1. Balneotherapy for Chronic Low Back Pain Prof. Dr. M. Zeki Karagülle

2. Department of Medical Ecology and Hydroclimatology Istanbul University, Istanbul Medical Faculty Istanbul, Turkey

4. Balneotherapy for LBP Is there evidence suggests that balneotherapy (the central therapeutic modality of every spa therapy package) is an effective intervention in the management of LBP?

5. Balneotherapy for LBP Konrad et al 1992 (Ann Rheum Dis) Yurtkuran et al 1997 (Eur J Phys Med Rehab)

6. Balneotherapy for chronic low back pain – RCT’s StudyKonrad et al 1992 (Ann Rheum Dis) Yurtkuran et al 1997 (Eur J Phys Med Rehab) Balneotherapy4-week, 3 times a week, total 12 baths 3-week, 6 times a week total 18 baths PatientsTreatment Groups: A: 42, B: 39, C: 44, Control Group: D: 53, Drop outs: 12 Treatment Gr: 30 Control Gr: 20 Type of treatment Ambulatory, patients received treatments after work Budapest, Hungary Ambulatory, patients received treatments during daily routine Bursa, Turkey

7. Balneotherapy for chronic low back pain – RCT’s StudyKonrad et al 1992 (Ann Rheum Dis) Yurtkuran et al 1997 (Eur J Phys Med Rehab) Balneo- therapy Gr.A: Bath in thermal water at 37 o C for 15 min. Gr.B: Underwater massage with a stream of hot water (37 o C, 1 atm, 10 cm) on effected part for 15 min Gr.C: Underwater traction in thermal water at 37 o C for 15 min Control Gr.D: only NSAID’s, no balneotherapy Treatment Gr. Bath in thermal pool 37 o C for 30 min + flexion exercises outside the pool after bath for 15 min. Control Gr. The same flexion exercises program that was applied to treatment group, no balneotherapy Other treatment No drugs, all patients were taught to use their back correctly No medication, no physical therapy

8. Balneotherapy for LBP Results; Outcome MeasureKonrad et al 1992 Balneotherapy/ Control Yurtkuran et al 1997 Balneotherapy/ Control Pain Reduction (VAS, cm) -3.2 / -0.8-2.4 / -0.9 Pain, Reduction Long term -1.4 / -0.7 1 year -2.9 / -1.3 1 month Drug consumption Analgesics Asprin -31.7 / -1.9 -13.9 / -0.6 -- Schober Index (mm) (modified) --+0.65 /+0.27 +0.81/ +0.31 Finger Floor Distance (cm) ---0.44/-0,20 -0.64/-0.10 N.S.

9. Overall Balneotherapy Effect Konrad et al 1992 (Ann Rheum Dis) Yurtkuran et al 1997 (Eur J Phys Med Rehab) The prescription of analgesics and the pain score were reduced significantly after the treatment. After one year only the analgesics consumption was significantly lower than in the control group. Statistically significant improvement was observed in the balneotherapy group in most of the measures both at the end of 3-week treatment and 1 month post treatment. “...balneotherapy seems to be a useful physiological means of reducing pain and analgesic consumption” “It can be suggested that balneotherapy might be used as an effective alternative treatment modality in low back pain”

10. Balneotherapy for LBP -non RCT’s Drinovec et al, 1994 Balneotherapy vs hydrotherapy (tap water) Aktaş, 1997 Balneotherapy vs Balneotherapy Crossover design: 10-day hydrotherapy 1tap water bath /day, at 32 ºC for 20 min, total 10 baths Than 10-day Balneotherapy 1 thermomineral water bath /day, at 36 ºC for 20 min, total 10 baths ?? (n:19) Gr.1 (n:15) 10-day Balneotherapy (2 baths /day, at 36-37 ºC for 20 min, total 20 baths ) + Exercise therapy, Gr.2 (n:15) 3-week Balneotherapy (1 Bath /day, at 36-37 ºC for 20 min, total 20 baths) + Exercise therapy Both therapies were applied Ambulatory, Patients resided near spa resort

11. Balneotherapy for LBP -non RCT’s Drinovec et al, 1994 Balneotherapy vs hydrotherapy (tap water) Aktaş, 1997 Balneotherapy vs Balneotherapy Balneotherapy has significantly decreased pain and stiffness of spine, improved sleeping and increased spine mobility. Most of the observed effects lasted even 6 weeks after therapy. Hydrotherapy exhibited minimal improvement, which did not last after 6 weeks Significant improvements were seen in VAS and Functional Index (Oswestry) in both groups after the treatment periods and at 1 month follow-up. There were no significant differences between the study groups

