Balneotherapy%20for%20Chronic%20Low%20Back%20Pain

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Balneotherapy for Chronic Low Back Pain

• Prof. Dr. M. Zeki Karagülle

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Department of Medical Ecology and
Hydroclimatology Istanbul University, Istanbul
Medical Faculty Istanbul, Turkey
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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?

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Balneotherapy for LBP
Konrad et al 1992 (Ann Rheum Dis)
Yurtkuran et al 1997 (Eur J Phys Med Rehab)
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Balneotherapy for chronic low back pain RCTs
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
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Balneotherapy for chronic low back pain RCTs
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 NSAIDs, 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
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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.
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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
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Balneotherapy for LBP -non RCTs
Drinovec et al, 1994 Balneotherapy vs hydrotherapy (tap water) Aktas, 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 ?? (n19) Gr.1 (n15) 10-day Balneotherapy (2 baths /day, at 36-37 ºC for 20 min, total 20 baths ) Exercise therapy, Gr.2 (n15) 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
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Balneotherapy for LBP -non RCTs
Drinovec et al, 1994 Balneotherapy vs hydrotherapy (tap water) Aktas, 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
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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

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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

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Why is balneotherapy effective?

• Thermal effects
• Mechanical effects
• Chemical effects

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Rowell,1993
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Gharib et al,1985
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• ANP was shown to reduce the secretion of
  inflammatory mediators
• Therefore, this cardiovascular hormone may
  possess anti-inflammatory potential

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Thermal bath versus isothermal
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• Pressure pain threshold (kg/cm2)
• increased after thermal bath (plt0,001)
• Decreased after isothermal bath (plt0,001)

Karagülle et al,1998
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Thermomineral vs tap water
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Karagülle et al,1998
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Water immersion
Factors 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)
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Thermomineral water immersion
Factors 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
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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

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A 3-week Balneotherapy for LBPHungarian-style
Modality Type Type Dur. Temp Total
Balneotherapy Bath in thermal water pool Bath in thermal water pool 15 min 37 ºC 12
Or Or Or Or Or Or
Balneotherapy Bath in thermal pool with underwater massage with pressured water stream Bath in thermal pool with underwater massage with pressured water stream 15 min 37 ºC 12
or or or or or or
Balneotherapy Bath in thermal pool with spinal traction 15 min 15 min 37 ºC 12
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A 3-week Balneotherapy for LBPTurkish-style
Modality Type Duration Duration Tem. Total/ Frequency Course
Bath in thermal pool Bath in thermal pool 30 min 37ºC 18 baths 6baths/week 3-week
or or or or or or
Bath in thermal pool Bath in thermal pool 20 min 36-37ºC 20 baths 2 baths/day 1 bath/day 3-week 10-day
plus plus plus plus plus plus
Exercise Exercise Exercise Exercise Exercise Exercise
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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
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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
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Do we need balneotherapy for LBP ?
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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.

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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.

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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.

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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

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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

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Thank You !!!
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