Spa therapy for lumbar Spa therapy for lumbar spine osteoarthritisspine osteoarthritis

M. Zeki KaragülleM. Zeki KaragülleIstanbul University Istanbul Medical FacultyIstanbul University Istanbul Medical Faculty

DepartmentDepartment of of Medical Ecology and Medical Ecology and HydroclimatologyHydroclimatology

OsteoarthritisOsteoarthritis

the most common form ofthe most common form of arthritis in arthritis in the Worldthe World

Over one-half of all people older than Over one-half of all people older than 65 show OA-associated changes in the 65 show OA-associated changes in the knees. knees.

After age 75, almost everyone has After age 75, almost everyone has these changes. these changes.

Peyron JG. Epidemiologic and etiologic approach to Osteoarthritis. Semin Arthritis Rheum 8; 288-306, 1979

OsteoarthritisOsteoarthritis

Patients with OA havePatients with OA have pain that pain that typically worsens with weight typically worsens with weight bearing andbearing and activity and improves activity and improves with restwith rest

as well as morningas well as morning stiffness and stiffness and gelling of the involved joint after gelling of the involved joint after periods ofperiods of inactivity inactivity

CCauses of OA are not auses of OA are not completely understoodcompletely understood biomechanicalbiomechanical stresses affecting stresses affecting

the articular cartilage andthe articular cartilage and subchondral bone subchondral bone

biochemical changes in the biochemical changes in the articulararticular cartilage and synovial cartilage and synovial membranemembrane

genetic factorsgenetic factors

all important in its pathogenesisall important in its pathogenesis

Areas Areas that that Osteoarthritis Osteoarthritis AffectsAffects most often at the most often at the

ends of the ends of the fingers, thumbs, fingers, thumbs, neck, lower back, neck, lower back, knees, and hipsknees, and hips

Classification Criteria for Classification Criteria for OsteoarthritisOsteoarthritisAmerican College

of Rheumatology HandHand KneeKnee HipHip Spine ???Spine ???

ACR OACR OA A GUIDELINESGUIDELINES 2000 2000 THE THE HIP AND KNEE HIP AND KNEE Nonpharmacologic Nonpharmacologic therapiestherapies Patient educationPatient education Self-management programs (e.g., Self-management programs (e.g.,

Arthritis Foundation Self-Management Arthritis Foundation Self-Management Program)Program)

Personalized social support through Personalized social support through telephone contacttelephone contact

Weight loss (if overweight)Weight loss (if overweight) Aerobic exercise programsAerobic exercise programs Physical therapyPhysical therapy Range-of-motion exercisesRange-of-motion exercises

ACR OACR OA A GUIDELINESGUIDELINES 2000 2000 THE THE HIP AND KNEE HIP AND KNEE Nonpharmacologic Nonpharmacologic therapiestherapies Muscle-strengthening exercisesMuscle-strengthening exercises Assistive devices for ambulationAssistive devices for ambulation Patellar tapingPatellar taping Appropriate footwearAppropriate footwear Lateral-wedged insoles (for genu varum)Lateral-wedged insoles (for genu varum) BracingBracing Occupational therapyOccupational therapy Joint protection and energy conservationJoint protection and energy conservation Assistive devices for activities of daily Assistive devices for activities of daily

livingliving

The goals of OA The goals of OA treatmenttreatment Reduce painReduce pain RRelieve symptomselieve symptoms MMaintain aintain and/or improve joint and/or improve joint

mobilitymobility Limit functional impairmentLimit functional impairment MMinimize disabilityinimize disability

Goals of balneotherapy Goals of balneotherapy for arthritisfor arthritis Improving range of joint motion Improving range of joint motion Increasing muscle strength Increasing muscle strength Eliminating muscle spasm Eliminating muscle spasm Enhancing functional mobility Enhancing functional mobility Easing pain Easing pain

Balneotherapy for lumbar Balneotherapy for lumbar OAOAObservational studyObservational study Effect on osteoarthritis of spa Effect on osteoarthritis of spa

therapy at Bourbonne-les-Bainstherapy at Bourbonne-les-Bains

F. GUILLEMIN, J-M. VIRION, P. F. GUILLEMIN, J-M. VIRION, P. ESCUDIER, N. DE TALANCÉ, G. WERYHA ESCUDIER, N. DE TALANCÉ, G. WERYHA Joint Bone Spine 2001 ; 68 : 499-503Joint Bone Spine 2001 ; 68 : 499-503

