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Evaluation of the efficacy of spa therapy on pain and quality of life in patients with chronic mechanical neck pain.

Currently, mechanical neck pain is the second most common type of pain after low back pain in chronic pain classifications. (1-3) At any given time, approximately 10 to 20% of the population reports neck problems. Because most neck pain has no specific, identifiable cause, it is diagnosed as mechanical neck pain. (4)

While symptoms of neck pain may spontaneously resolve within a few weeks, 30% of the symptoms may persist as chronic neck pain. Chronic neck pain increases the cost of treatment and decreases work capacity. Also, neck pain results in as much lost work days as low back pain in industrial work areas. (5) Thus, planning for effective treatment is considerably important. The goals of treatment in a patient with neck pain should be to reduce pain, restore mobility of cervical joints, and prevent disability in long-term. (6) Common treatment consists of drugs, massage and other manual treatments, physiotherapy and exercise, local and epidural injections, and patient education. (7)

Spa therapy, also known as balneotherapy or thermal therapy, has been widely used for the treatment of several musculoskeletal disorders since the 18th century in Europe. (8) During spa therapy, patients are treated with thermal mineral water and receive many other treatment modalities including massage, electrotherapy, and exercise. (9)

There are several studies reporting positive effects of spa therapy in patients with osteoarthritis in the literature. These studies have targeted specific joints such as knee and vertebral osteoarthritis. (10) Recent studies have reported effects of spa therapy on chronic painful conditions including low back pain and rheumatoid arthritis. (11)

To our knowledge, the only study in the literature to demonstrate the efficacy of spa therapy in patients with chronic neck pain is of Forestier et al. (12) who have compared the effects of spa therapy and electromagnetic field therapy in patients with chronic neck pain. In that study, no difference has been shown between spa therapy and electromagnetic field therapy except for the 20% decreased pain during the pain assessment at the sixth month evaluation.

In light of these findings, in this study, we aimed to evaluate the efficacy of spa therapy on pain and quality of life in patients with chronic mechanical neck pain.

PATIENTS AND METHODS

The study population was chosen among patients with chronic neck pain who attended the Outpatient Clinic of Department of Physical Medicine and Rehabilitation of Medical Faculty of Afyon Kocatepe University between August 2007 and July 2008. All patients' informed signed consent was obtained. The study was approved by our Institutional Research Ethics Committee. A total of 70 patients were enrolled in the study. Patients were randomized either to spa therapy group (7 males, 28 females; mean age 43.08 [+ or -] 9.76 years; range 26 to 66 years) or exercise therapy group (5 males, 30 females; 46.45 [+ or -] 9.65 years; range 27 to 65 years) by using the table of random numbers. Study inclusion criteria and exclusion criteria are shown in Table 1 and Table 2, respectively.

All patients' age, sex, body mass index, occupation, and duration of neck pain were recorded. Therapy-related changes in the severity of neck pain were evaluated by visual analog scale (VAS), Patient's Global Assessment (PatientVAS), and Physician's Global Assessment (DrVAS). Pain, and patient's and physician's global assessments were evaluated with 10 cm VAS, where 0 indicates no pain or best, whereas 10 indicates intractable pain or worst.

Changes in neck pain and disability were assessed by using Neck Pain Disability Scale (NPDS). NPDS is a 20-item questionnaire developed by using the Million visual analog scale as a template. The items explore pain intensity; its interference with vocational, recreational, social and functional aspects of living, as well as the presence and extent of associated emotional factors. Each item has a 10 cm VAS. Scoring of each item varies along a continuous scale from 0 to 5. (13) Scores above 23 indicate clinically significant neck pain and the higher the score, the greater the degree of pain and disability. (14)

Patients' quality of life was assessed by using Nottingham Health Profile (NHP). NHP assesses physical, social, and emotional health with 38 items answered 'yes' or 'no'. The 'weighted score' of the related question was given for each 'yes' and 0 point for each 'no'. The overall score was calculated separately for each parameter and then NHP total score was obtained from the sum of the scores of these six parameters. (15)

Patients allocated in the spa therapy group had total body bath with thermal water including the cervical region, and mud therapy and massage without massage oil to cervical region in the Cure Center of Department of Physical Medicine and Rehabilitation. All those therapies were given once daily for five days a week, for a total of 15 sessions. Additionally, they received the same home exercise program as given to the exercise therapy group.

