balneo-spa therapy in the management of rheumatoid arthritis
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Balneo-Spa Therapy in The Management of Rheumatoid Arthritis. Mine Karagülle,MD Istanbul University Istanbul Medical Faculty Medical Ecology and Hydroclimatology Department. Rheumatoid Arthritis (ACR 2002). - PowerPoint PPT PresentationTRANSCRIPT
Balneo-Spa Therapy in The Balneo-Spa Therapy in The Management of Rheumatoid Management of Rheumatoid ArthritisArthritis
Mine Karagülle,MDMine Karagülle,MDIstanbul University Istanbul Medical FacultyIstanbul University Istanbul Medical FacultyMedical Ecology and Hydroclimatology Medical Ecology and Hydroclimatology Department Department
Rheumatoid Arthritis (ACR 2002)Rheumatoid Arthritis (ACR 2002)
• Rheumatoid arthritis(RA) is an autoimmune disorder of unknown characterized by symmetric erosive synovitis and in some cases, extraarticular involvement
• RA affects 1% of the adult population
Rheumatoid Arthritis (ACR 2002)Rheumatoid Arthritis (ACR 2002)
• Most patients experience a chronic fluctuating course of disease that , despite therapy , may result in progresive joint destruction, deformity, disability, and even premature death.
• RA results in more than 9 million physician visits and more than 250,000 hospitalizations per year in USA.
• Disability from RA causes major economic loss and can have a profound impact on families
Management of RA (ACR 2002)Management of RA (ACR 2002)
Goals• Prevent or control joint
damage• Preventloss of function• Decrease pain
Management• Patient education• Start DMARD(s) • Consider NSAID• Consider local or Low
dose systemic dteroids• PhysicalTherapy/
occupational therapy
BalneotherapyBalneotherapy
• Is a therapeutic and/or rehabilitative option in the management of rheumatoid arthritis?
• Is balneotherapy an effective tool in the achievement of ultimate goals in managing RA?
• Is balneotherapy effective in preventing joint demage, preventing loss of function and decreasing pain in RA?
BalneotherapyBalneotherapy
• Balneotherapy and spa therapy for patients with arthritis is one of the oldest forms of therapy.
BalneotherapyBalneotherapy
• One of the aims of balneotherapy is to soothe the pain, improve joint motion and as a consequence to relieve people suffering and make them well.
BalneotherapyBalneotherapy
• Balneotherapy is the main component of Spa Therapy
Spa TherapySpa Therapy
Mud therapy
Climatic factors
Climatherapy
Hydrotherapy Massage
Exercise
Social&
Physicological
influences
Balneotherapy
Studies on Balneotherapy for RAStudies on Balneotherapy for RAAuthor/Year
No pat.
Treatment Control Concur.
Treat.
No of
week
Fol-Up
Results
Günter 1976
Bad Gastein
20 I: Radon Thermal bathing
II: Tap water bath.
III: No bathing
Cross-Over design
During 3 years
3 weks a year
N/A 3
W.
İmprovements in every 3 groups at the end of cure
Steiner 1986
Bad Gastein
24 Thermal water bathing (35oC)
3 times a week
Exercise programm in Amsterdam
Massage swim.
3,5 Wks
2 Year
Significant improv. in treatment group (several months)
Sukenik 1990a
Dead Sea
40 Group I: Daily mud pack
Group II: Daily sulphur bathing
Group III: Mudpacks+sulphur baths
Group IV: No-treatment control
N/A 2 wks
3 mo Signf improvement in all 3 treat. grps. Minor imprvm. İn contr grp (not significant)
Sukenik 1990b
30 Group I. Dead Sea salt baths
Grup II: Sodium chloride baths
Regular medication
2 wks
3 mo Larger improvement mostly in I compared to II,
Elkayam 1991
Tiberias
41 Group I: Mineral baths + mud packs
tap water baths N/A 2 wks
3 mo Improv. İn Ritchie Indx. both grps (at 3 mo. only in gr.I)
Author/Year No pat.
Treatment Control Concur.
Treat.
No of
week
Fol-Up
Results
Sukenik 1992
Dead Sea
28 Grp I: true Mud pack
Grp II: washed-out mud
N/A 2 wks no Sign. İmprov. İn true mud grp.
