinoline alkaloids	C16H21NO4	anti-inflammatory, antioxidant activity	Alstonia macrophylla Wall. ex G.Don	(Awaad et al. 2006)
1-Hydroxy-3-methoxy-7-primeverosyloxyxanthone	xanthones (polyphenols)	C24H26O6	anti-inflammatory activity, antioxidant activities	Croton kongensis Gagnep.	(Saleem et al. 2020)
1-Isomangostin	cinnamic acids (phenolic compound)	C17H22O10	anti-inflammatory activity, oxidative activity	Polygala chinensis L., Tadehagi triquetrum (L.) H.Ohashi	(Shankaranarayan et al. 1979; Chin et al. 2011)
1-O-Sinapoylglucose	cinnamic acids (phenolic compound)	C17H22O10	anti-inflammatory activity, oxidative activity	Polygala chinensis L., Tadehagi triquetrum (L.) H.Ohashi	(Nićiforović and Abramovič 2014)
2,2,4,4-Tetramethyl-6-(1-oxobutyl)-1,3,5-cyclohexanetrione	monoterpenoids	C14H20O4	anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don, Crinum asiaticum L., Plantago major L.	(Luetragoon et al. 2020)
2-Hydroxy-1,4-benzoquinone	quinones (phenolic compound derivatives)	C6H4O3	anti-inflammatory activity	Plantago major L.	(Petronzi et al. 2011)
2-Indolecarboxylic acid	indole alkaloids	C9H7NO2	antioxidant activity	Polygala chinensis L., Sambucus simpsonii Rehder	(Naik et al. 2012)
2-Methoxycarbonylphenyl beta-D-glucopyranoside	phenolic glycosides	C14H18O8	anti-inflammatory activity	Blumea balsamifera (L.) DC., Centella asiatica (L.) Urb.	(Hwang and Lee 2015)
2-O-Caffeoylarbutin	phenolic glycosides	C21H22O10	antioxidant activity, anti-inflammatory	Eurycoma longifolia Jack, Gmelina arborea Roxb., Polygala chinensis L., Sambucus javanica Reinw. ex Blume	(Ștefănescu et al. 2019)
3,4-DHPEA-EA	monoterpenoids	C19H22O8	antioxidant activity	Sambucus simpsonii Rehder	(Fuentes et al. 2018)
3-Indolecarboxylic acid	indole alkaloids	C13H19NO4	antioxidant activity, anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don, Croton kongensis Gagnep., Desmodium renifolium (L.) Schindl., Flacourtia jangomas (Lour.) Raeusch., Gmelina arborea Roxb., Sambucus simpsonii Rehder	(Naik et al. 2011; Ji et al. 2020)
3-O-Protocatechuoylceanothic acid	triterpenoids	C37H50O8	antioxidant activity, anti-inflammatory activity	Alstonia macrophylla Wall. ex G.Don	(Peng et al. 2018; Lim et al. 2019)
3-α(S)-Strictosidine	alkaloids	C27H34N2O9	anti-inflammatory activity, antioxidant activity	Desmodium renifolium (L.) Schindl., Sambucus simpsonii Rehder	(Sakamoto et al. 2020)
4’-Hydroxy-3’,5,6,7,8-pentamethoxyflavone	flavonoids	C20H20O8	anti-inflammatory activity	Gmelina arborea Roxb., Plantago major L., Sambucus simpsonii Rehder	(Wu et al. 2015)
4’-Methyl-(-)-epigallocatechin 3’-glucuronide	isoflavonoids	C22H24O13	antioxidant activity	Plantago major L.	(Natsume et al. 2003; Natsume et al. 2004)
4’-Methyl-(-)-epigallocatechin 7-glucuronide	flavonoids	C22H24O13	antioxidant activity	Elephantopus scaber L., Sambucus simpsonii Rehder	(Natsume et al. 2003)
4’-O-methyl-(-)-epicatechin-5-O-beta-glucuronide	flavonoids	C23H26O11	antioxidant activity	Croton kongensis Gagnep., Plantago major L., Sambucus javanica Reinw. ex Blume, Tadehagi triquetrum (L.) H.Ohashi	(Natsume et al. 2003)
5-Hydroxyflavone	flavonoids	C21H20O8	analgesic activity, anti-inflammatory activity	Desmodium renifolium (L.) Schindl.	(Ferraz et al. 2020)
5-Methoxytryptophol	Indole alkaloids	C11H13NO2	antioxidant activity, anti-inflammatory	Croton kongensis Gagnep.	(Savtekin et al. 2018)
5-O-Feruloylquinic acid	phenolic acids	C17H20O9	antioxidant activity, anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don, Chromolaena odorata (L.) R.M.King & H.Rob., Croton kongensis Gagnep., Flacourtia jangomas (Lour.) Raeusch., Tadehagi triquetrum (L.) H.Ohashi	(Erel et al. 2011; Sarı et al. 2019)
6,8-di-O-Methylaverufin	anthraquinones	C22H20O7	anti-inflammatory activity	Elephantopus scaber L.	(Kim et al. 2018)
6’’-Acetylapiin	flavonoids	C28H30O15	anti-inflammatory activity, antioxidant activity	Scleropyrum pentandrum (Dennst.) Mabb.	(Farzaei et al. 2013; de Menezes Epifanio et al. 2020)
6-Hydroxykaempferol	flavonoids	C15H10O7	anti-inflammatory activity, antioxidant activity	Polygala chinensis L.	(Williams et al. 1999; Yue et al. 2014)
6-Hydroxymusizin 8-O-b-D-glucopyranoside	phenolic glycosides	C19H22O9	anti-inflammatory activity, analgesic activity	Crinum asiaticum L., Flacourtia jangomas (Lour.) Raeusch., Gmelina arborea Roxb., Scleropyrum pentandrum (Dennst.) Mabb.	(Iizuka et al. 2004; Zheng et al. 2013)
6-Methylquinoline	alkaloids	C10H9N	anti-inflammatory, analgesic activity.	Crinum asiaticum L.	(Marella et al. 2013)
6-O-Acetylaustroinulin	diterpenoids	C22H36O4	anti-inflammatory activity	Gmelina arborea Roxb.	(Byun 2012; Cho et al. 2013; Zou et al. 2020)
6’’-O-Acetylgenistin	isoflavonoids	C23H22O11	antioxidant activity, anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don, Flacourtia jangomas (Lour.) Raeusch., Sambucus javanica Reinw. ex Blume, Tadehagi triquetrum (L.) H.Ohashi	(Kudou et al. 1991; de Melo et al. 2020)
7-Galloylcatechin	flavonoids	C22H18O10	anti-inflammatory activity, analgesic activity	Tadehagi triquetrum (L.) H.Ohashi	(Afsar et al. 2015)
7-Hydroxy-8-O-methylaloin B	anthraquinones	C22H24O	antioxidant activity, anti-inflammatory, anti-arthritic activity	Eurycoma longifolia Jack	(Lee et al. 2012; Salehi et al. 2018)
7-Hydroxyflavanone beta-D-glucopyranoside	flavonoids	C21H22O8	anti-inflammatory activity, analgesic activity	Flacourtia jangomas (Lour.) Raeusch.	(Zhang et al. 2020a)
7-Methylrosmanol	diterpene lactones	C21H28O5	antioxidant activity, anti-inflammatory activity	Blumea balsamifera (L.) DC.	(Lai et al. 2009; Fiume et al. 2018)
8-Hydroxypinoresinol 8-glucoside	lignan glycosides	C26H32O12	anti-inflammatory activity	Blumea balsamifera (L.) DC., Chromolaena odorata (L.) R.M.King & H.Rob., Elephantopus scaber L., Maclura cochinchinensis (Lour.), Pothos chinensis (Raf.) Merr., Tadehagi triquetrum (L.) H.Ohashi	(Choi and Park 2016)
9-Hydroxycalabaxanthone	xanthones (polyphenols)	C24H24O6	anti-inflammatory activity, antioxidant activity	Betula alnoides Buch.-Ham. ex D.Don, Blumea balsamifera (L.) DC., Crinum asiaticum L., Elephantopus scaber L., Eurycoma longifolia Jack, Flacourtia jangomas (Lour.) Raeusch., Plantago major L., Polygala chinensis L., Pothos chinensis (Raf.) Merr., Sambucus javanica Reinw. ex Blume, Tadehagi triquetrum (L.) H.Ohashi	(Gutierrez-Orozco and Failla 2013)
Acetyllycopsamine	alkaloids	C17H27NO6	antioxidant activity, anti-inflammatory, analgesic activity	Chromolaena odorata (L.) R.M.King & H.Rob.	(Bosi et al. 2013; Salehi et al. 2019)
Aconine	alkaloids	C25H41NO9	anti-inflammatory activity	Sambucus javanica Reinw. ex Blume	(Li et al. 2016)
Acuminoside	diterpenoid glycosides	C21H36O10	antioxidant activity, anti-inflammatory activity	Alstonia macrophylla Wall. ex G.Don, Betula alnoides Buch.-Ham. ex D.Don, Chromolaena odorata (L.) R.M.King & H.Rob., Crinum asiaticum L., Flacourtia jangomas (Lour.) Raeusch., Pothos chinensis (Raf.) Merr.	(Sharma and Rao 2009)
Agnuside	diterpenoid glycosides	C22H26O11	anti-arthritic activity, anti-inflammatory activity, analgesic activity	Eurycoma longifolia Jack	(Okuyama et al. 1998; Pandey et al. 2012)
Allamandin	iridoid monoterpene lactones	C15H16O7	analgesic activity, anti-inflammatory activity	Desmodium renifolium (L.) Schindl.	(Petricevich and Abarca-Vargas 2019)
Aloinoside B	anthraquinones	C27H32O13	anti-inflammatory activity, analgesic activity, antioxidant activity	Chromolaena odorata (L.) R.M.King & H.Rob., Croton kongensis Gagnep., Elephantopus scaber L., Sambucus javanica Reinw. ex Blume, Scleropyrum pentandrum (Dennst.) Mabb.	(Chandra et al. 2018)
