A meta-analysis of the effectiveness of mud-bath therapy on knee osteoarthritis.

OBJECTIVE: Osteoarthritis (OA) results from loss of cartilage in-tegrity in association with changes to the structure of the entire joint. Treatment of OA is based on different pharmaceutical and no phar-maceutical approaches and the latter include the use of spa-therapy. The biological effects of mud-bath therapy are mainly secondary to heat stimulation and to physic-chemical properties of mineral waters and mud-packs. Mud-bath therapy likely exerts its effects modulating several cytokines and other molecules involved in inflammation and cartilage degradation. Our aim was to perform an updated meta-analysis of the effectiveness of the mud-bath therapy on knee osteoarthritis and briefly to discuss the mechanisms of action of this treatment. MATERIALS AND METHODS: A MEDLINE on PubMed for articles on knee OA and spa therapy published from 1995 through up to April 2019 was performed. Then, we checked the Cochrane Central Register of Controlled Trials to find additional references included up to April 2019. Articles were included if in accordance with the eligibility cri-teria. Sample size and effect sizes were processed with the MedCalc software package. RESULTS: Twenty one studies met the inclusion criteria and were included in meta-analysis. We examined WOMAC Index and VAS pain. We found significant improvements in function scores and painful symptoms after mud-bath therapy in patients with knee joint osteoarthritis. CONCLUSIONS: Spa therapy is a non-drug treatment modalities, non invasive, complication-free, and cost-effective alternative modality for the conservative treatment of knee osteoarthritis. It cannot substitute for conventional therapy but can integrated or alternated to it. Treatment with mud-bath therapy may relieve pain, stiffness and improve functio-nal status in patients with knee OA.

Sulfurous-arsenical-ferruginous balneotherapy for osteoarthritis of the hand: results from a retrospective observational study.

Balneotherapy (BT) is a complementary therapy widely used in several rheumatic conditions, however, the evidence in hand osteoarthritis (HOA) is still scarce. The aim of this preliminary study is to retrospectively evaluate the symptomatic effects of a cycle of mud-bath therapy in HOA patients. Two hundred twelve outpatients with primary bilateral HOA treated with 12 daily local mud packs and generalized thermal baths with a sulfurous-arsenical-ferruginous mineral water added to usual treatment were included in the study. Each patient was examined at baseline and at the end of thermal therapy (2 weeks). Primary outcome measures were global spontaneous hand pain on a Visual Analogue Scale (VAS) and the Functional Index for Hand Osteoarthritis (FIHOA) score; secondary outcomes were handgrip strength, duration of morning stiffness, Health Assessment Questionnaire (HAQ), Short Form Health Survey (SF-12), tolerability and patients' and physicians' global impression of treatment efficacy and tolerability. Our results demonstrated that the efficacy of mud-bath therapy was significant in all the assessed parameters at the end of therapy, except for the physical component score of SF-12. The thermal treatment was well tolerated. The patient's and the physician's global assessments showed a high level of satisfaction in terms of efficacy and safety. In conclusion, our results may suggest a short-term effectiveness of mud-bath therapy in controlling pain and improving functionality in HOA patients, supporting the role of this treatment as a complementary strategy in the management of HOA; however, further randomized controlled trials with a long-term follow-up are needed.

Mud-bath treatment of seronegative spondyloarthritis: experience at the Euganean Thermal Area.

Mud-bath therapy (MBT) has been used as a treatment for rheumatic diseases and musculoskeletal complaints in the Euganean Thermal Area (near Padova, Italy) since ancient time. There is no consensus about the use of MBT in patients with inflammatory rheumatic diseases, although experimental studies have suggested a beneficial effect of MBT on chronic articular inflammation. To evaluate the effects of MBT in patients affected by seronegative spondyloarthritis, very common chronic inflammatory rheumatic diseases, randomized controlled trials (RCT) performed in the Euganean Thermal Area have been reviewed. A significant improvement of spondylitis parameters was observed in enteropathic spondylitis, without bowel symptom exacerbation. A long-term amelioration of clinical evaluation indices was found in ankylosing spondylitis. A significant improvement of cutaneous lesions, arthritis activity, and patient's functional ability was observed in psoriatic arthritis. MBT was usually well tolerated and adverse side effects were rarely reported. The review of the RCT suggests that MBT may exert additional beneficial effects in patients with seronegative spondyloarthritis treated with pharmacological therapy.

