Balneotherapy for Chronic Low Back Pain
Prof. Dr. M. Zeki Karagülle
Department of Medical Ecology and Hydroclimatology Istanbul University, Istanbul Medical Faculty Istanbul, Turkey
Balneotherapy for LBP
Is there evidence suggests that balneotherapy (the central therapeutic modality of every spa therapy package) is an effective intervention in the management of LBP?
Balneotherapy for LBP
Konrad et al 1992 (Ann Rheum Dis)
Yurtkuran et al 1997 (Eur J Phys Med Rehab)
Balneotherapy for chronic low back pain – RCT’s
Study Konrad et al 1992
(Ann Rheum Dis)
Yurtkuran et al 1997
(Eur J Phys Med Rehab)
Balneotherapy 4-week, 3 times a week, total 12 baths
3-week, 6 times a week
total 18 baths
Patients Treatment Groups:
A: 42, B: 39, C: 44,
Control Group: D: 53,
Drop outs: 12
Treatment Gr: 30
Control Gr: 20
Type of treatment
Ambulatory,
patients received treatments after work
Budapest, Hungary
Ambulatory,
patients received treatments during daily routine
Bursa, Turkey
Balneotherapy for chronic low back pain – RCT’s
Study Konrad et al 1992
(Ann Rheum Dis)
Yurtkuran et al 1997
(Eur J Phys Med Rehab)
Balneo-therapy
Gr.A: Bath in thermal water at 37oC for 15 min.
Gr.B: Underwater massage with a stream of hot water (37oC, 1 atm, 10 cm) on effected part for 15 min
Gr.C: Underwater traction in thermal water at 37oC for 15 min
Control Gr.D: only NSAID’s, no balneotherapy
Treatment Gr. Bath in thermal pool 37oC for 30 min + flexion exercises outside the pool after bath for 15 min.
Control Gr. The same flexion exercises program that was applied to treatment group, no balneotherapy
Other treatment
No drugs, all patients were taught to use their back correctly
No medication, no physical therapy
Balneotherapy for LBP Results;
Outcome Measure Konrad et al 1992
Balneotherapy/ Control
Yurtkuran et al 1997 Balneotherapy/ Control
Pain Reduction
(VAS, cm)
-3.2 / -0.8 -2.4 / -0.9
Pain, Reduction
Long term
-1.4 / -0.7
1 year
-2.9 / -1.3
1 month
Drug consumption Analgesics Asprin
-31.7 / -1.9
-13.9 / -0.6
--
Schober Index (mm) (modified)
-- +0.65 /+0.27
+0.81/ +0.31
Finger Floor Distance (cm)
-- -0.44/-0,20
-0.64/-0.10
N.S.
Overall Balneotherapy Effect
Konrad et al 1992
(Ann Rheum Dis)
Yurtkuran et al 1997
(Eur J Phys Med Rehab)
The prescription of analgesics and the pain score were reduced significantly after the treatment. After one year only the analgesics consumption was significantly lower than in the control group.
Statistically significant improvement was observed in the balneotherapy group in most of the measures both at the end of 3-week treatment and 1 month post treatment.
“...balneotherapy seems to be a useful physiological means of reducing pain and analgesic consumption”
“It can be suggested that balneotherapy might be used as an effective alternative treatment modality in low back pain”
Balneotherapy for LBP -non RCT’s
Drinovec et al, 1994
Balneotherapy vs hydrotherapy (tap water)
Aktaş, 1997
Balneotherapy vs Balneotherapy
Crossover design:
10-day hydrotherapy 1tap water bath /day, at 32 ºC for 20 min,
total 10 baths
Than 10-day Balneotherapy
1 thermomineral water bath /day, at 36 ºC for 20 min,
total 10 baths ?? (n:19)
Gr.1 (n:15) 10-day Balneotherapy (2 baths /day, at 36-37 ºC for 20 min, total 20 baths ) + Exercise therapy,
Gr.2 (n:15) 3-week Balneotherapy (1 Bath /day, at 36-37 ºC for 20 min, total 20 baths) + Exercise therapy
Both therapies were applied Ambulatory, Patients resided near spa resort
Balneotherapy for LBP -non RCT’sDrinovec et al, 1994 Balneotherapy vs hydrotherapy (tap water)
Aktaş, 1997
Balneotherapy vs Balneotherapy
Balneotherapy has significantly decreased pain and stiffness of spine, improved sleeping and increased spine mobility. Most of the observed effects lasted even 6 weeks after therapy.
