Laboratory and clinical correlates of brain atrophy in Neuro-Behçet's disease.

Background: Diagnostic evaluation of patients with parenchymal Neuro-Behçet's disease (NBD) requires magnetic resonance imaging (MRI), neuro-ophthalmologic, and neuropsychological evaluation. In this study, we aimed to find out the ideal diagnostic method that most closely reflects the progress in cognitive disability and brain atrophy in NBD. Methods: In this matched case-control study, we included patients with parenchymal NBD, Behçet's disease without neurological involvement (BD), rheumatoid arthritis, and healthy controls. Detailed ophthalmological examination, pattern-reversal visual evoked potentials (prVEP) test, optical coherence tomography (OCT), brain MRI volumetry and cognitive evaluation tests were performed. Disability status was assessed by revised EDSS. Results: Sixty-eight individuals (35 female, 33 male) were recruited. Mean ACE-R scores were significantly lower in the NBD group (NBD vs. healthy, 80±14.4, 93±4.9, p=0.002). prVEP values were similar across groups, but retinal nerve fiber layer thickness (RNFLT) were more frequently abnormal in the NBD group. We found considerable volume reduction in the brainstem, cerebellum, hippocampus, and thalamus in the NBD group. Regarding prVEP, 120 minutes P100 amplitude (p<0.001, r=0.97) and 60 minutes P100 amplitude values (p=0.006, r=0.90) were positively correlated with the total cerebral white matter volume. Conclusion: Our results confirmed previous observations on cognitive dysfunction in patients with NBD. We reported MRI volumetry data of patients with parenchymal neuro-Behçet's disease for the first time and elucidated novel brain regions with atrophy. Clinically determined scores and OCT failed to predict the status of brain atrophy. prVEP P100 amplitude may be used as a surrogate marker of cerebral white matter involvement in NBD.

Comparison of intermittent and consecutive balneological outpatient treatment (hydrotherapy and peloidotherapy) in fibromyalgia syndrome: a randomized, single-blind, pilot study.

To compare the efficacy of intermittent and consecutive balneological outpatient treatment (hydrotherapy and peloidotherapy) in fibromyalgia syndrome (FMS). A parallel 1:1, single-blind, pilot study was performed. Patients were recruited from musculoskeletal disorders outpatient clinic. Eligible participants were patients aged 18-60, diagnosed as FMS according to ACR 2010 criteria. They were randomly assigned to either consecutive or intermittent treatment groups. Both groups received 20 min of full body immersion in a tap water pool at 38-39 °C and 30 min of mud pack application on the back region at 45 °C. Delivery of the treatment was five times weekly during 2 weeks in consecutive group and two times weekly during 5 weeks in intermittent group. The primary outcomes were pain intensity and the number of patients achieving a minimal clinically important difference (MCID) on Fibromyalgia Impact Questionnaire (FIQ) at the 1st month after the completion of the treatment. Statistical analyses were based on intention to treat method. The assessing physician was blinded. Pain intensity significantly decreased in all post-treatment evaluations of both groups (except after treatment in the intermittent group). There was no significant difference between the groups. MCID for FIQ was achieved in 6 (24%) patients in the consecutive group and 12 (48%) in the intermittent group at the 1st month. There was no statistical difference in the secondary judgment criteria. The consecutive and intermittent deliveries of balneological outpatient treatment (hydrotherapy and peloidotherapy) seem to have similar effects on the clinical status of patients with FMS.

How does spa treatment affect cardiovascular function and vascular endothelium in patients with generalized osteoarthritis? A pilot study through plasma asymmetric di-methyl arginine (ADMA) and L-arginine/ADMA ratio.