Sukenik 1995
Dead Sea
36 Grp I: Dead Sea baths
Grup II. Sulphur baths. 35oC
Grp III. Dead Sea baths
+ Sulphur baths
Grp IV: Control No treatment
N/A 12 days 3 mo Signf improvement in all 3 treat. grps. No improvement in control group
Yurtkuran 1999
Bursa
57 Grp I: Thermomineral baths (n:32) 35oC
Grp II:
Cyclosporyn A (3,5 mg/kg) (n: 25) 2 moths
N/A 3 wks 2 mo Improvement in both groups.
No side effects in Balneotherapy grp
Franke 2000
Bad Branbach
55 Grp I. Natural radon-carbondioxide baths
Grp II: Artificial carbondioxide baths
N/A 4 wks 6 mo Improvement in both groups, at 6 months follow-up only in natural radon-car. grp
Karagülle 2002
Tuzla/İstanbul
37 Grp I: Natural Mineral water baths
(n: 15)
Grp II: Rutin medical care
(n: 22)
Massage, drinking cure, patient education
2 wks 6 mo Signf. İmprovement in mineral bath grp.
Partly conserved up to 6 months
Studies on Balneo-Spa therapy for Studies on Balneo-Spa therapy for RA in TurkeyRA in Turkey
Studien-designIndikation
Unkontrolliert Kontrolliert
Retrospektiv ProspektivNicht randomisiert
Randomisiert
Fibromyalgia 2 Studien n=60
Gonarthritis 1 Studie n=604 Studienn=164
Osteoarthritis 1 Studie n=36 2 Studien n=52
Rückenschmerz 2 Studien n=52 1 Studien=50
Rheumatoide Arthritis
2 Studienn=1703
1 Studien=57
Ankylosierende Spondylitis
2 Studienn=1712
1 Studien=45
Arthritis Psoriatica1 Studien=542
Evidence Based Medicine AproachEvidence Based Medicine Aproach
Evidence Based Medicine AproachEvidence Based Medicine Aproach
Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane Library, Issue 4, 2003.
Chichester, UK: John Wiley & Sons, Ltd. Date of most recent substantive amendment: 28 August 2003
“This review has shown the positive effects of balneotherapy on important outcomes for patients with RA.The reviewers concluded that balneotherapy can be used as an adjunct therapy. However, these conclusions are undermined by the poor methodological quality of the trials available and the potential harmful side effects for arthritic patients with associated medical conditions.”
Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane LibraryThe Cochrane Library, Issue 4, 2003., Issue 4, 2003.
• What is the bottom line?What is the bottom line?There is "silver" level evidence that balneotherapy or bathing in warm water may improve symptoms of rheumatoid arthritis. But most studies are of poor quality and therefore it cannot be concluded that balneotherapy works. It is also not clear if the effect of balneotherapy depends on water temperature and the addition of minerals to the water.
Implications for researchImplications for researchVerhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane LibraryThe Cochrane Library, Issue 4, 2003., Issue 4, 2003.
Large, high quality research is needed, focusing on appropriate allocation concealment, blinding and an adequate data presentation and analysis. The design and reporting of future trials should be conforming the CONSORT-statement.
Implications for researchImplications for researchVerhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane LibraryThe Cochrane Library, Issue 4, 2003., Issue 4, 2003.
New research should use outcome measures relevant to the patients, and adequate and responsive to the treatment under study. Follow-up should be of sufficient length to assess long-term effects.
New research should provide full data on outcome measures, including the mean and standard deviation or 95% confidence interval.
Implications for researchImplications for researchVerhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane LibraryThe Cochrane Library, Issue 4, 2003., Issue 4, 2003.
Future research should examine the effect of balneotherapy not only in pragmatic trials comparing various interventions with each other, but also in more explanatory trials comparing the intervention with a no treatment control group. When possible, the beneficial effect of the 'spa-environment' should be considered as a confounder or effect modifier and accounted for in the design of the trial.
Implications for researchImplications for researchVerhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane LibraryThe Cochrane Library, Issue 4, 2003., Issue 4, 2003.
We conclude that performing randomised studies with high methodological quality concerning the effectiveness of balneotherapy is both possible and necessary to provide strong evidence on the effects of balneotherapy.
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