1. Balneo-Spa Therapy in The Management of Rheumatoid Arthritis Mine Karagülle,MD Istanbul University Istanbul Medical Faculty Medical Ecology and Hydroclimatology Department

2. Rheumatoid Arthritis (ACR 2002) Rheumatoid arthritis(RA) is an autoimmune disorder of unknown characterized by symmetric erosive synovitis and in some cases, extraarticular involvement RA affects 1% of the adult population

3. Rheumatoid Arthritis (ACR 2002) Most patients experience a chronic fluctuating course of disease that, despite therapy, may result in progresive joint destruction, deformity, disability, and even premature death. RA results in more than 9 million physician visits and more than 250,000 hospitalizations per year in USA. Disability from RA causes major economic loss and can have a profound impact on families

4. Management of RA (ACR 2002) Goals Prevent or control joint damage Preventloss of function Decrease pain Management Patient education Start DMARD(s) Consider NSAID Consider local or Low dose systemic dteroids PhysicalTherapy/ occupational therapy

5. Balneotherapy Is a therapeutic and/or rehabilitative option in the management of rheumatoid arthritis? Is balneotherapy an effective tool in the achievement of ultimate goals in managing RA? Is balneotherapy effective in preventing joint demage, preventing loss of function and decreasing pain in RA?

6. Balneotherapy Balneotherapy and spa therapy for patients with arthritis is one of the oldest forms of therapy.

7. Balneotherapy One of the aims of balneotherapy is to soothe the pain, improve joint motion and as a consequence to relieve people suffering and make them well.

8. Balneotherapy Balneotherapy is the main component of Spa Therapy

9. Spa Therapy Mud therapy Climatic factors Climatherapy Hydrotherapy Massage Exercise Social& Physicological influences Balneotherapy

10. Studies on Balneotherapy for RA Author/Year No pat. TreatmentControlConcur. Treat. No of week Fol- Up Results Günter 1976 Bad Gastein 20I: Radon Thermal bathing II: Tap water bath. III: No bathing Cross-Over design During 3 years 3 weks a year N/A3 W. İmprovements in every 3 groups at the end of cure Steiner 1986 Bad Gastein 24Thermal water bathing (35 o C) 3 times a week Exercise programm in Amsterdam Massage swim. 3,5 Wks 2 Year Significant improv. in treatment group (several months) Sukenik 1990a Dead Sea 40Group I: Daily mud pack Group II: Daily sulphur bathing Group III: Mudpacks+sulphur baths Group IV: No- treatment control N/A2 wks 3 moSignf improvement in all 3 treat. grps. Minor imprvm. İn contr grp (not significant) Sukenik 1990b 30Group I. Dead Sea salt baths Grup II: Sodium chloride baths Regular medicati on 2 wks 3 moLarger improvement mostly in I compared to II, Elkayam 1991 Tiberias 41Group I: Mineral baths + mud packs tap water bathsN/A2 wks 3 moImprov. İn Ritchie Indx. both grps (at 3 mo. only in gr.I)

11. Author/YearNo pat. TreatmentControlConcur. Treat. No of week Fol- Up Results Sukenik 1992 Dead Sea 2828Grp I: true Mud pack Grp II: washed-out mud N/A2 wksnoSign. İmprov. İn true mud grp. Sukenik 1995 Dead Sea 36Grp I: Dead Sea baths Grup II. Sulphur baths. 35 o C Grp III. Dead Sea baths + Sulphur baths Grp IV: Control No treatment N/A12 days3 moSignf improvement in all 3 treat. grps. No improvement in control group Yurtkuran 1999 Bursa 57Grp I: Thermomineral baths (n:32) 35 o C Grp II: Cyclosporyn A (3,5 mg/kg) (n: 25) 2 moths N/A3 wks2 moImprovement in both groups. No side effects in Balneotherapy grp Franke 2000 Bad Branbach 55Grp I. Natural radon- carbondioxide baths Grp II: Artificial carbondioxi de baths N/A4 wks6 moImprovement in both groups, at 6 months follow-up only in natural radon-car. grp Karagülle 2002 Tuzla/İstanbul 37Grp I: Natural Mineral water baths (n: 15) Grp II: Rutin medical care (n: 22) Massage, drinking cure, patient education 2 wks6 moSignf. İmprovement in mineral bath grp. Partly conserved up to 6 months

12. Studies on Balneo-Spa therapy for RA in Turkey

13. Studien-design Indikation UnkontrolliertKontrolliert RetrospektivProspektiv Nicht randomisiert Randomisiert Fibromyalgia2 Studien n=60 Gonarthritis1 Studie n=60 4 Studien n=164 Osteoarthritis1 Studie n=362 Studien n=52 Rückenschmerz2 Studien n=521 Studien=50 Rheumatoide Arthritis 2 Studien n=1703 1 Studie n=57 Ankylosierende Spondylitis 2 Studienn=171 2 1 Studien=45 Arthritis Psoriatica 1 Studien=542

14. Evidence Based Medicine Aproach

15. Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd. Date of most recent substantive amendment: 28 August 2003

16. “This review has shown the positive effects of balneotherapy on important outcomes for patients with RA. The reviewers concluded that balneotherapy can be used as an adjunct therapy. However, these conclusions are undermined by the poor methodological quality of the trials available and the potential harmful side effects for arthritic patients with associated medical conditions.”

17. Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane Library, Issue 4, 2003. What is the bottom line? What is the bottom line? There is "silver" level evidence that balneotherapy or bathing in warm water may improve symptoms of rheumatoid arthritis. But most studies are of poor quality and therefore it cannot be concluded that balneotherapy works. It is also not clear if the effect of balneotherapy depends on water temperature and the addition of minerals to the water.

18. Implications for research Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane Library, Issue 4, 2003.  Large, high quality research is needed, focusing on appropriate allocation concealment, blinding and an adequate data presentation and analysis. The design and reporting of future trials should be conforming the CONSORT-statement.

19. Implications for research Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane Library, Issue 4, 2003.  New research should use outcome measures relevant to the patients, and adequate and responsive to the treatment under study. Follow-up should be of sufficient length to assess long-term effects.  New research should provide full data on outcome measures, including the mean and standard deviation or 95% confidence interval.

20. Implications for research Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane Library, Issue 4, 2003.  Future research should examine the effect of balneotherapy not only in pragmatic trials comparing various interventions with each other, but also in more explanatory trials comparing the intervention with a no treatment control group. When possible, the beneficial effect of the 'spa-environment' should be considered as a confounder or effect modifier and accounted for in the design of the trial.

21. Implications for research Verhagen AP, Bierma-Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, de Vet HCW. Balneotherapy for rheumatoid arthritis (Cochrane Review). In: The Cochrane Library, Issue 4, 2003.  We conclude that performing randomised studies with high methodological quality concerning the effectiveness of balneotherapy is both possible and necessary to provide strong evidence on the effects of balneotherapy.

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