alpha-Citronellol	monoterpenoids	C10H20O	anti-inflammatory activity, analgesic activity	Crinum asiaticum L., Eurycoma longifolia Jack, Scleropyrum pentandrum (Dennst.) Mabb., Tadehagi triquetrum (L.) H.Ohashi	(Katsukawa et al. 2011; Brito et al. 2012)
Altersolanol A	quinones	C16H16O8	anti-inflammatory activity	Croton kongensis Gagnep., Tadehagi triquetrum (L.) H.Ohashi	(Teiten et al. 2013)
Amaroswerin	secoiridoid glucosides (cardiac glycosides)	C29H30O14	anti-inflammatory activity	Flacourtia jangomas (Lour.) Raeusch., Scleropyrum pentandrum (Dennst.) Mabb.	(Xiang et al. 2019)
Anhydrosafflor Yellow B	flavonoids	C48H52O26	antioxidant activity, anti-inflammatory activity	Eurycoma longifolia Jack	(Song et al. 2020; Zhang et al. 2020d)
Anisotine	quinazoline alkaloids	C20H19N3O3	anti-inflammatory activity, antioxidant activity	Eurycoma longifolia Jack	(Shanawany et al. 2014)
APIIN	flavonoids	C26H28O14	anti-inflammatory activity	Polygala chinensis L.	(Mencherini et al. 2007; Ramezani et al. 2009)
Arbutin	hydroquinone glucosides (phenolic glycosides)	C12H16O7	anti-inflammatory activity, antioxidant activity	Centella asiatica (L.) Urb., Flacourtia jangomas (Lour.) Raeusch., Plantago major L., Sambucus simpsonii Rehder	(Lee and Kim 2012)
Archangelolide	sesquiterpene lactones	C29H40O10	anti-inflammatory activity	Elephantopus scaber L.	(Rimpelová et al. 2019)
Arjunolic acid	triterpenoids	C30H48O5	anti-inflammatory activity, antinociceptive activity, antioxidant activity	Centella asiatica (L.) Urb.	(Manna et al. 2009; Santos et al. 2011)
Artemisinin	sesquiterpene lactones	C15H22O5	anti-inflammatory activity, antioxidant activity	Blumea balsamifera (L.) DC., Maclura cochinchinensis (Lour.), Polygala chinensis L., Tadehagi triquetrum (L.) H.Ohashi	(Kim et al. 2015; Shi et al. 2015)
Asiaticoside B	triterpene glycosides	C48H78O20	anti-inflammatory activity, antinociceptive activity, antioxidant activity	Plantago major L.	(Huang et al. 2011; Ayumi et al. 2020; Wang et al. 2020a)
Asperuloside	iridoid monoterpenoid glycosides	C18H22O11	anti-inflammatory activity	Alstonia macrophylla Wall. ex G.Don, Plantago major L.	(He et al. 2018; Zhang et al. 2020b)
Astragalin	flavonoids	C21H20O11	antinociceptive activity, anti-inflammatory activity, analgesic activity, antioxidant activity	Plantago major L., Polygala chinensis L., Sambucus simpsonii Rehder	(Qnais et al. 2014; Riaz et al. 2018)
Aucubin	iridoid monoterpenoid glycosides	C15H22O9	anti-inflammatory activity	Desmodium renifolium (L.) Schindl.	(Park 2020 ; Park et al. 2004; Koley et al. 2019)
Austroinulin	diterpenoids	C20H34O3	anti-inflammatory activity, antioxidant activity	Elephantopus scaber L., Tadehagi triquetrum (L.) H.Ohashi	(Byun 2012; Cho et al. 2013)
Avenanthramide L	phenolic alkaloids	C10H9N	anti-inflammatory activity, antioxidant activity	Crinum asiaticum L.	(Sur et al. 2008; Landberg et al. 2020; Zhang et al. 2020c)
Baccatin III	tetracyclic diterpenoids	C31H38O11	anti-nociceptive activity	Betula alnoides Buch.-Ham. ex D.Don, Maclura cochinchinensis (Lour.), Tadehagi triquetrum (L.) H.Ohashi	(Küpeli et al. 2003)
Basellasaponin B	triterpene saponins	C47H68O21	anti-inflammatory activity	Desmodium renifolium (L.) Schindl.	(Kotakadi 2014)
beta-Damascenone	cyclic monoterpene ketone	C13H18O	analgesic activity, anti-inflammatory	Centella asiatica (L.) Urb., Plantago major L.	(Sharif et al. 2020)
Bopindolol	methylindoles (alkaloids)	C23H28N2O3	antioxidant activity	Alstonia macrophylla Wall. ex G.Don, Eurycoma longifolia Jack, Scleropyrum pentandrum (Dennst.) Mabb.	(Aniya et al. 1995)
Bruceine D	diterpenes	C20H26O9	anti-inflammatory activity	Blumea balsamifera (L.) DC., Desmodium renifolium (L.) Schindl., Eurycoma longifolia Jack, Plantago major L.	(Hall et al. 1983)
Bryotoxin A	cardiac glycosides	C32H42O12	anti-inflammatory activity, antioxidant activity	Elephantopus scaber L., Eurycoma longifolia Jack, Pothos chinensis (Raf.) Merr., Sambucus simpsonii Rehder	(Rahman et al. 2019)
Camellianin A	flavonoid glycosides	C29H32O15	antioxidant activity	Alstonia macrophylla Wall. ex G.Don, Sambucus javanica Reinw. ex Blume	(Yuan et al. 2008; Liu et al. 2014)
Capsianoside I	diterpene glycosides (phenolic compounds)	C32H52O14	analgesic activity, anti-inflammatory activity	Blumea balsamifera (L.) DC., Maclura cochinchinensis (Lour.)	(Jolayemi and Ojewole 2013)
Castanospermine	indolizidine alkaloid	C8H15NO4	anti-inflammatory activity	Scleropyrum pentandrum (Dennst.) Mabb.	(Hong et al. 2016)
Catalposide	iridoid monoterpene glycosides	C22H26O12	antinociceptive activity, anti-inflammatory activity	Blumea balsamifera (L.) DC., Elephantopus scaber L., Flacourtia jangomas (Lour.) Raeusch., Plantago major L.	(Küpeli et al. 2005)
Chrysosplenol D	flavonoids	C18H16O8	anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don	(Li et al. 2015)
Colforsin	diterpenenoid derivatives	C22H34O7	anti-inflammatory activity	Blumea balsamifera (L.) DC.	(Hayashida et al. 2001)
Contignasterol	steroids	C18H16O8	anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don	(Burgoyne et al. 1992; Cheung et al. 2016)
Convallatoxin	cardiac glycosides	C29H42O10	antioxidant activity, anti-inflammatory	Scleropyrum pentandrum (Dennst.) Mabb.	(Xu et al. 2017b; Li et al. 2019b)
Convolamine	tropane alkaloids	C17H23NO4	anti-inflammatory activity, anti-inflammatory activity	Sambucus simpsonii Rehder	(Agarwal et al. 2014; Balkrishna et al. 2020)
Corchoroside A	cardiac glycosides	C29H42O9	antioxidant activity, anti-inflammatory activity, analgesic activity	Chromolaena odorata (L.) R.M.King & H.Rob.	(Snafi 2016)
Cortisone	steroids	C21H28O5	anti-inflammatory activity	Blumea balsamifera (L.) DC.	(Park et al. 2013)
Crocin 3	diterpenoids	C32H44O14	anti-inflammatory activity, antioxidant activity, analgesic activity	Blumea balsamifera (L.) DC.	(Lee et al. 2005; Erfanparast et al. 2015; Li et al. 2017b)
Cucurbitacin E	steroids	C32H44O8	anti-inflammatory activity, analgesic activity	Betula alnoides Buch.-Ham. ex D.Don, Chromolaena odorata (L.) R.M.King & H.Rob., Crinum asiaticum L., Croton kongensis Gagnep., Desmodium renifolium (L.) Schindl., Plantago major L., Tadehagi triquetrum (L.) H.Ohashi	(Peters et al. 1997; Abdelwahab et al. 2011)
Cynaroside A	flavonoid glycosides	C21H32O10	antioxidative activity, anti-inflammatory activity	Plantago major L., Polygala chinensis L.	(Zou et al. 2018; Nguyen et al. 2020a; Szekalska et al. 2020)
Dalpanin	flavonoids	C26H30O12	antioxidant activity	Betula alnoides Buch.-Ham. ex D.Don, Eurycoma longifolia Jack, Scleropyrum pentandrum (Dennst.) Mabb.	(Mekky et al. 2015)
Demethyloleuropein	flavonoid glycosides	C24H30O13	antioxidant activity, anti-inflammatory activity	Chromolaena odorata (L.) R.M.King & H.Rob., Gmelina arborea Roxb.	(Servili et al. 2009; Nardi et al. 2014)
Deoxypodophyllotoxin	flavolignan	C22H22O7	analgesic activity, anti-inflammatory activity	Croton kongensis Gagnep.	(Lee et al. 2004; Guerrero et al. 2013; Khaled et al. 2013)
Dihydrocapsaicin	capsaicinoid (terpene alkaloid)	C18H29NO3	analgesic activity	Alstonia macrophylla Wall. ex G.Don, Sambucus javanica Reinw. ex Blume, Scleropyrum pentandrum (Dennst.) Mabb.	(Zak et al. 2018)
Dihydrovaltrate	iridoid monoterpenoids	C22H32O8	anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don, Blumea balsamifera (L.) DC., Crinum asiaticum L., Croton kongensis Gagnep., Flacourtia jangomas (Lour.) Raeusch., Plantago major L., Polygala chinensis L., Pothos chinensis (Raf.) Merr., Sambucus javanica Reinw. ex Blume, Scleropyrum pentandrum (Dennst.) Mabb., Tadehagi triquetrum (L.) H.Ohashi	(Subhan et al. 2007)
