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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
gutenbrunner.christoph@mh-hannover.de
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