A randomized, controlled study of balneotherapy in patients with rheumatoid arthritis

Integrated Thermal Rehabilitation: A New Therapeutic Approach for Disabilities

A mutual link between somatic and visceral neural pathways is known in medicine. This study addresses therapeutic effectiveness of an integrated rehabilitative approach of thermal aquatic environment, combined with neuromuscular manual stimulation, on activation of afferent sensory visceral and somatic efferent neuronal motor pathways in different pathologies of neuromuscular motor and respiratory systems. The study included 63 patients subjected to a protocol consisting of hydroponic treatment, hydrokinesitherapy associated with ozonized vascular pathway, and mud therapy associated with cardiorespiratory treatment performed in aquatic environment and aided by neuromuscular manual therapy. The therapeutic protocol consisted of rehabilitation sessions 5 days a week for 2 months. The outcome measures were spirometry tests and the following evaluation instruments: Tinetti Gait and Balance assessment scale, Functional Independence Measurement, visual analogue scale, and the EQ-5D-5 L instrument. The tests were applied before and after the protocol completion. The findings demonstrate a general increase in patients' everyday living autonomy and quality of life, with a particular improvement in respiratory function tests. We conclude that the integrated thermal approach holds promise in therapeutic rehabilitation of disabilities.

Spa therapy adjunct to pharmacotherapy is beneficial in rheumatoid arthritis: a crossover randomized controlled trial

This study aims to investigate whether 2-week spa therapy, as an adjunct to usual pharmacological therapy, has any beneficial effect in patients with rheumatoid arthritis (RA). In this single-blind crossover study, 50 patients were randomly assigned in a 1:1 manner to receive usual pharmacological therapy plus 2-week spa therapy or usual pharmacological therapy alone (period 1.6 months); after a 9-month washout, patients were crossed over to the opposite assignment (period 2.6 months). Spa therapy program included a daily saline balneotherapy session at 36-37 °C for 20 min except Sundays. The clinical outcomes were evaluated at baseline, after spa therapy (2 weeks) and 3 and 6 months after the spa therapy in both period and were pain (Visual Analogue Scale (VAS)), patient and physician global assessments (VAS), Health Assessment Questionnaire (HAQ), and Disease Activity Score (DAS28). Spa therapy was superior to control therapy in improving all the assessed clinical outcomes at the end of the spa therapy. This superiority persisted significantly in physician global assessment (p = 0.010) and with a trend in favor of spa group in patient global assessment (p = 0.058), function (p = 0.092), and disease activity (p = 0.098) at 3 months. Statistically significant improvements were found in spa therapy compared to control in disease activity (p = 0.006) and patient (p = 0.020) and physician global (p = 0.011) assessments, and a trend toward improvements in pain (p = 0.069) and swollen joints (p = 0.070) at 6 months. A 2-week spa therapy adjunct to usual pharmacological therapy provided beneficial clinical effects compared to usual pharmacological therapy alone, in RA patients treated with traditional disease-modifying antirheumatic drugs. These beneficial effects may last for 6 months.

Effect of spa therapy with saline balneotherapy on oxidant/antioxidant status in patients with rheumatoid arthritis: a single-blind randomized controlled trial