Ellagic acid	polyphenols	C14H6O8	anti-inflammatory activity, antioxidant activity	Scleropyrum pentandrum (Dennst.) Mabb.	(Favarin et al. 2013; Kilic et al. 2014)
epi-Tulipinolide diepoxide	sesquiterpenoids	C17H22O6	antioxidant activity	Blumea balsamifera (L.) DC., Sambucus javanica Reinw. ex Blume	(Kang et al. 2014)
Ethylvanillin glucoside	phenolic glycosides	C15H20O8	antioxidant activity	Maclura cochinchinensis (Lour.), Scleropyrum pentandrum (Dennst.) Mabb.	(Tai et al. 2011; Tong et al. 2019)
Evoxine	alkaloids	C18H21NO6	antioxidant activity	Scleropyrum pentandrum (Dennst.) Mabb.	(Kiplimo et al. 2011)
Fasciculol C	steroids	C30H52O6	anti-inflammatory activity, antioxidant activity	Betula alnoides Buch.-Ham. ex D.Don, Flacourtia jangomas (Lour.) Raeusch., Plantago major L., Polygala chinensis L., Tadehagi triquetrum (L.) H.Ohashi	(Ványolós et al. 2020)
Feruloyl-beta-sitosterol	steroids	C39H58O4	antioxidant activity	Alstonia macrophylla Wall. ex G.Don, Centella asiatica (L.) Urb., Chromolaena odorata (L.) R.M.King & H.Rob., Maclura cochinchinensis (Lour.)	(Islam et al. 2009; Islam et al. 2011)
Fluocinonide	steroids	C26H32F2O7	anti-inflammatory activity	Pothos chinensis (Raf.) Merr.	(Mutasim 2006)
Germacrone	sesquiterpenoids	C15H22O	antinociceptive activity, anti-inflammatory activity, antioxidant activity	Elephantopus scaber L.	(Ozaki 1990; Hamdi et al. 2015; Hossain et al. 2015)
Ginkgolide C	diterpenic lactones	C20H24O11	anti-inflammatory activity, antioxidant activity	Flacourtia jangomas (Lour.) Raeusch.	(Zhang et al. 2018b; Li et al. 2020a)
Grayanotoxin I	diterpenoids	C22H36O7	analgesic activity	Sambucus javanica Reinw. ex Blume	(Gunduz et al. 2014; Sun et al. 2019)
GW 0742	steroid derivatives	C21H17F4NO3S2	anti-inflammatory activity	Plantago major L.	(Gamdzyk et al. 2020)
Harpagoside	iridoid monoterpene glycosides	C24H30O11	analgesic activity, anti-inflammatory activity	Eurycoma longifolia Jack, Flacourtia jangomas (Lour.) Raeusch.	(Lanhers et al. 1992; Rahimi et al. 2016)
Hesperetin 7-O-glucoside	flavonoid glycosides	C22H24O11	anti-inflammatory activity	Blumea balsamifera (L.) DC., Eurycoma longifolia Jack	(Wan et al. 2020)
Hesperetin-7-O-glucuronide	flavonoid glycosides	C21H22O12	anti-inflammatory activity	Tadehagi triquetrum (L.) H.Ohashi	(Yamamoto et al. 2013)
Hirsuteine	alkaloids	C22H26N2O3	antioxidant activity	Alstonia macrophylla Wall. ex G.Don	(Kawakami et al. 2011)
Homocapsaicin	capsaicinoids	C19H29NO3	analgesic activity, anti-inflammatory activity, antioxidant activity	Plantago major L.	(Luo et al. 2011; Ercan et al. 2013)
Irigenin	flavonoids	C18H16O8	anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don	(Ahn et al. 2006; Wang et al. 2017)
Isoacteoside	phenolic glycosides	C29H36O15	antioxidant activity, anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don, Blumea balsamifera (L.) DC., Croton kongensis Gagnep., Desmodium renifolium (L.) Schindl., Elephantopus scaber L., Flacourtia jangomas (Lour.) Raeusch., Gmelina arborea Roxb., Polygala chinensis L., Tadehagi triquetrum (L.) H.Ohashi	(Chao-Hsiang et al. 2012; Nam et al. 2015; Simamora et al. 2020)
Isochlorogenic acid b	phenolic glycosides	C25H24O12	antioxidant activity	Betula alnoides Buch.-Ham. ex D.Don, Centella asiatica (L.) Urb., Elephantopus scaber L.	(Li et al. 2019a)
Isoflupredone acetate	steroids	C23H29FO6	anti-inflammatory activity	Gmelina arborea Roxb., Maclura cochinchinensis (Lour.)	(Trahan et al. 2018)
Isomangiferin	xanthone glycosides (polyphenol glycosides)	C19H18O11	antioxidant activity	Centella asiatica (L.) Urb.	(Xu et al. 2017a)
Isorhynchophylline	alkaloids	C22H28N2O4	anti-nociceptive activity, anti-inflammatory activity	Gmelina arborea Roxb.	(Yuan et al. 2009; Gao et al. 2020)
Kukoamine A	alkaloids	C28H42N4O6	anti-inflammatory activity, antioxidant activity	Scleropyrum pentandrum (Dennst.) Mabb.	(Hadjipavlou-Litina et al. 2009; Li et al. 2018; Wang et al. 2020b)
L-1,2,3,4-Tetrahydro-beta-carboline-3-carboxylic acid	indole alkaloids	C12H12N2O2	antioxidant activity	Crinum asiaticum L., Sambucus javanica Reinw. ex Blume	(Herraiz and Galisteo 2002)
Lamioside	iridoid monoterpenoids	C18H28O11	antioxidant activity	Blumea balsamifera (L.) DC., Chromolaena odorata (L.) R.M.King & H.Rob., Desmodium renifolium (L.) Schindl., Scleropyrum pentandrum (Dennst.) Mabb.	(Goodla et al. 2019)
Lappaol C	flavonoids	C30H34O10	antioxidant activity	Desmodium renifolium (L.) Schindl.	(Su and Wink 2015)
Leonuriside A	phenolic glycosides	C14H20O9	anti-inflammatory activity	Alstonia macrophylla Wall. ex G.Don, Centella asiatica (L.) Urb., Gmelina arborea Roxb., Maclura cochinchinensis (Lour.), Polygala chinensis L., Sambucus javanica Reinw. ex Blume, Tadehagi triquetrum (L.) H.Ohashi	(Shrestha et al. 2013; Dang et al. 2020)
Lignans	lignans	C22H22O8	analgesic activity, anti-inflammatory activity, antioxidant activity	Flacourtia jangomas (Lour.) Raeusch.	(Borsato et al. 2000; Teponno et al. 2016; Chopade et al. 2020)
Ligustroside	phenolic glycosides	C25H32O12	antioxidant activity	Croton kongensis Gagnep., Flacourtia jangomas (Lour.) Raeusch., Sambucus simpsonii Rehder	(Gülçin et al. 2009; Varga et al. 2019)
Linusitamarin	Phenolic glucosides	C17H22O9	antioxidant activity	Blumea balsamifera (L.) DC., Elephantopus scaber L., Gmelina arborea Roxb., Plantago major L.	(Zhang et al. 2013a)
Liriodendrin	lignan glycosides	C34H46O18	anti-inflammatory activity, anti-nociceptive activity	Crinum asiaticum L., Croton kongensis Gagnep., Elephantopus scaber L., Gmelina arborea Roxb., Sambucus javanica Reinw. ex Blume, Sambucus simpsonii Rehder, Tadehagi triquetrum (L.) H.Ohashi	(Jung et al. 2003)
Lirioresinol A	furanoid lignans	C22H26O8	anti-inflammatory activity, antioxidant activity	Betula alnoides Buch.-Ham. ex D.Don	(Kim et al. 2020; Li et al. 2020b)
Lithocholic acid	steroids	C24H40O3	anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don, Blumea balsamifera (L.) DC., Croton kongensis Gagnep., Elephantopus scaber L., Eurycoma longifolia Jack, Flacourtia jangomas (Lour.) Raeusch., Plantago major L., Sambucus javanica Reinw. ex Blume, Scleropyrum pentandrum (Dennst.) Mabb.	(Sun et al. 2008; Ward et al. 2017)
Lonicerin	flavonoids	C21H26N2O4	anti-inflammatory activity	Alstonia macrophylla Wall. ex G.Don	(Lee et al. 1995)
Lucidone A	steroids	C24H34O5	anti-inflammatory activity	Eurycoma longifolia Jack	(Kumar et al. 2010a)
Lumichrome	alkaloids	C12H10N4O2	antioxidant activity	Eurycoma longifolia Jack, Flacourtia jangomas (Lour.) Raeusch.	(Qais and Etu 2020)
Magnoshinin	neolignan	C24H30O6	anti-inflammatory activity	Scleropyrum pentandrum (Dennst.) Mabb.	(Kimura et al. 1991)
Mangostanol	xanthones (polyphenols)	C24H26O7	anti-inflammatory activity	Pothos chinensis (Raf.) Merr.	(Pan et al. 2017)
Manniflavanone	flavonoids	C30H22O13	antioxidant activity, anti‐inflammatory activity	Polygala chinensis L.	(Bibi et al. 2014)
Maritimetin	flavonoids	C15H10O6	antioxidant activity	Crinum asiaticum L., Plantago major L., Polygala chinensis L., Sambucus javanica Reinw. ex Blume, Sambucus simpsonii Rehder	(Wang et al. 2015)
Melengestrol acetate	steroids	C25H32O4	anti-inflammatory activity	Alstonia macrophylla Wall. ex G.Don	(Baydoun et al. 2014)
Mesaconitine	alkaloids	C33H45NO11	analgesic activity	Eurycoma longifolia Jack	(Murayama et al. 1984; Sun et al. 2020)
Mezerein	terpenes	C38H38O10	anti-inflammatory activity, antioxidant activity	Eurycoma longifolia Jack	(Barton et al. 1989)
Miglustat	piperidines	C10H21NO4	anti-inflammatory activity	Scleropyrum pentandrum (Dennst.) Mabb.	(Dechecchi et al. 2008)
