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Evaluation of the overall effect of the spa treatment in patients with clinically
symptomatic osteoarthritis of weight-carrying joints
Rybár, I., Zimanová, T., Vajcík, J., Vlčková, V., Jurča, J.
Research Institute of Rheumatic Diseases, Piešťany
Director: prof. MUDr. Jozef Rovenský, DrSc.
Health Spa Piešťany
Director General: Ing. I. Drábek
Objective:
Assessment of the effects of the complex spa treatment in patients of the Health Spa
Piešťany, as, suffering from osteoarthritis of the weight-carrying joints (knee and hip
joints).
Solution:
Examination of patients of the spa houses Balnea Splendid and Balnea Grand in 2000
with the clinically symptomatic form of gonarthrosis or coxarthrosis.
Indications for enrollment in the study:
Consecutive patients of the spa houses Balnea Splendid and Balnea Grand,
Diagnosis of gonarthrosis or coxarthrosis according to Kellgren and Lawrence,
1963,
Presence of clinical symptoms – pain, stiffness, movement restrictions.
Exclusion criteria:
Absence of clinical symptoms.
The need for daily application of anti-flammatory and/or chondroprotective drugs
Instillation of glucocorticoids one month before the spa treatment or during the
spa treatment.
During the monitoring, the evaluation focused on pain, stiffness and physical activity.
Methods usually used for verifying the effects of pharmacotherapy for osteoarthritis,
were used also during this assessment. All parameters were evaluated before the complex
spa treatment and after it. The complex spa treatment consisted of individual
balneorehabilitation program including hyperthermic thermal bath, mud wraps, massages,
electrotherapy and rehabilitation with individual isometric exercises and exercises in tow.
Pain was assessed by the visual analogue scales (VAS).
The overall condition of the patient was assessed by the patient himself/herself, as well as
by his/her physician before and after the spa treatment with a five-level verbal scale.
Pain, stiffness and movement activities were assessed using a standardized questionnaire
of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
which consisted of 3 parts: Part A had 5 questions for assessment of the pain intensity,
Part B had 2 questions for assessment of stiffness and Part C had 17 questions on the
study of the joint mobility. Each question was answered using the five-level verbal scale.
In the WOMAC questionnaire, pain, stiffness and joint mobility were assessed
individually and at the same time, the condition of the patient was expressed by total
scores calculated by counting individual items.
Statistical processing was done for the VAS pain by the help of the pair t – test and for
the assessment of the patient’s condition by the patient himself/herself, by the physician
and the WOMAC questionnaire assessment was done by the nonparametric paired
Wilcoxon test.
Results:
In 2000, 53 patients fulfilling the above mentioned criteria were examined. The group
consisted of 14 men and 39 women. The average age of the examined patients was
53.19±10.41 years, from 22 to 73 years and median of 55 years. The average duration of
the spa treatment was 20.57±2.20 days, from 11 to 25 days and median of 21 days. There
were no changes in the duration of the stay between men and women, duration of the stay
in both genders reached the median of 21 days. Distribution of patients according to the
duration of the spa treatment is shown in Table 1. Most of the patients - 47 - had
coxarthrosis, gonarthrosis was confirmed in 6 patients. In the group of 53 patients with
osteoarthritis of the weight-carrying joints the radiological stage II was confirmed in 13
patients, the stage II in 40 patients.
Pain intensity of the weight-carrying joints assessed by VAS decreased from the initial
average value of 63.25±16.33 before the treatment to the value of 32.45±17.85 after the
treatment, what statistically meant a significant decrease (t=13.89, p= 0.000) (Table 2)
(Diagram 1).
The assessment of the overall condition of the joint disease by the patients confirmed
improvement in the vast majority of the observed patients, representing a change in the
median values from 3 to 2, and the above mentioned change was statistically significant
(Table 3) (Z=5.72, p=<0.001). A similar positive shift in achieving the statistically
significant change (Z=5.97, p=<0.001) was recorded also in assessment of the overall
condition of the joint disease by the physician (Table 4).
The average value of the joint pain assessed by the WOMAC questionnaire has
significantly decreased after the balneorehabilitation from 14.17±3.07 to 10.26±2.83,
Z=6.19, p<0.001 (Table 5), (Diagram 2) and stiffness assessed by the same questionnaire
has decreased from 5.38±1.51 to 3.83±1.22 reaching again a statistical significance
Z=5.55, p<0.001 (Table 6), (Diagram 3). Joint activity of patients with osteoarthritis of
hip and knee joints has significantly improved during their stay in spa from the value of
47.2±10.25 to 35.04±9.69, Z=6.16, p<0.001 (Table 7) (Diagram 4). Accordingly, the
overall WOMAC questionnaire score has improved, characterised by a statistically
significant decrease of the value from 66.62±14.11 to 49.23±13.40, Z=6.21, p<0.001
(Table 8) (Diagram 5).
Discussion
Treatment of osteoarthritis includes pharmacological and non-pharmacological therapy.
