1. Spa therapy for lumbar spine osteoarthritis M. Zeki Karagülle Istanbul University Istanbul Medical Faculty Department of Medical Ecology and Hydroclimatology

2. Osteoarthritis the most common form of arthritis in the World the most common form of arthritis in the World Over one-half of all people older than 65 show OA-associated changes in the knees. Over one-half of all people older than 65 show OA-associated changes in the knees. After age 75, almost everyone has these changes. After age 75, almost everyone has these changes. Peyron JG. Epidemiologic and etiologic approach to Osteoarthritis. Semin Arthritis Rheum 8; 288-306, 1979

3. Osteoarthritis Patients with OA have pain that typically worsens with weight bearing and activity and improves with rest Patients with OA have pain that typically worsens with weight bearing and activity and improves with rest as well as morning stiffness and gelling of the involved joint after periods of inactivity as well as morning stiffness and gelling of the involved joint after periods of inactivity

4. Causes of OA are not completely understood biomechanical stresses affecting the articular cartilage and subchondral bone biomechanical stresses affecting the articular cartilage and subchondral bone biochemical changes in the articular cartilage and synovial membrane biochemical changes in the articular cartilage and synovial membrane genetic factors genetic factors all important in its pathogenesis

5. Areas that Osteoarthritis Affects most often at the ends of the fingers, thumbs, neck, lower back, knees, and hips most often at the ends of the fingers, thumbs, neck, lower back, knees, and hips

6. Classification Criteria for Osteoarthritis American College of Rheumatology Hand Hand Knee Knee Hip Hip Spine ??? Spine ???

7. ACR OA GUIDELINES 2000 THE HIP AND KNEE Nonpharmacologic therapies Patient education Patient education Self-management programs (e.g., Arthritis Foundation Self-Management Program) Self-management programs (e.g., Arthritis Foundation Self-Management Program) Personalized social support through telephone contact Personalized social support through telephone contact Weight loss (if overweight) Weight loss (if overweight) Aerobic exercise programs Aerobic exercise programs Physical therapy Physical therapy Range-of-motion exercises Range-of-motion exercises

8. ACR OA GUIDELINES 2000 THE HIP AND KNEE Nonpharmacologic therapies Muscle-strengthening exercises Muscle-strengthening exercises Assistive devices for ambulation Assistive devices for ambulation Patellar taping Patellar taping Appropriate footwear Appropriate footwear Lateral-wedged insoles (for genu varum) Lateral-wedged insoles (for genu varum) Bracing Bracing Occupational therapy Occupational therapy Joint protection and energy conservation Joint protection and energy conservation Assistive devices for activities of daily living Assistive devices for activities of daily living

9. The goals of OA treatment Reduce pain Reduce pain Relieve symptoms Relieve symptoms Maintain and/or improve joint mobility Maintain and/or improve joint mobility Limit functional impairment Limit functional impairment Minimize disability Minimize disability

10. Goals of balneotherapy for arthritis Improving range of joint motion Improving range of joint motion Increasing muscle strength Increasing muscle strength Eliminating muscle spasm Eliminating muscle spasm Enhancing functional mobility Enhancing functional mobility Easing pain Easing pain

11. Balneotherapy for lumbar OA Observational study Effect on osteoarthritis of spa therapy at Bourbonne-les-Bains Effect on osteoarthritis of spa therapy at Bourbonne-les-Bains F. GUILLEMIN, J-M. VIRION, P. ESCUDIER, N. DE TALANCÉ, G. WERYHA Joint Bone Spine 2001 ; 68 : 499-503 21-day course of spa therapy; daily sessions of balneotherapy and physiotherapy

12. Effect on osteoarthritis of spa therapy at Bourbonne- les-Bains F. GUILLEMIN, J-M. VIRION, P. ESCUDIER, N. DE TALANCÉ, G. WERYHA Joint Bone Spine 2001 ; 68 : 499-503 Quality of life was markedly decreased as compared to the population at large (1996, CFES). The two pretreatment evaluations produced similar quality- of-life scores. Spa therapy was associated with significant improvements in overall quality of life (P=0.004), self-esteem (P=0.009),and pain (P=0.01).

13. Effect on osteoarthritis of spa therapy at Bourbonne- les-Bains F. GUILLEMIN, J-M. VIRION, P. ESCUDIER, N. DE TALANCÉ, G. WERYHA Joint Bone Spine 2001 ; 68 : 499-503 These findings support those of other studies conducted in France and in other European countries. They indicate that patients report meaningful improvements in their quality of life after spa therapy.