Miscanthoside	flavonoids	C21H22O11	antioxidant activity	Desmodium renifolium (L.) Schindl., Eurycoma longifolia Jack, Maclura cochinchinensis (Lour.), Pothos chinensis (Raf.) Merr., Scleropyrum pentandrum (Dennst.) Mabb.	(Barreca et al. 2016)
Mitoxantrone	anthraquinones	C22H28N4O6	analgesic activity	Betula alnoides Buch.-Ham. ex D.Don, Blumea balsamifera (L.) DC., Desmodium renifolium (L.) Schindl., Elephantopus scaber L., Eurycoma longifolia Jack, Tadehagi triquetrum (L.) H.Ohashi
Monotropein	iridoid monoterpenoids	C16H22O11	antinociceptive activity, anti-inflammatory activity	Sambucus javanica Reinw. ex Blume	(Choi et al. 2005; Shin et al. 2013)
Morroniside	iridoid monoterpene glycosides	C17H26O11	antioxidant activity	Croton kongensis Gagnep., Elephantopus scaber L., Eurycoma longifolia Jack, Flacourtia jangomas (Lour.) Raeusch., Gmelina arborea Roxb., Maclura cochinchinensis (Lour.), Polygala chinensis L., Pothos chinensis (Raf.) Merr., Sambucus javanica Reinw. ex Blume, Sambucus simpsonii Rehder, Scleropyrum pentandrum (Dennst.) Mabb.	(Chen et al. 2018)
Morusin	flavonoids	C25H24O6	antinociceptive activity	Blumea balsamifera (L.) DC., Plantago major L.	(De Souza et al. 2000)
Multiflorin B	flavonoids	C27H30O15	antioxidant activity, anti-inflammatory activity	Desmodium renifolium (L.) Schindl., Plantago major L., Tadehagi triquetrum (L.) H.Ohashi	(Kim et al. 2008; Choe et al. 2012; Eid et al. 2018)
Naringenin-7-O-Glucoside	flavonoid qlycosides	C21H22O10	antioxidant activity	Blumea balsamifera (L.) DC., Flacourtia jangomas (Lour.) Raeusch., Tadehagi triquetrum (L.) H.Ohashi	(Han et al. 2008)
Nepitrin	flavonoids	C22H22O12	anti-inflammatory activity	Blumea balsamifera (L.) DC., Croton kongensis Gagnep., Polygala chinensis L.	(Agarwal 1982; Akram et al. 2015; Garayev et al. 2018)
Nordihydrocapsiate	capsaicinoids	C17H26O4	anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don, Elephantopus scaber L., Tadehagi triquetrum (L.) H.Ohashi	(Sancho et al. 2002; Shintaku et al. 2012)
Norvaline	flavonoids	C5H11NO2	anti-inflammatory activity	Croton kongensis Gagnep.	(Ming et al. 2009)
Nudicauline	alkaloids	C38H50N2O11	analgesic activity	Eurycoma longifolia Jack	(Liu and Tong 2005)
Oleandrin	cardiac glycoside	C32H48O9	anti-inflammatory activity, antioxidant activity	Eurycoma longifolia Jack	(Kanwal et al. 2020)
Oleoside dimethyl ester	terpene glycosides	C18H26O11	antioxidant activity	Gmelina arborea Roxb., Pothos chinensis (Raf.) Merr., Scleropyrum pentandrum (Dennst.) Mabb.	(Pang et al. 2015)
Ononin	flavonoid glycosides	C22H22O9	anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don, Flacourtia jangomas (Lour.) Raeusch.	(Luo et al. 2019)
Paeoniflorin	terpene glycosides	C23H28O11	analgesic activity, antioxidant activity, anti-inflammatory activity	Blumea balsamifera (L.) DC., Croton kongensis Gagnep.	(Zhang et al. 2013b; Tu et al. 2019; Wu et al. 2020; Zhang and Wei 2020)
Physalin E	steroids	C28H32O11	anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don, Eurycoma longifolia Jack, Plantago major L., Polygala chinensis L., Sambucus javanica Reinw. ex Blume, Sambucus simpsonii Rehder, Tadehagi triquetrum (L.) H.Ohashi	(Pinto et al. 2010; Yang et al. 2017)
Physalin L	steroids	C28H32O10	anti-inflammatory activity	Flacourtia jangomas (Lour.) Raeusch., Scleropyrum pentandrum (Dennst.) Mabb.	(Ji et al. 2012)
Pomiferin	flavonoids	C25H24O6	antioxidant activity	Crinum asiaticum L., Croton kongensis Gagnep., Elephantopus scaber L., Eurycoma longifolia Jack, Flacourtia jangomas (Lour.) Raeusch., Pothos chinensis (Raf.) Merr., Sambucus javanica Reinw. ex Blume, Scleropyrum pentandrum (Dennst.) Mabb.	(Bartosikova et al. 2007; Mazumder and Rahman 2008)
Poncirin	flavonoids	C28H34O14	analgesic activity, anti-inflammatory activity	Chromolaena odorata (L.) R.M.King & H.Rob., Croton kongensis Gagnep., Flacourtia jangomas (Lour.) Raeusch., Polygala chinensis L.	(Kim et al. 2007; Afridi et al. 2019; Ullah et al. 2020)
Protobassic acid	triterpenoids	C30H48O6	antioxidant activity	Croton kongensis Gagnep.	(Pawar and Bhutani 2004)
Pulmatin	anthraquinone glycosides	C21H20O9	antioxidant activity	Blumea balsamifera (L.) DC., Scleropyrum pentandrum (Dennst.) Mabb., Tadehagi triquetrum (L.) H.Ohashi	(Mishra et al. 2014)
Quercetagetin	flavonoids	C15H10O8	anti-inflammatory activity	Croton kongensis Gagnep.	(Boots et al. 2008; Kang et al. 2013; Kang et al. 2014; Gutiérrez-Venegas et al. 2017)
Quercetin 3-O-(6’’-acetyl-glucoside)	flavonoids	C23H22O13	antioxidant activity	Betula alnoides Buch.-Ham. ex D.Don	(Anh et al. 2011; Kim and Jang 2011)
Quercetin 3-O-(6-O-malonyl-β-D-glucoside)	flavonoids	C24H22O15	antioxidant activity	Blumea balsamifera (L.) DC.	(Apea-Bah et al. 2020; Pollini et al. 2020)
Remifentanil	alkaloids	C20H28N2O5	analgesic activity	Eurycoma longifolia Jack	(Black et al. 1998; Xiang et al. 2014; Torun et al. 2017)
Robinetin	flavonoids	C15H10O7	antioxidant activity	Blumea balsamifera (L.) DC., Sambucus simpsonii Rehder	(Edenharder and Grünhage 2003; Ruiz-Cruz et al. 2017; Manrique-de-la-Cuba et al. 2019)
Safflomin A	flavonoids	C27H32O16	anti-inflammatory activity	Maclura cochinchinensis (Lour.)	(Jin et al. 2016; Lee et al. 2020; Qin et al. 2020; Wang et al. 2020c)
Salannin	terpenoids	C34H44O9	anti-inflammatory activity	Chromolaena odorata (L.) R.M.King & H.Rob.	(Akihisa et al. 2011)
Savinin	lignan	C20H16O6	anti-inflammatory activity, antioxidant activity	Flacourtia jangomas (Lour.) Raeusch.	(Cho et al. 2001; Bulle et al. 2016; Li et al. 2019c)
Scolymoside	flavonoid glycosides	C27H30O14	anti-inflammatory activity, antioxidant activity	Flacourtia jangomas (Lour.) Raeusch.	(Kim et al. 2000; Kang et al. 2015; Lee and Bae 2016)
Shanzhiside	terpenoid	C16H24O11	antioxidant activity	Eurycoma longifolia Jack	(Shan et al. 2019)
Silandrin	flavonolignans	C25H22O9	antioxidant activity	Eurycoma longifolia Jack	(Samu et al. 2004)
Sterebin A	sesquiterpenoids	C18H30O4	anti-inflammatory activity	Croton kongensis Gagnep.	(Ibrahim et al. 2007)
Strictosamide	alkaloids	C26H30N2O8	analgesic activity, anti-inflammatory activity	Alstonia macrophylla Wall. ex G.Don	(Li et al. 2014; Li et al. 2017a)
Symphytine	alkaloids	C20H31NO6	antioxidant activity	Chromolaena odorata (L.) R.M.King & H.Rob.	(Oberlies et al. 2004)
Tabersonine	alkaloids	C21H24N2O2	anti-inflammatory activity	Alstonia macrophylla Wall. ex G.Don	(Zhang et al. 2018a)
Terretonin	steroids	C26H32O9	anti-inflammatory activity	Croton kongensis Gagnep.	(Wu et al. 2019)
Theaflavic acid	flavonoids	C21H16O10	antioxidant activity	Betula alnoides Buch.-Ham. ex D.Don, Centella asiatica (L.) Urb.	(Li et al. 2020c)
Trigonelline	alkaloids	C7H8NO2	anti-inflammatory activity, antioxidant activity	Chromolaena odorata (L.) R.M.King & H.Rob.	(Omidi-Ardali et al. 2019; Costa et al. 2020)
Verbenalin	iridoid terpene glycoside	C17H24O10	anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don	(Deepak and Handa 2000; Miao et al. 2016)
Vinyl caffeate	phenolic compounds	C11H10O4	antioxidant activity	Flacourtia jangomas (Lour.) Raeusch., Pothos chinensis (Raf.) Merr.	(Tada et al. 1996)
Vulgarone B	sesquiterpenoids	C15H22O	anti-inflammatory activity	Betula alnoides Buch.-Ham. ex D.Don, Croton kongensis Gagnep., Eurycoma longifolia Jack, Plantago major L., Tadehagi triquetrum (L.) H.Ohashi	(Chung and Shin 2009)
y-Morphine	alkaloids	C34H36N2O6	analgesic activity	Crinum asiaticum L.	(Caute et al. 1988; Laville et al. 2005)
β-Estradiol	steroids	C18H24O2	anti-inflammatory activity	Blumea balsamifera (L.) DC.	(Cuzzocrea et al. 2000; Song et al. 2019)