Oxidative stress has been shown to play a contributory role in the pathogenesis of rheumatoid arthritis (RA). Recent studies have provided evidence for antioxidant properties of spa therapy. The purpose of this study is to investigate whether spa therapy with saline balneotherapy has any influence on the oxidant/antioxidant status in patients with RA and to assess clinical effects of spa therapy. In this investigator-blind randomized controlled trial, we randomly assigned 50 patients in a 1:1 ratio to spa therapy plus standard drug treatment (spa group) or standard drug treatment alone (control group). Spa group followed a 2-week course of spa therapy regimen consisting of a total of 12 balneotherapy sessions in a thermal mineral water pool at 36-37 °C for 20 min every day except Sunday. All clinical and biochemical parameters were assessed at baseline and after spa therapy (2 weeks). The clinical parameters were pain intensity, patient global assessment, physician global assessment, Health Assessment Questionnaire disability index (HAQ-DI), Disease Activity Score for 28-joints based on erythrocyte sedimentation rate (DAS28-4[ESR]). Oxidative status parameters were malondialdehyde (MDA), nonenzymatic superoxide radical scavenger activity (NSSA), antioxidant potential (AOP), and superoxide dismutase (SOD). The NSSA levels were increased significantly in the spa group (p = 0.003) but not in the control group (p = 0.509); and there was a trend in favor of spa therapy for improvements in NSSA levels compared to control (p = 0.091). Significant clinical improvement was found in the spa group compared to the control in terms of patient global assessment (p = 0.011), physician global assessment (p = 0.043), function (HAQ-DI) (p = 0.037), disease activity (DAS28-4[ESR]) (0.044) and swollen joint count (0.009), and a trend toward improvement in pain scores (0.057). Spa therapy with saline balneotherapy exerts antioxidant effect in patients with RA as reflected by the increase in NSSA levels after spa therapy; whether this antioxidant effect contributes to the clinical improvements observed remains to be verified.

Balneotherapy in rheumatoid arthritis-a systematic review

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterized by persistent inflammation of synovial joints with pain, often leading to joint destruction and disability, and despite intensive research, the cause of RA remains unknown. Balneotherapy-also called mineral baths or spa therapy-uses different types of mineral water compositions like sulphur, radon, carbon dioxin, etc. The role of balneotherapy is on debate; Sukenik wrote that the sulphur mineral water has special proprieties to rheumatologic diseases, including in the course of active inflammatory phases in RA. The aim of this review is to summarize the available evidence on the effects of balneotherapy on patients with rheumatoid arthritis. We have made a systematic search of the articles published from 1980 to 2014 on this topic in PubMed, Scopus, CRD, PEDro, Web of Science and Embase databases. We have followed the method set by the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA). These that have compared balneotherapy with other therapeutic modalities or with no intervention were considered. The inclusion criteria of these papers were randomized control trial (RCT); languages: English, French, Spanish, Italian and Portuguese; evaluation of efficacy (analysis of outcomes); use of natural mineral water baths; and participants with RA. A total of eight articles documenting RCTs were found and included for full review and critical appraisal involving a total of 496 patients. The studies selected highlighted an important improvement and statistically significant in several clinical parameters, in spite of their heterogeneity between the various studies. One study emphasized an important improvement on functional capacity up to 6 months of follow-up (FU). Some of the studies (std.) reveal an improvement on morning stiffness (5 std.), number of active joints (3 std.), Ritchie index (2 std.) and activities of daily living (2 std.) up to 3 months of FU. Three studies reveal the improvement on handgrip strength up to 1 month of FU. About pain (VAS), the three studies which evaluated this parameter were inconclusive about real significant improvement. Our tables summarize the published papers about this topic. Different authors emphasize the same problems: methodologies differing from study to study, treatment modalities, outcomes and their analysis. On the one hand, it is particularly difficult to have homogeneity on this population in all the parameters (patient's clinical heterogeneity, diverse clinical course of the disease, variety of the drugs), and on the other hand, natural mineral water composition is always unique with potential specific biological effects. This comprehensive review has revealed that there are very few published studies about the use of natural mineral water in RA. International multicentre studies, using the same methodologies, could be achieved by carrying the scientific arguments to support our clinical practice.

The effect of balneotherapy on patients with ankylosing spondylitis

OBJECTIVE

To compare the effect of balneotherapy on physical activity and quality of life as well as the symptoms of pain and stiffness with exercise alone in ankylosing spondylitis (AS) patients.