Hydrotherapy exhibited minimal improvement, which did not last after 6 weeks
Significant improvements were seen in VAS and Functional Index (Oswestry) in both groups after the treatment periods and at 1 month follow-up. There were no significant differences between the study groups
Balneotherapy for LBP
passive immersion in thermomineral water
underwater massage with a stream of hot water on low back in thermomineral water
underwater traction in thermomineral water
superior to hydrotherapy (passive immersion in tap water)
superior to exercise when combined with exercise in land
Balneotherapy for LBP
Even though an overall effect is established in two RCTs and two nonRCTs, results are not generalisable
There is still limited evidence for therapeutic efficacy of balneotherapy for LBP
Why is balneotherapy effective?
Thermal effects
Mechanical effects
Chemical effects
Rowell,1993
Gharib et al,1985
ANP was shown to reduce the secretion of inflammatory mediators
Therefore, this cardiovascular hormone may possess anti-inflammatory potential
Thermal bath versus isothermal
012345678
37-38ºC 33-34ºC BeforeAfter
Pressure pain threshold (kg/cm2)
increased after thermal bath (p<0,001)
Decreased after isothermal bath (p<0,001)
p<0,001
p<0,001
Karagülle et al,1998Karagülle et al,1998
Thermomineral vs tap water
0
5
10
15
20
25
30
% Increase inPressure Pain
Threshold
Thermalwater36ºC
Tapwater36ºC
p<0,001
Karagülle et al,1998Karagülle et al,1998
Water immersionFactors Effects
Temperature Thermal effects; anti-algetic relaxation, anti-inflammatory ie.
Hydrostatic Pressure
Cardiovascular and urinary effects; Diuresis, central blood redistribution, ANF secretion
Buoyancy Mechanical relaxation, ability to float, easily lying position
Viscosity Resistance of motion through water
(during walking and exercising)
Thermomineral water immersionFactors Biologic Effects
Mineral composition
Poorly understood
Immunologic system,
Neuropeptidergic system
Sulphur,
CO2,
Radon,
NaCl
Immunomodulatory
Peripheral vasodilatation
Realise of beta endorphins
Anti-inflammatory
Anti-algic
Balneotherapy prescription for chronic LBP
Let us attempt to prescribe a balneotherapy regimen for chronic low-back pain with a evidence based approach rather than empiricism and tradition
A 3-week Balneotherapy for LBPHungarian-style
Modality Type Dur. Temp
Total
Balneotherapy Bath in thermal water pool
15 min
37 ºC
12
Or
Balneotherapy Bath in thermal pool with underwater massage with pressured water stream
15 min
37 ºC
12
or
Balneotherapy Bath in thermal pool with spinal traction
15 min 37 ºC
12
A 3-week Balneotherapy for LBPTurkish-style
Modality Type
Duration Tem.
Total/
Frequency
Course
Bath in thermal pool
30 min 37ºC 18 baths
6baths/week
3-week
or
Bath in thermal pool
20 min 36-37ºC
20 baths
2 baths/day 1 bath/day
3-week
10-day
plus
Exercise
Exemplary evidence based balneotherapy prescription for LBP
Bath Type
Bath Duration
Bath water Temp.
Total baths
Course of therapy
Bath in thermal water (pool or tube ?)
20 to 30 min
36-37ºC 12 or 18 or 20 baths
10-day
3-week
4-week
Exemplary Evidence Based Balneotherapy Prescription for LBP
Water Type
Combine therapy
Bath frequency
Bath Type Course
Type
Mixed Thermal Mineral Water
Exercise
Patient Education
3-6 baths /week
2 baths/day
Passive immersion
Ambulatory
Do we need balneotherapy for LBP ?
Balneotherapy for LBP
Turkey and Hungary have a lot of spa resorts and thermal mineral springs and are looking back on a still vivid tradition of spa therapy and balneotherapy, especially for the treatment of rheumatic diseases including LBP.
Balneotherapy for LBP
Europe maintains the tradition, as do Japan, Israel and elsewhere.
The challenge is still coming from America and England where spa medicine is eclipsed by new ethos in medicine during mid 20.century.
Balneotherapy for LBP
To generate cogent scientific data will facilitate to find cost-effective and culturally acceptable ways of incorporating balneotherapy into health care systems of the countries where spa therapy or balneotherapy facilities are available.
Balneotherapy for LBP
In future we need methodologically sound studies to confirm that balneotherapy has either broadly beneficial effects or it is effective only for relieving chronic back pain
Balneotherapy for LBP
“Our management of low back pain is not so perfect that we can afford to ignore any form of treatment that can be shown to work.” Konrad et al 1992
Thank You !!!Thank You !!!