BALNEOTHERAPY AND PAIN

Dr Arif Dönmez

20.01.2006

Balçova-İzmir

Pain and Balneotherapy

Musculoskeletal disorders are the most common reason for the patients taken balneotherapy. Such as Osteoarthritis Chronic low back pain Fibromyalgia and myofascial pain

syndromes Soft tissue disorders ……..

Pain is the most prominent symptom in this group of patients

Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

A sample list of frequently used terms from: Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, © 1994, pp. 209-214.

Pain

Pain has sensory, emotional, and cognitive components.These 3 components of pain are reflected in the mechanisms of the transmission and modulation of painful stimuli. Such mechanisms are mediated through the nociceptor neurons (pain receptors and nerve fibers), the spinal cord, and the brain.Katz WA, Rothenberg R. The Nature of Pain: Pathophysiology. Journal of Clinical Rheumatology 2005(11) 2:11-5

How amount of pain decrease is clinically important?

In Visual Analog Scale, more than %30 or 2 point (0 -10) decrease is accepted as clinically important change in chronic pain

Farrara J T,. Young JP, L La Moreaux L, et al: Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 94 (2001) 149–158

Is balneotherapy effective on pain in different musculoskeletal disorders?

Balneotherapy studies which are evaluated pain intensity in Fibromyalgia Syndrome

Dönmez A, Karagülle MZ,Tercan N et al: Spa therapy in fibromyalgia:

A randomised controlled clinic study Rheumatol Int. 2005 Dec;26(2):168-72.

  Week 0

Week 2

1st

month3rd

month6th

month9th

monthX2 p

Pain (VAS) 6.75 2.9 b 2.8 b 4.2 b 4.3 b 4.3 b 21.75 <0.001

b: p<0.05difference

3.85 3.90 2.55 2.40 2.40

change %57 %57 %37 %35 %35

0

10

20

30

40

50

60

70

before-after

before-1.month

before-3.month

before - 6. month

before - 9 months

Dönmez A Evcik D Buskila DYurtkuran M Altan L G1 Altan L G2

% decrease in pain

intensity

Fibromyalgia studies

Balneotherapy studies which are evaluated pain intensity in osteoarthritis

Pain (VAS) Before spa

Before discharge change in pain

(0-10) %

 Cervical OA, 34

5.9 ± 3.6

2.3 ± 1.5 3.6 %61

 Lumbar OA, 33

6.5±1.9 2.8 ± 1.2 3.7 %61

 Coxarthrosis, 29

6.0 ± 2.5

1.3 ± 1.2* 4.7 %78

 Gonarthrosis, 117

6.3 ± 3.0

1.5 ± 1.4* 4.8 %76

 Ankle arthrosis, 9

6.8 ± 3.8* 1.8 ± 1.5 5.0 %73

 Poliarthrosis, 49

6.6 ± 2.8* 2.3 ± 1.5 4.3 %65

Pain VAS scores after therapy compared to baseline by type of

pathology.

Cımbız A, Bayazıt V, Hallaceli H, Cavlak U: The effect of combined therapy (spa and physical therapy) on pain in various chronic diseases. Complementary Therapies in Medicine (2005) 13, 244—250

Group I %37.31

Group II %30.12

Odabaşı E, Karagülle MZ, Karagülle M et al. Comparison of two traditional spa therapy regimens in patients with knee osteoarthritis; an exploratory study. Phys Med Rehab Kuror 2002;12:337-341

Pain (VAS) change

Spa before-after

%30

Before-24 weeks

%18

Nguyen M , Revel M, Dougados M. Prolonged effects of 2 week therapy in a spa resort on lumbar spine, knee and hip osteoarthritis: Follow-up after 5 months. A randomized controlled trial. British Journal of Rheumatology 1997:36;77-81

Pain (VAS) change

0

5

10

15

20

25

30

35

40

before-after before - 6. month

Odabaşı E1 Odabaşı E2 Forrestier R1Forrestier R2 Nguyen M Kovacs I% decrease in pain

intensity

Balneotherapy studies on knee osteoarthritis some references

Systematic Review of balneotherapy for knee OA RCTs

Brosseau L, Macleay L, Robinson V. Efficacy of balneotherapy for osteoarthritis f the knee; a systematic review. Physical Therapy Reviews. 2002;7:209-222

“ The results of this review suggest that balneotherapy can be effective on a short-term basis for measures of pain severity and function as well as for improved ROM and timed stair climbing.”

Balneotherapy studies which are evaluated pain intensity in low back pain

Pain intensity in low back pain

0

10

20

30

40

50

60

70

80

before-after

before-3.month

before - 6. month

before - 9 months

before - 1 year

Balogh Z Guillemin F Constant F1Constant F2 Konrad K Yurtkuran M

% decrease in pain

intensity

These data have shown that balneotherapy is effective on pain in musculoskeletal disorders.

What is the mechanism of action?

MECHANISM of ACTION

HeatPeripheral Vasodilatation BuoyancyIncrease B endorphin levels Decrease Muscle Tonus- Increase pain thresholdGate-Control TheoryIncreases Connective Tissue stretchingEnvironmental changesNon- competitive atmosphereAbsence of work duties

Heat

Cutaneous counterirritant effectVasodilatation Endorphin-mediated responseAlteration of nerve conduction

Weber DC, Brown AW: Physical agent modalities. Braddom RL (ed.) Physical Medicine and Rehabilitation WB Saunders Company.Philadelphia 2000 p:440-458

Peripheral Vasodilatation

Vasodilatation resulting in decreased ischemic painVasodilatation resulting in washout of pain mediators

Buoyancy

.... the hydrostatic force can help alleviate pain by decreasing joint load.

Mechanical mechanisms such as increased buoyancy and hydrostatic pressure have been thought to affect muscle tone, joint mobility and pain intensity.42

Brosseau L, Macleay L, Robınson V. Efficacy of balneotherapy for osteoarthritis of the knee: a systematic review.Physical Therapy Reviews 2002; 7: 209–222

Increase in ß endorphin levels

Beta endorphineKubota K, Kurabayashi H, Tamura K, et al (1992) A transient rise in plasma beta-endorphin after a traditional 47 degrees C hot-spring bath in Kusatsu-spa, Japan. Life Sci. 51(24):1877-80.      

Beta endorphine (12/20) , (2/20) (6/20)

Yurtkuran M, Ulus H, Irdesel J (1993) The effect of balneotherapy on plasma beta endorphine level in patient with osteoarthritis. Phys Rehab Kur Med 3:130-132

Environmental changes

Non- competitive atmosphere