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Effects of Spa Therapy on Pain and Fatigue – Mechanisms and Assessment Effets de la cure thermale sur la douleur et la fatigue – mécanismes et principes d´évaluation Christoph Gutenbrunner Professor Christoph Gutenbrunner, MD, PhD, Department for Physical Medicine and Rehabilitation Medical University Hanover Carl-Neuberg-Str. 1 D-30625 Hannover email@example.com Introduction Chronic pain is defined by pain perception not (only) related to a specific damage of tissue (chronification mechanisms related to neuroplasticity as well as to psychological an vegetative functions) Pain perception and pain thresholds are influenced by the autonomous regulation (e.g. circadian variations of pain intensity and thresholds) Chronic fatigue is a non-specific symptom of exhaustion and severe diseases (chronic overstrain, cancer, inflammatory diseases) Fatigue is also related to disturbances of the autonomous regulation (e.g. circadian rhythms) Acute effects of balneotherapy on pain and pain-related functions Rheumatoid arthritis (pain) Design of the Study: - Controlled study, cross-over-design Patients: - Patients suffering from rheumatoid arthritis (n=17) Intervention: - head-out water immersion, sulphuric water (20 mg H2S/l, 36°C, 20 min) - head-out water immersion, plain water (36°C, 20 min) Main Outcome Parameter: - pain (Visual Analogue Scale) - microcirculation (Laser-Doppler-flow, forearm) Rheumatoid arthritis (pain) [cm] 6 Pain 5 (Visual analogue scale) 4 3 2 Sulphur baths * Tap water baths ** n=17 1 *=p<0,05 bath **=p<0,01 0 0 10 20 30 40 [min] 50 60 Fibromyalgia (pain and well being) Design of the Study: - Controlled study, cross-over-design Patients: - Patients with fibromyalgia (ACR-criteria) (n=17) Intervention: - head-out water immersion, sulphuric water (20 mg/l, 36°C, 20 min, one arm excluded) - cold-camber expositions (-76°C, 3 min, one arm thermo-isolated) - rest (20 min) Main Outcome Parameters: - pain intensity (visual analogue scale) - overall well being (visual analogue scale) Fibromyalgia (pain and well being) [cm] resting pain during pain during overall well- Visual 2 pain movements strain pain being analogue scale 1 Difference before - after 0 -1 *** Controls -2 *** *** ** Sulphur baths *** *** *** Cryo chamber *** *** je n=17 -3 * *=p<0,05 **=p<0,01 *** ***=p<0,001 -4 Low Back Pain (muscle tension) Study design: - Controlled study in cross-over design Patients: - 21 patients with cLBP lasting at least for 6 weeks (10 men, 11 women, age: 47,3 ± 2,9 years) Intervention: - A single brine (6% NaCl, Solequelle Bad Münder) or tap water plain bath (360C, 16 min), respectively Outcome parameters: - IEMG activity on defined muscles (M. erector spinae cervicales et lumbales, M. trapezius, M. ext. carpi radialis, M. rectus abdominis) - Pain intensity (VAS) - Subjective muscle tension (Chromatic Analogue Scale) Low Back Pain (muscle tension) p=0,000 4 (both groups) Subjective muscle tension 3 Scale 2 1 Tap water Brine water n=21 0 Before bath Bath After bath (M1) (M2) (M3) Difference of 0,0 subjective muscle tension -0,5 Scale -1,0 -1,5 Difference Difference M1-M2 M1-M3 Psychological variables (immersion) Design of the Study: - Controlled study, cross-over-design Patients: - Healthy subjects (n=20) Intervention: - isothermal head-out water immersion, tap water (36°C, 20 min) - rest (20 min) Main Outcome Parameters: - mood (Rating scale) - overall well-being (VAS) - depression, anxiety (pre-test for patient study) Psychological variables (immersion) 2 Mood (Differences) n.s. 1 p<0,05 Score 0 isothermal bath rest -1 n=20 2,0 Overall p<0,05 well being 1,5 (Differences) Visual Analogue Scale p<0,05 1,0 0,5 0,0 before - bath before - after Conclusion (1) Relevant effects of spa treatment on pain are - increase of pain thresholds (sulphur baths) - decrease of pain in rheumatoid arthritis (sulphur baths) - decrease of pain in fibromyalgia (sulphur baths) - decrease of muscle tension and pain in low back pain (thermo-neutral immersion) - improvement of well being in healthy subjects and patients with fibromyalgia (thermo-neutral immersion, sulphur baths) Mechanisms of long-term effects of balneotherapy: functional adaptation Introduction Spa treatment is prescribed mostly in chronic conditions (chronic generalised pain, metabolic syndrome and other) Spa treatment is performed during limited periods of time (two to six weeks) The time interval between treatment periods amounts to months or even years (12 months to four years) Therefore long-term effects are crucial - disease activity - health behaviour Adaptation physiology Autonomous adaptation of the cerebral cortex duration (learning, change of behaviour) Trophoblastic adaptation and plasticity (growth, increase of functional capacity) Functional adaptation (increase of economy of regulatory processes) Habituation (set point shift, increase of tolerance) Neural inhibition (e.g. of the spinal irradiation) Autonomous local adaptation (e.g. increase of tissue tolerance) Adaptive normalisation Systolic blood pressure Hypertension (n=8) Normal blood pressure (n=80) Low blood pressure (n=16) Days of treatment Adaptive normalisation Increase Target value Normalisation Change of blood pressure (linear of the systolic regression) days 4-28 blood pressure Decrease Normal range From Gutenbrunner & Ruppel (1992) Initial values (classes