The exercise therapy group was given a home exercise program. These exercises were instructed to the patients in both groups by the same physiotherapist including one practice session and a descriptive exercise brochure was provided. Exercises included isometric neck exercises and stretching exercises for muscles of the back and neck. Stretching exercises were applied on the scalene, upper part of trapezius, pectoralis minor muscles, interspinous muscles, and ligamentum nuchae. Patients were instructed to perform the exercise program once daily as one session for 15 days and to repeat each exercise 10 times during one session. Patients were contacted by phone every 3-4 days to assess their compliance with the exercise program and by this way, completion of the exercise program was achieved. Patients were evaluated before treatment, at the first week after treatment and at the third month after treatment, three times in total.

Statistical analysis

For statistical evaluation of the study findings, IBM SPSS Statistics version 21.0 software program (IBM Corporation, Armonk, NY, USA) was used. For descriptive statistics, numerical data were expressed as mean [+ or -] standard deviation and median (25th-75th percentiles), categorical variables as numbers and percentages. Yates Chi-square test was used for comparing categorical data between groups. Independent Samples t-test was used for comparing normally distributed continuous variables. Mann-Whitney U test was used for comparing non-normally distributed continuous variables. In addition, within-group changes were assessed by using Friedman test for repetitive measurements of non-normally continuous data for each group. Shapiro-Wilk test was used to determine the normality. A p value less than 0.05 was considered statistically significant.

RESULTS

Groups were similar with respect to sex distribution and mean ages (p=0.751, p=0.151, respectively). Demographic characteristics of patients are depicted in Table 3.

Mean pre-treatment values of parameters used for follow-up of patients are depicted in Table 4. There was no statistically significant difference between two groups at baseline.

In the spa therapy group, a significant improvement was found in NHP subscales during assessments at the first week and three months after completion of therapy (for all subscales p < 0.001).

Mean NPDS values were 20.42 [+ or -] 15.12 and 17.97 [+ or -] 12.86 at the first week and three months after treatment in the spa therapy group, respectively. A statistically significant improvement was detected in mean NPDS values at both assessments (p < 0.001).

A significant improvement was found in VAS, PatientVAS, and DrVAS values in the exercise therapy group at one week and three months posttreatment (p < 0.001, p < 0.001, and p < 0.001, respectively).

A significant improvement was demonstrated in NHP subscales during assessments at one week and three months after completion of therapy in the exercise therapy group (p=0.003 for sleep; p < 0.001 for all the other subscales).

Mean NPDS values of 28.54 [+ or -] 18.30 and 23.97 [+ or -] 18.72 were detected at one week and three months posttreatment in the exercise therapy group, respectively. A statistically significant improvement was found in mean NPDS values at both assessments (p < 0.001).

Tables 5 and 6 show the mean follow-up measurements and p values according to the results of Friedman test in the spa therapy and exercise therapy groups, respectively.

Statistically significant improvements were observed in all parameters assessed at both one week and three months after completion of treatment in spa therapy and exercise therapy groups. Then, mean changes achieved at one week and three months posttreatment were compared in both groups to determine which group had greater improvement.

Statistically significantly greater decrease in VAS value was found in the spa therapy group when mean change score obtained from VAS values in the spa therapy group was compared to the mean change score in the exercise therapy group (p < 0.001).

Comparison of mean change score in the NPDS value of the spa therapy group at one week to the mean change score of the exercise therapy group showed that the decrease was statistically significantly greater in spa therapy group (p=0.001).

A comparison of mean change scores in the follow-up parameters measured at one week posttreatment based on pretreatment values in both groups is shown in Table 7.

There was statistical difference between groups when mean change score of NPDS value in spa therapy group at three months posttreatment was compared to the mean change score in the exercise therapy group (p=0.024) (Table 8).

DISCUSSION

In our study, we observed significantly greater reductions in pain and disability level of patients with chronic mechanical neck pain with spa therapy in the early period of the treatment. Spa therapy was consisting of thermal, mud, and massage therapies applied to neck region.