[Sulphureous mud-bath therapy and changes in blood pressure: observational investigation]. / Fangobalneoterapia sulfurea e variazioni della pressione arteriosa: studio osservazionale.

BACKGROUND AND OBJECTIVE: The chronic arthropathies currently appear to be a major cause of disability with a negative impact on quality of life and health care spending. The mud-bath therapy is a spa treatment that induces benefic effects in chronic rheumatic diseases. It has long been debated on the assumption that the mud-bath spa therapy could have adverse cardiovascular effects which often induce caution and even a contraindication to the use of this treatment in chronic arthropathies associated with cardiovascular alterations such as hypertension. The aim of this observational study was to investigate, in arthrorheumatic subjects, the effects of sulphureous mud-bath cycle on blood pressure and the possible appearance of adverse drug reaction. PATIENTS AND METHODS: 169 patients, with age range 42-86 years, suffering by chronic arthropathies were treated with sulphureous mud-bath therapy for 2 weeks. According to the arterial pressure values, measured before the spa treatment, the patients considered were divided in three groups: with normal blood pressure (NOR group); with high blood pressure, after, the latter group was divided in IPET (patients in treatment with antihypertensive drugs) and IPENT (patients not in antihypertensive therapy). The arterial pressure values, maximum and minimum, expressed in mmHg, were detected in the first (T1) - sixth (T6) and twelfth (T12) day of spa treatment. The media arterial pressure values collected before and after T1, before and after T6, before and after T12 , before T1 and after T12 were compared. The data, presented as mean±SD, were compared with the paired Student t test. A p value ≤0.05 was considered significant. RESULTS: The comparison between the mean values detected in pre and post T1, pre and post T6, pre and post T12 have showed that sulphureous mud-bath therapy induced a significant (p<0.05) reduction of arterial blood pressure values in patients suffering of chronic arthropathies with high blood pressure in antihypertensive therapy or not (IPET and IPENT groups); while in patients with normal blood pressure (NOR group) were observed modest reduction at the limit of statistical significance. Similarly, the comparison between the data detected at the end of sulphureous mud-bath therapy (post-T12) vs baseline (pre-T1) have demonstrated: in IPET and IPENT groups a significant (p<0,01) decrease of arterial blood pressure values; in NOR group very small decrease, this reduction is significant (p<0.05) only for maximum arterial pressure value. Were not observed adverse drug reaction. CONCLUSIONS: The results of our study, in according with the few data in the literature, evidenced that is possible include the sulphureous mud-bath therapy in interdisciplinary therapeutic p rotocol of patients suffering of chronic arthropathies and arterial hypertension.

Circulating levels of adiponectin, resistin, and visfatin after mud-bath therapy in patients with bilateral knee osteoarthritis.

Adipocytokines, including adiponectin, resistin, and visfatin may play an important role in the pathophysiology of osteoarthritis (OA). Spa therapy is one of the most commonly used non-pharmacological approaches for OA, but its mechanisms of action are not completely known. The aim of the present study was to assess whether a cycle of mud-bath therapy (MBT) influences the serum levels of adiponectin, resistin, and visfatin in patients with knee OA. As part of a prospective randomized, single blind-controlled trial evaluating the efficacy of MBT in knee OA, we included in this study 95 outpatients. One group (n = 49) received a cycle of MBT at the spa center of Chianciano Terme (Italy) in addition to the usual treatment, and one group (control group; n = 46) continued their regular care routine alone. Patients were assessed at basal time and at the end of the study (15 days) for clinical and biochemical parameters. Clinical assessments included spontaneous pain on a visual analog scale (VAS) score and the Western Ontario and McMaster Universities index (WOMAC) subscores for knee OA evaluated as total pain score (W-TPS), total stiffness score (W-TSS), and total physical function score (W-TPFS). Adiponectin, resistin and visfatin serum levels were assessed by enzyme immunoassay methods. At the end of the mud-bath therapy, serum adiponectin levels showed a significant decrease (p < 0.001), while no significant modifications were found in the control group at day 15. Serum resistin showed a significant decrease (p < 0.0001) in the MBT group at the end of the study and a significant increase in the control patients (p < 0.001). No significant modifications of visfatin were found in MBT. Furthermore, we tested the relationships between demographic and clinical parameters and adipocytokine concentrations measured in the MBT group at basal and at the end of the study. In conclusion, the present study shows that a cycle of MBT can modify serum levels of adiponectin and resistin but not the circulating levels of visfatin. In view of the recent evidences about the involvement of adiponectin and resistin in the pathogenesis and progression of OA, the decrease of these adipokines after mud-bath therapy may play a protective role in the course of the disease. However, it remains to be clarified which of the mechanisms of action of MBT may have determined the changes in serum levels of adiponectin and resistin that we observed.