21-day course of spa therapy; daily sessions of balneotherapy and physiotherapy

Effect on osteoarthritis of spa therapy at Effect on osteoarthritis of spa therapy at Bourbonne-les-BainsBourbonne-les-Bains F. GUILLEMIN, J-M. VIRION, F. GUILLEMIN, J-M. VIRION, P. ESCUDIER, N. DE TALANCÉ, G. WERYHA P. ESCUDIER, N. DE TALANCÉ, G. WERYHA Joint Bone Spine 2001 ; 68 : 499-503Joint Bone Spine 2001 ; 68 : 499-503

Quality of life was markedly decreased as compared to the population at large (1996, CFES). The two pretreatment evaluations produced similar quality-of-life scores. Spa therapy was associated with significant improvements in overall quality of life (P=0.004), self-esteem (P=0.009),and pain (P=0.01).

Effect on osteoarthritis of spa therapy at Effect on osteoarthritis of spa therapy at Bourbonne-les-BainsBourbonne-les-Bains F. GUILLEMIN, J-M. VIRION, F. GUILLEMIN, J-M. VIRION, P. ESCUDIER, N. DE TALANCÉ, G. WERYHA P. ESCUDIER, N. DE TALANCÉ, G. WERYHA Joint Bone Spine 2001 ; 68 : 499-503Joint Bone Spine 2001 ; 68 : 499-503

These findings support those of other studies conducted in France and in other European countries.

They indicate that patients report meaningful improvements in their quality of life after spa therapy.

Balneotherapy for lumbar Balneotherapy for lumbar OAOARCTRCT Prolonged effects of 2 week Prolonged effects of 2 week

therapy in a spa resort on therapy in a spa resort on lumbar lumbar spinespine, knee and hip osteoarthritis: , knee and hip osteoarthritis: follow-up after 5 months. A follow-up after 5 months. A randomized controlled trial, M. randomized controlled trial, M. NGUYEN, M. REVEL and M. NGUYEN, M. REVEL and M. DOUGADOS DOUGADOS British Journal of British Journal of Rheumatology Rheumatology 1997;36:77-811997;36:77-81

Prolonged effects of 2 week therapy in a spa Prolonged effects of 2 week therapy in a spa resort on resort on lumbar spinelumbar spine, knee and hip , knee and hip osteoarthritis: follow-up after 5 months. A osteoarthritis: follow-up after 5 months. A randomized controlled trial, randomized controlled trial, M. NGUYEN, M. REVEL and M. DOUGADOS M. NGUYEN, M. REVEL and M. DOUGADOS British Journal of Rheumatology British Journal of Rheumatology 1997;36:77-811997;36:77-81

Changes in the assessment criteria after a 5 month follow-up period showed improvement in terms of pain, functional impairment and quality of life, with a reduced intake of symptomatic drugs "NSAID and analgesic drugs in the spa group,

Prolonged effects of 2 week therapy in a spa Prolonged effects of 2 week therapy in a spa resort on resort on lumbar spinelumbar spine, knee and hip , knee and hip osteoarthritis: follow-up after 5 months. A osteoarthritis: follow-up after 5 months. A randomized controlled trial, randomized controlled trial, M. NGUYEN, M. REVEL and M. DOUGADOS M. NGUYEN, M. REVEL and M. DOUGADOS British Journal of Rheumatology British Journal of Rheumatology 1997;36:77-811997;36:77-81

This study suggests that spa therapy of 2 weeks duration has a prolonged beneficial symptomatic effect in (lumbar spine) osteoarthritis.

Spa therapy for lumbar Spa therapy for lumbar spine OA in Turkeyspine OA in Turkey We aimed to determine the

effectiveness of spa therapy in short and long term on functions and pain, in patients with lumbar spine OA

Study designStudy design

Randomized Controlled Single blind Follow up 3 months

Study GroupsStudy Groups

Balneotherapy group (n:20)

2-week stay atGönen Spa Hotel

Balneotherapy + exercise therapy group (n:24)

2-week stay atGönen Spa Hotel

PatientsPatients

Balneotherapy and exercise (n=24)

Balneotherapy only (n=20)

Female/Male 17/7 15/5

Age (year) (SD) 64,7 (±11,3) 61,7 (± 9,4)