METHODS

A total of 60 patients who had a diagnosis of AS according to the modified New York criteria were included in the study. The patients were randomly assigned to two groups. In Group I (n = 30) the patients received balneotherapy in a therapeutic pool for 30 min once a day for 3 weeks. All patients received instructions on the exercise programme, which they were requested to repeat once a day for 30 min during the study. The patients in this group continued the same exercise programme after the end of the balneotherapy protocol to complete a course of 6 months. In Group II the patients were given the same exercise protocol but did not receive balneotherapy. Patients were evaluated before the start of the study and at 3 weeks and 24 weeks. Evaluation parameters were daily and night pain, morning stiffness, the patient's global evaluation and the physician's global evaluation (according to a scoring system of 1 to 5), the Bath Ankylosing Spondilitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Dougados Functional Index (DFI), tragus-wall distance, chest expansion, modified Shober test (MST), fingertip-fibula head distance, and Nottingham Health Profile (NHP).

RESULTS

Evaluations were completed in 54 patients in the two groups. Comparison of the groups showed significantly superior results for Group I for parameters of BASDAI, NHP total, pain, physical activity, tiredness and sleep score, patient's global evaluation and the physician's global evaluation at 3 weeks, but only for the parameters of patient's global evaluation and MST at 24 weeks.

CONCLUSION

Balneotherapy has a supplementary effect on improvement in disease activity and functional parameters in AS patients immediately after the treatment period. However, in the light of our medium-term evaluation results, we suggest that further research is needed to assess the role of balneotherapy applied for longer durations in AS patients.

Balneotherapy and tap water therapy in the treatment of knee osteoarthritis

To investigate if spa water is superior to tap water (TW) in relieving the symptoms of pain, joint motion, life quality in knee osteoarthritis (KOA) patients. In this randomized placebo-controlled trial, 52 patients with KOA were followed in two groups. In group I (n = 27), patients were treated in the pool full of spa water at 37 degrees C for 20 min a day, 5 days a week, for a period of 2 weeks. In group II (n = 25), the same protocol was used but spa water was replaced by TW heated to 37 degrees C. Patients in both groups were given a home-based standardized exercise program. Evaluation parameters were pain (pVAS), tenderness score (TS), 50-ft walking duration, quadriceps muscle strength (QMS), active flexion degree (AFD), WOMAC OA index, and Nottingham Health Profile (NHP). The first evaluation was done after the informed consent was obtained. Second and third evaluations were done at the 2nd and 12th week. PVAS, 50-ft walking duration, AFD, TS, WOMAC, and NHP variables improved in group I. Same variables except QMS improved also in group II. Comparison of the groups just after treatment showed that only pVAS (P = 0.015), NHP pain score (P = 0.020), and TS (P = 0.002) differed significantly in favor of group I at the 2nd or 12th week. Both of the thermal treatment modalities were found to be effective in the management of the clinical symptoms and quality of life in KOA patients. However, pain and tenderness improved statistically better with balneotherapy. There were no significant differences between the groups for the other variables.

Hydrotherapy, balneotherapy, and spa treatment in pain management

The use of water for medical treatment is probably as old as mankind. Until the middle of the last century, spa treatment, including hydrotherapy and balneotherapy, remained popular but went into decline especially in the Anglo-Saxon world with the development of effective analgesics. However, no analgesic, regardless of its potency, is capable of eliminating pain, and reports of life-threatening adverse reactions to the use of these drugs led to renewed interest in spa therapy. Because of methodologic difficulties and lack of research funding, the effects of 'water treatments' in the relief of pain have rarely been subjected to rigorous assessment by randomised, controlled trials. It is our opinion that the three therapeutic modalities must be considered separately, and this was done in the present paper. In addition, we review the research on the mechanism of action and cost effectiveness of such treatments and examine what research might be useful in the future.

Investigation of the effects of pool-based exercise on fibromyalgia syndrome

OBJECTIVE

The aim of this study was to compare pool-based exercise and balneotherapy in fibromyalgia syndrome (FMS) patients.

