The Effects of
Balneotherapy on Knee
Osteoarthritis
Prof.Dr. Arif Dönmez
İstanbul University, İstanbul Medical Faculty,
Department of Medical Ecology and
Hydroclimatology
III. Hungarian-Turkish Balneological Symposium
1 APRIL 2005
The Effects of Balneotherapy on
Knee Osteoarthritis
Knee OA and disability
 EULAR Recommendations 2003 : an
evidence based approach to the
management of knee osteoarthritis
 Balneotherapy studies on knee
osteoarthritis
 Problems in balneotherapy studies
 Mechanisms of action
 Efficacy of balneotherapy in OA
 Proposals for high quality studies

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Knee OA and disability

As an estimation, 10 % of people older than 55
years have disabling knee symptoms


~25 % of them are severely disabled
According to WHO report on global burden of
disease, knee OA is likely to be one of the most
important global cause of disability in the society

Fourth most important in women and eighth most
important in men
Peat G, Mc Carney R, Croft P. Knee pain and osteoarthritis in older adults: a review of community
burden and current use of health care. Ann Rheum Dis 2001;60:91–7
Murray CJL, Lopez AD. The global burden of disease. Geneva: World Health Organization, 1997
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EULAR Recommendations 2003
Non-pharmacological
Pharmacological
Intraarticular
Surgical
Education
Paracetamol
Corticosteroid
Arthroscopy
Exercise
NSAIDs
Insoles
Opioid analgesics
Hyaluronic acid
Osteotomy
Orthotic devices
Sex hormones
Weight Loss
SYSADOA
Tidal irrigation
Uni-compartmental
Laser
Psychotropic drugs
Spa
Topical NSAIDs
Telephone
Topical capsaicin
Vitamins / Minerals
knee replacement
Total knee
replacement
Pulsed EMF
Ultrasound
TENS
Acupuncture
Nutrients
Herbal remedies
Jordan K M, Arden N K, Doherty M et al. EULAR Recommendations 2003: an evidence based approach to the management of
knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic
Trials (ESCISIT) Ann Rheum Dis 2003;62:1145–1155.
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Evidence : Categories
Category Evidence provided from:
1A
Meta-analysis of RCTs
1B
At least one RCT
2A
At least one controlled study without randomization
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 authorities
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The strength of recommendation is
based on
the level of evidence
 the effect size of the intervention
 the side effect profile
 the applicability of the evidence to the
population of interest
 practicality of delivery
 economic considerations

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Strength of recommendation and
the level of evidence
Category Directly based on
A
category 1 evidence
B
category 2 evidence
OR
extrapolated recommendation from category 1 evidence
C
category 3 evidence
OR
extrapolated recommendation from category 1 or 2 evidence
D
category 4 evidence
OR
extrapolated recommendation from category 2 or 3 evidence
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Balneotherapy studies on knee
osteoarthritis
Observational studies (OSs)
 Controlled Clinical Trials (CCTs)
 Randomized Controlled Clinical Trials
(RCCTs)

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Observational studies
Selected References
1.
2.
3.
4.
5.
Dönmez A, Karagülle Z, Turan M: Balneotherapie mit Akratoterme
bei Gonartrose. Zeitschrift Naturamed 1995;7-20-3
Forestier R.Magnitude and duration of the effects of two spa
therapy courses on knee and hip osteoarthritis: an open
prospective study in 51 consecutive patients. Joint Bone Spine
2000;67(4):296-304.
Guillemin F, Virion JM, Escudier P et al. Effect on osteoarthritis of
spa therapy at Bourbonne-les-Bains. Joint Bone Spine 2001 ; 68 :
499-503
Fioravanti A, Valenti M, Altobelli E et al. Clinical efficacy and costeffectiveness evidence of spa therapy in osteoarthritis. The results
of "Naiade" Italian Project. Panminerva Med.2003 Sep;45(3):2117.
Yılmaz B, Goktepe SA, Alaca R et al.Comparison of a generic and
a disease specific quality of life scale to assess a comprehensive
spa therapy program for knee osteoarthritis. Joint Bone Spine.
2004 Nov;71(6):563-6.
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Results of Observational studies
Pain  1,2,3,4
 Lequesne Knee Index score 
 Walking distance  2
 Flexion range  2
 Quality of life  3,5
 Drug consumption  4

