1. Effects of Spa Therapy on Pain and Fatigue – Mechanisms and Assessment Effets de la cure thermale sur la douleur et la fatigue – mécanismes et principes d´évaluation Christoph Gutenbrunner Professor Christoph Gutenbrunner, MD, PhD, Department for Physical Medicine and Rehabilitation Medical University Hanover Carl-Neuberg-Str. 1 D-30625 Hannover gutenbrunner.christoph@mh-hannover.de

2. Introduction  Chronic pain is defined by pain perception not (only) related to a specific damage of tissue (chronification mechanisms related to neuroplasticity as well as to psychological an vegetative functions)  Pain perception and pain thresholds are influenced by the autonomous regulation (e.g. circadian variations of pain intensity and thresholds)  Chronic fatigue is a non-specific symptom of exhaustion and severe diseases (chronic overstrain, cancer, inflammatory diseases)  Fatigue is also related to disturbances of the autonomous regulation (e.g. circadian rhythms)

3. Acute effects of balneotherapy on pain and pain-related functions

4.  Design of the Study: - Controlled study, cross-over-design  Patients: - Patients suffering from rheumatoid arthritis (n=17)  Intervention: - head-out water immersion, sulphuric water (20 mg H 2 S/l, 36°C, 20 min) - head-out water immersion, plain water (36°C, 20 min)  Main Outcome Parameter: - pain (Visual Analogue Scale) - microcirculation (Laser-Doppler-flow, forearm) Rheumatoid arthritis (pain)

5. [min]

6. Fibromyalgia (pain and well being)  Design of the Study: - Controlled study, cross-over-design  Patients: - Patients with fibromyalgia (ACR-criteria) (n=17)  Intervention: - head-out water immersion, sulphuric water (20 mg/l, 36°C, 20 min, one arm excluded) - cold-camber expositions (-76°C, 3 min, one arm thermo-isolated) - rest (20 min)  Main Outcome Parameters: - pain intensity (visual analogue scale) - overall well being (visual analogue scale)

7. Fibromyalgia (pain and well being)

8. Low Back Pain (muscle tension)  Study design: - Controlled study in cross-over design  Patients: - 21 patients with cLBP lasting at least for 6 weeks (10 men, 11 women, age: 47,3 ± 2,9 years)  Intervention: - A single brine (6% NaCl, Solequelle Bad Münder) or tap water plain bath (36 0 C, 16 min), respectively  Outcome parameters: - IEMG activity on defined muscles (M. erector spinae cervicales et lumbales, M. trapezius, M. ext. carpi radialis, M. rectus abdominis) - Pain intensity (VAS) - Subjective muscle tension (Chromatic Analogue Scale)

9. Low Back Pain (muscle tension)

10. Psychological variables (immersion)  Design of the Study: - Controlled study, cross-over-design  Patients: - Healthy subjects (n=20)  Intervention: - isothermal head-out water immersion, tap water (36°C, 20 min) - rest (20 min)  Main Outcome Parameters: - mood (Rating scale) - overall well-being (VAS) - depression, anxiety (pre-test for patient study)

11. Psychological variables (immersion)

12. Conclusion (1)  Relevant effects of spa treatment on pain are - increase of pain thresholds (sulphur baths) - decrease of pain in rheumatoid arthritis (sulphur baths) - decrease of pain in fibromyalgia (sulphur baths) - decrease of muscle tension and pain in low back pain (thermo-neutral immersion) - improvement of well being in healthy subjects and patients with fibromyalgia (thermo-neutral immersion, sulphur baths)

13. Mechanisms of long-term effects of balneotherapy: functional adaptation

14. Introduction  Spa treatment is prescribed mostly in chronic conditions (chronic generalised pain, metabolic syndrome and other)  Spa treatment is performed during limited periods of time (two to six weeks)  The time interval between treatment periods amounts to months or even years (12 months to four years)  Therefore long-term effects are crucial - disease activity - health behaviour

