Termas de Cuntis May 4-7, 2012

Thermal medicine in elderly patients

Fabio Monzani
Geriatrics Section, Department of Internal Medicine, University of Pisa

The Aging World

Green and its nuances: > 70 aa Ocher: 50-69 aa Red and its nuances: < 50 aa Brown: < 35 aa

Data updated to 2006

European aging

Map of Europe showing the percentage of the population over 65 in 2010 for each country
Data from the CIA World Factbook

Chronic (degenerative) diseases

Risk factors Effect

Increased risk

Cardiovascular diseases Respiratory diseases Tumors Dementia Parkinson disease Osteoarthritis

Slow onset (years) Slow progression (years/decades) Progressive deterioration

Subjects older than 60 years affected by chronic diseases in UK from 1996 to 2066

Prevalence of chronic disease in elderly population in Italy (Studio ILSA)

65-69

70-74

75-79

80-84

Total

Angina Pectoris
Myocardical infarction Arrhythmia Systemic hypertension

6,1
5,9 18,4 60,0

8,3
8,7 22,1 67,4

8,0
8,2 26,5 66,6

7,6
7,4 26,7 64,7

7,3
7,3 22,4 64,0

Heart failure

3,7

6,5

7,7

11,8

6,5

Age Diabetes represent

- Type I - Type II

the most important14,1 factor for risk 11,9 13,2 11,7 15,5 the developing of osteoarthritis 0,3 0,3 0,3 0,2 0,3
10,9 15,1 13,4 11,4 12,6

Osteoarthritis
COPD Peripheral vascular disease

61,7
19,1 4,8

59,8
19,9 7,0

61,1
24,0 7,9

60,2
22,5 8,7

60,9
20,9 6,5

The impact of Musculoskeletal diseases on the new millennium

"There are effective ways to prevent and treat these disabling disorders, but we must act now. Joint diseases, back complaints, osteoporosis and arthropathies have an enormous impact on individuals and societies, and on healthcare services and economies."
Kofi Annan, UN Secretary General 1999

OA epidemiology
Muscoloskeletal diseases are the major cause of severe pain
and long-term disability1

About 1/4 european subject is affected by some kind of

arthropathies; 1/5 assumes chronic therapy 1,2 most important cause of disability1 about 11 billions/year.

OA is the most common joint disease in elderly and it is the

The cost of OA for healthcare services and economies is

1. European Bone and Joint Health Strategies Project. European Action Toward Better Musculoskeletal Health, 2005. 2. European Opinion Research Group. EEIG. Health, food and alcohol and safety. Special Eurobarometer 186, 2003.s

Arthropathies as the first cause of disability (USA)1,2

About 39 milions of medical examination/year2 > 500.000 hospitalization/year2
Arthropathies Spinal disorders Cardiac diseases Pulmonary diseases Hearing impairment Leg and harm stiffness Mental disorders Diabetes Visual impairment Ictus
0 2 4 6 8 10 Disabilit (%) 12 16 18

1. McNeil JM, Binette J.MMWR. 2001;50:120-125 2. CDC. National Arthritis Action Plan. A Public Health Strategy. 1999.

Therapy
joint supplements : Chondroitin, Glucosamine Nonsteroidal Anti-inflammatory Drugs e COX-1 inhibitor Analgesic drugs: paracetamol, tramadol Physiotherapy Thermal medicine

NSAID adverse events

GI Tract: Ulcers, perforations, bleeding, obstruction strictures, enteropathy Kidney: NSAIDs tend to promote Sodium and water retention and edema. PGs have minimal impact on normal renal blood flow, but become important in the compromised kidney. Patients (particularly elderly and volume depleted) are at risk of renal ischemia with NSAIDs. Liver: NSAID can cause an hepatocellular damage, including an acute liver failure, through a immunological idiosyncrasy. The epidemiological risk of clinically apparent liver injury is low (18 cases per 100000 patient years of NSAID use). Myelopoiesis: platelet Dysfunction. Occasionally, NSAIDs have been associated with myelotoxicity, thereby creating a toxic neutropenia.