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Controlled Clinical Trials
Selected References
1.
2.
3.
Wigler I, Elkayam O, Paran D, Yaron M. Spa
therapy for gonartrosis: prospective study.
Rheumatol Int 1995;15:65-68.
Flusser D, Abu-Shakra M, Friger M, et al.Therapy
With Mud Compresses for Knee Osteoarthritis
Comparison of Natural Mud Preparations With
Mineral-Depleted Mud. J Clin Rheumatol
2002;8:197–203
Odabaşı E, Karagülle MZ, Karagülle M et al.
Comparison of two traditional spa therapy
regimens in patients with knee osteoarthritis; an
exploratory study. Phys Med Rehab Kuror
2002;12:337-341
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Results of CCTs

Wigler I, Elkayam O, Paran D, Yaron M. Spa
therapy for gonartrosis: prospective study.
Rheumatol Int 1995;15:65-68.
Mineral water bath and mud pack combination is
bettter than:


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Mineral water bath + rinsed mud pack
Tap water bath + rinsed mud pack
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Results of CCTs

Flusser D, Abu-Shakra M, Friger M, et al.
Therapy With Mud Compresses for Knee
Osteoarthritis Comparison of Natural Mud
Preparations With Mineral-Depleted Mud. J Clin
Rheumatol 2002;8:197–203
Mineral mud compresses are far effective than
mineral-depleted mud compresses
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Results of CCTs

Odabaşı E, Karagülle MZ, Karagülle M et al.
Comparison of two traditional spa therapy
regimens in patients with knee osteoarthritis; an
exploratory study. Phys Med Rehab Kuror
2002;12:337-341
Thermal water bath and peloid pack combination is
better than twice-a-day thermal water bath
application
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Randomized Controlled Trials
Selected References I
Balneotherapy group vs. Tap water group
1.
2.
3.
Szucs L, Ratko I, Lesko T et al. Double-blind trial on the
effectiveness of the Puspokladany thermal water on
arthrosis of the knee-joints. J R Soc Health 1989; 109:7–9
Kovács I, Bender T. The therapeutic effects of Cserkeszölö
thermal water in osteoarthritis of the knee: a double
blind,controlled, follow-up study Rheumatol Int (2002) 21:
218–221
Balint G, Ádam A, Ratko I et al. Double blind study about
the effectivity of the thermal mineral water of
Nagybaracska in patient with knee joint
osteoarthritis.2.Turkish-Hungarian Balneological Workshop,
Pamukkale, Turkey 16-18 September 2004
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Randomized Controlled Trials
Selected References II
Balneotherapy group vs. Outpatient medical care group
1.
2.
3.
Nguyen M , Revel M, Dougados M. Prolonged effects of 2 week therapy in
a spa resort on lumbar spine, knee and hip osteoarthritis: Follow-up after
5 months. A randomized controlled trial. British Journal of
Rheumatology1997:36;77-81
Tishler M Rosenberg O, Levy O et al. The effect of balneotherapy on
osteoarthritis. Is an intermittent regimen effective? Eur J Intern Med 2004
15(2): 93-96
Uysal B, Dönmez A, Karagülle MZ et al. Wirksamkeit der Balneotherapie
bei Patienten mit Gonarthrose im Kurort Gönen: eine randomisierte
kontrollierte Studie. 5.Deutsch-Türkischer Kongress für Balneologie und
Medizinische Klimatologie 27-28 Juni 2003
Balneotherapy and control groups stayed at the
same area
1.
Sukenik S, Flusser D, Codish S. Balneotherapy at the Dead Sea
area for knee osteoarthritis IMAJ 1999;1:83-85
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Systematic Review of RCTs

