Terme, salute e benessere

BALNEOTHERAPY IN THE PREVENTION AND REHABILITATION OF PSORIATIC SPONDYLOARTHRITIS

Dr Franco Furia
Medical director of the Società degli Alberghi e delle Terme di Porretta
Vice-president of the Italian Medical Association of Hydroclimatology, Talassotherapy and Physical Therapy

Prof. Giorgio Miccoli
President of the Technical-Scientific Committee of the Società degli Alberghi e delle Terme di Porretta

INTRODUCTION
Spa therapy is one of the most ancient forms of therapy.
Used as early as pre-historical times, it underwent a considerable development in the Roman period, also becoming a form of recreation.
Many spa centres sprung up in late nineteenth and early twentieth centuries, a period that coincided with numerous studies into the properties of water.
Today, in the third millennium, spa therapy continues to play an important role in the prevention and treatment of many diseases, standing out as the most natural form of treatment and one that is suitable for people of all ages.

Psoriatic arthritis is one of the diseases that can benefit greatly from thermal treatment.

PSORIATIC ARTHRITIS
Psoriatic arthritis (P.A.) is a seronegative inflammatory arthritis that can present either with psoriatic skin lesions and joint involvement, or only with involvement of the peripheral and axial joints.
P.A., in its various forms, is found in 25% (6-39%) of patients affected by psoriasis (who, in turn, account for 1-3% of the global population).
It can thus be calculated that of 1,200,000 people affected by psoriasis in Italy, P.A. affects around 300,000.
In 75% of cases the first manifestation of the disease is psoriasis, which is subsequently complicated by joint disorders.
In 15% of cases the joint disorders precede the appearance of the psoriasis.
In the remaining 10% of cases the two manifestations appear contemporaneously.

William et al. developed the following classification criteria:
 Presence of inflammatory involvement of the peripheral joints, spine, enthesis, associated with at least 3 of the 5 points below:
1. evidence or a history of cutaneous psoriasis, or a family history of psoriasis
2. onychosis, ungueal pitting, hyperkeratosis
3. negative rheumatoid factor
4. evidence of, or a history of, dactylitis
5. radiological abnormalities of the hands and feet

LOCALISATION
The most common clinical pictures are those in which there is joint involvement:
1. In 60-70% of cases this takes the form of asymmetrical oligoarthritis which can affect both large and small joints
2. In 18% of cases it is rheumatoid-like polyarthritis characterised by symmetrical involvement of the joints of the hands and feet
3. In 5-10% of cases it is distal arthritis with involvement of the distal interphalangeal joints of the hands often associated with ungueal lesions
4. In 5-20% of cases it manifests as asymmetrical sacroileitis, often accompanied by facet joint involvement (PSORIATIC SPONDYLOARTHRITIS)
5. In 1-2% of cases it takes the form of mutilating arthritis, due to osteolysis of the phalanges of the hands and feet
(Moll and Wright classification - 1973)

LABORATORY
1) laboratory findings:
 Raised inflammatory markers (especially VES and C-reactive protein)
 Elevated alpha-2 and beta-2 globulins
 Often raised uricemia
 The rheumatoid factor is normally negative, except in rare cases in which an association between P.A. and rheumatoid arthritis (R.A.) must be suspected.
 Tissue typing can be useful but it is not a determining factor. The antigens to look for are B27 (an indicator of predisposition to axial involvement that is, in any case, less strongly associated with P.A. than with ankylosing spondylitis) and other antigens linked more or less closely to psoriasis and P.A.: Cw6, B17, B13 (cutaneous psoriasis), B38 and B39 (P.A.), DR7 (according to some authors present both in psoriasis and in P.A.).
2) synovial fluid analysis is often aspecific and not particularly helpful.

DIAGNOSTIC IMAGING
Radiological differential diagnosis is between P.A. and R.A.

Features typical of P.A. are involvement of the proximal interphalageal joints, asymmetrical involvement of the small joints of the hands and feet, and osteoporosis which is less marked than that seen in R.A., the bone erosions are generally more obvious and centrally located, sometimes with schlerotic borders or with an adjacent bone proliferation.
The radiological images show a tendency towards joint ankylosis.
Additional bone is often present at the level of the entheses, particularly around the pelvis, at the heel (calcaneal spurs) and at the level of the body of the phalanges (“mouse ear” appearance).

At spinal level, the pictures are similar to those of spondylitis associated with reactive arthritis; they also recall those seen in ankylosing spondylitis.

Scintigraphy (especially using labelled IgGs) can indicate, sensitively, the areas of involvement.

Magnetic resonance imaging (MRI) and ultrasonography are useful for highlighting tendinous sheaths and joint effusion.

DIFFERENTIAL DIAGNOSIS
In clinical practice, the differential diagnosis is made:
1. versus R.A., in the case of polyarticular forms,
2. versus interphalangeal osteoarthrosis, in the case of distal forms,
3. versus the other forms of spondyloarthritis (especially Reiter syndrome in which the plantar keratoderma can simulate pustulous psoriasis), in the case of oligoarticular forms
4. versus idiopathic ankylosing spondylitis, in the case of the axial form.