In the pharmacological therapy are used analgesics, nonsteroid anti-flammatory drugs,
intraarticularly administered drugs as glucocorticoids and hyaluronic acid and orally
administered chondroprotectives, mainly chondroitin sulfate, glycosamine sulfate and
diacylrhein. Their use and combination depends upon the actual clinical condition of the
patient. Development of new drugs based on advanced technologies is associated with a
sharp increase in treatment costs. Therefore, the medical research currently focuses on the
verification of non-pharmacological therapies, which at some period in the life of the
affected person can replace pharmacotherapy or can be combined with drugs and so lead
to a reduction in their consumption.
One of the non-pharmacological ways of osteoarthritis treatment is the spa treatment. For
the Health Spa Piešťany is osteoarthritis one of the main therapeutical indications and
Spa Piešťany have in it a dominant position not only in Slovakia, but also in the whole
Central Europe. The permanently increasing level of medicine with increasing demands
for assessing the advanced therapeutical procedures force the spa treatment to undergo a
new assessment of activities also in such classical indications as osteoarthritis is.
Our objective is to verify the effects of the complex spa treatment in patients suffering
from osteoarthritis of the weight-carrying joints. We used for its assessment a
methodology usually used in clinical trials of new drugs, mainly analgesics and non-
steroid anti-flammatory drugs for this disease.
Changes in intensity of joint pain were assessed by the visual analogue scale. The effect
of the spa treatment was evaluated by assessment of the overall status of the joint disease
by the patient himself/herself as well as by the physician using the 5-level verbal scale.
For assessment of the joint activity we choose the standardized questionnaire of the
Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC). The above
mentioned methodology is recommended to be used for clinical trials verifying the
effectiveness of new drugs for osteoarthritis (1). The WOMAC questionnaire was
developed specifically for assessment of osteoarthritis of lower extremities joints. The
questionnaire consists of three parts assessing pain, stiffness and joint activity, and the
sum of the above mentioned parts could be expressed in the form of the total score. When
compared to the Lequesnev algo-functional index, WOMAC has a higher explanatory
value in the osteoarthritis of lower extremities (2). Its individual items are internally
consistent and correlate with the radiological level of osteoarthritis and also with the
range of motion.
Our results show, that a complex spa treatment with an average duration of stay of 21
days lead in patients with osteoarthritis of hip and knee joints to a proven pain and
stiffness relief and improvement of the overall condition also of the joint activity. It
affected most the perception of the joint pain, when the improvement assessed by VAS
was up to 49 % (Table 9). Using the 5-level verbal scales in assessment of other
monitored parameters, a different level of improvement was recorded – between 25-29%.
The degree of objectivity of assessment reflects consistency between the assessment of
the disease by the patient himself/herself and the physician (Tables 3, 4 and 9).
It can be concluded, that the used assessment methodology of the pharmacotherapy in
osteoarthritis was applied also in assessment of the non-pharmacological treatment.
Among the obtained results, the attention was taken by the significant analgesic effect of
the spa treatment. This result requires a longer study. Therefore it seems to be necessary
to continue in monitoring changes of the neuroendocrine parameters during the spa
treatment and the research to extend further on determination of endogenous opioids. At
the same time, continuation of the research under the conditions of rigorous design in a
form of randomized and controlled studies could help to choose more efficient ways,
combinations and determination of an optimal duration of spa balneorehabilitation in
osteoarthritis.
Conclusion:
A complex spa treatment in the Health Spa Piešťany in patients with osteoarthritis of the
hip and knee joints lead to a statistically significant decrease of the joint pain intensity, to
alleviation of stiffness and improvement of the overall conditions and activity of the
affected joints.
Evaluation of the overall effect of the spa treatment in patients with clinically
symptomatic osteoarthritis of weight-carrying joints
Rybár, I., Zimanová, T., Vajcík, J., Vlčková, V., Jurča, J.
Research Institute of Rheumatic Diseases, Piešťany
Director: prof. MUDr. Jozef Rovenský, DrSc.
Health Spa Piešťany
Director General: Ing. I. Drábek
Summary
The open clinical study in 53 ill people with clinical symptomatic osteoarthritis of hip
and knee joints in the II and III stages (according to Kellgren and Lawrence, 1963) has
confirmed, after a complex spa treatment in the Health Spa Piešťany with and average
duration of stay of 21 days, a statistically significant decrease of the pain intensity
(according to VAS: 63.25±16.33 versus 32.45±17.85, t=13.89, p=0.000, according to
WOMAC: 14.17±3.07 versus 10.26±2.83, Z=6.19, p<0.001), alleviation of stiffness
(5.38±1,51 versus 3.83±1.22, Z=5.55, p<0.001 according to WOMAC), improvement of
the joint activity (47.02±10.25 to 35.04±9.49, Z=6.16, p<0.001 according to WOMAC)
as well as improvement of the WOMAC total scores (66.62±14.11 to 49.23±13.40,
Z=6.21, p<0.001).
