TREATMENT AND REHABILITATION OF RHEUMATIC DISEASES

Report
TREATMENT AND REHABILITATION OF
RHEUMATIC DISEASES IN BALKAN SPAS;
THE EVIDENCE
Müfit Zeki Karagülle
TURKSPA
Balkan Spas for health
• A vivid custom; still popular and “widely” used
• have been considered mainstream
• at least in part, reimbursed by health
insurance systems
Therapy and Rehabilitation
of Rheumatism in Balkan Spas
• frequently indicated for the patients with
chronic disorders,
• in particular of the musculoskeletal system
– one of the oldest forms of therapy for patients
with arthritis
– to soothe the pain,
– improve joint motion
– and as a consequence to relieve people' suffering
– and make them feel well
Medicine at Balkan Spas/Health Resorts
• Comprehensive medical practice for a diversity of
health conditions including rheumatic and
musculoskeletal diseases;
– Prevention
– Treatment
– Rehabilitation
• Based on balneo- hydro- peloido- and
climatotherapy and “healing environment”
• Institutions/facilities
• thermal cure centers
• thermal hotels
• special spa clinics, hospitals, sanatoriums
Core and combined spa treatments
• the use of water
– Balneotherapy
• thermal / mineral waters
– Hydrotherapy
• Plain water
• the use of medicinal
muds (peliods)
– Mud therapy
• the use of climate and
environment
– Climatoherapy
– Thalassotherapy
– Forest therapy
• the use of other factors
• the use of other
therapeutics
–
–
–
–
–
Exercise therapy
Massage therapy
Diet (nutrition) therapy)
Health education
Authentic therapies
•
•
•
•
Hamam
Sauna
Herbs
Nutrition
Evidence Based Medicine
Research Design for Evidence
*
Research that is descriptive, anecdotal or authoritative;
**
Research without intervention, with results that may be
used in future studies;
***
Research not involving a control group or randomization
but with an evaluation;
Research involving a systematic study with control groups
****
but without randomisation;
Research involving a systematic study with a randomized
*****
control group.
Metaanalyzes
Categories of evidence
Ann Rheum Dis 2003;62;1145-1155
adapted from the classification of the United States Agency for Health Care Policy and Research.
Category
Evidence from:
1A
Meta-analysis of RCTs
1B
At least one Randomised Control Trial - RCT
2A
At least one controlled study without randomisation
2B
At least one quasi-experimental study
3
Descriptive studies, such as comparative,
correlation or case-control studies
4
Expert committee reports or opinions and/or clinical
experience of respected authors
In the year 2004 there was 1B and 2A level of evidence for
efficacy and effectiveness of spa therapy on the main
rheumatic diseases
• Osteoarthritis - 2A
• Rheumatoid arthritis - 1B
• Fibromyalgia - 1B
• Ankylosing spondylitis - 1B
• Low back pain - 1B
• Now, a decade later since our article for Turkey was
published, we aimed to review and evaluate the current
evidence on the treatment and rehabilitation of rheumatic
musculoskeletal diseases (RMSD) in Balkan spas
• A comprehensive search of databases to identify the metaanalysiz and randomized controlled trials on the
effectiveness of balneotherapy and spa therapy in Balkans
for patients with RMSD were published in peer reviewed
journals in English during last decade.
Fibromyalgia syndrome
Meta-Analysis, 1A
•
•
•
•
•
Pamukkale (Ardıç et al)
Afyon (Evcik et al)
Bursa (Yurtkuran et al)
Balçova (Dönmez et al)
Tuzla-Istanbul (Özkurt et al)
Systematic reviews and RCTs;
Rheumatoid Arthritis
Systematic reviews
Rheumatoid Arthritis
Systematic reviews and RCTs;
Rheumatoid Arthritis
RCTs; Rheumatoid Arthritis
Terme Ilidza, Sarajevo, Bosnia and Herzegovina
University Clinical Center and a nearby spa (rehabilitation hospital)
BANJSKO-REHABILITACIJSKI CENTER BANJA TERME ILIDŽA
RCTs; Rheumatoid Arthritis
Bursa, Turkey
Osteoarthritis, Controlled studies
Serbia and Turkey
Obadasi E, Karagülle MZ, Karagülle Z, Turan M, Karagülle O. Comparison of
two spa therapy regimens in patients with knee OA, an exploratory study.
Phys Med Rehab Kuror 2002; 12: 337-41.
Odabası E, Turan M, Erdem H, Pay S, Gülec¸ M, Karagülle MZ. The effect of Mud
pack treatment in knee osteoarthritis. Turk J Rheumatol 2009;24:72–76.
Bostan B, Sen U, Günes T et al. Comparison of intra-articular hyaluronic acid
injections and mud-pack therapy in the treatment of knee osteoarthritis. Acta
Orthop Traumatol Turc 2010;44:427.
