Aktuelle Aspekte der Kurortmedizin
Aktuelle Aspekte der Kurortmedizin
Aktuelle Aspekte der Kurortmedizin
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OUTCOME-RESEARCH in Thermalism<br />
Nuevos retos en medicina<br />
The New Challenge of Medicine<br />
Helmut G. Pratzel, MD, PhD<br />
President of the International Society of Medical Hydrology and Climatology<br />
(I.S.M.H.)
Situación n y competencia térapéutica<br />
• Sano<br />
• Agotado<br />
• Enfermedades crónicas<br />
• Enfermedades agudas<br />
• Caso de emergencia<br />
Médico de familia<br />
Vacaciones<br />
de salud<br />
en<br />
spa<br />
Hospital<br />
en spa<br />
Tratamiento
Criterios de excelencia de las curas hydrotermales<br />
y de los lugares del termalismo dentro de las<br />
grandes opciones terapeuticas<br />
Spas and Health Resorts Rank within<br />
Health Care Systems Criteria of<br />
Efficient Treatments
¿Equivalencia de resultados clínicos?<br />
Long time experience<br />
by many patients<br />
Controlled trials<br />
by few patients
Clinical Trial Protocol<br />
by the Guidelines for Good Clinical Practice (GCP) of<br />
the European Community<br />
• Trial objectives and purpose<br />
• Trial design<br />
• Randomisation, Blinding<br />
• Selection and withdrawal of<br />
subjects<br />
• inclusion and exclusion<br />
criteria<br />
• Treatment of subjects and control<br />
medication<br />
• Assessment of efficacy<br />
• Assessment of safety<br />
• Control of side effects and<br />
interactions<br />
• Control of Compliance<br />
• Statistics<br />
• Direct Access to Source<br />
Data/Documents<br />
• Quality control and Quality<br />
Assurance Procedures<br />
• Ethics
Primary Efficacy Variable<br />
• Only validated parameters should be used.<br />
• Only one efficacy parameter is to defined.<br />
• Endpoints used to determine efficacy should<br />
be clearly specified.<br />
• Multiple parameters should be assembled to<br />
one score parameter.<br />
• An efficacy threshold is to defined.
Los métodos m<br />
siguentes están<br />
permitidos<br />
• Comparación clinica<br />
• Comparación de los gastos antes y despues<br />
del tratamiento<br />
• Comparación del tiempo sin trabajo
Tiempo sin trabajo<br />
Controlled trial in Bad Wörishofen W<br />
1991-1994<br />
1994<br />
Non-working days<br />
5,53<br />
Out-patient<br />
In-patient Treatment<br />
6<br />
4,24<br />
5<br />
4<br />
3,55<br />
2,4<br />
2,58<br />
3,41<br />
n=115 n=115<br />
3<br />
2<br />
1<br />
1,92<br />
1,67<br />
1,26<br />
1,15<br />
1,53<br />
1,91<br />
n=248 n=248<br />
0<br />
Initial End 3 months later 6 months later 9 months later 12 months later<br />
Pelka et al. 1995
Controlled Double-Blind<br />
Trials<br />
• Placebo-controlled trials in spa treatment are<br />
not required and are ethically suspicious.<br />
• Comparison of different treatments or different<br />
dosage without changing the normal basic<br />
complex strategy could be realised.<br />
• Trials with mono therapies have no relevance to<br />
balneotherapeutic practise
Double-blind<br />
blind-control equipment<br />
Electronic<br />
control with<br />
bar-co<strong>der</strong>ea<strong>der</strong><br />
Tap-water line<br />
Magnetic<br />
valves<br />
Bar-co<strong>der</strong>ea<strong>der</strong><br />
Radon-water line<br />
Bath -tub<br />
Technical room<br />
