The%20Effects%20of%20Balneotherapy%20on%20Knee%20Osteoarthritis

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The Effects of Balneotherapy on Knee
Osteoarthritis

• Prof.Dr. Arif Dönmez
• Istanbul University, Istanbul Medical Faculty,
  Department of Medical Ecology and Hydroclimatology

III. Hungarian-Turkish Balneological Symposium 1
APRIL 2005
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The Effects of Balneotherapy on Knee
Osteoarthritis

• Knee OA and disability
• EULAR Recommendations 2003 an evidence based
  approach to the management of knee osteoarthritis
• Balneotherapy studies on knee osteoarthritis
• Problems in balneotherapy studies
• Mechanisms of action
• Efficacy of balneotherapy in OA
• Proposals for high quality studies

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Knee OA and disability

• As an estimation, 10 of people older than 55
  years have disabling knee symptoms
• 25 of them are severely disabled
• According to WHO report on global burden of
  disease, knee OA is likely to be one of the most
  important global cause of disability in the
  society
• Fourth most important in women and eighth most
  important in men
• Peat G, Mc Carney R, Croft P. Knee pain and
  osteoarthritis in older adults a review of
  community burden and current use of health care.
  Ann Rheum Dis 200160917
• Murray CJL, Lopez AD. The global burden of
  disease. Geneva World Health Organization, 1997

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EULAR Recommendations 2003
Non-pharmacological Pharmacological Intraarticular Surgical
Education Paracetamol Corticosteroid Arthroscopy
Exercise NSAIDs
Insoles Opioid analgesics Hyaluronic acid Osteotomy
Orthotic devices Sex hormones
Weight Loss SYSADOA Tidal irrigation Uni-compartmental
Laser Psychotropic drugs knee replacement
Spa Topical NSAIDs
Telephone Topical capsaicin Total knee
Vitamins / Minerals replacement
Pulsed EMF
Ultrasound
TENS
Acupuncture
Nutrients
Herbal remedies
Jordan K M, Arden N K, Doherty M et al. EULAR
Recommendations 2003 an evidence based approach
to the management of knee osteoarthritis Report
of a Task Force of the Standing Committee for
International Clinical Studies Including
Therapeutic Trials (ESCISIT) Ann Rheum Dis
20036211451155.
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Evidence Categories
Category Evidence provided from
1A Meta-analysis of RCTs
1B At least one RCT
2A At least one controlled study without randomization
2B At least one quasi-experimental study
3 Descriptive studies such as comparative, correlation or case-control studies
4 Expert committee reports or opinions and/or clinical experience of respected authorities
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The strength of recommendation is based on

• the level of evidence
• the effect size of the intervention
• the side effect profile
• the applicability of the evidence to the
  population of interest
• practicality of delivery
• economic considerations

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Strength of recommendation and the level of
evidence
Category Directly based on
A category 1 evidence
B category 2 evidence OR extrapolated recommendation from category 1 evidence
C category 3 evidence OR extrapolated recommendation from category 1 or 2 evidence
D category 4 evidence OR extrapolated recommendation from category 2 or 3 evidence
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Balneotherapy studies on knee osteoarthritis

• Observational studies (OSs)
• Controlled Clinical Trials (CCTs)
• Randomized Controlled Clinical Trials (RCCTs)

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Observational studies Selected References

1. Dönmez A, Karagülle Z, Turan M Balneotherapie
   mit Akratoterme bei Gonartrose. Zeitschrift
   Naturamed 19957-20-3
2. Forestier R.Magnitude and duration of the effects
   of two spa therapy courses on knee and hip
   osteoarthritis an open prospective study in 51
   consecutive patients. Joint Bone Spine
   200067(4)296-304.
3. Guillemin F, Virion JM, Escudier P et al. Effect
   on osteoarthritis of spa therapy at
   Bourbonne-les-Bains. Joint Bone Spine 2001 68
   499-503
4. Fioravanti A, Valenti M, Altobelli E et al.
   Clinical efficacy and cost-effectiveness evidence
   of spa therapy in osteoarthritis. The results of
   "Naiade" Italian Project. Panminerva Med.2003
   Sep45(3)211-7.
5. Yilmaz B, Goktepe SA, Alaca R et al.Comparison of
   a generic and a disease specific quality of life
   scale to assess a comprehensive spa therapy
   program for knee osteoarthritis. Joint Bone
   Spine. 2004 Nov71(6)563-6.

