Effect of balneotherapy on plasma cytokine levels Dr. Gabriella Mészáros, Dr. György Nagy Ph.D. Polyclinic of the Hospitaller Brothers of the St. John of God in Budapest Semmelweis University, I. Dept. of Rheumatology

Mud Pack Therapy and Thermal Bath Chronic low back pain Osteoarthritis Fibromyalgia Rheumatoid arthritis Spondylarthritis ankylopoetica Arthropathia psoriatica

Mud Pack Therapy and Thermal Bath Effect of mud-pack and thermal bath treatment Physical-thermal effects Chemical effects Biological / molecular changes

Mud Pack Therapy and Thermal Bath in Rheumatoid Arthritis 1 . . Cosh (1982) : spa treatment is recommended only in remission . . Elkayam (1991) Sukenik (1992) Shlomi (2003) Thermal bath, mud pack treatment or combination .

Mud Pack Therapy and Thermal Bath in Rheumatoid Arthritis 2 . Reducing objective and subjective parameters of activity and severity Morning stiffness, hand grip strength, activities of daily living, patient self-assessment of disease severity, reduction in number of active joints, Ritchie index.

Mud Pack Therapy and Thermal Bath in Rheumatoid Arthritis 3 . Bellometti (2000): se NO , se MPO , se GSH-peroxidase level - -37 Rheumatoid arthritis patients- mud bath treatment (20’,45°C, daily)  bath (20’, 38°C, daily) Background: NO (nitric-oxid): - produced by chondrocytes, fibroblasts, endothel cells affected by pro-inflammatory cytokines (eg.:TNF-; IL-1); - inhibits collagen and proteoglycan synthesis; - activates MMP-s; - induces apoptosis. -se nitrate (>18,6 mol/l), nitrite (>1,7 mol/l) concentrations are higher in RA than in healthy controls (p<0.01). -in active RA the serum level of nitrate and nitrite are higher than in remission (p<0.01). Degradation of articular cartilage (Y Ersoy Ann Rheum Dis 2002)

Mud Pack Therapy and Thermal Bath in Rheumatoid Arthritis 4 . Cozzi (2004): Lewis rat adjuvant-arthritis (subplantar FCA inj.) macrophage activation , pro-inflammatory cytokines  expansion of autoreactive T-and B-cells + mud (15 min; 40-42°C)- thermal bath (10 min, 37-38°C)

TNF- IL-1 Time/day Time/day Mud-bath p<0,05 vs control Mud-bath /F. Cozzi et al. Clinical and Exp. Rheumatology 2004 /

Mud Pack Therapy and Thermal Bath in Rheumatoid Arthritis 5. Thermal effect Minerals (trace elements) Muscle-tone Joint mobility Pain intensity Neuroendocrine- system -endorphine, ACTH, cortisol Antiinflammatory effect Reduction of objective and subjective indices Change of some cytokines/ biochemical marker‘s levels (Jezova 1985) (Bender T 1997-2005) Skin microcirculation  pl.:NO , MPO , IGF-1  (Bellometti 1998) TNF-α , IL-1β  (Bellometti 1997) PGE2  (Bellometti 1998) Leukotriene B4  Hydromechanical effect Tissue compresses Zn ? Trace elements?

Mud Pack Therapy and Thermal Bath in Osteoarthritis 1 . OA patomechanisms Kelley’s Textbook of Rheumatology

Mud Pack Therapy and Thermal Bath in Osteoarthritis 2 . . Elkayam (1991) Wigler (1995) . Bath and mud pack treatments on the knees . Index of severity, night pain, tenderness on palpation and pain on motion.

Mud Pack Therapy and Thermal Bath in Osteoarthritis 3 . Bellometti (1997): -22 osteoarthritis patients a total of 12 mud pack treatments (20’,40°C, daily)+ bath (10-12’,37-38°C, total of 12 days, daily)  22 control group of patient - bath (10-12’,37-38°C, daily, total of 12) -se IGF-1 and se TNF- level 30 min. before the first and 2 hours after the last (12 th ) treatment;

Mud Pack Therapy and Thermal Bath in Osteoarthritis 4 . TNF- pg/ml IGF-1 ng/ml 120 100 80 60 40 20 Before treatment IGF-1 TNF- After treatment p<0,01 Bellometti Clinica Chimica Acta (1997)

Mud Pack Therapy and Thermal Bath in Osteoarthrosis 5 . Bellometti (2005): MMP-3 , MMP 8,9  50 patients with osteoarthritis I. group: mud bath therapy (20’,40° C,5 times) II.group: mud bath therapy (20’,40°C,10 times)  30 patients with osteoarthritis- control group -Values of MMP-1,-2,-3,-8,-9, TIMP-1,-2 se MMP-3 value  in the II.group  Control group (p<0,05)

Conclusion

Mud packs treatment and thermal bath Kelley’s Textbook of Rheumatology

Thank You for Your Attention!