METHODS

Fifty female patients diagnosed with FMS according to the American College of Rheumatism (ACR) criteria were randomly assigned to two groups: group 1 (n=25) with pool-based exercise, and in group 2 (n=25) balneotherapy was applied in the same pool without any exercise for 35 min three times a week for 12 weeks. In both groups, pre- (week 0) and post-treatment (weeks 12 and 24) evaluation was performed by one of the authors, who was blind to the patient group. Evaluation parameters included pain, morning stiffness, sleep, tender points, global evaluation by the patient and the physician, fibromyalgia impact questionnaire, chair test, and Beck depression inventory. Statistical analysis was done on data collected from three evaluation stages.

RESULTS

Twenty-four exercise and 22 balneotherapy patients completed the study. Pretreatment (week 0) measurements did not show any difference between the groups. In group 1, statistically significant improvement was observed in all parameters ( P<0.01) except for the chair test at both weeks 12 and 24. In group 2, week 12 measurements showed significant improvement in all parameters ( P<0.01) except for the chair test and Beck depression inventory. Week 24 evaluation results in group 2 showed significant improvements in pain and fatigue according to visual analogue scale (VAS), 5-point scale, number of tender points, algometric and myalgic scores, and patient and physician global evaluation (P<0.01 and P<0.05, respectively), while improvements were nonsignificant in morning stiffness, sleep, fibromyalgia impact questionnaire (FIQ), chair test, and Beck depression inventory parameters in this group. Comparison of the two groups based on the post-treatment (weeks 12 and 24) percent changes and difference scores relative to pretreatment (week 0) values failed to show a significant difference between the groups for any parameter except Beck depression inventory (P<0.01).

CONCLUSION

The results of our study showed that pool-based exercise had a longer-lasting effect on some of the FMS symptoms, but statistical analysis failed to show a significant superiority of pool-based exercise over balneotherapy without exercise. While we believe that exercise is a gold standard in FMS treatment, we also suggest in light of our results that balneotherapy is among the valid treatment options in FMS, and further research regarding the type and duration of the exercise programs is necessary.

Balneotherapy for rheumatoid arthritis

BACKGROUND

Balneotherapy (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 feel well.

OBJECTIVES

To perform a systematic review on the effectiveness of balneotherapy for rheumatoid arthritis.

SEARCH STRATEGY

Using the Cochrane search strategy, studies were found by screening: 1) The MEDLINE CD-ROM database from 1966 to June 2002 and 2) the database from the Cochrane 'Rehabilitation and Related Therapies' Field, the Pedro database up to June 2002. Also, 3) reference checking and 4) personal communications with authors was carried out to retrieve eligible studies. Date of the most recent literature search: June, 2002

SELECTION CRITERIA

Studies were eligible if they were randomised controlled trials (RCTs) comparing balneotherapy with any other intervention or with no intervention. Included participants all suffered from definite or classical rheumatoid arthritis (RA) as defined by the American Rheumatism Association Criteria (ARA) or by the criteria of Steinbrocker. At least one of the WHO/ILAR core set of endpoints for RA clinical trials had to be among the main outcome measures.

DATA COLLECTION AND ANALYSIS

The Delphi list was the criteria list used to assess the components of methodological quality. Two reviewers carried out quality assessment and data extraction of the studies. Disagreements were solved by consensus.

MAIN RESULTS

Six trials, representing 355 people, were included in this review. Most trials reported positive findings (the absolute improvement in measured outcomes ranged from 0 to 44%), but were methodologically flawed to some extent. A 'quality of life' outcome was reported by two trials. None of the trials performed an intention-to-treat analysis and only two performed a comparison of effects between groups. Pooling of the data was not performed; because of heterogeneity of the studies, multiple outcome measurements, and the overall data presentation was too scarce.

REVIEWER'S CONCLUSIONS

One cannot ignore the positive findings reported in most trials. However the scientific evidence is insufficient because of the poor methodological quality, the absence of an adequate statistical analysis, and the absence, for the patient, of most essential outcome measures (pain, self assessed function, quality of life). Therefore, the noted "positive findings" should be viewed with caution. Because of the methodological flaws an answer about the apparent effectiveness of balneotherapy cannot be provided at this moment. A large, methodological sound trial is needed.