Bathroom
The Barcode-Rea<strong>der</strong>
Tres grados de la investigación n son<br />
importantes<br />
• Efecto del tratamiento médico durante la cura<br />
• Resultados médicos y socio-médicos a largo<br />
plazo<br />
• Diferencia entre los gastos y el efecto
Measurement of pressure pain threshold<br />
Pressure Areas<br />
1. M. levator scapulae<br />
2. M. supraspinatus<br />
3. M. teres minor<br />
4. M. deltoideus<br />
5. M. glutaeus maximus<br />
6. M. glutaeus medius<br />
7. M. bizeps femoris<br />
8. M. semimembranosus
Pressure pain threshold<br />
by Sulphur bath series<br />
kg/cm 2<br />
1,8<br />
2,1<br />
2,4<br />
2,7<br />
1 week later<br />
2 weeks later<br />
Sulphur Water<br />
Tap Water<br />
3,0<br />
3 weeks later<br />
3,3<br />
Period of inspection
Pressure pain threshold<br />
by Radon baths series<br />
kg/cm 2 After 1 week<br />
3,0<br />
End of Treatment<br />
2,8<br />
2,6<br />
2,4<br />
2,2<br />
2,0<br />
Ende <strong>der</strong> Behandlung<br />
After 2 weeks<br />
After 3 weeks<br />
After 2 month<br />
Period of inspection<br />
After 4 month<br />
RADON WATER<br />
TAP WATER
Subjective pain feeling<br />
Rheumatoide Arthritis (Radon trial Bad Brambach 1997)<br />
mm VAS<br />
1st value<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
-5<br />
-10<br />
-15<br />
-20<br />
-25<br />
Differences to 1st value<br />
and 95%-Confidence interval<br />
N = 30 N = 30/27<br />
end of<br />
treatment<br />
N = 28/30<br />
3 month later 6 month later<br />
CO 2<br />
Radon+ CO 2<br />
Improvement
Moving test by Keitel<br />
• To bend the fingers<br />
• Motility of hand joins and<br />
arms<br />
• Stand up from lying<br />
• Active straddle of legs from<br />
lying<br />
• Stand up from a stool<br />
• Standing on toes and heel<br />
• Knee-crooking<br />
• Standing on one foot<br />
• Outside Rotation of the hit join<br />
• Mobility of legs and feet<br />
• Walking<br />
• Climbing stairs
Moving Test by Keitel<br />
Rheumatoide Arthritis (Radon trial Bad Brambach<br />
1997)<br />
Skt<br />
Differenzen zum Ausgangswert<br />
und 95%-Konfidenzintervall<br />
1st value<br />
8<br />
6<br />
4<br />
2<br />
0<br />
-2<br />
-4<br />
-6<br />
-8<br />
N = 30 N = 28/30 N = 30/29<br />
end of<br />
treatment<br />
3 month later 6 month later<br />
Radon+CO 2<br />
CO 2<br />
Improvement
Measurement of Patient Outcome - MOPO<br />
Physical handicap and psychosocial Consequences by Rheumatoid Arthritis<br />
Assessment included:<br />
• Mobility<br />
• Physical activity<br />
• Skill<br />
• Activities at home<br />
• Activities in daily life<br />
• Social activities<br />
• Pain<br />
• Depression<br />
• Anxiety
(MOPO)<br />
Measurement of Patient Outcome (MOPO)<br />
Rheumatoide Arthritis (Radon trial Bad Brambach 1997)<br />
Differenzen zum Ausgangswert<br />
und 95%-Konfidenzintervall<br />
1st value<br />
Skt<br />
0,8<br />
0,6<br />
0,4<br />
0,2<br />
0<br />
-0,2<br />
-0,4<br />
-0,6<br />
-0,8<br />
N = 29/30 N = 29/30<br />
3 month later 6 month later<br />
Radon+CO 2<br />
CO 2<br />
Improvement
Structural Assessments<br />
Musculoskeletal<br />
• upper extremity<br />
• lower extremity<br />
• Back<br />
• more Regions<br />
DASH<br />
WOMAC<br />
NASS<br />
HAQ<br />
Sangha O et.al. Rheumatol 56:322-333, 1997
Disease Assessments<br />
• Rheumatoide A.<br />
• Bechterew<br />