14. Balneotherapy for lumbar OA RCT 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, M. NGUYEN, M. REVEL and M. DOUGADOS British Journal of Rheumatology 1997;36:77-81 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, M. NGUYEN, M. REVEL and M. DOUGADOS British Journal of Rheumatology 1997;36:77-81

15. 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, M. NGUYEN, M. REVEL and M. DOUGADOS British Journal of Rheumatology 1997;36:77-81 Changes in the assessment criteria after a 5 month follow-up period showed improvement in terms of pain, functional impairment and quality of life, with a reduced intake of symptomatic drugs "NSAID and analgesic drugs in the spa group,

16. 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, M. NGUYEN, M. REVEL and M. DOUGADOS British Journal of Rheumatology 1997;36:77-81 This study suggests that spa therapy of 2 weeks duration has a prolonged beneficial symptomatic effect in (lumbar spine) osteoarthritis.

17. Spa therapy for lumbar spine OA in Turkey We aimed to determine the effectiveness of spa therapy in short and long term on functions and pain, in patients with lumbar spine OA

18. Study design Randomized Controlled Single blind Follow up 3 months

19. Study Groups Balneotherapy group (n:20) 2-week stay at Gönen Spa Hotel Balneotherapy + exercise therapy group (n:24) 2-week stay at Gönen Spa Hotel

20. Patients Balneotherapy and exercise (n=24) Balneotherapy only (n=20) Female/Male17/715/5 Age (year) (SD)64,7 (±11,3)61,7 (± 9,4) Duration of Disease (year)(SD) 9,9 (± 7,3)11,6 (± 7,7) Duration of pain (month) (SD) 2,3 (± 1,0)2,4 (± 1,2) ESR (mm/h) (SD)19,2 (± 11,4)16,8 (± 8,0)

21. Balneotherapy Group Thermomineral water (Na, SO 4, HCO 3, Cl, Fl) Bath in thermal pool at 36-37ºC, for 20 min, once a day, total 12-14 baths Bath in tub, at 38ºC, for 20 min, once a day, total 12-14 baths

22. Balneotherapy+Exercise Group Bath in thermal pool at 36-37ºC, for 20 min, once a day, total 12-14 baths Bath in tub, at 38ºC, for 20 min, once a day, total 12-14 baths Williams exercises; every day 15 minutes duration

23. Outcome measures Pain (VAS) Patient’s global assessment (VAS) Doctor’s global assessment (VAS) Health assessment questionnaire - HAQ WADDELL Finger-floor distance Schober index

24. Assessments Before spa therapy After spa therapy (within a week) At 3. month follow-up

25. Pain-VAS Significant reduction was seen in Pain VAS scores in both groups. Significant reduction was seen in Pain VAS scores in both groups. P=0,000 P=0,001

26. Patient’s global assesment (VAS) Significant reduction was seen in both groups. Significant reduction was seen in both groups. P=0,001P=0,000 P=0,001

27. Doctor’s global assesment (VAS) Significant reduction was seen in both groups. Significant reduction was seen in both groups. P=0,000

28. HAQ Significant reduction was seen in both groups. Significant reduction was seen in both groups. P=0,001 P=0,015P=0,006 P=0,014

29. Function WADDELL Improvement (not significant) in balneotherapy+exercise group at the end of spa therapy and significant improvement at 3. month. Significant improvement in balneotherapy group at the end of spa therapy and at 3. month. P=0,128P=0,02 P=0,000

30. Finger-Floor Distance (cm) Significant reduction was seen in both groups. Significant reduction was seen in both groups. P=0,007 P=0,006 P=0,022P=0,026

31. Schober (cm) Improvement in both groups at the end of spa therapy and at 3. month, but significant only in balneotherapy + exercise group at 3. month. P=0,092 P=0,218 P=0,081 P=0,024

32. Conclusions Both of 2 week-spa therapy were effective in reducing pain and improving function and spinal mobility and flexibility in patients with lumbar OA.

33. Conclusions The significant improvement, seen in Schober Index at 3 month in balneotherapy + exercise group was probably related to the added exercise therapy.

34. Conclusions Spa therapy combining balneotherapy and exercise therapy had advantage over sole balneotherapy in improving mobility and flexibility in patients with lumbar spine OA.

35. Conclusions However, it is needed further well designed randomized controlled trials with a higher number of patients with a sufficient power to show the superiority of combined spa therapy over mono balneotherapy for lumbar OA.

36. to improve mobility and flexibility to show the superiority of combined belly dance therapy We need further Workshops; to improve mobility and flexibility and to show the superiority of combined belly dance therapy Further Perspectives

37. Thank you !! Çeşme, Izmir for the 4th Turkish Hungarian Balneology Workshop