Brosseau L, Macleay L, Robinson V. Efficiacy of
balneotherapy for osteoarthritis f the knee; a
systematic review. Physical Therapy Reviews.
2002;7:209-222
“ The results of this review suggest that
balneotherapy can be effective on a short-term basis
for measures of pain severity and function as well as
for improved ROM and timed stair climbing.”
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Problems in balneotherapy studies

Type of treatment


Treatment characteristics


in the sea, hospital, home
Constituents of the treatment agent


duration of study, frequency, number of treatments,
duration of treatment, temperature
Setting


mud pack, sulphur bath, radon and carbon dioxide bath,
Dead Sea bath salts, NaCl baths salts, and mineral water
bath
Na, Ca, K, Cl…
Individual who prepared bath

patient, medical staff
Brosseau L, Macleay L, Robınson V. Efficacy of balneotherapy for osteoarthritis of the
knee: a systematic review. Physical Therapy Reviews 2002; 7: 209–222
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Problems in balneotherapy studies

Verhagen AP, de Vet HCW, de Bie RA et al. Balneotherapy
for rheumatoid arthritis and osteoarthritis (Cochrane
Review) In: The Cochrane Library, Issue 2, 2002. Oxford:
Update Software.
“… the positive findings reported in most trials. However the
scientific evidence is weak



the poor methodological quality,
the absence of an adequate statistical analysis,
the absence of most essential outcome measures (pain, quality of life)
Therefore, the noted "positive findings" should be viewed with
caution.”
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Mechanisms of action

A combination of mechanical, thermal and chemical effects

Heat







Buoyancy and hydrostatic pressure







Analgesia
Anti inflammatory effect
Muscle tonus decrease
Peripheral vasodilatation
ß-endorphin level
Gate-control theory
affect muscle tone,
joint mobility
pain intensity by decreasing joint load
Mineral water chemical implications
Environmental change
Non-competitive atmosphere
Absence of work duties
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Efficacy of balneotherapy in OA - I
TNF α  *
IL-1  **
TNF α ***
IL-1  ***
IGF-1  ***
CRP  *,**
Haptoglobulin  *,**
*
Tütüncü ZN,Turan M, Barut A: Changes in TNF α plasma levels in
osteoarthritic patients under balneotherapy with acratotermal water.
Phys Rehab Kur Med 1996;6:80-82
** Turan M :Wirkungen der Balneotherapie auf die Akute-Phase-Reaction.
IV.Deutsch-Türkischer Ärtzekongress Balneologie und Klimatologie,
İzmir,Türkie 2000, Kongressbuch: 39-41
*** Bellometti S, Giannini S, Sartori L, Crepaldi G: Cytokine levels in
osteoarthrosis patients undergoing mud bath therapy. Int J Clin
Pharmacol Res. 1997;17(4):149-53
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Efficacy of balneotherapy in OA - II

Beta endorphine 
Kubota K, Kurabayashi H, Tamura K, et al (1992) A
transient rise in plasma beta-endorphin after a traditional
47 degrees C hot-spring bath in Kusatsu-spa, Japan. Life
Sci. 51(24):1877-80.

Beta endorphine (60%) , (30%) , (10%) 
Yurtkuran M, Ulus H, Irdesel J (1993) The effect of
balneotherapy on plasma beta endorphine level in patient
with osteoarthritis. Phys Rehab Kur Med 3:130-132
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Proposals for high quality studies

Standardization

application method, medium, environment. …
Proper/Current outcome measures
 Appropriate sampling


representative number of patients
Intent-to-treat analysis
 Randomization
 Blinded studies



single, double
Placebo controlled studies
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THANK YOU
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