The study aims to investigate the effect of spa treatment on vascular endothelium and clinical symptoms of generalized osteoarthritis. Forty generalized osteoarthritis (GOA) patients referred to a government spa hospital, and 40 GOA patients followed on university hospital locomotor system disease ambulatory clinics were included as study and control groups, respectively. Study group received spa treatment including thermal water baths, physical therapy modalities, and exercises. Control group was followed with home exercises for 15 days. Plasma ADMA, L-arginine, L-arginine/ADMA ratio, routine blood analyses, 6-min walking test, including fingertip O2 saturation, systolic/diastolic blood pressure, and pulse rate, were measured at the beginning and at the end of treatment. Groups were evaluated with VAS pain, patient, and physician global assessment; HAQ; and WOMAC at the beginning, at the end, and after 1 month of treatment. In study group, L-arginine and L-arginine/ADMA ratio showed statistically significant increase after treatment. Plasma ADMA levels did not change. There is no significant difference in intergroup comparison. Study group displayed statistically significant improvements in all clinical parameters. The study showed that spa treatment does not cause any harm to the vascular endothelium through ADMA. Significant increase in plasma L-arginine and L-arginine/ADMA ratio suggests that balneotherapy may play a preventive role on cardiovascular diseases. Balneotherapy provides meaningful improvements on clinical parameters of GOA.

Effects of Balneotherapy on Serum Levels of Shingosine-1-Phosphate in Patients With Osteoarthritis.

Context • Balneotherapy is one of the most commonly used nonpharmacological interventions for osteoarthritis (OA), but its mechanism of action in relieving pain and stiffness and in improving physical function is not well understood. Studies have found that therapy provokes a series of neuroendocrinal reactions with anti-inflammatory and analgesic effects. Sphingosine-1-phosphate (S1P), a bioactive lipid, has been implicated as an important mediator in the maintenance of physiological processes (eg, vascular barrier integrity) and in pathophysiologic processes such as inflammatory conditions. Accordingly, targeting S1P and S1P receptors may offer a potential therapy for arthritis. Objective • The aims of the present study were to determine whether (1) balneotherapy modified the circulating levels of S1P as well as some inflammatory parameters and stress markers, in patients with OA; and (2) to assess the relationship of those parameters to therapeutic efficacy. Design • This study was designed as an uncontrolled longitudinal study. Setting • The study took place at the Bolu Physical Therapy and Rehabilitation Hospital (Bolu, Turkey). Participants • Forty patients who suffered from general OA in at least 3 positions on the body, one of which could be the vertebral column, and who fulfilled the American College of Rheumatology Classification criteria and the Kellgren-Moore radiologic criteria, were enrolled in the intervention group in the study. Intervention • During balneotherapy, the participants were fully immersed in warm thermo-mineral water for 20 min at a temperature of 38°C to 40°C. A total of 15 immersions were performed in a period of 15 d. Outcome Measures • A baseline clinical evaluation of participants' pain, stiffness, and physical function was carried out using the Western Ontario and McMaster Universities questionnaire. Baseline serum levels of S1P, cyclooxygenase 2 (COX-2), matrix metalloproteinase 3 (MMP-3), and heat shock protein 70 (HSP-70) were measured using enzyme-linked immunosorbent assays and high-sensitivity C-reactive protein, with an immunoturbidimetric assay. The clinical evaluations and the biochemical measurements were repeated after completion of the balneotherapy period. Results • Balneotherapy caused a significant reduction in circulating levels of S1P and high-density lipoprotein and a limited increase in HSP-70 levels, in addition to a reduction in pain and stiffness and an improvement in physical function. In the Spearman's correlation analysis, S1P was found to be positively associated with serum levels of HSP-70, COX-2, and MMP-3. Conclusion • Balneotherapy modulated serum S1P levels in patients with OA. The effect of S1P modulation on the clinical outcome of patients with OA should be further investigated.

Does addition of 'mud-pack and hot pool treatment' to patient education make a difference in fibromyalgia patients? A randomized controlled single blind study.

