1. BALNEOTHERAPY AND PAIN Dr Arif Dönmez 20.01.2006 Balçova-İzmir

2. Pain and Balneotherapy Musculoskeletal disorders are the most common reason for the patients taken balneotherapy. Such as Osteoarthritis Chronic low back pain Fibromyalgia and myofascial pain syndromes Soft tissue disorders …….. Pain is the most prominent symptom in this group of patients

3. Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. A sample list of frequently used terms from: Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, © 1994, pp. 209-214.IASP Press

4. Pain Pain has sensory, emotional, and cognitive components. These 3 components of pain are reflected in the mechanisms of the transmission and modulation of painful stimuli. Such mechanisms are mediated through the nociceptor neurons (pain receptors and nerve fibers), the spinal cord, and the brain. Katz WA, Rothenberg R. The Nature of Pain: Pathophysiology. Journal of Clinical Rheumatology 2005(11) 2:11-5

5. How amount of pain decrease is clinically important? In Visual Analog Scale, more than %30 or 2 point (0 -10) decrease is accepted as clinically important change in chronic pain Farrara J T,. Young JP, L La Moreaux L, et al: Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 94 (2001) 149–158

6. Is balneotherapy effective on pain in different musculoskeletal disorders?

7. Balneotherapy studies which are evaluated pain intensity in Fibromyalgia Syndrome

8. Dönmez A, Karagülle MZ,Tercan N et al: Spa therapy in fibromyalgia: A randomised controlled clinic study Rheumatol Int. 2005 Dec;26(2):168-72. Week 0 Week 2 1 st month 3 rd month 6 th month 9 th month X2X2 p Pain (VAS) 6.75 2.9 b 2.8 b 4.2 b 4.3 b 21.75 <0.001 b: p<0.05 difference3.853.902.552.40 change %57 %37%35

9. % decrease in pain intensity Fibromyalgia studies

10. Balneotherapy studies which are evaluated pain intensity in osteoarthritis

11. Pain (VAS) Before spaBefore discharge * * change in pain (0-10) % Cervical OA, 345.9 ± 3.62.3 ± 1.5 3.6 %61 Lumbar OA, 336.5±1.92.8 ± 1.2 3.7 %61 Coxarthrosis, 296.0 ± 2.51.3 ± 1.2 ** ** 4.7 %78 Gonarthrosis, 1176.3 ± 3.01.5 ± 1.4 ** ** 4.8 %76 Ankle arthrosis, 96.8 ± 3.8 ** ** 1.8 ± 1.5 5.0 %73 Poliarthrosis, 496.6 ± 2.8 ** ** 2.3 ± 1.5 4.3 %65 Pain VAS scores after therapy compared to baseline by type of pathology. Cımbız A, Bayazıt V, Hallaceli H, Cavlak U: The effect of combined therapy (spa and physical therapy) on pain in various chronic diseases. Complementary Therapies in Medicine (2005) 13, 244—250

12. Group I %37.31 Group II %30.12 Odabaşı 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 2002;12:337-341 Pain (VAS) change

13. Spa before-after%30 Before-24 weeks%18 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 Rheumatology 1997:36;77-81 Pain (VAS) change

14. % decrease in pain intensity Balneotherapy studies on knee osteoarthritis some references

15. Systematic Review of balneotherapy for knee OA RCTs Brosseau L, Macleay L, Robinson V. Efficacy of balneotherapy for osteoarthritis f the knee; a systematic review. Physical Therapy Reviews. 2002;7:209-222 “ 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.”

16. Balneotherapy studies which are evaluated pain intensity in low back pain

17. Pain intensity in low back pain % decrease in pain intensity

18. These data have shown that balneotherapy is effective on pain in musculoskeletal disorders.

19. What is the mechanism of action?

20. MECHANISM of ACTION Heat Peripheral Vasodilatation Buoyancy Increase B endorphin levels Decrease Muscle Tonus- Increase pain threshold Gate-Control Theory Increases Connective Tissue stretching Environmental changes Non- competitive atmosphere Absence of work duties

21. Heat Cutaneous counterirritant effect Vasodilatation Endorphin-mediated response Alteration of nerve conduction Weber DC, Brown AW: Physical agent modalities. Braddom RL (ed.) Physical Medicine and Rehabilitation WB Saunders Company.Philadelphia 2000 p:440-458

22. Peripheral Vasodilatation Vasodilatation resulting in decreased ischemic pain Vasodilatation resulting in washout of pain mediators

23. Buoyancy.... the hydrostatic force can help alleviate pain by decreasing joint load. Mechanical mechanisms such as increased buoyancy and hydrostatic pressure have been thought to affect muscle tone, joint mobility and pain intensity. 42 Brosseau L, Macleay L, Robınson V. Efficacy of balneotherapy for osteoarthritis of the knee: a systematic review.Physical Therapy Reviews 2002; 7: 209–222

24. Increase in ß endorphin levels 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 (12/20), (2/20) (6/20) Yurtkuran M, Ulus H, Irdesel J (1993) The effect of balneotherapy on plasma beta endorphine level in patient with osteoarthritis. Phys Rehab Kur Med 3:130-132

25. Environmental changes

26. Non- competitive atmosphere