Among musculoskeletal disorders, neck pain is the second most common problem after low back pain in the general population. (16) The goals of therapy in chronic neck pain include decreasing pain and disability, and improving endurance. (17)

There are several conservative treatment methods applied for this purpose. A randomized, double-blind, placebo-controlled study of low-level laser therapy in 90 subjects with chronic neck pain was conducted with the aim of determining the efficacy of 300 mW, 830 nm laser in the management of chronic neck pain. Significant improvements were seen in the active group compared to placebo. (18)

Exercise therapy has well-known positive effects on the muscular and cardiovascular system, such as increasing muscular strength and coordination as well as aerobic capacity. Furthermore, exercise therapy is known to be a powerful instrument in the treatment of musculoskeletal chronic pain. (11)

Ylinen et al. (19) compared the effects of manual therapy and stretching exercise on neck pain and disability. Both stretching exercise and manual therapy considerably decreased neck pain and disability in females with non-specific neck pain. The difference in effectiveness between the two treatments was minor.

To our knowledge, the only study in the literature to demonstrate the efficacy of spa therapy in patients with chronic neck pain was conducted by Forestier et al. (12) who compared the effects of spa therapy and electromagnetic field therapy in patients with chronic neck pain. In this study, 20% or greater decrease in pain from baseline values as measured by VAS was considered as improvement. In the same study, more patients in the electromagnetic field therapy group showed improvement compared to spa therapy group and no difference was found between two groups except for the 20% decrease in VAS values at sixth month.

In our study, a significant reduction was seen in VAS values at one week and three months with spa therapy and exercise therapy when groups were evaluated within themselves. However, the reduction in VAS value obtained at one week after treatment in the spa therapy group was significantly superior compared to the control group. In the view of the results obtained from VAS values, we can say that patients experienced reduced pain with both spa therapy and exercise therapy and this was much more evident with spa therapy in the early posttreatment period.

Our study demonstrated significant improvements in patient's and physician's global assessments at one week and three months after treatment in spa therapy and exercise therapy groups. However, there was no statistically significant difference between two groups. Consistent with our study findings, Wigler et al. (20) observed significant improvements in patient's and physician's global assessments over 16 weeks in patients with gonarthrosis who were given spa therapy for two weeks.

Furthermore, we observed significant reductions in neck pain and disability level evaluated by NPDS with spa therapy and exercise therapy at one week and three months after treatment. However, the reduction in NPDS value achieved at the first week after treatment was better in the spa therapy group compared to the exercise therapy group. Based on the results obtained from NPDS values, we might consider that patients experienced reduced neck pain and disability with both spa therapy and exercise therapy and this was much more evident with spa therapy in the early posttreatment period.

In our study, an active therapeutic exercise treatment including isometric strength exercises for the neck and neck-back stretching exercises was given to spa therapy group in addition to thermal, mud, and massage therapies. The same exercises were given to the exercise therapy group as home exercise program. Consistent with literature, we demonstrated considerably improved pain, functional capacity and quality of life scales during follow-up at one week and three months in both groups. (4,17,21) However, improved pain and functional capacity were statistically significantly superior in spa therapy group at the first week posttreatment compared to the exercise therapy group. This supports the argument that when combined with exercise, spa therapy might achieve more successful results in the early period.

The main limitation of spa therapy related studies were lack of a control population. It is very difficult to maintain the blindness factor, since the physicochemical properties (color, odor, feel by touch) of mineral water significantly differ from tap (control) water and can easily be discerned by patients. (22)

Fioravanti et al. (23) assessed both the short-and long-term effectiveness of spa therapy in patients with primary knee OA. In this study, patients were randomized as a spa therapy group and control group, and continued regular routine ambulatory care (exercise, non-steroidal antiinflammatory drugs, and/or analgesics). Authors observed a significant improvement in all evaluated parameters at the end of the cycle of spa therapy, whereas no significant differences were noted in the control group.

In another study, Karagulle et al. (24) compared spa therapy and drug therapy differences in patients with severe knee osteoarthritis. Twenty patients were randomized into spa and drug therapy groups. Spa group (n=10) stayed at a hotel for a 10 day spa therapy course. Drug therapy group (n=10) stayed at home and followed their individually prescribed drug therapy (nonsteroidal antiinflammatory drugs and paracetamol). Consistent with our study, Karagulle et al. (24) demonstrated that a 10 day course of spa therapy may be beneficial in short and medium term by reducing pain and improving functional status.