Key words: osteoarthritis, pain, WOMAC, spa treatment
Literature:
1. Bellamy, N.: Design of clinical trials for evaluation of DMOADs and of new
agent for symptomatic treatment of osteoarthritis. In: Osteoarthritis, Eds. Brands,
K.D., Doherty, M., Lohmander, L.S., Oxford University Press, Oxford, 1998, 598
p.
2. Theiler, R., Sangha, O., Schaeren, S., Michel, B.A., Tyndall, A., Dick, W., Stucki,
G.: Superior responsiveness of the pain and function sections of the Western
Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as compared
to the Lequesne-Algofunctional Index in patients with osteoarthritis of the lower
extremities. Osteoarthritis cartilage, 7, 1999, 515-510
3. Stucki, G., Sangha, O., Stucki, S., Michel, B.A., Tyndall, A., Dick, W., Theiler,
R.: Comparison of the WOMAC (Western Ontario and McMaster Universities)
osteoarthritis index with knee and hip osteoarthritis. Osteoarthritis Cartilage, 6,
1998, 79-86.
Annexes: Tables
Table 1
Duration of Spa therapy
Duration of stay in days Number of patients
11 1
12 1
17 1
18 3
19 1
20 1
21 39
22 3
23 1
24 1
25 1
Table 2
Effect of complex spa treatment on the joint pain assessed by the visual analogue scale
(VAS)
VAS before the treatment VAS after the treatment
Number of examined 53 53
Average 63.25 32.45
Standard deviation 16.33 17.85
Binary t – test, t = 13.89 p = 0.000
Table 3
Effect of the complex spa treatment according to the overall status of the joint disease
Overall assessment of
status by the patient before
the treatment
Overall assessment of
status by the patient after
the treatment
Number of examined 53 53
Average 3.26 2.21
Standard deviation 0.56 0.49
Min - max 2 - 5 1 - 4
Median 3 2
Wilcoxon test Z=5.72 p< 0.001
Table 4
Effect of the complex spa treatment according to the assessment of the overall status by
the doctor
Assessment of the overall
status by the doctor before
the treatment
Assessment of the overall
status by the doctor after
the treatment
Number of examined 53 53
Average 3.30 2.11
Standard deviation 0.61 0.51
Min - max 2 - 5 1 - 3
Median 3 2
Wilcoxon test Z=5.97 p< 0.001
Table 5
Effect of the complex spa treatment on the joint pain assessed by the WOMAC
questionnaire
Pain intensity before the
treatment
Pain intensity after the
treatment
Number of examined 53 53
Average 14.17 10.26
Standard deviation 3.07 2.83
Min - max 7 - 19 5 - 17
median 14 10
Wilcoxon test Z=6.19 p< 0.001
Table 6
Balneorehabilitation effect on the joint stiffness assessed by the WOMAC questionnaire
Stiffness before the
treatment
Stiffness after the treatment
Number of examined 53 53
Average 5.38 3.83
Standard deviation 1.51 1.22
Min - max 2 - 9 2 - 7
Median 5 4
Wilcoxon test Z=5.55 p< 0.001
Table 7
Balneorehabilitation effect on the joint mobility assessed by the WOMAC questionnaire
Joint activity before the
treatment
Joint activity after the
treatment
Number of examined 53 53
Average 47.02 35.04
Standard deviation 10.25 9,69
Min - max 23-67 18-56
Median 47 35
Wilcoxon test Z=6.16 p< 0.001
Table 8
Balneorehabilitation effect in patients with osteoarthritis of weight-carrying joints
assessed by the total scores of the WOMAC questionnaire
Total scores before the
treatment
Total scores after the
treatment
Number of examined 53 53
Average 66.62 49.23
Standard deviation 14.11 13.49
Min - max 34-95 26-85
Median 66 48
Wilcoxon test Z=6.21 p< 0.001
Table 9
Changes in monitored parameters during the spa balneorehabilitation
Monitored parameters Improvement
Pain (VAS) 49%
Assessment by the patient (five-point scale) 20%
Assessment by the physician (five-point scale) 20%
Pain (WOMAC) 29%
Stiffness (WOMAC) 29%
Joint mobility (WOMAC) 25%
Total scores (WOMAC) 26%
Health Spa Piešťany
Balneorehabilitation effect on joint pain
VAS pain
VAS after
the treatment
VAS – before
the treatment
Health Spa Piešťany
Balneorehabilitation effect on joint pain
before the
treatment
after the
treatment
WOMAC pain
Health Spa Piešťany
Balneorehabilitation effect on joint stiffness
before the
treatment
after the
treatment
WOMAC stiffness
Health Spa Piešťany
Balneorehabilitation effect on joint pain, joint
stiffness and joint mobility
before the
treatment
after the treatment
WOMAC total
score
Health Spa Piešťany
Balneorehabilitation effect on joint mobility
before the
treatment
after the treatment
WOMAC joint
functions
