1. BALNEOTHERAPY IN THE TREATMENT OF FIBROMYALGIA SYNDROME Doç Dr Lale Altan, Uludağ University Medical Faculty Atatürk Rehabilitation Center Kükürtlü Spa Bursa/ Türkiye

2.  Uludag University Atatürk Rehabilitation center has an area of 23 thousand square meters  It is in Çekirge, the well-known spa district of Bursa  Kükürtlü spa is a big ancient building. Different architects built separate sections in various times  Men’s bath section of the ancient spa was built by Sultan Murat Hudavendigar Gazi 1st (1359-1384). Small Kükürtlü women baths were built by Sultan Beyazıt the 2nd (1481-1512)

3.  It is the first center run by the University since 1983  Mostly locomotor system diseases are treated in the center  Our outpatient number reaches 13.000 a year.

5. Fibromyalgia syndrome (FMS)  FMS is a chronic disease and it affects mostly females.  Pain, stiffness, fatigue, sleep disturbance, headache, and impaired muscular performance are the common symptoms of FMS

6. Essential targets of FMS treatment  To maintain peripheral and central analgesia  To improve sleep disturbance  To avoid psychological factors  To increase blood perfusion of muscles and superficial tissues

7. Treatments choices  Medical treatment (Psychtroph drugs, Antidepressants, bensodiazepine, hormones, Malik acit etc..)  Physical therapy (TENS, Hydrotherapy, Biofeedback, acupuncture…)  Exercise

8. Balneotherapy in FMS  Thermal and hydromechanical stimulus affects muscle tone, joint mobility and pain intensity.  Thermal stimulus may decrease pain through the gate-control mechanism and by counteracting muscular spasm.  Heating causes vasodilation. This may improve muscular ischemia and help clearance of algesic mediators.

9.  Balneotherapy may stimulate secretion of opioids  The antiinflammatory effect of sulphur on inflammatory diseases was suggested by some authors

10.  In a study done in Dead Sea,  48 patients participated in the study Half of the patients received hydrotherapy, and half did not  Conclusion : Staying at the Dead Sea spa, in addition to balneotherapy, can transiently improve the QoL of patients with FM

11.  42 FMS patient  Group 1 (n=22) received 20 min bathing once a day and five times per week for 3 weeks ; Group 2 was accepted as the control group  Results:In Group 1, there were significant difference in number of tender points, pain scores, BDI and FIQ scores following the treatment program  Conclusion: Balneotherapy is an effective treatment in FMS

12.  Thirty women with FM were randomized into two groups  16 patients had spa treatment for 2 weeks in addition to their medical treatment  Conclusion: The addition of spa therapy to medical therapy has in both short and long term (9 months) beneficial effects in the FM patients

13. Exercise in FMS  Exercise programs were reported to be helpful in FMS patients in several studies  But standard exercise programs are yet not available  Pool-based, as well as land-based exercise studies were done for FMS.

14. Pool exercise

15.  Objective: To evaluate the effects of 6 months of pool exercise combined with a education program for patients with FMS  58 patients were randomized into two groups  In Group 1, the patients performed an exercise program in a temperate pool, once a week for 6 months  Additionally an education program was given to the patients

16.  Results: Significant differences between treatment group and control group were found for almost all parameters.  Conclusion: Exercise in pool and education significantly improved symptoms of FMS.

17.  The previous study was extended. Symptom severity, physical and social function parameters were found still improved at 24 months.

18.  To compare pool-based exercise and balneotherapy in fibromyalgia syndrome patients.

19. PATIENTS  50 female patients with FMS were included.  NSAID medication was discontinued.  Basic education on FMS was given to patients  Then 2 groups were formed in blind fashion

20.  In Group I, pool-based exercise program was given by a physiotherapist to 25 patients in a therapeutic pool for 35 minutes a day, 3 times a week, for 12 weeks  The program comprised warming, active exercises, relaxation, and out-of-pool exercises

21.  In Group II, 25 patients received balneotherapy sessions of 35 minutes, 3 times a week, for 12 weeks in the same pool but they were instructed not to perform any exercise activity during the sessions

23. Evaluation parameters  Pain (Using VAS and 5 point scale)  Morning stiffness  Fatigue  Sleep  Tender points : With pressure algometer - Number of tender points - Algometer score - myalgic score  Global evaluation of the patient and physician  Fibromyalgia impact questionnaire (FIQ)  Chair test  Beck depression inventory (BDI)

24.  Evaluations were performed just before (Week 0), immediately after (Week 12), and 12 weeks following the treatment (Week 24) by the same researcher who was totally unaware of the group the patients belonged to

26. Results

29. Conclusion  The results of our study did not show a significant superiority of pool-based exercise over balneotherapy.  However, since some symptoms (sleep disturbance and morning stiffness) benefited from pool-based exercise for a longer time, we may suggest that pool- based exercise has a longer-lasting effect on at least some of the symptoms of FMS  On the other hand, our results were in accordance with previous balneotherapy studies. We believe that balneotherapy should be an essential component of FMS treatment.

30. Thank you