Effects of mud-bath therapy in psoriatic arthritis patients treated with TNF inhibitors. Clinical evaluation and assessment of synovial inflammation by contrast-enhanced ultrasound (CEUS).

OBJECTIVES: Despite the efficacy of TNF inhibitors, most patients with psoriatic arthritis maintain a residual synovial inflammation. The main aim of the study was to evaluate the effects of mud-bath therapy on clinical picture of PsA patients treated with TNF inhibitors. The secondary outcome was to assess synovial inflammation in hand joints detected by contrast-enhanced ultrasound. Other aims were to verify the risk of arthritis flare and to evaluate the effects of spa treatment on functional ability and on quality of life. METHODS: Thirty-six patients with psoriatic arthritis, treated in the last 6 months with TNF inhibitors, were enrolled. After 1:1 randomisation, 18 patients (group A) underwent mud-bath therapy (12 mudpacks and 12 thermal baths), maintaining treatment with TNF inhibitors; 18 patients (group B) continued pharmacological therapy alone. CRP, PASI, DAS28, swollen and tender joint count, VAS pain, HAQ and SF-36 were evaluated at baseline (T0) and after 45 days (T1). Synovial inflammation detected by contrast-enhanced ultrasound, analysed by a software system, was also assessed. RESULTS: A significant improvement in PASI (P<0.005), DAS28 (P<0.05), swollen joint count and tender joint count (P<0.001), and HAQ (P<0.001) between T0 and T1 was observed in group A. No patient underwent a flare-up of arthritis. Ultrasound videos demonstrated a significant appearance delay (P<0.05) and faster washout (P<0.02) of contrast dye in group A patients with respect to group B. CONCLUSIONS: These data suggest a decrease of residual synovial inflammation and a beneficial clinical effect of spa therapy in psoriatic arthritis patients treated with TNF inhibitors.

07-4One-year effectiveness of mud-bath therapy in knee osteoarthritis / 日本温泉気候物理医学会雑誌

<b>Objective: </b>To assess both the short-term and the long-term effectiveness of spa therapy in patients with primary knee osteoarthritis (OA) in a prospective, randomized, single blind, controlled trial.<BR><b>Materials and Methods:</b> 103 outpatients with OA of the knee according to the ACR criteria (1) were enrolled. Patients were randomized 1 : 1 and allocated into two groups: 53 patients (Group A) received in addition to usual treatment (exercise, NSAIDs and/or analgesics, established SYSADOAs) a combination of daily local mud-packs applied on both knees for 20 min at an initial temperature of 45°C and bicarbonate-sulphate-calcic mineral bath water at 38°C for 15 min, from the spa centre of Chianciano Terme (Siena, Italy) for 12 applications carried out over a period of 2 weeks. 50 patients (Group B, controls) continued routine ambulatory care. Clinical assessments were performed at basal time after 2 weeks, after 3, 6, 9 and 12 months - end of the study. The primary outcome criteria were the change from baseline to month 12 in WOMAC - Total Pain Score (W-TPS) (range 0-20)* and in WOMAC - Total Physical Function Score (W-TPFS) (range 0-68)* scored by a 5-point Likert scale. A set of secondary outcomes was also assessed such as WOMAC Total Stiffness Score (W-TSS), Physical Component Summary (PCS) and Mental Component Summary (MCS) of SF-12 (ranges 0-100) and consumption of analgesic medications (paracetamol and/or NSAIDs).<BR><b>Results:</b> Ten patients (9.5%) withdrew from the study: 2 in the spa-group and 8 (16%) in the control group. The assessment of pain showed a very significant improvement (p<0.001) in patients treated with mud-packs until 6 months and a less significant reduction (p<0.05) after 9 and 12 months. The control group showed a significant improvement after 2 weeks and 3 months, however this improvement is less expressed than in group A.<BR>  The differences between the two groups were significant already from 2 weeks and lasted during the follow-up.<BR>  A similar trend was observed for the WOMAC - Physical Function in the group A, group B showed a significant worsening after 6 months persisting throughout the follow-up.<BR>  The results obtained from the quality of life, SF-12 survey showed a significant improvement (p<0.001) in Physical Component, persisting throughout the follow-up period in group A. No significant modifications were found in group B during the study period.<BR>  On the contrary, significant improvement of the Mental Component Summary of SF-12 was shown at the end of the therapy in group A, but no significant differences were observed in the other time of the follow-up.<BR>  These effect on pain and function were also confirmed by the observed reduction of symptomatic drugs consumption. Tolerability of spa therapy seemed to be good, with light and transitory side effects.<BR><b>Conclusions:</b> In conclusion our results, in keeping with other studies (2, 3) confirm that the beneficial effects of mud-bath therapy in patients with knee OA last over time, with significant reduction on the painful symptomatology and a significant improvement on functional capacities and on quality of life. Spa therapy can represent a useful backup to pharmacological treatment of knee OA or a valid alternative for patients who do not tolerate pharmacological treatments.