Discussion

Diversity of medicinal plants used to treat MSD

Karen people use a diversity of plants to treat MSD. The species number ranged between 46–94 species in the studied villages. In total, 139 species were recorded which correspond to 80% of species which were reported to treat MSD among Karen people in previous study (Kantasrila et al. 2020) and they made up 20% of medicinal plant species in Thailand reported by Phumthum et al. (2020). High number of species could be related to high prevalence of MSD among the Karen people. Most Karen are farmers with rural livelihoods that may provoke symptoms and illnesses related to MSD (Phumthum et al. 2020).

Important species for treating MSD

The use value (UV) and choice values (CV) made it possible to evaluate important species for treating MSD. Plants with high UV tend to have good properties for treating ailments (Mahmood et al. 2012; Malik et al. 2018) while CV determined the most preferred plant species used in each ailment category (Kremen et al. 1998). Both the UV and CV indices are useful for selecting plants for further phytochemical and pharmacological studies (Malik et al. 2018; Nguyen et al. 2020b). The species with the highest UV and CV was Sambucus javanica. In this study, it was used in 11 categories of the classification of MSD such as ankle symptom/complaint, back symptom/complaint, fracture: other, hand/finger symptom/complaint, etc. The use of this plant was reported from all the studied villages and by most informants (80%). This plant is well-known for its medicinal properties to treat MSD, not only by the Karen, but several other ethnic groups, including Akha (Anderson 1993; Inta 2008), Hmong (Srithi 2012), Lua (Srithi 2012), Mien (Anderson 1993; Srithi 2012), and Tai Yuan (Srithi 2012).