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Results of Observational studies

• Pain ? 1,2,3,4
• Lequesne Knee Index score ? 1,2
• Walking distance ? 2
• Flexion range ? 2
• Quality of life ? 3,5
• Drug consumption ? 4

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Controlled Clinical TrialsSelected References

1. Wigler I, Elkayam O, Paran D, Yaron M. Spa
   therapy for gonartrosis prospective study.
   Rheumatol Int 19951565-68.
2. Flusser D, Abu-Shakra M, Friger M, et al.Therapy
   With Mud Compresses for Knee Osteoarthritis
   Comparison of Natural Mud Preparations With
   Mineral-Depleted Mud. J Clin Rheumatol
   20028197203
3. Odabasi E, Karagülle MZ, Karagülle M et al.
   Comparison of two traditional spa therapy
   regimens in patients with knee osteoarthritis an
   exploratory study. Phys Med Rehab Kuror
   200212337-341

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Results of CCTs

• Wigler I, Elkayam O, Paran D, Yaron M. Spa
  therapy for gonartrosis prospective study.
  Rheumatol Int 19951565-68.
• Mineral water bath and mud pack combination is
  bettter than
• Mineral water bath rinsed mud pack
• Tap water bath rinsed mud pack

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Results of CCTs

• Flusser D, Abu-Shakra M, Friger M, et al. Therapy
  With Mud Compresses for Knee Osteoarthritis
  Comparison of Natural Mud Preparations With
  Mineral-Depleted Mud. J Clin Rheumatol
  20028197203
• Mineral mud compresses are far effective than
  mineral-depleted mud compresses

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Results of CCTs

• Odabasi E, Karagülle MZ, Karagülle M et al.
  Comparison of two traditional spa therapy
  regimens in patients with knee osteoarthritis an
  exploratory study. Phys Med Rehab Kuror
  200212337-341
• Thermal water bath and peloid pack combination
  is better than twice-a-day thermal water bath
  application

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Randomized Controlled TrialsSelected References I

• Balneotherapy group vs. Tap water group
• Szucs L, Ratko I, Lesko T et al. Double-blind
  trial on the effectiveness of the Puspokladany
  thermal water on arthrosis of the knee-joints. J
  R Soc Health 1989 10979
• Kovács I, Bender T. The therapeutic effects of
  Cserkeszölö thermal water in osteoarthritis of
  the knee a double blind,controlled, follow-up
  study Rheumatol Int (2002) 21 218221
• Balint G, Ádam A, Ratko I et al. Double blind
  study about the effectivity of the thermal
  mineral water of Nagybaracska in patient with
  knee joint osteoarthritis.2.Turkish-Hungarian
  Balneological Workshop, Pamukkale, Turkey 16-18
  September 2004

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Randomized Controlled TrialsSelected References
II

• Balneotherapy group vs. Outpatient medical care
  group
• Nguyen M , Revel M, Dougados M. Prolonged effects
  of 2 week therapy in a spa resort on lumbar
  spine, knee and hip osteoarthritis Follow-up
  after 5 months. A randomized controlled trial.
  British Journal of Rheumatology19973677-81
• Tishler M Rosenberg O, Levy O et al. The effect
  of balneotherapy on osteoarthritis. Is an
  intermittent regimen effective? Eur J Intern Med
  2004 15(2) 93-96
• Uysal B, Dönmez A, Karagülle MZ et al.
  Wirksamkeit der Balneotherapie bei Patienten mit
  Gonarthrose im Kurort Gönen eine randomisierte
  kontrollierte Studie. 5.Deutsch-Türkischer
  Kongress für Balneologie und Medizinische
  Klimatologie 27-28 Juni 2003
• Balneotherapy and control groups stayed at the
  same area
• 1. Sukenik S, Flusser D, Codish S. Balneotherapy
  at the Dead Sea area for knee osteoarthritis IMAJ
  1999183-85