• Narrow spinal channel<br />
• Osteoarthrosis<br />
HAQ<br />
BASFI<br />
LSS-Inst.<br />
WOMAC<br />
German translation by Sangha O et.al. Rheumatol 56:322-333, 1997
BASFI für f r Morbus Bechterew<br />
(Ankylosing Spondylitis)<br />
• Ohne Hilfe und Hilfsmittel Socken und Strümpfe anziehen<br />
• Ohne Hilfe von <strong>der</strong> Hüfte aus nach vorn beugen um einen<br />
Kugelschreiber vom Boden aufzuheben<br />
• Ohne Hilfe etwas von einem Regal nehmen<br />
• Von einem Wohnzimmerstuhl ohne Armlehne aufstehen ohne<br />
dabei die Hände o<strong>der</strong> eine an<strong>der</strong>e Hilfe zu benutzen<br />
• Ohne Hilfe vom Boden aufstehen, wenn Sie auf dem Rücken<br />
liegen<br />
German translation by Sangha O et.al. Rheumatol 56:322-333, 1997
BASFI für f r Morbus Bechterew<br />
(Ankylosing Spondylitis)<br />
• Ohne Schmerzen 10 Minuten stehen ohne sich anzulehnen<br />
• Ohne Benutzung eines Gelän<strong>der</strong>s o<strong>der</strong> Gehhilfen 12-15<br />
Treppenstufen steigen. 1 Fuß pro Stufe<br />
• Über die Schulter schauen ohne dabei den Körper abzudrehen.<br />
• Körperlich anstrengende Tätigkeiten verrichten (z.B.<br />
krankengymnastische Übungen, Gartenarbeit o<strong>der</strong> Sport)<br />
• Zu Hause o<strong>der</strong> bei <strong>der</strong> Arbeit den ganzen Tag aktiv sein.<br />
German translation by Sangha O et.al. Rheumatol 56:322-333, 1997
BASFI für f r Morbus Bechterew<br />
(Bath Ankylosing Spondylitis Functional Index)<br />
Easy<br />
Unimportant<br />
Each question 11 positions !<br />
Ruof J et al, Z. Rheumatol 58:218-225 (1999)
Mineral water for bathing<br />
• Chemical quality can be used only in bath tubs<br />
– Without any disinfections of water<br />
– With minimal concentrations of following substances<br />
• H 2 S > 10 mg/l<br />
• Radon > 1 kBq/l<br />
• CO 2 > 1 g/l<br />
• Brine 10-150 g/l (Dermatitis low – Psoriasis high)<br />
• In pools only physical quality can be used<br />
– With disinfections (chlorine)<br />
– Temperature must be more than 30 °C
Indications<br />
• Sulphured water in bath tubs in rheumatology<br />
• Radon water in bath tubs and Radon-gas-baths or Radon-mines<br />
• CO 2 water in bath tubs and CO 2 -gas-baths<br />
• Brine water in bath tubs<br />
• Brine water in pools for kinesitherapy<br />
• Thermo-neutral baths (35 °C)<br />
• Cold baths (39 °C)
Indications<br />
Sulphured-Water in bath tubs in Rheumatology<br />
• Degenerative joint disease<br />
• Extra-articular rheumatism<br />
• Chronic articular rheumatism<br />
• Posttraumatic lesions<br />
• Postoperative therapies
Indications<br />
Radon-Water in bath tubs and Radon-Gas<br />
Gas-baths or<br />
Radon-mines<br />
• Ankylosing spondylitis<br />
• Degenerative joint disease<br />
• Spondylarthrosis<br />
• Myofascial soft tissue syndrome<br />
• Ovarian hypofunction<br />
• Allergic bronchial Asthma
Indications<br />
CO 2 -Water in bath tubs and CO 2 -Gas-baths<br />
• Disor<strong>der</strong> of microcirculation of the skin<br />
• Trophic ulcera of the skin, venous ulcera<br />
• Decubitus<br />
• Peripheral arterial occlusive disease in any stage<br />
• Functional disor<strong>der</strong> of vascularity<br />
• Polyneuropathy (Malum perforans)<br />
• Cerebral disor<strong>der</strong>s of microcirculation<br />
• Arterial hypertension<br />
• Algodystrophy (M. Sudeck)