Sambucus simpsonii, is another species with high UV and CV similar to those of S. javanica. These two species were considered to be the same species (ethno-species) by the Karen people since both of them were called by the same name. Other species with high UV and CV values included Betula alnoides, Blumea balsamifera, Plantago major, Crinum asiaticum, Pothos chinensis, Flacourtia jangomas, Pothos scandens, Polygala chinensis L. (Polygalaceae), Cymbopogon citratus, Duhaldea cappa, Curcuma longa L. (Zingiberaceae), Elephantopus scaber, and Gmelina arborea Roxb. (Lamiaceae). These plants are commonly used as medicine to treat MSD in Thailand and around the world (Table 6). For example, B. alnoides has been reported for its properties to treat muscle pain (Inta and Pongamornkul 2015b), back pain (Boonkorn 1997; Archam 2011), bone pain (Boonkorn 1997; Archam 2011), and joint pain (Muangyen 2013). In India, it has been used for treating microfractures, dislocated bones, joint pains, and sprain (Manandhar 1995; Singh et al. 1996; Changkija 1999).

Table 6. Medicinal plant used to treat musculoskeletal system disorders (MSD) among the Skaw Karen in Thailand.

Species	Voucher specimen number	Ailments of MSD	References
Betula alnoides Buch.-Ham. ex D.Don	Kantasrila MSD011	muscle pain, back pain, bone pain, joint pain, microfracture, dislocated bones, sprain	(Manandhar 1995; Singh et al. 1996; Boonkorn 1997; Changkija 1999; Pongamornkul 2006b; Archam 2011; Inta et al. 2011a; Muangyen 2013; Inta and Pongamornkul 2015b, 2015a).
Blumea balsamifera (L.) DC.	Kantasrila MSD013	Muscle pain, lumbago, joint pain, rheumatoid arthritis, back pain, knee pain	(Pongamornkul 2010; Inta et al. 2011a; Pongamornkul and Muangyen 2012; Srithi 2012; Pongamornkul and Muangyen 2013; Inta 2014; Pang et al. 2014a; Inta and Pongamornkul 2015b; Songsangchun 2015)
Centella asiatica (L.) Urb.	Kantasrila MSD017	Muscle pain, lumbago pain, back pain, bone pain, fracture bone	(Winjchiyanan 1995; Pongamornkul 2006a, 2006b; Inta 2008; Sukkho 2008; Muangyen 2013)
Chromolaena odorata (L.) R.M.King & H.Rob.	Kantasrila MSD020	Muscle pain, back pain, lumbago pain, knee pain	(Yaso 2000; Pongamornkul 2006b; Pongamornkul 2009; Inta and Pongamornkul 2015a; Kantasrila 2016; Kaewsangsai 2017)
Crinum asiaticum L.	Kantasrila MSD023	Sprain, muscle pain, fracture bone, joint pain	(Pongsattayapipat 1992; Tovaranonte 1998; Pipitkul 2001; Pongamornkul 2006b; Kamwong 2009; Inta et al. 2011b; Junkhonkaen 2012; Panyadee 2012; Srithi 2012; Inta 2014; Tangjitman 2017)
Curcuma longa L.	Kantasrila MSD113	Fracture bone	(Winjchiyanan 1995; Kaewsangsai 2017; Kantasrila et al. 2020)
Cymbopogon citratus (DC.) Stapf	Kantasrila MSD028	Muscle pain, fracture bone	(Winjchiyanan 1995; Srithi 2012; Inta 2014; Kaewsangsai 2017)
Duhaldea cappa (Buch.-Ham. ex D.Don) Pruski & Anderb.	Kantasrila MSD036	Muscle pain, knee pain, joint pain, sprain	(Pipitkul 2001; Sukkho 2008; Tangjitman 2014; Kantasrila 2016)
Elephantopus scaber L.	Kantasrila MSD037	Muscle pain, lumbago pain	(Winjchiyanan 1995; Sukkho 2008; Kamwong 2009; Tangjitman 2014; Kaewsangsai 2017)
Flacourtia jangomas (Lour.) Raeusch.	Kantasrila MSD043	Muscle pain	(Kamwong 2009; Kantasrila et al. 2020)
Gmelina arborea Roxb.	Kantasrila MSD046	Muscle pain, fracture bone, knee pain	(Winjchiyanan 1995; Sukkho 2008; Junsongduang 2013; Tangjitman 2014; Kantasrila 2016)
Plantago major L.	Kantasrila MSD073	Joint pain, lumbago pain, back pain, muscle pain, sprain, knee pain, tendinitis, fracture bone	(Winjchiyanan 1995; Ponpim 1996; Puling 2001; Pongamornkul 2003; Inta 2008; Mahawongsanan 2008; Sukkho 2008; Pongamornkul 2010; Inta et al. 2011b; Supawimolpan 2011; Srithi 2012; Udompanid 2012; Waripo 2012; Muangyen 2013; Tangjitman 2014; Hutasingha 2015)
Polygala chinensis L.	Kantasrila MSD077	Muscle pain, lumbago pain, back pain	(Pongamornkul 2006a; Trisonthi and Trisonthi 2009; Inta and Pongamornkul 2015b; Kaewsangsai 2017)
Pothos chinensis (Raf.) Merr.	Kantasrila MSD078	Muscle pain, leg pain, fracture bone, sprain, joint pain	(Srithi 2012; Inta and Pongamornkul 2015b, 2015a; Kantasrila 2016; Kaewsangsai 2017)
Pothos scandens L.	Kantasrila MSD079	Back pain, lumbago pain, sprain, muscle pain	(Sukkho 2008; Tangjitman 2014)
Sambucus javanica Reinw. ex Blume	Kantasrila MSD085	Fractures, muscle pain, sprain, joint pain, lumbago pain	(Puling 2001; Pongamornkul 2003, 2006b; Inta 2008; Mahawongsanan 2008; Sukkho 2008; Trisonthi and Trisonthi 2009; Pongamornkul 2010; Srithi 2012; Junsongduang 2013; Pongamornkul and Muangyen 2013; Tangjitman 2014; Inta and Pongamornkul 2015b; Kantasrila 2016; Kaewsangsai 2017; Moonjai 2017)
Sambucus simpsonii Rehder	Kantasrila MSD086	Muscle pain, sprain, fracture bone	(Pongsattayapipat 1992; Tovaranonte 1998; Sukkho 2008; Kamwong 2009; Srithi 2012)

Blumea balsamifera has also been reported for its uses to treat rheumatism and lumbago in many south-east Asia countries (Pang et al. 2014a). This plant has a strong aromatic fragrance from its many phytochemical constituents (Shirota et al. 2011). The important active compounds, such as sesquiterpenoids and flavonoids, are useful for their anti-inflammatory and antioxidative activities (Nessa et al. 2004; Shirota et al. 2011; Pang et al. 2014b).

Plantago major is one of the most abundant species, which could be found in many areas, especially in home gardens. Therefore, it is always available for use at any time and in this study, it was used in 12 MSD ailment categories. The species was also commonly used for treating MSD among other ethnic groups in Thailand. For example, Tai Yai (Areekun and Onlamun 1978; Udompanid 2012), Mien (Areekun and Onlamun 1978; Anderson 1993), Akha (Anderson 1993), and Hmong (Anderson 1993). It was used to treat rheumatic ailments, bone fractures, and muscle pains. Moreover, it has many active compounds like flavonoids, terpenoids, pectins, iridoid glycosides, and tannins which are all related to anti-inflammatory and antioxidant activities (de Padua 1999; Hussan et al. 2015).

In addition, Crinum asiaticum (Mahomoodally et al. 2021), F. jangomas (Sasi et al. 2018), Cymbopogon citratus (Kumar et al. 2010b), Duhaldea cappa (Kaur et al. 2017), Curcuma longa (Ahmad et al. 2010; Oghenejobo and Bethel 2017), Elephantopus scaber (Wang et al. 2013; Wang et al. 2014) and Gmelina arborea (Kaswala et al. 2012; Lawal 2016; Arora and Tamrakar 2017; Gandigawad et al. 2018) all have many active compounds that determine their medicinal properties, based on antioxidative, analgesic, antinociceptive, antipyretic and anti-inflammatory activities.