12. Balneotherapy for LBP passive immersion in thermomineral water underwater massage with a stream of hot water on low back in thermomineral water underwater traction in thermomineral water superior to hydrotherapy (passive immersion in tap water) superior to exercise when combined with exercise in land

13. Balneotherapy for LBP Even though an overall effect is established in two RCTs and two nonRCTs, results are not generalisable There is still limited evidence for therapeutic efficacy of balneotherapy for LBP

14. Why is balneotherapy effective? Thermal effects Mechanical effects Chemical effects

15. Rowell,1993

16. Gharib et al,1985

17. ANP was shown to reduce the secretion of inflammatory mediators Therefore, this cardiovascular hormone may possess anti- inflammatory potential

18. Thermal bath versus isothermal Pressure pain threshold (kg/cm 2 ) increased after thermal bath (p<0,001) Decreased after isothermal bath (p<0,001) p<0,001 Karagülle et al,1998

19. Thermomineral vs tap water p<0,001 Karagülle et al,1998

20. Water immersion FactorsEffects TemperatureThermal effects; anti-algetic relaxation, anti-inflammatory ie. Hydrostatic Pressure Cardiovascular and urinary effects; Diuresis, central blood redistribution, ANF secretion BuoyancyMechanical relaxation, ability to float, easily lying position ViscosityResistance of motion through water (during walking and exercising)

21. Thermomineral water immersion FactorsBiologic Effects Mineral composition Poorly understood Immunologic system, Neuropeptidergic system Sulphur, CO 2, Radon, NaCl Immunomodulatory Peripheral vasodilatation Realise of beta endorphins Anti-inflammatory Anti-algic

22. Balneotherapy prescription for chronic LBP Let us attempt to prescribe a balneotherapy regimen for chronic low-back pain with a evidence based approach rather than empiricism and tradition

23. A 3-week Balneotherapy for LBP Hungarian-style ModalityTypeDur.Tem p Total BalneotherapyBath in thermal water pool 15 min 37 º C12 Or BalneotherapyBath in thermal pool with underwater massage with pressured water stream 15 min 37 º C12 or BalneotherapyBath in thermal pool with spinal traction 15 min37 º C12

24. A 3-week Balneotherapy for LBP Turkish-style Modality Type DurationTem.Total/ Frequency Course Bath in thermal pool 30 min37 º C18 baths 6baths/week 3-week oror Bath in thermal pool 20 min36- 37 º C 20 baths 2 baths/day 1 bath/day 3-week 10-day plus Exercise

25. Exemplary evidence based balneotherapy prescription for LBP Bath Type Bath Duration Bath water Temp. Total baths Course of therapy Bath in thermal water (pool or tube ?) 20 to 30 min 36-37 º C12 or 18 or 20 baths 10-day 3-week 4-week

26. Exemplary Evidence Based Balneotherapy Prescription for LBP Water Type Combine therapy Bath frequency Bath TypeCourse Type Mixed Thermal Mineral Water Exercise Patient Education 3-6 baths /week 2 baths/day Passive immersion Ambula tory

27. Do we need balneotherapy for LBP ?

28. Balneotherapy for LBP Turkey and Hungary have a lot of spa resorts and thermal mineral springs and are looking back on a still vivid tradition of spa therapy and balneotherapy, especially for the treatment of rheumatic diseases including LBP.

29. Balneotherapy for LBP Europe maintains the tradition, as do Japan, Israel and elsewhere. The challenge is still coming from America and England where spa medicine is eclipsed by new ethos in medicine during mid 20.century.

30. Balneotherapy for LBP To generate cogent scientific data will facilitate to find cost-effective and culturally acceptable ways of incorporating balneotherapy into health care systems of the countries where spa therapy or balneotherapy facilities are available.

31. Balneotherapy for LBP In future we need methodologically sound studies to confirm that balneotherapy has either broadly beneficial effects or it is effective only for relieving chronic back pain

32. Balneotherapy for LBP “Our management of low back pain is not so perfect that we can afford to ignore any form of treatment that can be shown to work.” Konrad et al 1992

33. Thank You !!!