The aim of this randomized controlled single-blind study is to explore whether addition of mud-pack and hot pool treatments to patient education make a significant difference in short and mild term outcomes of the patients with fibromyalgia. Seventy women with fibromyalgia syndrome were randomly assigned to either balneotherapy with mud-pack and hot pool treatments (35) or control (35) groups. After randomization, five patients from balneotherapy group and five patients from control group were dropped out from the study with different excuses. All patients had 6-h patient education programme about fibromyalgia syndrome and were given a home exercise programme. The patients in balneotherapy group had heated pool treatment at 38 °C for 20 min a day, and mud-pack treatment afterwards on back region at 45 °C. Balneotherapy was applied on weekdays for 2 weeks. All patients continued to take their medical treatment. An investigator who was blinded to the intervention assessed all the patients before and after the treatment, at the first and the third months of follow-up. Outcome measures were FIQ, BDI and both patient's and physician's global assessments. Balneotherapy group was significantly better than control group at after the treatment and at the end of the first month follow-up assessments in terms of patient's and physician's global assessment, total FIQ score, and pain intensity, fatigue, non-refreshed awaking, stiffness, anxiety and depression subscales of FIQ. No significant difference was found between the groups in terms of BDI scores. It is concluded that patient education combined with 2 weeks balneotherapy application has more beneficial effects in patients with fibromyalgia syndrome as compared to patient education alone.

Spa therapy for generalized osteoarthritis: an open, observational, preliminary study.

OBJECTIVES: Open, prospective study to evaluate the effect of spa therapy on generalized osteoarthritis (GOA). METHODS: Patients diagnosed as GOA were recruited from a private outpatient clinic. The treatment protocol was designed with 6 different spa modalities, 3 for each consecutive day, during 18 days. Interventions were Berthollet's technique (local mineral water cloud application), peloidotherapy, hydrotherapy, under water /standard (dry) massage, supervised water exercise, bath in hydro-massage pool, bath in tub with hydro-jets, free immersion in mineral water pool. The primary outcome was a clinically relevant improvement in 50% of patients at the end of the treatment. Statistical analyses were based on intention-to-treat method. Health care providers were blinded to the study. RESULTS: Ninety nine patients were included between March 7th-April 29th 2011 and all were analyzed for the primary outcome. Clinically relevant improvement was observed in 61% of the patients at the end of the treatment, and 68% at the 8th month. Patient acceptable symptom state was achieved in 33% of the patients at the 3rd week and 75% at the 8th month and Outcome Measures in Rheumatology-Osteoarthritis Research Society International Criteria (OMERACT-OARSI criteria) response in 41% of the patients at the 3rd week and 19% at the 8th month. Improvement was also observed in other judgment criteria evaluating pain, function and quality of life and continued until the 8th month for some of the parameters. No serious adverse effect was observed. CONCLUSIONS: Spa treatment may improve the clinical status of patients with GOA and seems to be well tolerated.

Balneotherapy in fibromyalgia: a single blind randomized controlled clinical study.

We aimed to evaluate the effectiveness of balneotherapy in fibromyalgia management. Fifty women with fibromyalgia under pharmacological treatment were randomly assigned to either the balneotherapy (25) or the control (25) group. Four patients from the balneotherapy group and one patient from the control group left the study after randomization. The patients in the balneotherapy group (21) had 2 thermomineral water baths daily for 2 weeks in Tuzla Spa Center. The patients in the control group (24) continued to have their medical treatment and routine daily life. An investigator who was blinded to the study arms assessed the patients. All patients were assessed four times; at the beginning of the study, at the end of the 2nd week, the 1st month, and the 3rd month after balneotherapy. Outcome measures of the study were pain intensity, Fibromyalgia Impact Questionnaire (FIQ), Beck Depression Inventory (BDI), patient's global assessment, investigator's global assessment, SF-36 scores, and tender point count. Balneotherapy was found to be superior at the end of the cure period in terms of pain intensity, FIQ, Beck Depression Inventory, patient's global assessment, investigator's global assessment scores, and tender point count as compared to the control group. The superiority of balneotherapy lasted up to the end of the 3rd month, except for the Beck Depression Inventory score and the investigator's global assessment score. Significant improvements were observed in PF, GH, and MH subscales of SF-36 during the study period in the balneotherapy group; however, no such improvement was observed in the control group. Balneotherapy was superior only in VT subscale at the end of therapy and at the end of the third month after the therapy as compared to the controls. It was concluded that balneotherapy provides beneficial effects in patients with fibromyalgia.