In the study by Forestier et al., (25) the only study in the literature to show the efficacy of spa therapy in patients with chronic neck pain, a total of 86 patients with chronic mechanical neck pain were randomized to receive spa therapy (n=44) or intermittent electromagnetic field therapy (n=42). In the first part of their study, researchers. (25) compared the efficacy of spa therapy with electromagnetic field therapy in patients with chronic neck pain and then evaluated the medico-economic aspects in the second part. As a result, they showed that electromagnetic field therapy and spa therapy provided cost-effective medical benefits compared to conventional therapy in the treatment of chronic neck pain.

Several aspects of spa therapy can be distinguished as potentially therapeutically effective. These are (i) natural remedies such as mud and thermal water, (ii) additional therapies such as massages and electrotherapy, (iii) living in a resort environment, and (iv) having a respite from work. (11)

The limitations of our study is that the follow-up period was relatively short, so we were unable to assess the effects of spa therapy in longer durations. In conclusion, combined use of thermal, mud, massage and exercise therapies, also known as spa therapy, results in a greater reduction in pain and improved functional capacity in the early period compared to exercise therapy alone in patients with chronic mechanical neck pain. Spa therapy contributes positively to functional capacity of the neck in long-term period. Thus, we conclude that spa therapy should be considered as a treatment option in patients with chronic mechanical neck pain, but our findings should be supported with further studies with longer follow-up period and larger sample size.

doi: 10.5606/ArchRheumatol.2015.5445

Declaration of conflicting interests

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding

The authors received no financial support for the research and/or authorship of this article.

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Aycan TUREL, [1] Ozlem SOLAK, [2] Umit DUNDAR, [2] Hasan TOKTAS, [2] Umit Secil DEMIRDAL, [3] Volkan SUBASI, [4] Vural KAVUNCU [2]

[1] Department of Physical Medicine and Rehabilitation, Afyonkarahisar State Hospital, Afyonkarahisar, Turkey

[2] Department of Physical Medicine and Rehabilitation, Medical Faculty of Afyon Kocatepe University, Afyonkarahisar, Turkey

[3] Department of Physical Medicine and Rehabilitation, Medical Faculty of Izmir Katip Celebi University, Izmir, Turkey

[4] Department of Physical Medicine and Rehabilitation, OzgUr Yasam Physical Medicine and Rehabilitation Center, Mersin, Turkey

Received: September 17, 2014 Accepted: April 24, 2015 Published online: August 10, 2015

Correspondence: Volkan Subasi, MD. Mersin OzgUr Yasam Fizik Tedavi ve Rehabilitasyon Merkezi, 33110 Yenisehir, Mersin, Turkey. Tel: +90 324-325 76 57 e-mail: vsubasi@yahoo.com
Table 1. Study inclusion criteria

Patients with mechanical neck pain lasting for more than 12 weeks

Patients with a visual analog scale score of 5 or above

Patients who did not receive thermal therapy for neck pain within
less than one year

Patients who agree to discontinue their medical therapy for neck
pain at least one week before initiating treatment

Patients with a normal C-reactive protein value

Table 2. Study exclusion criteria

Presence of an unregulated cardiac, pulmonary, kidney or thyroid
gland condition or diabetes mellitus

Presence of an inflammatory rheumatic condition

Presence of magnetic resonance imaging confirmed cervical
herniation requiring surgery or causing neurological deficit

Presence of spondylolisthesis

Patients with structural disorders such as scoliosis

Patients who are allergic to oils used in the massage therapy

Table 3. Comparison of patients' demographic data

                             Spa therapy group (25th-75th) percentiles

                       n    Mean [+ or -] SD      Median   Min.-Max.

Gender
  Female               28
  Male                 7
Mean age (years)            43.08 [+ or -] 9.76    43        34-51
Mean body mass index        28.08 [+ or -] 4.41   28.04    24.22-30.80
Duration of                 17.45 [+ or -] 9.62    12        12-24
  disease (months)

                             Exercise therapy group (25th-75th)
                                              percentiles

                       n    Mean [+ or -] SD      Median   Min.-Max.