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Systematic Review of RCTs

• Brosseau L, Macleay L, Robinson V. Efficiacy of
  balneotherapy for osteoarthritis f the knee a
  systematic review. Physical Therapy Reviews.
  20027209-222
• The results of this review suggest that
  balneotherapy can be effective on a short-term
  basis for measures of pain severity and function
  as well as for improved ROM and timed stair
  climbing.

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Problems in balneotherapy studies

• Type of treatment
• mud pack, sulphur bath, radon and carbon dioxide
  bath, Dead Sea bath salts, NaCl baths salts, and
  mineral water bath
• Treatment characteristics
• duration of study, frequency, number of
  treatments, duration of treatment, temperature
• Setting
• in the sea, hospital, home
• Constituents of the treatment agent
• Na, Ca, K, Cl
• Individual who prepared bath
• patient, medical staff
• Brosseau L, Macleay L, Robinson V. Efficacy of
  balneotherapy for osteoarthritis of the knee a
  systematic review. Physical Therapy Reviews 2002
  7 209222

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Problems in balneotherapy studies

• Verhagen AP, de Vet HCW, de Bie RA et al.
  Balneotherapy for rheumatoid arthritis and
  osteoarthritis (Cochrane Review) In The Cochrane
  Library, Issue 2, 2002. Oxford Update Software.
• the positive findings reported in most
  trials. However the scientific evidence is weak
• the poor methodological quality,
• the absence of an adequate statistical analysis,
• the absence of most essential outcome measures
  (pain, quality of life)
• Therefore, the noted "positive findings" should
  be viewed with caution.

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Mechanisms of action

• A combination of mechanical, thermal and chemical
  effects
• Heat
• Analgesia
• Anti inflammatory effect
• Muscle tonus decrease
• Peripheral vasodilatation
• ß-endorphin level
• Gate-control theory
• Buoyancy and hydrostatic pressure
• affect muscle tone,
• joint mobility
• pain intensity by decreasing joint load
• Mineral water chemical implications
• Environmental change
• Non-competitive atmosphere
• Absence of work duties

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Efficacy of balneotherapy in OA - I

• TNF a ? TNF a?
• IL-1 ? IL-1 ?
• IGF-1 ?
• CRP ? ,
• Haptoglobulin ? ,

Tütüncü ZN,Turan M, Barut A Changes in TNF a
plasma levels in osteoarthritic patients under
balneotherapy with acratotermal water. Phys Rehab
Kur Med 1996680-82 Turan M Wirkungen der
Balneotherapie auf die Akute-Phase-Reaction.
IV.Deutsch-Türkischer Ärtzekongress Balneologie
und Klimatologie, Izmir,Türkie 2000,
Kongressbuch 39-41 Bellometti S, Giannini S,
Sartori L, Crepaldi G Cytokine levels in
osteoarthrosis patients undergoing mud bath
therapy. Int J Clin Pharmacol Res.
199717(4)149-53
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Efficacy of balneotherapy in OA - II

• Beta endorphine ? Kubota K, Kurabayashi H,
  Tamura K, et al (1992) A transient rise in plasma
  beta-endorphin after a traditional 47 degrees C
  hot-spring bath in Kusatsu-spa, Japan. Life Sci.
  51(24)1877-80.      
• Beta endorphine (60) ?, (30) ?, (10)
  ?Yurtkuran M, Ulus H, Irdesel J (1993) The
  effect of balneotherapy on plasma beta endorphine
  level in patient with osteoarthritis. Phys Rehab
  Kur Med 3130-132

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Proposals for high quality studies

• Standardization
• application method, medium, environment.
• Proper/Current outcome measures
• Appropriate sampling
• representative number of patients
• Intent-to-treat analysis
• Randomization
• Blinded studies
• single, double
• Placebo controlled studies

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