The efficacy of balneotherapy and physical modalities on the pulmonary system of patients with fibromyalgia.

Effects of balneotherapy on Primary Fibromyalgia Syndrome (FMS) have been studied well, except for its effect on the respiratory symptoms of FMS. In this study we allocated 56 patients with FMS into three groups who matched according to age, gender and duration of illness. All three groups received the same three physical therapy modalities (PTM): transcutaneous electrical nerve stimulation (TENS), ultrasound (US) and infrared (IR). The first group received PTM plus balneotherapy (PTM+BT), the second group received PTM alone (PTM), whilst the third group received PTM plus hydrotherapy (PTM+HT). All groups were treated for three weeks and in the same season. All patients were assessed at four time points: (a) at baseline, (b) on the 7th day of therapy, (c) at the end of therapy (after 3 weeks) and (d) at 6 months after the end of therapy. The effectiveness of treatments in all groups were evaluated in three main categories (pain, depressive and respiratory symptoms). Tender point count, total algometric measurements and pain with visual analog scale for pain; Beck Depression Inventory (BDI) and Hamilton Depression Rating Scale (HDRS) for depression; dyspnea scale, and spirometric measurements for respiratory symptoms; plus quality of life with visual analog scale as a general measurement of effectiveness were taken at all four assessment time points.Both at the end of therapy and at the 6 months follow up significant improvements in dyspnea scale, and spirometric measurements, as well as in other measured parameters were observed in group PTM+BT. All groups achieved significant improvements in BDI and HDRS but scores of PTM and PTM+HT groups had overturned at 6 months follow up. Except second group which receieved PTM alone, pain evaluation assessments were improved at 6 month follow up in PTM+HT and PTM+BT groups. But PTM+BT group had more significant improvements at the end of therapy. PTM group had no significant change for dyspnea scale and spirometric measurements. PTM combined BT and HT groups achieved significant improvements at the end of therapies for dyspnea scale and spirometric measurements, but only PTM +BT group had significant improvements for dyspnea scale and spirometric measurements at six month follow up. The group of PTM+BT was significantly better than other groups. Our results suggest that supplementation of PTM with balneotherapy is effective on the respiratory and other symptoms of FMS and these effects were better than other protocols at 6 month follow up.

Effect of balneotherapy on temporospatial gait characteristics of patients with osteoarthritis of the knee.

Effects of balneotherapy on gait properties of patients with osteoarthritis of the knee were investigated prospectively. A total of 30 patients with knee osteoarthritis received balneotherapy consisting of two daily thermomineral water baths for 2 weeks. Patients were evaluated using gait analysis and clinical scores, both within 2 weeks, before and after spa treatment. Patients were walking faster in their control analyses (0.81 +/- 0.21 to 0.89 +/- 0.19 m/s; P = 0.017), with a shorter mean stance time (63.0 +/- 3.3 to 61.8 +/- 2.5% stride; P = 0.007), an increased cadence (96 +/- 13.1 to 100 +/- 11.9 steps/min; P = 0.094) and stride length (996 +/- 174 to 1,058 +/- 142 mm; P = 0.017). Balneotherapy also resulted in a significant decrease in Lequesne knee osteoarthritis index (12.1 +/- 3.7 to 10.0 +/- 3.3 points; P = 0.003), VAS for pain (58 +/- 25 to 33 +/- 15; P = 0.0001), VAS for patients' (56 +/- 24 to 29 +/- 19; P < 0.001) and investigator's global assessment (55 +/- 20 to 26 +/- 15; P < 0.0001) and WOMAC score (2.1 +/- 0.7 to 1.6 +/- 0.8; P = 0.0004). Balneotherapy has positive effects on gait properties and clinical health quality parameters of patients with knee osteoarthritis in short-term evaluations.