15.  Autonomous adaptation of the cerebral cortex (learning, change of behaviour)  Trophoblastic adaptation and plasticity (growth, increase of functional capacity)  Functional adaptation (increase of economy of regulatory processes)  Habituation (set point shift, increase of tolerance)  Neural inhibition (e.g. of the spinal irradiation)  Autonomous local adaptation (e.g. increase of tissue tolerance) duration Adaptation physiology

16. Adaptive normalisation Systolic blood pressure Days of treatment Hypertension (n=8) Normal blood pressure (n=80) Low blood pressure (n=16)

17. Adaptive normalisation Initial values (classes of 10 mmHg) days 1-3 Change of blood pressure (linear regression) days 4-28 Normalisation of the systolic blood pressure From Gutenbrunner & Ruppel (1992) Target value Normal range Decrease Increase

18. Conclusions (2)  Functional adaptive processes evoked by balneological stimuli may lead to adaptive normalisations of functions controlled by the autonomous regulation system - e.g. cardio-respiratory, metabolic, digestive or immune functions  Adaptive normalisation is formally characterised by - convergence of functional parameters - aiming at normal values - coincidence of normal values with functional optima  Functional adaptation may influence - pain sensitivity - muscle tension - overall well being - fatigue

19. Clinical trials on the efficacy of balneotherapy on pain and fatigue

20.  Design of the Study: - Follow-up study during spa treatment  Patients: - Patients with autonomous dysregulation and fatigue  Intervention: - complex spa treatment (incl. training; all patients) - hydrotherapy (n = 1,925) - CO 2 -baths (n = 1,414)  Main Outcome Parameters: - vegetative symptoms - quality of sleep - tiredness - mood Autonomous regulation (Hildebrandt 1998)

21. days Mean vote [%] Mean frequencies [%] Hydrotherapy CO 2 -balneotherapy Well being Complaints Well being Restlessness Sleep disturbances Tiredness Bad mood Tiredness Bad mood Feeling of sickness dreams Autonomous regulation (Hildebrandt 1998)

22. Patients with Breast Cancer  Design of the Study: - Follow-up study during and after rehabilitation in a health resort  Patients: - Patients with breast cancer (n = 71)  Intervention: - complex rehabilitation programme - pool exercise - physical therapies according to individual needs  Main Outcome Parameters: - psychological symptoms (incl. anxiety and depression) - functional state (IRES = Indicators of Rehab Status; Gerdes & Jäckel)

23. Patients with Breast Cancer

25. Autonomic functions  Design of the Study: - Prospective controlled with long-term follow-up (1 year)  Patients: - Patients with autonomous dysregulation and fatigue  Intervention: - study group: complex spa treatment, esp. hydrotherapy and training (n = 48) - control group: care by the family doctor (n = 54)  Main Outcome Parameters: - blood pressure - lung function - pressure-frequency-product (under strain)

26. Autonomic functions

27. Cervico-bracial pain  Design of the Study: - Follow-up study before, during and after rehabilitation in a health resort  Patients: - Patients with functional or degenerative cervico- brachial pain (n = 149) - exclusion criteria: radiculopathia, medullopathia  Intervention: - complex rehabilitation programme - physical therapies according to individual needs  Main Outcome Parameters: - local pain and pain irradiation - sleep disturbances (caused by pain)

28. Cervico-bracial pain

29. Fibromyalgia  Design of the Study: - Prospective controlled study, pilot study  Patients: - Patients suffering from fibromyalgia (ACR-criteria; n=32; up to now)  Intervention: - serial head-out water immersion, sulphuric water (20 mg/l, 36°C, 20 min, three weeks, 2-3 times a week) - serial head-out water immersion, tap water (36°C, 20 min, three weeks, 2-3 times a week)  Main Outcome Parameters: - Lautenschläger pain score - thermal pain thresholds (forearm, bilateral) - physical complaints (questionnaire)

30. Fibromyalgia

32. Meta-analysis

33. From Pittler et al. 2006 Meta-analysis

34. Conclusions (3)  Complex spa treatments induce functional adaptive processes with relevant effects on - vegetative functions - sleep quality and fatigue (even in cancer patients)  Long-term effects are shown in - cervico-brachial pain - low back pain - fibromyalgia  Meta-ananlyses show at least some evidence in - rheumatoid arthritis - low back pain Thank you!