Reported adverse events of the most prescribed drugs in elderly in 2008

114 102 100 80 60 40 20 0 27 24 17 15 76 1 7 4 4 21 35 27 15 543 2 1310 14 5 4 12 533 91 101

120

lod ipi na ce lec ox ib di clo fe na c di go ss in a en ala pr il fu ro se m id e ni m es ul ide ni tro gl ice rin a om ep ra zo lo

totale da 61 a 70 da 60 a 80 oltre 80

am

AS A

NSAID and upper gastrointestinal hemorrhage

Prevalence on NSAID use and hospital admission for upper gastrointestinal hemorrhage Risk for hospitalization for upper gastrointestinal hemorrhage among elderly patients using prescribed NSAIDs

The effect of age on the relative risk of upper gastrointestinal hemorrhage

(Hernandez Diaz e Rodriguez, Arch Intern Med, 2000)

Thermal treatments (bath therapy, mud treatments, mud-bath treatments, inhalations and thermal rehabilitation treatments) can be considered as a true and natural answer to prevention, rehabilitation and treatment of serious pathologies.
Moreover, thermal environment can promote a correct life style and balanced diet

Major indications of thermal hydrokinesitherapy

Neurological disease:
Peripheral paralysis (poliomyelitis, neuritis..) Central nervous system disease (paraplegia, hemiplegia..) Myopathy

Traumatology
Fractures Muscle trauma, Tendon injuries

Rheumatology
Degenerative joint disease Inflammatory joint disease (not in acute phase) Back and neck pain Periarteritis Muscle stiffness and hypotonia

Orthopedic disease
Dysmorphism of the developmental age (scoliosis, kyphosis..) Effects of surgical interventions

G.U. n. 57 - 9 marzo 1995

d.m. 15 dicembre 1994

8 GRUPPI DI MALATTIE SENSIBILI ALLA TERAPIA TERMALE

UNIVERSIT DI PISA UNIVERSIT DI PISA

Facolt di Medicina e Chirurgia Scuola di Specializzazione in Idrologia Medica Scuola di Specializzazione in Idrologia Medica

Decreto ministeriale 15 dic 1994

AFFEZIONI ACCREDITABILI S.S.N.

MAL. ARTROREUMOPATICHE
Osteoartrosi e altre forme degener. Reumatismi extra articolari

MAL. ORL
Rinopatia vasomotoria Faringolaringiti croniche Sinusiti croniche Sordit rinogena (ototubarite e otitie catarrale cronica) Otiti croniche purul. non colesteatomatose

MAL. VIE RESPIRATORIE

Sindr. rino-sinuso-bronchiali cron. Broncopneumopatie croniche semplici ostruttive (escluso asma o enfisema avanzato complicato o no da insuff. resp. grave o cuore polmonare cronico)

MAL. APPARATO URINARIO

Urolitiasi e sue recidive

MAL. DERMATOLOGICHE
Psoriasi Eczema e dermatite atopica Dermatite seborroica ricorrente

MAL. GASTROENTERICHE
Dispepsia di origine gastroenterica e biliare Sindrome del colon iirritabile nella variet con stipsi

MAL. VASCOLARI
Postumi di flebopatie di tipo cronico

MAL. GINECOLOGICHE
Sclerosi dolorosa connettivo pelvico Leucorrea persistente da vaginiti Croniche aspecifiche o distrofiche

Balneotherapy in patients with chronic inflammatory musculoskeletal diseases

Balneotherapy in patients with chronic noninflammatory musculoskeletal diseases

osteoarthritis of the knee

chronic low back pain

Gal J et al 2008

Group 1: Balneotherapy (n=25; 36 C, 20 min; 10 sessions) Group 2: Mud-pack therapy (n=25; 42 C, 20 min; 10 sessions) Group 3: Hot-pack therapy (n=25; 42 C, 20 min; 10 sessions) Join Bone Spine 2007

The maximum walking distance was improved in both Group 1 and 2 (p<0.05) but not in group 3. Joint Bone Spine 2007

237 outpatients: 117 patients assigned to BT 120 patients to paroxetine.

Improvement HAM-A scores in BT group 12.0 In paroxetine group 8.7 (p < 0.001).