CLASSIFICATION OF THE SPONDYLOPATHIES
The International Statistical Classification of Diseases and Related Health Problems places the spondylopathies under the heading of “dorsopathies” and divides them into five separate groups:
1. ankylosing spondylitis
2. other inflammatory spondylopathies
3. spondylosis
4. other spondylopathies
5. spondylopathies in diseases classified elsewhere

PSORIATIC SPONDYLOARTHRITIS
Axial involvement in psoriatic arthritis is therefore frequent.
Low back pain together with negative serology could suggest a psoriatic origin when:
 the symptoms appeared before 40 years of age
 the onset was insidious
 the pain is accompanied by progressively worsening stiffness
 there is accentuation of the symptomatology after prolonged rest
 and reduction of the symptomatology with physical exercise

The objective examination in these cases includes:
 assessment of rib cage expansion (>5 cm at the level of the IV intercostal space): this parameter may show early reduction.
 Forrester’s arrow sign: the presence of an occiput-wall distance is a consequence both of the dorsal kyphosis and of the reduced extension capacity of the cervical tract
 evaluation of the chin-sternum distance (reduced capacity for flexion and rotation of the cervical spine)
 Evaluation of the pelvis. The presence of at least two of the following must increase the diagnostic suspicion:
1. direct compression of the sacro-iliac joints
2. bilateral compression of the anterior-superior iliac spines
3. compression of the pelvis when the patient is lying on his side
4. maximum flexion of one hip and maximum extension of the contralateral one
5. maximum flexion, abduction, external rotation of the hip, blocking the contralateral hemipelvis

SPA AND PSORIATIC ARTHRITIS
The complexity of and difficulties in diagnosing this condition explain why the specialist in medical hydrology may find himself in some difficulty in the presence of a patient suspected of having psoriatic arthritis.
Too often, patients arrive for thermal treatments without a diagnosis, or with one that is imprecise or incomplete.
In particular, even though many patients come to spa centres to treat psoriasis, and an even larger number to treat osteoarticular problems, it is very rare to come across one presenting with a diagnosis of psoriatic arthritis.
Unfortunately, the time an individual spends at a spa centre is often short, therefore the thermal therapist who suspects this kind of disorder must always act with extreme caution, given that treatment of P.A. must avoid the use of excessively high temperatures like those used in mud therapy.

THERMAL TREATMENTS
Indeed, as in R.A., the use of mud therapy is absolutely contraindicated in P.A. as the high temperature of the mud (49°C in our centre) can cause acute relapses of the disease.
Therefore, for P.A., confirmed or suspected, the thermal treatment of choice is balneotharpy , in a tub or in a pool, at temperatures of between 35° and 38° C.
Balnotherapy in a tub can be associated with hydromassage or hydrobubble massage, both ozonising treatments whose effects are enhanced by their positive action on haemolymphatic circulation, beneficial effects on the osteoarticular system and muscle-relaxing action.
The choice of water to use will depend on which types are available at the centre.

SULPHURIC WATERS
Sulfurous waters are the ones most widely used in the treatment of psoriasis.
The keratolytic and keratoplastic actions of sulphuric waters (stimulation of the spinous layer and of keratinisation; corneal softening) have beneficial effects on the symptoms and skin lesions associated with psoriasis.
Hydrogen sulfide is also inhaled and, on reaching the joint cartilage, has beneficial metabolic effects.

SALSO-BROMINE-IODINE WATERS
Salso-bromine-iodine waters are instead characterised by a high sodium chloride level and by sufficient quantities of bromine and iodine to have a therapeutic effect.
Among a series of biological effects, it is recalled :
1. that sodium chloride (which, together with bicarbonate, is the predominant mineral salt contained in plasma and extracellular fluids) contributes to the maintenance of osmotic pressure and of the acid-base balance
2. that sodium influences muscle excitability and capillary permeability
3. that bromine exerts a depressive action on the CNS, inducing calm, mild analgesia, and sleep. Furthermore it induces reduction of the excitability of the motor centres in the cerebral cortex and impedes stimulus diffusion through the nervous system
4. that iodine, indispensable for normal thyroid function, exerts a typically revulsive and antiseptic action on the skin and mucous membranes, stimulates exchange (especially purine exchange), reduces blood viscosity, and increases secretory activity in the mucous membranes. It also seems to favour the resorption of chronically inflamed tissue.
It has to be appreciated, however, that the biological effect of a mineral water is far greater than that of its components, making it necessary to talk of the overall STRUCTURE of the water.
Overall, balneotherapy with salso-bromine-iodine spa waters promotes:
1. adrenergic effects (stimulation of the sympathetic nervous system),
2. reduced muscle excitability
3. various effects on the endocine system (release of ACTH, cortisol, parathormone, precursors of vitamin D, calcitonin, osteocalcin, beta-endorphins, etc.)
4. important antinflammatory effects
THE PHYSICAL EFFECTS OF BALNEOTHERAPY
In addition to these biological effects there are physical ones produced by the heat:
1. increase in the pain threshold (thus analgesia),
2. increase in circulation, both local and general (this is an important effect because it leads to the carrying away of pro-inflammatory substances like amines and plasma kinins and of pro-inflammatory enzymes like hyaluronidases)
3. and thus reduction of the imbibition of joint tissues, reduction of muscle hypertonia and of internal muscle pressure.
If the therapy is carried out in the pool there are other important advantages, such as the reduction of bodyweight (to a degree that depends on the level of immersion) and suppression of antigravity muscle activity, a factor that facilitates improvement of joint stiffness.

