BALNEOTHERAPY IN THE TREATMENT BALNEOTHERAPY IN THE TREATMENT OF FIBROMYALGIA SYNDROMEOF FIBROMYALGIA SYNDROME

Doç Dr Lale Altan, Doç Dr Lale Altan, Uludağ University Medical FacultyUludağ University Medical Faculty

Atatürk Rehabilitation Center Kükürtlü Atatürk Rehabilitation Center Kükürtlü Spa Bursa/ TürkiyeSpa Bursa/ Türkiye

Uludag University Atatürk Uludag University Atatürk Rehabilitation center Rehabilitation center has an area has an area of 23 thousand square metersof 23 thousand square meters

It is in Çekirge, the well-known It is in Çekirge, the well-known spa district of Bursaspa district of Bursa

Kükürtlü spa is a big ancient Kükürtlü spa is a big ancient building. building. DDifferent architects built ifferent architects built separate sections in various timesseparate sections in various times

Men’s bath section of the ancient Men’s bath section of the ancient spa was built by Sultan Murat spa was built by Sultan Murat Hudavendigar Gazi 1st (1359-Hudavendigar Gazi 1st (1359-1384). 1384). SSmall Kükürtlü women mall Kükürtlü women baths baths were built by were built by Sultan Beyazıt Sultan Beyazıt the 2nd (1481-1512)the 2nd (1481-1512)

It is the first center run by the It is the first center run by the University since 1983University since 1983

Mostly locomotor system diseases Mostly locomotor system diseases are treated in the center are treated in the center

Our outpatient number reaches Our outpatient number reaches 13.000 a year.13.000 a year.

Fibromyalgia syndrome Fibromyalgia syndrome (FMS)(FMS)

FMS is a chronic disease and it FMS is a chronic disease and it affects mostly females.affects mostly females.

Pain, stiffness, fatigue, sleep Pain, stiffness, fatigue, sleep disturbance, headache, and impaired disturbance, headache, and impaired muscular performance are the muscular performance are the common symptoms of FMScommon symptoms of FMS

Essential targets of FMS Essential targets of FMS treatmenttreatment

To maintain peripheral and central To maintain peripheral and central analgesia analgesia

To improve sleep disturbance To improve sleep disturbance To avoid psychological factorsTo avoid psychological factors To increase blood perfusion of To increase blood perfusion of

muscles and superficial tissuesmuscles and superficial tissues

Treatments choicesTreatments choices

Medical treatment (Psychtroph drugs, Medical treatment (Psychtroph drugs, Antidepressants, bensodiazepine, Antidepressants, bensodiazepine, hormones, Malik acit etc..)hormones, Malik acit etc..)

Physical therapy (TENS, Physical therapy (TENS, Hydrotherapy, Hydrotherapy, Biofeedback, acupuncture…)Biofeedback, acupuncture…)

ExerciseExercise

Balneotherapy in FMSBalneotherapy in FMS

Thermal and hydromechanical Thermal and hydromechanical stimulus affects muscle tone, joint stimulus affects muscle tone, joint mobility and pain intensity. mobility and pain intensity.

Thermal stimulus may decrease pain Thermal stimulus may decrease pain through the gate-control mechanism through the gate-control mechanism and by counteracting muscular and by counteracting muscular spasm. spasm.

Heating causes vasodilation. This Heating causes vasodilation. This may improve muscular ischemia and may improve muscular ischemia and help clearance of algesic mediators.help clearance of algesic mediators.

Balneotherapy may stimulate Balneotherapy may stimulate secretion of opioidssecretion of opioids

The antiinflammatory effect of The antiinflammatory effect of sulphur on inflammatory diseases sulphur on inflammatory diseases was suggested by some authorswas suggested by some authors

In a study done in Dead Sea,In a study done in Dead Sea, 48 patients participated in the study 48 patients participated in the study Half of the Half of the

patients received hydrotherapy, and half did notpatients received hydrotherapy, and half did not Conclusion : Staying at the Dead Sea spa, in Conclusion : Staying at the Dead Sea spa, in

addition to balneotherapy, can transiently addition to balneotherapy, can transiently improve the QoL of patients with FMimprove the QoL of patients with FM

42 FMS patient42 FMS patient Group 1 (n=22) received 20 min bathing once a Group 1 (n=22) received 20 min bathing once a

day and five times per week for 3 weeks ; Group day and five times per week for 3 weeks ; Group 2 was accepted as the control group2 was accepted as the control group

Results:In Group 1, there were significant Results:In Group 1, there were significant difference in number of tender points, pain scores, difference in number of tender points, pain scores, BDI and FIQ scores following the treatment BDI and FIQ scores following the treatment programprogram

Conclusion: Balneotherapy is an effective Conclusion: Balneotherapy is an effective treatment in FMStreatment in FMS

Thirty women with FM were randomized Thirty women with FM were randomized into two groupsinto two groups