Duration ofDisease (year)(SD)

9,9 (± 7,3) 11,6 (± 7,7)

Duration of pain (month) (SD)

2,3 (± 1,0) 2,4 (± 1,2)

ESR (mm/h) (SD) 19,2 (± 11,4) 16,8 (± 8,0)

Balneotherapy GroupBalneotherapy Group

Thermomineral water (Na, SO4, HCO3, Cl, Fl)

Bath in thermal pool at 36-37ºC, for 20 min, once a day, total 12-14 baths

Bath in tub, at 38ºC, for 20 min, once a day, total 12-14 baths

Balneotherapy+Exercise Balneotherapy+Exercise GroupGroup Bath in thermal pool at 36-37ºC,

for 20 min, once a day, total 12-14 baths

Bath in tub, at 38ºC, for 20 min, once a day, total 12-14 baths

Williams exercises; every day 15 minutes duration

Outcome measuresOutcome measures Pain (VAS) Patient’s global assessment (VAS) Doctor’s global assessment (VAS) Health assessment questionnaire -

HAQ WADDELL Finger-floor distance Schober index

AssessmentsAssessments

Before spa therapy After spa therapy (within a week) At 3. month follow-up

Pain-VASPain-VAS

0

10

20

30

40

50

60

70

80

before after 3. month

baln+ exer baln

Significant Significant reduction was reduction was seen in Pain seen in Pain VAS scores in VAS scores in both groups.both groups.

P=0,000 P=0,000

P=0,000 P=0,001

Patient’s gPatient’s globallobal assesment assesment (VAS)(VAS)

0

10

20

30

40

50

60

70

before after 3. month

baln+ exer baln

Significant Significant reduction was reduction was seen in both seen in both groups.groups.

P=0,001P=0,000

P=0,000 P=0,001

Doctor’sDoctor’s global global assesment assesment (VAS)(VAS)

0

10

20

30

40

50

60

70

before after 3. month

baln+exer baln

Significant Significant reduction was reduction was seen in both seen in both groups.groups.

P=0,000

P=0,000 P=0,000

P=0,000

HAQ HAQ

0

0,2

0,4

0,6

0,8

1

1,2

before after 3. month

baln+ exer baln

Significant Significant reduction was reduction was seen in both seen in both groups.groups.

P=0,001

P=0,015P=0,006

P=0,014

Function WADDELLFunction WADDELL

0

1

2

3

4

5

6

7

before after 3. month

baln+ exer baln

Improvement (not significant) in balneotherapy+exercise group at the end of spa therapy and significant improvement at 3. month.

Significant improvement in balneotherapy group at the end of spa therapy and at 3. month.

P=0,128 P=0,02

P=0,000 P=0,000

Finger-Floor Distance Finger-Floor Distance (cm)(cm)

SignificantSignificant reduction was reduction was seen in both seen in both groups.groups.

0

2

4

6

8

10

12

14

before after 3.month

baln+ exer baln

P=0,007P=0,006

P=0,022

P=0,026

Schober (cm)Schober (cm)

13,4

13,6

13,8

14

14,2

14,4

14,6

14,8

15

before after 3. month

baln+ exer baln

Improvement in both groups at the end of spa therapy and at 3. month, but significant only in balneotherapy + exercise group at 3. month.

P=0,092

P=0,218

P=0,081

P=0,024

ConclusionsConclusions

Both of 2 week-spa therapy were effective in reducing pain and improving function and spinal mobility and flexibility in patients with lumbar OA.

ConclusionsConclusions

The significant improvement, seen in Schober Index at 3 month in balneotherapy + exercise group was probably related to the added exercise therapy.

ConclusionsConclusions

Spa therapy combining balneotherapy and exercise therapy had advantage over sole balneotherapy in improving mobility and flexibility in patients with lumbar spine OA.

ConclusionsConclusions

However, it is needed further well designed randomized controlled trials with a higher number of patients with a sufficient power to show the superiority of combined spa therapy over mono balneotherapy for lumbar OA.

We need further Workshops;to to improvimprovee mobility and mobility and flexibilityflexibilityand to show the to show the superiority of superiority of combined combined belly belly dancedance therapy therapy

Further PerspectivesFurther Perspectives

Thank Thank you !!you !!

Çeşme, Izmir for the 4th Turkish Hungarian Balneology Workshop