balneo-spa therapy in the management of rheumatoid arthritis

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?


• Balneotherapy and spa therapy for patients with arthritis is one of the oldest forms of therapy.


• 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.


• 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.


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.


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.


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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balneo-spa therapy in the management of rheumatoid arthritis

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