07-4 One-year effectiveness of mud-bath therapy in knee osteoarthritis / 日本温泉気候物理医学会雑誌

Objective: To assess both the short-term and the long-term effectiveness of spa therapy in patients with primary knee osteoarthritis (OA) in a prospective, randomized, single blind, controlled trial. Materials and Methods: 103 outpatients with OA of the knee according to the ACR criteria (1) were enrolled. Patients were randomized 1 : 1 and allocated into two groups: 53 patients (Group A) received in addition to usual treatment (exercise, NSAIDs and/or analgesics, established SYSADOAs) a combination of daily local mud-packs applied on both knees for 20 min at an initial temperature of 45°C and bicarbonate-sulphate-calcic mineral bath water at 38°C for 15 min, from the spa centre of Chianciano Terme (Siena, Italy) for 12 applications carried out over a period of 2 weeks. 50 patients (Group B, controls) continued routine ambulatory care. Clinical assessments were performed at basal time after 2 weeks, after 3, 6, 9 and 12 months - end of the study. The primary outcome criteria were the change from baseline to month 12 in WOMAC - Total Pain Score (W-TPS) (range 0-20)* and in WOMAC - Total Physical Function Score (W-TPFS) (range 0-68)* scored by a 5-point Likert scale. A set of secondary outcomes was also assessed such as WOMAC Total Stiffness Score (W-TSS), Physical Component Summary (PCS) and Mental Component Summary (MCS) of SF-12 (ranges 0-100) and consumption of analgesic medications (paracetamol and/or NSAIDs). Results: Ten patients (9.5%) withdrew from the study: 2 in the spa-group and 8 (16%) in the control group. The assessment of pain showed a very significant improvement (p<0.001) in patients treated with mud-packs until 6 months and a less significant reduction (p<0.05) after 9 and 12 months. The control group showed a significant improvement after 2 weeks and 3 months, however this improvement is less expressed than in group A.   The differences between the two groups were significant already from 2 weeks and lasted during the follow-up.   A similar trend was observed for the WOMAC - Physical Function in the group A, group B showed a significant worsening after 6 months persisting throughout the follow-up.   The results obtained from the quality of life, SF-12 survey showed a significant improvement (p<0.001) in Physical Component, persisting throughout the follow-up period in group A. No significant modifications were found in group B during the study period.   On the contrary, significant improvement of the Mental Component Summary of SF-12 was shown at the end of the therapy in group A, but no significant differences were observed in the other time of the follow-up.   These effect on pain and function were also confirmed by the observed reduction of symptomatic drugs consumption. Tolerability of spa therapy seemed to be good, with light and transitory side effects. Conclusions: In conclusion our results, in keeping with other studies (2, 3) confirm that the beneficial effects of mud-bath therapy in patients with knee OA last over time, with significant reduction on the painful symptomatology and a significant improvement on functional capacities and on quality of life. Spa therapy can represent a useful backup to pharmacological treatment of knee OA or a valid alternative for patients who do not tolerate pharmacological treatments.