of 10 mmHg) days 1-3 Conclusions (2) Functional adaptive processes evoked by balneological stimuli may lead to adaptive normalisations of functions controlled by the autonomous regulation system - e.g. cardio-respiratory, metabolic, digestive or immune functions Adaptive normalisation is formally characterised by - convergence of functional parameters - aiming at normal values - coincidence of normal values with functional optima Functional adaptation may influence - pain sensitivity - muscle tension - overall well being - fatigue Clinical trials on the efficacy of balneotherapy on pain and fatigue Autonomous regulation (Hildebrandt 1998) Design of the Study: - Follow-up study during spa treatment Patients: - Patients with autonomous dysregulation and fatigue Intervention: - complex spa treatment (incl. training; all patients) - hydrotherapy (n = 1,925) - CO2-baths (n = 1,414) Main Outcome Parameters: - vegetative symptoms - quality of sleep - tiredness - mood Autonomous regulation (Hildebrandt 1998) Mean frequencies [%] Hydrotherapy CO2-balneotherapy Well being Well being Complaints Complaints Restlessness Restlessness Sleep disturbances Sleep disturbances Tiredness Mean vote [%] Tiredness Bad mood Bad mood dreams dreams Feeling of sickness Feeling of sickness days days Patients with Breast Cancer Design of the Study: - Follow-up study during and after rehabilitation in a health resort Patients: - Patients with breast cancer (n = 71) Intervention: - complex rehabilitation programme - pool exercise - physical therapies according to individual needs Main Outcome Parameters: - psychological symptoms (incl. anxiety and depression) - functional state (IRES = Indicators of Rehab Status; Gerdes & Jäckel) Patients with Breast Cancer Complaints [v. Zerssen] *** Depression [ADS-L] ** Fear [STAI] ** Anxiousness [STAI] *** Health status [EORTC] ** IRES total score (x10) ** Somatic status [IRES] (x10) * Begin Funktional status [IRES] (x10) End *** * = p<0,05 Psychosocial status [IRES] (x10) ** = p<0,01 *** = p<0,001 n = 71 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 Score Patients with Breast Cancer 9 Functional state (n = 21) 8 * * * * 7 6 Initial value (M1) 1,0 0,8 Effect size 0,6 0,4 0,2 0,0 M1 M2b M3 M4 M5 Autonomic functions Design of the Study: - Prospective controlled with long-term follow-up (1 year) Patients: - Patients with autonomous dysregulation and fatigue Intervention: - study group: complex spa treatment, esp. hydrotherapy and training (n = 48) - control group: care by the family doctor (n = 54) Main Outcome Parameters: - blood pressure - lung function - pressure-frequency-product (under strain) Autonomic functions 1,0 0,5 Difference of pressure-frequency- Difference of PFP 0,0 product -0,5 during ergometry -1,0 -1,5 p<0,01 p<0,05 -2,0 0,8 Effect size 0,6 Effect size 0,4 Intervention (n=48) 0,2 Controls (n=54) Daten from Baier (unpublished) 0,0 before-after before-1 y later before-after before-1 y later Cervico-bracial pain Design of the Study: - Follow-up study before, during and after rehabilitation in a health resort Patients: - Patients with functional or degenerative cervico- brachial pain (n = 149) - exclusion criteria: radiculopathia, medullopathia Intervention: - complex rehabilitation programme - physical therapies according to individual needs Main Outcome Parameters: - local pain and pain irradiation - sleep disturbances (caused by pain) Cervico-bracial pain Catamnesis [U] 2,8 Intensity of pain of the 2,6 cervical spine 2,4 Score 2,2 2,0 1,8 p<0,001 (Rep.-Mes.-ANOVA) Tr n=149 1,6 [%] 90 Cervico- brachial 80 pain irradiation ** Percent 70 ** ** *** 60 *** 2 Chi -test of the post- 50 treatment course: ** = p<0,01 *** = p<0,001 40 Tr n=149 80 [%] Sleep 70 disturbances 60 caused by pain Percent 50 40 *** *** *** *** *** 30 2 Chi -test of the post- 20 treatment course: *** = p<0,001 10 Tr n=149 0 1 3 6 Months 9 12 Fibromyalgia Design of the Study: - Prospective controlled study, pilot study Patients: - Patients suffering from fibromyalgia (ACR-criteria; n=32; up to now) Intervention: - serial head-out water immersion, sulphuric water (20 mg/l, 36°C, 20 min, three weeks , 2-3 times a week) - serial head-out water immersion, tap water (36°C, 20 min, three weeks , 2-3 times a week) Main Outcome Parameters: - Lautenschläger pain score - thermal pain thresholds (forearm, bilateral) - physical complaints (questionnaire) Fibromyalgia [Score] 15 12 H2S-baths Lautenschläger (iso-thermal) 10 pain score Difference from initial value 5 0 n.s. -5 p<0,001 -10 -15 Sulphur baths (n=19) Tap water baths -20 (n=13) 0 1 2 3 4 Months after begin of treatment Institut für Balneologie und nnov er Fibromyalgia Medizinische Klimatologie schule Ha ch he Ho inisc Mediz [Score] 55 Treatment period Fibromyalgia 50 Impact Questionnaire (FIQ) 45 n.s. 40 n.s. 35 p<0,05 p<0,05 Thermal pool baths p<0,001 (n=16) 30 No baths (n=13) (Dönmez et al. 2005) 25 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Months after start of treatment Meta-analysis Meta-analysis From Pittler et al. 2006 Conclusions (3) Complex spa treatments induce functional adaptive processes with relevant effects on - vegetative functions - sleep quality and fatigue (even in cancer patients) Long-term effects are shown in - cervico-brachial pain - low back pain - fibromyalgia Meta-ananlyses show at least some evidence in - rheumatoid arthritis - low back pain