Gender
Female                 30
Male                   5
Mean age (years)            46.45 [+ or -] 9.65    47         38-53
Mean body mass index        30.26 [+ or -] 4.74   30.11    27.89-32.89
Duration of                 --                    --       --
  disease (months)

                          p

Gender
Female                 0.751
Male
Mean age (years)       0.151 *
Mean body mass index   0.051 *
Duration of            0.795 *
  disease (months)

SD: Standard deviation; Min.: Minimum; Max.: Maximum; * Yates'
Chi-square test; ** Independent Samples t-test; *** Mann-Whitney U
test.

Table 4. Comparison of mean pretreatment measurements of follow-up
parameters

                                    Spa therapy group
                                 (25th-75th) percentiles

Follow-up parameters    Mean [+ or -] SD    Median    Min.-Max.

VAS                    58.9 [+ or -] 8.0      60        50-60
PatientVAS             44.0 [+ or -] 24.6     50        20-60
DrVAS                  45.1 [+ or -] 22.1     50        30-60
Nottingham Health
Profile
  Energy               58.1 [+ or -] 30.5   39.20     39.20-76
  Pain                 59.8 [+ or -] 20.8   59.78    42.35-79.52
  Emotional reaction   39.2 [+ or -] 30.3   35.72    9.76-63.22
  Sleep                48.4 [+ or -] 31.0   48.96    16.10-77.63
  Social isolation     22.6 [+ or -] 29.9     0        0-42.66
  Physical mobility    32.6 [+ or -] 18.2   31.29    21.77-43.27
Neck Pain and          47.2 [+ or -] 2.0      49        34-64
Disability Scale

                                  Exercise therapy group
                                 (25th-75th) percentiles

Follow-up parameters    Mean [+ or -] SD    Median    Min.-Max.

VAS                    56.0 [+ or -] 7.7      50        50-60
PatientVAS             42.6 [+ or -] 25.4     50        20-60
DrVAS                  41.4 [+ or -] 20.7     40       820-60
Nottingham Health
Profile
  Energy               59.2 [+ or -] 38.3     76      39.20-100
  Pain                 59.1 [+ or -] 30.6   62.21    29.44-80.26
  Emotional reaction   44.8 [+ or -] 29.3   49.58    16.21-69.80
  Sleep                47.3 [+ or -] 28.6   55.93    16.10-77.63
  Social isolation     26.5 [+ or -] 31.1   20.13      0-48.49
  Physical mobility    29.7 [+ or -] 19.8   30.66    19.87-41.86
Neck Pain and          43.0 [+ or -] 18.7     40        25-61
Disability Scale

Follow-up parameters      p

VAS                    0.095 *
PatientVAS             0.707 *
DrVAS                  0.425 *
Nottingham Health
Profile
  Energy               0.733 *
  Pain                 0.851 *
  Emotional reaction   0.356 *
  Sleep                0.892 *
  Social isolation     0.551 *
  Physical mobility    0.538 **
Neck Pain and          0.374 **
Disability Scale

SD: Standard deviation; Min.: Minimum; Max.: Maximum; VAS: Visual
analog scale; PatientVAS: Patient's Global Assessment; DrVAS:
Physician's Global Assessment; * Mann Whitney U test; ** Independent
Samples t-test.

Table 5. Mean follow-up measurements and p values according to
results of Friedman test in spa group

Follow-up                           Pretreatment (1)
parameters                      (25th-75th) percentiles

                        Mean [+ or -] SD    Median    Min.-Max.

VAS                    58.9 [+ or -] 78.0     60        50-60
PatientVAS             44.0 [+ or -] 24.6     50        20-60
DrVAS                  45.1 [+ or -] 22.1     50        30-60
NHP
  Energy               58.1 [+ or -] 30.5   32.20     39.20-76
  Pain                 59.8 [+ or -] 20.8   59.78    42.35-79.52
  Emotional reaction   39.2 [+ or -] 30.3   35.72    9.76-63.22
  Sleep                48.4 [+ or -] 31.0   48.96    16.10-77.63
  Social isolation     22.6 [+ or -] 29.9     0        0-42.66
  Physical mobility    32.6 [+ or -] 18.1   31.29    21.77-43.27
NPDS                   47.2 [+ or -] 20.0     49        34-64

Follow-up                      One week posttreatment (2)
parameters                      (25th-75th) percentiles

                        Mean [+ or -] SD    Median   Min.-Max.