Important categories of MSD by ICF

The musculoskeletal system disorders (MSD) are a group of ailments with high prevalence among the Karen people (Phumthum et al. 2020). These diseases accounted for one-third of all use reports of medicinal plants among the Karen (Phumthum et al. 2020). There were 23 categories of ailments related to MSD, which were reported from the key informants. The muscle pain category was the most prevalent category of MSD in this study, which agreed with the study of other Karen communities (Kantasrila et al. 2020). This ailment relates to the Karen lifestyle, especially their agricultural activities (Kantasrila et al. 2020; Phumthum et al. 2020), e.g., working in rice fields. Therefore, many species were reported to be used to treat this illness. Moreover, muscle pain was also reported as one of the most prevalent ailments of MSD in other regions around the world such as northern Pakistan (Malik et al. 2018), and Spain (Cavero and Calvo 2015).

Other ailment categories with high numbers of use reports included flank/axilla symptom/complaint, back symptom/complaint, knee symptom/complaint and joint symptom/complaint NOS. Lumbago was the most common ailment in the flank/axilla symptom/complaint category. Most Karen people have suffered from this ailment (Kantasrila et al. 2020; Phumthum et al. 2020). The load of hard work in rice fields was the main cause of back pain and lumbago. One of the most prevalent MSD in farmers was pain in the lower back caused by physical activities such as excessive bending, twisting, and carrying of loads (Puntumetakul et al. 2011). This result agrees with a study of the prevalence of musculoskeletal pain in Korean farmers, which indicated that low back pain was more frequent than pain in other parts of the body (Min et al. 2016). The workload in the rice field also affects other parts of the body such as legs/feet, knees, and shoulders (Rosecrance et al. 2006; Min et al. 2016).

Phytochemical analysis

Prevalence of phytochemical constituents and pharmacological activities related to MSD

A total of 172 active compounds which are potentially useful for treating MSD are reported. These active compounds possessed the properties which related to anti- inflammatory, analgesic, antinociceptive, anesthetics, anti-arthritic, and antioxidative activities. The most prevalent active compounds included 9-hydroxycalabaxanthone, dihydrovaltrate, and morroniside. 9-Hydroxycalabaxanthone, benzopyrans have been reported for their anti-inflammatory and antioxidative treatments (Gutierrez-Orozco and Failla 2013). Dihydrovaltrate is a terpenoid, which is related to anti-inflammatory properties (Subhan et al. 2007). Morroniside is an iridoid (monoterpenoid) glycosides, which has been used as an anti-inflammatory agent (Chen et al. 2018).

Moreover, there were other prevalent active compounds, including isoacteoside, lithocholic acid, pomiferin, cucurbitacin E, leonuriside A, liriodendrin, and physalin E. Isoacteoside are a hydroxycinnamic acid, which are related to antioxidative and anti-inflammatory activities (Chao-Hsiang et al. 2012; Nam et al. 2015; Simamora et al. 2020). Lithocholic acid is a steroid which has been used as anti-inflammatory activity (Sun et al. 2008; Ward et al. 2017). Pomiferin is a flavonoid, which is related to antioxidative activity (Bartosikova et al. 2007; Mazumder and Rahman 2008). Cucurbitacin E is a natural product in member of steroid, which is related to anti-inflammatory and analgesic activities (Peters et al. 1997; Abdelwahab et al. 2011). Leonuriside A is a phenolic glycoside, which has been used for anti-inflammatory activity (Shrestha et al. 2013; Dang et al. 2020). Liriodendrin, a lignan glycosides, has been used elsewhere for anti-inflammatory and anti-nociceptive activities (Jung et al. 2003). Physalin E is a physalin, which includes anti-inflammatory activity (Pinto et al. 2010; Yang et al. 2017).

The flavonoids and their glycosides were the main class of active compounds found in this study. They were found in important medicinal plants used for treating MSD. They consist of a large group of polyphenolic compounds having a benzo-γ-pyrone structure and they have been found in many plants (Kumar and Pandey 2013). Several studies have documented the pharmacological relevance of flavonoids to their anti-inflammatory, analgesic, and antioxidative activities (Kanadaswami et al. 2005; Serafini et al. 2010; Barros et al. 2011; Carocho and Ferreira 2013). Flavonoids can promote human health and lower the risk of diseases (Kumar and Pandey 2013). Moreover, the flavonoids are reported to possess anti-inflammatory and analgesic effects by inhibiting the enzyme which is related to inflammation including nitric oxide synthase, cyclooxygenase, and lipoxygenase (Rice-evans et al. 1995; Kumar and Pandey 2013).

Other active compounds were in the classes of terpenoids, alkaloids, and steroids. Terpenoids are the largest groups of natural compounds, which provide medical benefits for an organism. They are mostly found in plants, especially, in essential oils. Many terpenoids were reported to their anti-inflammatory, antioxidative and analgesic activities (Akihisa et al. 2011; Erfanparast et al. 2015; Shan et al. 2019), which are related to treating the MSD. In this study, many terpenoids were found to be related to treating MSD such as acuminoside (Sharma and Rao 2009), bruceine D (Hall et al. 1983), agnuside (Pandey et al. 2012), grayanotoxin I (Gunduz et al. 2014; Sun et al. 2019), salannin (Akihisa et al. 2011), etc.

Alkaloids are important compounds in many plant species. These compounds have properties related to anti-inflammatory activities (Barbosa-Filho et al. 2006). For example, berbamine, berberine, cepharanthine, tetrandine and aconitine have been reported to have anti-inflammatory activity (Wong et al. 1992; Barbosa-Filho et al. 2006). In this study, many alkaloids were found which in other studies have been demonstrated to be related to anti-inflammatory, analgesic and antioxidative properties, e.g., 3-α(S)-strictosidine (Sakamoto et al. 2020), aconine (Li et al. 2016), castanospermine (Hong et al. 2016), drotaverine (Debski et al. 2007; Dash et al. 2012), and hirsuteine (Kawakami et al. 2011).

Another important phytochemical compound group is steroids. Many steroidal agents are used to treat inflammatory disorders (Vyvey 2010; Patel and Savjani 2015). Glucocorticoids are steroids, which are mostly used as anti-inflammatory agents (Nunes et al. 2020). Extracts from many medicinal plants, which are rich in steroids, are reported elsewhere to be used for their analgesic and anti-inflammatory activities such as Echinops kebericho Mesfin (Asteraceae) (Yimer et al. 2020) and Solanum xanthocarpum Schrad (Solanaceae) (Patel and Savjani 2015). In this study, many steroidal compounds, which are related to anti-inflammatory activity, were detected, for example, contignasterol (Burgoyne et al. 1992; Cheung et al. 2016), cortisone (Park et al. 2013), cucurbitacin E (Peters et al. 1997; Abdelwahab et al. 2011), fasciculol C (Ványolós et al. 2020), and fluocinonide (Mutasim 2006).

Phytochemical compounds and pharmacological activity in important species to treat MSD

The medicinal plants with the highest number of active compounds were Eurycoma longifolia and Flacourtia jangomas. The number of active compounds found in E. longifolia and F. jangomas were one-sixth of total active compounds found in the 20 selected medicinal plants. Eurycoma longifolia was reported for its uses as medicine in many countries around the world (Muhamad et al. 2009; Park et al. 2014; Baiee et al. 2018), especially in Southeast Asia (Muhamad et al. 2009). It has been used to treat many illnesses such as malaria, fever (Bhat and Karim 2010), gout (Liu et al. 2009), and bone pain (Kuo et al. 2003). The chemical compounds in this plant were found to possess antioxidative (Lulu et al. 2015) and anti-inflammatory activities (Varghese et al. 2013). This species had many prevalent compounds, which had pharmacological activities related to MSD such as cis-p-coumaric acid (Pei et al. 2016) and vulgarone B (Chung and Shin 2009).

Flacourtia jangomas was another well-known species which is used to treat muscle pain among the Karen people (Kamwong 2009). This plant has also been used as medicine in India, Cambodia, Laos, Vietnam, and elsewhere in Thailand (Sasi et al. 2018). It produces various compounds such as anthocyanin, alkaloids, β-carotene, flavonoids, tannins, saponins, amino acids, and phenolic compounds (Dubey and Pandey 2013; Sasi et al. 2018). Some of the active chemical constituents that have been reported for many medicinal properties include analgesic, anti-inflammatory, antibacterial, antidiarrheal, antiviral, antioxidant, and anti-amylase activities (Jeyachandran and Mahesh 2007).

