JOURNAL CLUB

BY
Dr . VEDAHARSHNI
CLINICAL NATUROPATHY
 MUD-BATH TREATMENT IN SPONDYLITIS ASSOCIATED
WITH INFLAMMATORY BOWEL DISEASE –
A PILOT RANDOMIZED CLINICAL TRIAL

 AUTHORS : Franco Cozzi*, Marta Podswiadek, Gabriella

Cardinale, Francesca Oliviero, Lara Dani,Paolo S Friso,
Leonardo Punzi
 JOURNAL : Joint Bone Spine
 PUBLISHED ON : 30 MAY 2007
 IMPACT FACTOR : 1.953
 ABSTRACT
 OBJECTIVE : The effects & the tolerability of mud packs and thermal baths on
S-IBD.
 METHODS : n = 24
12 mud packs &12 thermal baths (2 weeks)
 RESULTS: * A significant reduction of indices of spondylitis.
* BASDAI50 improvement remained significant.
* C reactive protein serum levels didn’t show significant changes.
* No significant changes in IBD activity indices and in CRP serum
levels were observed in the control group
 CONCLUSION: Mud-bath treatment in patients with S-IBD is well tolerated and
may improve spinal symptoms and function for several months.
INTRODUCTION
Spondyloarthropathy is J Rheumatol 2000 The appearance of SpA
dddddddddddddddddddddddddddddddddddddd
underestimated in occurs irrespective of the
inflammatory bowel extent of the bowel
ddddddde
disease: prevalence and disease with a related
HLA association. pathogenic mechanism.

Nonsteroidal anti- Annals of internal Nonsteroidal anti-

inflammatory drugs medicine 1987 inflammatory drugs can
activate quiescent have noxious effects on
inflammatory bowel the distal intestine as well
disease. as on the proximal gut,
exacerbation of
ulcerative colitis have
been reported
Toxic effects of Joint Bone Spine NSAIDs can trigger
nonsteroidal anti 2005 exacerbations of
inflammatory drugs on ulcerative colitis or
the small bowel, colon, Crohn's disease.
and rectum.
Effects of nonsteroidal
antiinflammatory drugs on 2000
inflammatory bowel
disease: a case-control
study.
Am J Gastroenterol NSAIDs provoke disease
activity in both ulcerative
colitis and Crohn's disease
and should be avoided in
patients with a history of
IBD whenever
possibleASAS/EULAR
recommendations for the
management of ankylosing
spondylitis

ASAS/EULAR Annals of Rheumatic The final recommendations

recommendations for the disease 2006 considered NSAIDs, disease
management of ankylosing modifying antirheumatic
spondylitis drugs, treatments with
biological agents, simple
analgesics, local and
systemic steroids, non-
pharmacological treatment
(including education,
exercise, and
physiotherapy), and surgical
interventions.
Effect of Spa therapy in
Tiberias on patients with
ankylosing spondylitis
Spa therapy for ankylosing
spondylltis at the Dead Sea
Clinical rheumatology combination of hot mineral
1995 water baths and mud packs.
A significant improvement
was noticed in morning
stiffness, finger to floor
distance and the overall
well-being assessment both
by the patient and the
physician.
Isr Med Assoc J Climatotherapy at the Dead
2005 Sea area can improve the
condition of patients
suffering from long-
standing ankylosing
spondylitis.
METHODS
 PATIENT SELECTION
• 52 24 (CDAI >150 or Powell-Tuck Index >4)
• IBD diagnosed by clinical, endoscopic, histological & radiological criteria.
• ESSG criteria
 INTERVENTION

42-45°C for 15 min 37- 38 °C for 10 min.

 EVALUATION

T0 T1 T2 T3
Before Immediately to 12 weeks 24 weeks
MBT Cycle MBT Cycle
EVALUATION INDICES

 BASDAI
 BASFI
 BAS-G
 VAS
 CDAI
 Powell-Tuck Index
 C Reactive Protein
CRONHS DISEASE ACTIVITY INDEX
POWELL TUCK INDEX
BATH ANKYLOSING SPONDYLITIS DISEASE ACTIVITY INDEX
STATISTICAL ANALYSIS

 Wilcoxon signed-rank test

 Chi-square
 Fisher’s exact test
RESULTS
DISCUSSION

 Significant improvement of clinical indices was observed at the end of

thermal treatment.
 BAS-G & BASFI at 12 weeks,
 BASDAI &VAS at 24 weeks.
 No significant changes in parameters in the controls.
 MBT was well tolerated (CDAI and Powell-Tuck)
 No relapse of spondylitis
 CRP levels remained unchanged in all patients.
 TITLE INTERVENTION RESULTS

Combined Spa–Exercise Standardized spa–exercise spa–exercise therapy, drug

Therapy Is Effective in therapy of 3 weeks duration treatment and
Patients With Ankylosing consisted of group physical weekly group physical
Spondylitis: exercises, therapy alone, provides
A Randomized Controlled walking, correction therapy beneficial effects. These
Trial (lying supine on a bed), beneficial effects may last
hydrotherapy, sports, for at least 40 weeks.
ASTRID et al exposure to Gasteiner
Heilstollen and sauna
Arthritis Care & Research
2001
Improvement of the clinical
outcome in Ankylosing
Spondylitis
by balneotherapy
MerihYurtkuran et al
Joint Bone Spine 2004
BT, BT+ NSAID and NSAID • Heat to the inflamed tissue
therapy brings in fresh blood
supply to remove the
BT -20 MINS; 5 days a week nociceptive elements
for 3 weeks • Effect the pain sensation
as a counter-irritant
• Action of peripheral
betaendorphines
• Adhering collagen fibers
caused by immobilization
tend to unlink with
increasing temperature
during treatment.
Capsular and tendinous
flexibility is thus regained.
Hypothalamic-pituitary-
adrenal
axis dysregulation in
healthy subjects undergoing
mud-bath applications
Cozzi F et al
Anti - inflammatory effect
of mud-bath applications
on adjuvant arthritis in rats
mud-bath application • Increase of serum levels
40 - 42°C mud for 15 endorphins
minutes • Down regulation of some
pro-inflammatory
cytokines, leading to an
anti-inflammatory effect
40-42°C mud for 15 The significant
minutes, followed by decrease of TNFa and IL-1b
immersion in 37- serum levels suggest an anti-
38°C thermal water for 10 inflammatory effect of mud-
minutes bath applications on rat
adjuvant arthritis.
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CRITICAL APPRAISAL