Cutovic M, Jovic S, Konstantinovic L, Lazovic M, Jovanovic T, Vesovic V.
The effects of balneotherapy on knee osteoarthritis. Med Pregl 2006;59
Suppl 1: 47-50.
Jokic A, Sremcevic N, Karagülle Z, Pekmezovic T, Davidovic V. Oxidative
stress, hemoglobin content, superoxide dismutase and catalase activity
influenced by sulphur baths and mud packs in patients with osteoarthritis.
Vojnosanit Pregl 2010;67:5738.
Osteoarthritis, RCTs
Karagülle M, Karagülle MZ, Karagülle O, Dönmez A, Turan M. A 10-day course
of SPA therapy is beneficial for people with severe knee OA. A 24-week
randomized,
controlled pilot study. Clin Rheumatol 2007; 12: 2063-71.
Evcik D, Kavuncu V, Yeter A, Yigit Ilktur. The efficacity of balneotherapy and
mud pack therapy in patients with knee OA. Joint Bone Spine 2007; 74(1):60-5.
Yurkturan M, Yurkturan M, Alp A, Nasicilar A, Bingol U, Altan L, Sarpdere G.
Balneotherapy and tap water in the treatment of knee OA. Rheumatol int 2006;
27: 19-27.
Alaçatı, Çeşme, Izmir
Ankylosing Spondylitis
Case control studies ; Turkey
Ankylosing Spondylitis RCTs; Turkey
Ankylosing Spondylitis; RCT,
Turkey and Mentenegro
Low Back Pain, Meta-Analysis
Pittler MH, Karagülle MZ, Karagülle M, Ernst E. Spa therapy
and balneotherapy for treating low back pain: meta-analysis
of randomized trials. Rheumatology (Oxford). 2006;45:880-4.
significant intergroup differences in favor of balneotherapy compared with control groups
(weighted mean difference 18.8 mm, 95% CI 10.3–27.3, n = 138)
Yurtkuran M, Kahraman Z, Sivrioğlu K, Afşin Y, Doğan M, Balneotherapy in Low Back Pain. Eur J Phys Med Rehabil 1997; 7: 120-123
© The Author 2006. Published by Oxford University Press on behalf of the British Society for
Rheumatology. All rights reserved. For Permissions, please email:
[email protected]
Low Back Pain, New RCTs, Turkey
• Demirel R, Ucok K, Kavuncu V, Gecici O, Evcik D, Dundar U, Solak O,
Mollaoglu H. Effects of balneotherapy with exercise in patients with low
back pain. J Back Musculoskelet Rehabil. 2008;21: 263-72
• Dogan M, Sahin O, Elden H, Hayta E, Kaptanoglu E. Additional therapeutic
effect of balneotherapy in low back pain. South Med J. 2011;104:574-8.
• Kesiktaş N, Karakaş S, Gün K, Gün N, Murat S, Uludağ M. Balneotherapy for
chronic low back pain: a randomized, controlled study. Rheumatol Int.
2012;32:3193-9.
• Onat SS, Taşoğlu O, Güneri FD, Özişler Z, Safer VB, Özgirgin N. The
effectiveness of balneotherapy in chronic low back pain. Clin Rheumatol.
2014 Oct;33(10):1509-15. doi: 10.1007/s10067-014-2545-y. Epub 2014
Mar 6.
Mud in
Balkans
Mud therapy; Meta-Analysis
Forest plot of the mean differences in visual analogue pain scores with 95%
confidence intervals (CI) in the mud therapy group versus control group, and the
overall total, in six studies included in a meta-analysis conducted to examine the
effect of mud therapy on pain relief in patients with knee osteoarthritis.
Liu H et al. Journal of International Medical Research
2013;41:1418-1425
Copyright © by a Creative Commons Attribution License, unless otherwise noted.
Forest plot of the mean differences in the Western Ontario and McMaster Universities
Osteoarthritis Index pain scores with 95% confidence intervals (CI) in the mud therapy group
versus control group, and the overall total, in four studies included in a meta-analysis conducted
to examine the effect of mud therapy on pain relief in patients with knee osteoarthritis.
Liu H et al. Journal of International Medical Research
2013;41:1418-1425
Copyright © by a Creative Commons Attribution License, unless otherwise noted.
Message for the audiance
The available high level evidence suggests that
balneotherapy and spa therapy in Balkan Spas is
effective in the treatment and rehabilitation of
major rheumatic musculoskeletal diseases;
•
•
•
•
•
Osteoarthritis
Fibromyalgia
Ankylosing Spondylitis
Rheumatoid arthritis
Chronic low back pain
There is
encouraging and
compelling
evidence -level 1A
and 1B - for spa and
balneotherapy in
Balkan spas for
treatment and
rehabilitation of
rheumatic
musculoskeletal
diseases
Future; Balkan Trials !
More high-quality,
randomized,
controlled trials
need to be
conducted in
Balkans to confirm
this conclusion.

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