Other species with high numbers of active compounds were Croton kongensis, Plantago major, Blumea balsamifera, Betula alnoides, Tadehagi triquetrum, Scleropyrum pentandrum, Sambucus javanica and Polygala chinensis. Croton kongensis is a popular medicine among several ethnic groups in Thailand. This species was not only used to treat muscular pain, but also for dysmenorrhea (Salatino et al. 2007). The active compounds of this species can inhibit the inflammatory process such as norvaline (Ming et al. 2009), vulgarone B (Chung and Shin 2009), terretonin (Wu et al. 2019), and quercetagetin (Boots et al. 2008; Kang et al. 2013; Gutiérrez-Venegas et al. 2017). In addition, many compounds in this species have been reported to be related with antioxidative and analgesic activities such as benzocaine (Eslamian et al. 2016), morroniside (Chen et al. 2018), and lithocholic acid (Sun et al. 2008).

Plantago major was used to treat many MSD ailments such as rheumatic ailments, bone fractures and muscle pains (Areekun and Onlamun 1978; Anderson 1993). Extractions from this species had many active compounds related to MSD treatment properties, such as asperuloside (He et al. 2018), benzocaine (Eslamian et al. 2016), dihydrocapsaicin (Zak et al. 2018), piplartine and lithocholic acid (Sun et al. 2008; Ward et al. 2017).

Blumea balsamifera is a common medicinal plant, which has been used to treat various illnesses among many ethnic groups in Thailand, especially for postpartum recovery of women (Srithi et al. 2009; Tangjitman et al. 2015). The prevalent compounds found in this species were artemisinin (Kim et al. 2015; Shi et al. 2015), β-estradiol (Cuzzocrea et al. 2000; Song et al. 2019), cis-5-caffeoylquinic acid (Ma et al. 2011), lithocholic acid (Sun et al. 2008; Ward et al. 2017), and colforsin (Hayashida et al. 2001).

The extracted solution from the bark of Betula alnoides has been used as medicine for a long time in many countries around the world (Rastogi et al. 2015). A decoction from the bark of this plant has been used to treat micro-fractures and dislocated bones (Manandhar 1995; Rajbhandari 2001). The solution of this plant was reported for its anti-inflammatory and antioxidative activities (Sur et al. 2002; Ghimire et al. 2012). In this study, many active compounds which related to MSD treatment were found, such as benzocaine (Eslamian et al. 2016), 5-O-feruloylquinic acid (Erel et al. 2011; Sarı et al. 2019) and calcitroic acid (Bishop et al. 2021).

Tadehagi triquetrum has been used in many Thai folk medicines to treat various ailments including treatments of muscle pain and for improving physical and sexual performances in men (Wisuitiprot et al. 2020). It was used in traditional Chinese medicine and reported for its anti-inflammatory activity (Yan et al. 2018). The ethanolic and water extracts of this plant were also reported to have potent antioxidant activity (Wisuitiprot et al. 2020). In this study, many active compounds related to anti-inflammatory, antioxidative, and analgesic activities were found, e.g., artemisinin (Kim et al. 2015; Shi et al. 2015), cis-p-coumaric acid (Pei et al. 2016), leonuriside A (Shrestha et al. 2013; Dang et al. 2020), etc.

Some active compounds in Scleropyrum pentandrum were reported to be anti-inflammatory such as ellagic acid (Favarin et al. 2013; Kilic et al. 2014), castanospermine (Hong et al. 2016), cytosine (Amir et al. 2007), isofraxidin (Niu et al. 2012; Lin et al. 2018). Moreover, many active compounds from S. pentandrum were related to antioxidative and analgesic properties such as morroniside (Chen et al. 2018) and α-citronellol (Katsukawa et al. 2011; Brito et al. 2012).

Polygala chinensis was used as a tonic and to treat muscle pain by brewing and drinking it in a water or alcoholic decoction (Areekul et al. 2008). Many active compounds in this species were related to anti-inflammation activity such as 9-hydroxycalabaxanthone (Gutierrez-Orozco and Failla 2013), leonuriside A (Dang et al. 2020), antioxidative activity such as isoacteoside (Simamora et al. 2020), fasciculol C (Ványolós et al. 2020) and anti-analgesic activity such as astragalin (Qnais et al. 2014; Riaz et al. 2018).

Another species, with many active compounds was Sambucus javanica, which is used as medicine by several ethnic groups in Thailand (Areekul et al. 2008; Inta 2008; Kantasrila 2016). However, its phytochemical compounds are not well studied yet. In this study, many active compounds were found in S. javanica, which were related to anti-inflammatory, antioxidative and analgesic properties such as 4-guanidinobutanoic acid (Hwang and Jeong 2012), 2-hydroxy-1,4-benzoquinone (Petronzi et al. 2011), leonuriside A (Shrestha et al. 2013; Dang et al. 2020), etc.

These promising plants have phytochemical compounds, which related to treat MSD. However, the study about medicinal plants has many concerns such as translational hurdles of phytoconstituents and safety concern. Although medicinal plants play vital roles in disease prevention. There is little scientific evidence to determine the safety and efficacy of most herbal products. There are reports that medicinal plants remedies in the form of complementary and alternative medicine effect adverse reactions among pediatric patients (Lombardi et al. 2019). In regard to using medicinal plants, oral administration was the predominant route of administration for most of medicinal plants to treat MSD. However, the oral route of administration needs a high dose of phytomolecule to attain the desired therapeutic plasma concentration (Sharma et al. 2004). Many phytochemical compounds have a low percentage of oral bioavailability and have hurdles in clinical translation of molecule due to low solubility and permeability, extensive metabolism, high protein binding, rapid elimination, unstable at physiological pH, poor absorption, etc. (Sayed et al. 2019). Therefore, the selection of medicinal plants to study in future clinical tests should consider these hurdles.

Future clinical studies and the road map to the widespread use of medicinal plants to treat MSD for a global patient population

The promising plants such as Sambucus javanica, Betula alnoides, Blumea balsamifera, Plantago major and Flacourtia jangomas and their active components e.g., 9-hydroxycalabaxanthone, dihydrovaltrate and morroniside will be chosen for further clinical investigation. First, we will study in in vitro. The extracts of each plant and pure components will be performed on the critical musculoskeletal system disorders (MSD), e.g., the reduction of prostaglandins (PG) which can cause chronic pain and inflammation. The arachidonic pathway and nuclear factor kappa-B pathway control the production of PG. Therefore, we will focus on related genes and protein expression of this mechanism, especially on cyclooxygenase-2 (COX-2) enzyme. The most effective plant will be further developed into commercial products while the active component will be used as a marker. After that, we will confirm their pharmacological activities, together with their active compounds. The most effective plant will be developed as cream or spray or ointment. Then the effectiveness will be confirmed again in in vitro, in vivo, and clinical studies. The product will be registered for FDA and validated in market in Thailand and in other countries. Use on a global population level might be happening in no more than 6 years.

Conclusions

Medicinal plants used for treating musculoskeletal disorders (MSD) among the Karen were studied in the six villages in Chiang Mai province, Thailand. There were 139 species, 117 genera, 62 families, and 3731 use reports. The phytochemical analysis with (LC-MS/MS) revealed 172 active phytochemical compounds in the 20 examined medicinal species. Most active compounds were flavonoids. The species, which were candidate species in this study, were Sambucus javanica, Betula alnoides, Blumea balsamifera, Plantago major, and Flacourtia jangomas. The occurrence of various active compounds in the 20 most used ethnomedicinal plants validates the traditional knowledge relating to them as remedies for treating MSD. Quantitative method of ethnobotanical study can be used for selecting plants for medicinal development and can be applied for studying other groups of medicinal plants used to treat other disorders in Thailand such as digestive system disorders, infections/infestations disorders, genitourinary system disorders, etc. Moreover, this study provides a valuable information, demonstrating low-cost medicinal plants which are locally available. It is a choice of treatment for the people living in remote areas because medicinal plants can be easily available to poorer segments of the ethnic population. In addition to being a guideline in the field of medicine, it can be used for plant conservation and management.

Acknowledgments

We would like to thank the Karen people in Chiang Mai, Thailand, for sharing their knowledge with us. We are also thankful to the Human Resource Development in Science Project (Science Achievement Scholarship of Thailand, SAST) for supporting the PhD study of Rapeeporn Kantasrila and the Chiang Mai University for partial financial support.

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Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.