Indications<br />
Brine-Water in bath tubs<br />
• Psoriasis vulgaris<br />
+ UV-B-irradiation<br />
• Neuro<strong>der</strong>mitis<br />
+ UV-A-irradiation
Indications<br />
Brine-Water in pools for kinesitherapy<br />
• Degenerative joint disease<br />
• Spondylarthrosis<br />
• Osteoporosis<br />
• Posttraumatic and postoperative<br />
state
Bath effects<br />
Indications thermoneutral baths (35 °C)<br />
• Relaxation of muscles and exoneration of joints<br />
– Rheumatic Diseases<br />
• Relaxation effect by sympathicolysis, suppression of<br />
stress hormones and muscle relaxation<br />
– Psycho-vegetative syndrome<br />
– Psycho-physical overloading<br />
– Convalescence
Bath effects<br />
Indications thermoneutral baths (35 °C)<br />
• Dehydration by increase of capillary reabsorption<br />
and diuresis<br />
– Rheumatic diseases<br />
– Posttraumatic und postoperative state<br />
– Oedema<br />
• Training vegetative-hormonal functions like<br />
blood volume, blood pressure and<br />
electrolyte regulation<br />
– Convalescence<br />
– Disor<strong>der</strong> of heart-circulation-regulation<br />
– Psycho-vegetative syndrome
Bath effects<br />
Indications cold baths (
Bath effects<br />
Indications cold-warm changing baths<br />
• Thermic stimuli for training of vegetativehormonal<br />
functions<br />
– Convalescence<br />
– Psycho-vegetative syndrome<br />
– Disor<strong>der</strong> of heart-circulation-regulation<br />
– Metabolic disor<strong>der</strong>s
Bath effects<br />
Indications hot baths (>39 °C)<br />
• Muscle relaxation<br />
• Increase of distensibility of connective tissue<br />
structures<br />
• Analgesic<br />
• Antiphlogistic by hyperthermia<br />
– Rheumatic diseases<br />
– Chronic-inflammatory diseases of the urogenital<br />
system<br />
– Posttraumatic und postoperative state
Risks of bathing<br />
• By immerse:<br />
increased cardiac preload result in a decompensation risk<br />
Precaution by disor<strong>der</strong>s of heart rhythm and Angina pectoris<br />
• By get out:<br />
Collapse risk<br />
Precaution by venous diseases and<br />
orthostatic irregularity<br />
• During bathing:<br />
Loading of respiratory and lung function<br />
Precaution by respiratory insufficiency
Controles de calidad (DIN ISO 9001ff)<br />
de la prescripción<br />
de los remedios<br />
naturales usados<br />
de la ejecución de los<br />
métodos terapéuticos<br />
de los resultados<br />
terapéuticos
Quality of Health Resort Medicine<br />
• Quality control of<br />
•Mineral waters<br />
•Air and climate<br />
•Treatment strategies<br />
• Quality assurance by<br />
•Technical systems<br />
•Protection of resources<br />
•Definition of performance standards
Conclusión<br />
• Pacientes con enfermedades crónicas<br />
dependen de los ofrecimientos de las<br />
estaciones balnearias<br />
• En Europa no conocemos métodos mejores<br />
para esos pacientes
International Congress on<br />
Natural Spa Therapy of the<br />
I.S.M.H.<br />
Dead Sea Israel<br />
21-24 November, 2001<br />
Contact: dorit@ofakim.co.il
34th WORLD CONGRESS of the<br />
I.S.M.H.<br />
Budapest-Heviz (Hungary)<br />
14-19 October, 2002<br />
Contact: http://www.ismh2002.hu<br />
Videofilm during this Congress !
News of the I.S.M.H.<br />
http://www.med.uni-muenchen.de/ismh
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