TREATMENT
Balneotherapy can be carried out in a single tub (PHOTO 1) or in the thermal pool (PHOTO 2) in 12-day cycles (generally with a day’s rest mid-way through the cycle). These cycles can be repeated with a frequency that depends on the clinical picture and on the objective that has been set: in the case of preventive treatments the intervals between one cycle and the next will obviously be longer than when what is required is a rehabilitative treatment with reduction of joint impairment).
In our experience the best results are obtained when balneotherapy is associated with individual or group sessions of water gym.
Crenokinesitherapy (PHOTOS 4, 5, 6) is clearly indicated in P.A. and can have undeniable benefits, providing the treatment is not regarded as a panacea but rather as means of treating, or better still preventing, the often disabling effects of this disease.
Once the patient has been diagnosed and his general conditions have been carefully assessed, the hydrologist, in collaboration with the physical medicine specialist and the rehabilitation therapists, each working within their specific roles, will evaluate the subject’s functional level and the prospects for recovery, working out, and subsequently modifying, as necessary, a personalised treatment plan.
We are thus talking of holistic management of the patient rather than the mere application of pre-established, general protocols whose only aim is to get a differently-abled person moving.
The advantages of this “global rehabilitation tool” lie in the scope it offers for associating the biological effects of spa waters with their physical properties (which, moreover, are greater than those of non-mineral waters: one need only imagine the application of Archimede’s principle to water with a decidedly higher-than-normal specific weight), in the possibility of creating a microgravitational environment, and in the undoubted psychological benefits experienced by the patient during a treatment that increases his motor potential.

BIBLIOGRAPHY
1) Leonard DG et al., Prospective analysis of psoriasic arthritis in patients hospitalised for psoriasis, Mayo Clin Proc 1978
2) Federici PC, Prolegomeni di chimica e farmacologia idrologica, Oppici ed., 1979
3) Gladmann DD et al., QJ Med, 1987
4) Messina B and Grossi F, Elementi di idrologia medica, SEU, 1988
5) Torre Alonso JC et al., Br J Rheumatol, 1991
6) WongK et al., Arth Rheum, 1997
7) Sabee et al., The epidemiology of psoriasic arthritis in Olmstead Country, J Rheum 2000
8) Agostini G, Manuale di medicina termale, 2000, Guidotti
9) Salonen S et al., The EUROPSO psoriasic study. Spring symposium of the European Academy of Dermatology and Venerology, Malta 2003
10) Furia F, La crenokinesiterapia nell’ artrite psoriasica, relazione convegno “l’ artropatia psoriasica”, Castrocaro 2004
11) Furia F, La crenokinesiterapia nell’ artrite psoriasica, relazione convegno “l’ artropatia psoriasica”, Castrocaro 2004
12) Gelfand JM et al., Epidemiology of psoriasic arthritis in the population of the USA, J Am Acad Dermatol 2005
13) National Psoriasis Foundation (online), March 2006
14) William T et al., Classification criteria for psoriasic arthritis: development of new criteria from a large international study, Arthritis and Rheumat 2006
15) Furia F, La terapia termale delle spondilopatie, atti VI corso di aggiornamento urgenze in reumatologia “Le artropatie da cristalli”, 2006
16) Monari N, et al., La riabilitazione delle lombalgie in ambiente termale, 2007
17) Abbiate I, Problematiche riabilitative nell’ artropatia psoriasica, XXV convegno ANAP (online), 2007
18) Furia F, La balneoterapia, Salute e benessere (online), 2009
19) Furia F, Miccoli G, Efficacia della balneoterapia nel programma di prevenzione e recupero della spondiloartrite psoriasica, La clinica termale, July-December 2009, SEU

Questo articolo è stato pubblicato Sabato, 31 Luglio 2010 alle 10:20 e classificato in Artroreumopatie, Malattie della pelle. Puoi seguire i commenti a questo articolo tramite il feed RSS 2.0. Puoi inviare un commento, o fare un trackback dal tuo sito.

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BALNEOTHERAPY IN THE PREVENTION AND REHABILITATION OF PSORIATIC SPONDYLOARTHRITIS

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