16 patients had spa treatment for 2 weeks 16 patients had spa treatment for 2 weeks in addition to their medical treatmentin addition to their medical treatment

Conclusion: The addition of spa therapy to Conclusion: The addition of spa therapy to medical therapy has in both short and long medical therapy has in both short and long term (9 months) beneficial effects in the term (9 months) beneficial effects in the FM patients FM patients

Exercise in FMSExercise in FMS

Exercise programs were reported to Exercise programs were reported to be helpful in FMS patients in several be helpful in FMS patients in several studiesstudies

But standard exercise programs are But standard exercise programs are yet not available yet not available

Pool-based, as well as land-based Pool-based, as well as land-based exercise studies were done for FMS.exercise studies were done for FMS.

Pool exercisePool exercise

Objective: To evaluate the effects of 6 Objective: To evaluate the effects of 6 months of pool exercise combined with a months of pool exercise combined with a education program for patients with FMSeducation program for patients with FMS

58 patients were randomized into two 58 patients were randomized into two groupsgroups

In Group 1, the patients performed an In Group 1, the patients performed an exercise program in a temperate pool, exercise program in a temperate pool, once a week for 6 monthsonce a week for 6 months

Additionally an education program was Additionally an education program was given to the patientsgiven to the patients

Results: Significant differences Results: Significant differences between treatment group and control between treatment group and control group were found for almost all group were found for almost all parameters.parameters.

Conclusion: Exercise in pool and Conclusion: Exercise in pool and education significantly improved education significantly improved symptoms of FMS.symptoms of FMS.

The previous study was extended. The previous study was extended. Symptom severity, physical and Symptom severity, physical and social function parameters were social function parameters were found still improved at 24 months.found still improved at 24 months.

To compare pool-based exercise and To compare pool-based exercise and balneotherapy in fibromyalgia balneotherapy in fibromyalgia syndrome patients. syndrome patients.

PATIENTSPATIENTS

50 female patients with FMS were included. 50 female patients with FMS were included.

NSAID medication was discontinued.NSAID medication was discontinued.

Basic education on FMS was given to Basic education on FMS was given to patientspatients

Then 2 groups were formed in blind fashionThen 2 groups were formed in blind fashion

In Group I, pool-based In Group I, pool-based exercise program was exercise program was given by a physiotherapist given by a physiotherapist to 25 patients in a to 25 patients in a therapeutic pool for 35 therapeutic pool for 35 minutes a day, 3 times a minutes a day, 3 times a week, for 12 weeksweek, for 12 weeks

The program comprised The program comprised warming, active exercises, warming, active exercises, relaxation, and out-of-pool relaxation, and out-of-pool exercisesexercises

In Group II, 25 In Group II, 25 patients received patients received balneotherapy balneotherapy sessions of 35 sessions of 35 minutes, 3 times a minutes, 3 times a week, for 12 weeks week, for 12 weeks in the same pool in the same pool but they were but they were instructed not to instructed not to perform any perform any exercise activity exercise activity during the sessionsduring the sessions

Evaluation parametersEvaluation parameters Pain (Using VAS and 5 point scale)Pain (Using VAS and 5 point scale) Morning stiffnessMorning stiffness FatigueFatigue SleepSleep Tender points : With pressure algometer Tender points : With pressure algometer - Number of tender pointsNumber of tender points- Algometer scoreAlgometer score- myalgic scoremyalgic score Global evaluation of the patient and physicianGlobal evaluation of the patient and physician Fibromyalgia impact questionnaire (FIQ)Fibromyalgia impact questionnaire (FIQ) Chair testChair test Beck depression inventory (BDI)Beck depression inventory (BDI)

Evaluations were performed just Evaluations were performed just before (Week 0), immediately after before (Week 0), immediately after (Week 12), and 12 weeks following (Week 12), and 12 weeks following the treatment (Week 24) by the the treatment (Week 24) by the same researcher who was totally same researcher who was totally unaware of the group the patients unaware of the group the patients belonged tobelonged to

ResultsResults

CConclusiononclusion TThe results of our study did not show a significant he results of our study did not show a significant

superiority of pool-based exercise over superiority of pool-based exercise over balneotherapy. balneotherapy.

However, since some symptoms (However, since some symptoms (sleep sleep disturbance and morning stiffness)disturbance and morning stiffness) benefited from benefited from pool-based exercise for a longer time, wpool-based exercise for a longer time, we may e may suggest that pool-based exercise has a longer-suggest that pool-based exercise has a longer-lasting effect on at least some of the symptoms of lasting effect on at least some of the symptoms of FMSFMS

On the other hand, oOn the other hand, our results were in ur results were in accordance with previous balneotherapy studies. accordance with previous balneotherapy studies. We believe that balneotherapy should be an We believe that balneotherapy should be an essential component of FMS treatment.essential component of FMS treatment.

Thank youThank you