Dubois O et al. 2010

Balneotherapy in metabolic conditions

Stress hormones liberated by fangotherapy. ACTH and -endorphin levels under heat stress
Giusti P, Cima L, Tinello A, Cozzi F, Targa L, Lazzarin P, Todesco

The repeated brief increases in plasma endorphin during thermal treatment result in progressive improvement in articular and muscular symptomatology. The results of our study on plasma levels of ACTH confirm that the thermal stress associated with mud therapy activates the pituitary gland.

Fortschr Med. 1990

Beta-endorphin and stress hormones in patients affected by osteoarthritis undergoing thermal mud therapy

It may be suggested that thermal

treatment, by reducing inflammation, reduced pain and therefore diminished the cause of stress.

Pizzoferrato et al. Minerva Medica 2000

Is mud an anti-inflammatory?
Giacomino MI, de Michele DF.

Mud modifies NO, myeloperoxidase and glutathione peroxidase serum levels in arthritic patients and endorphin and stress hormones in patients affected by osteoarthritis by reducing inflammation. Thermal stress associated with mud therapy activates the pituitary gland. The biochemical effects of peat components are aside from their physical-thermal effects.

An Med Interna. 2007

Balneotherapy for osteoarthritis.

Verhagen AP Bierma-Zeinstra SM Boers M Cardoso JR Lambeck J de Bie RA de Vet HC

We found silver level evidence concerning the beneficial effects of mineral baths compared to no treatment. However, the scientific evidence is weak because of the poor methodological quality and the absence of an adequate statistical analysis and data presentation. Therefore, the noted "positive findings" should be viewed with caution.

Cochrane Database Syst Rev. 2007

Sauna bath and in general thermal therapies have been traditionally considered inappropriate for patients with congestive heart failure (CHF).

Repeated thermal therapy improves impaired vascular endothelial function in patients with coronary risk factors

Imamura M et al. J Am Coll Cardiol 2001

Repeated sauna treatment improves vascular endothelial and cardiac function in patients with chronic heart failure

20 patients (62 15 yrs) in NYHA functional class II or III CHF were treated in a dry sauna at 60 degrees C for 15 and then kept on bed rest with a blanket for 30, daily for 2 weeks. 10 patients, matched for age, gender and NYHA functional class, served as control group

Kihara T et al M et al. J Am Coll Cardiol 2002

41 patients with chronic heart failure (mean age 68.3 13.5 years old) underwent Waon therapy 5 times a week for 3 weeks.
6-minute walk distance increased from 337120 to 379 126 m, (p <0.001) FMD improves from 3.52.3% to 5.52.7% (p <0.001)

Ohori T et al. Am J Cardiol 2012

In summary
Many evidences documented an improvement of cardiovascular hemodynamics in patients with chronic CHF due to ischemic or idiopathic dilated cardiomyopathy. This is presumably due to a reduction in cardiac preload and afterload by thermal systemic arterial, pulmonary arterial, and venous vasodilation. These data suggest that thermal vasodilation has salutary effects even for patients with severe heart failure and may represent a novel nonpharmacological therapy for patients with CHF. The long-term benefits of these interventions warrant further investigation.

In conclusion, thermal therapy could represent an important step in the therapeutic approach to elderly patients affected by OA. Thermal therapy could not only act on joint disease, reducing pain and disability, but also could improve heart failure and depressive symptoms as well as quality of life. Moreover a decrease of pain could reduce the assumption of anti-inflammatory drugs and their adverse effects

Project of multicenter study

To evaluate the role of crenokinesiterapia and balneotheraphy in reducing pain and improving joint mobility and functional autonomy in patients older than 65 years affected by ostheoarthrosis.
All patients will be submitted to 2 complete thermal treatment of six days length (total 12 days). Biochemical (i.e. CBC, renal function, glycemia, BNP, inflammatory indices) and clinical parameters will be evaluated. Moreover, all patients will be submitted to a complete multifunctional assessment [The Arthritis Impact Measurement Scales (AIMS), Lequesne index, Roland and Morris Disability Questionnaire, Neck Pain Disability Index, Short Form 36 (SF-36), Geriatric Depression Scale (GDS)]. Pain will be assessed by VAS.

All these evaluations will be performed before and after the treatment and also after 3 and 6 months.