Balneotherapy for Chronic Low Back Pain

Prof. Dr. M. Zeki Karagülle

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

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?

Balneotherapy for LBP

Konrad et al 1992 (Ann Rheum Dis)

Yurtkuran et al 1997 (Eur J Phys Med Rehab)

Balneotherapy for chronic low back pain – RCT’s

Study Konrad et al 1992

(Ann Rheum Dis)

Yurtkuran et al 1997

(Eur J Phys Med Rehab)

Balneotherapy 4-week, 3 times a week, total 12 baths

3-week, 6 times a week

total 18 baths

Patients Treatment 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

Balneotherapy for chronic low back pain – RCT’s

Study Konrad et al 1992

(Ann Rheum Dis)

Yurtkuran et al 1997

(Eur J Phys Med Rehab)

Balneo-therapy

Gr.A: Bath in thermal water at 37oC for 15 min.

Gr.B: Underwater massage with a stream of hot water (37oC, 1 atm, 10 cm) on effected part for 15 min

Gr.C: Underwater traction in thermal water at 37oC for 15 min

Control Gr.D: only NSAID’s, no balneotherapy

Treatment Gr. Bath in thermal pool 37oC 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

Balneotherapy for LBP Results;

Outcome Measure Konrad 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.

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”

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

Balneotherapy for LBP -non RCT’sDrinovec 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

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

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

Why is balneotherapy effective?

Thermal effects

Mechanical effects

Chemical effects

Rowell,1993

Gharib et al,1985

ANP was shown to reduce the secretion of inflammatory mediators

Therefore, this cardiovascular hormone may possess anti-inflammatory potential

Thermal bath versus isothermal

012345678

37-38ºC 33-34ºC BeforeAfter

Pressure pain threshold (kg/cm2)

increased after thermal bath (p<0,001)

Decreased after isothermal bath (p<0,001)

p<0,001

p<0,001

Karagülle et al,1998Karagülle et al,1998

Thermomineral vs tap water

0

5

10

15

20

25

30

% Increase inPressure Pain

Threshold

Thermalwater36ºC

Tapwater36ºC

p<0,001

Karagülle et al,1998Karagülle et al,1998

Water immersionFactors Effects

Temperature Thermal effects; anti-algetic relaxation, anti-inflammatory ie.

Hydrostatic Pressure

Cardiovascular and urinary effects; Diuresis, central blood redistribution, ANF secretion

Buoyancy Mechanical relaxation, ability to float, easily lying position

Viscosity Resistance of motion through water

(during walking and exercising)

Thermomineral water immersionFactors Biologic Effects

Mineral composition

Poorly understood

Immunologic system,

Neuropeptidergic system

Sulphur,

CO2,

Radon,

NaCl

Immunomodulatory

Peripheral vasodilatation

Realise of beta endorphins

Anti-inflammatory

Anti-algic

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

A 3-week Balneotherapy for LBPHungarian-style

Modality Type Dur. Temp

Total

Balneotherapy Bath in thermal water pool

15 min

37 ºC

12

Or

Balneotherapy Bath in thermal pool with underwater massage with pressured water stream

15 min

37 ºC

12

or

Balneotherapy Bath in thermal pool with spinal traction

15 min 37 ºC

12

A 3-week Balneotherapy for LBPTurkish-style

Modality Type

Duration Tem.

Total/

Frequency

Course

Bath in thermal pool

30 min 37ºC 18 baths

6baths/week

3-week

or

Bath in thermal pool

20 min 36-37ºC

20 baths

2 baths/day 1 bath/day

3-week

10-day

plus

Exercise

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

36-37ºC 12 or 18 or 20 baths

10-day

3-week

4-week

Exemplary Evidence Based Balneotherapy Prescription for LBP

Water Type

Combine therapy

Bath frequency

Bath Type Course

Type

Mixed Thermal Mineral Water

Exercise

Patient Education

3-6 baths /week

2 baths/day

Passive immersion

Ambulatory

Do we need balneotherapy for LBP ?

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.

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.

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.

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

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

Thank You !!!Thank You !!!