VAS                    29.1 [+ or -] 22.5     30       10-50
PatientVAS             20.6 [+ or -] 19.2     20       0-40
DrVAS                  19.4 [+ or -] 18.1     20       0-30
NHP
  Energy               32.1 [+ or -] 28.8   39.20     0-39.20
  Pain                 31.1 [+ or -] 28.7   28.73     0-53.57
  Emotional reaction   23.6 [+ or -] 27.0   12.01     0-33.02
  Sleep                34.2 [+ or -] 29.3   28.60     0-61.53
  Social isolation      8.8 [+ or -] 15.9     0       0-20.13
  Physical mobility    17.2 [+ or -] 17.5   11.20     0-23.81
NPDS                   20.4 [+ or -] 15.1     17       9-32

Follow-up                     Three months posttreatment (3)
parameters                      (25th-75th) percentiles

                        Mean [+ or -] SD    Median    Min.-Max.

VAS                    26.9 [+ or -] 22.7     30        0-50
PatientVAS             19.1 [+ or -] 19.8     10        0-30
DrVAS                  16.6 [+ or -] 17.0     10        0-30
NHP
  Energy               35.8 [+ or -] 27.6   39.20      0-63.20
  Pain                 27.8 [+ or -] 24.6   25.57      0-51.60
  Emotional reaction   24.7 [+ or -] 25.4   20.23      0-36.47
  Sleep                33.1 [+ or -] 28.3   27.26    12.57-61.53
  Social isolation      8.9 [+ or -] 15.9     0        0-22.01
  Physical mobility    16.3 [+ or -] 14.9   11.20      0-30.66
NPDS                   18.0 [+ or -] 12.9     13        8-29

Follow-up                       Multiple comparisons for
parameters                         significant groups

                         P

VAS                    <0.001           1-2, 1-3
PatientVAS             <0.001           1-2, 1-3
DrVAS                  <0.001           1-2, 1-3
NHP
  Energy               <0.001           1-2, 1-3
  Pain                 <0.001           1-2, 1-3
  Emotional reaction   <0.001           1-2, 1-3
  Sleep                <0.001           1-2, 1-3
  Social isolation     <0.001           1-2, 1-3
  Physical mobility    <0.001           1-2, 1-3
NPDS                   <0.001           1-2, 1-3

SD: Standard deviation; Min.: Minimum; Max.: Maximum; VAS: Visual
analog scale; PatientVAS: Patient's Global Assessment; DrVAS:
Physician's Global Assessment; NHP: Nottingham Health Profile; NPDS:
Neck Pain and Disability Scale.

Table 6. Mean follow-up measurements and p values according to
results of Friedman test in exercise group

Follow-up                             Pretreatment (1)
parameters                        (25th-75th) percentiles

                        Mean [+ or -] SD    Median    Min.-Max.

VAS                    56.0 [+ or -] 7.7      50        50-60
PatientVAS             42.6 [+ or -] 25.4     50        20-60
DrVAS                  41.4 [+ or -] 20.7     40        20-60
NHP
  Energy               59.2 [+ or -] 38.3     76      39.20-100
  Pain                 59.1 [+ or -] 30.6   63.21    29.44-80.26
  Emotional reaction   44.8 [+ or -] 29.3   49.58    16.21-69.80
  Sleep                47.3 [+ or -] 28.6   55.93    16.10-77.63
  Social isolation     26.5 [+ or -] 31.1   20.13      0-48.49
  Physical mobility    29.7 [+ or -] 19.8   30.66    19.87-41.86
NPDS                   43.0 [+ or -] 18.7     40        25-61

Follow-up                        One week posttreatment (2)
parameters                        (25th-75th) percentiles

                        Mean [+ or -] SD    Median    Min.-Max.

VAS                    42.0 [+ or -] 16.4     40        30-50
PatientVAS             30.9 [+ or -] 25.0     30        0-50
DrVAS                  27.7 [+ or -] 23.3     30        0-50
NHP
  Energy               44.2 [+ or -] 38.3   39.20       0-76
  Pain                 36.7 [+ or -] 29.0   37.18    11.22-59.40
  Emotional reaction   26.8 [+ or -] 26.7   19.07      0-44.61
  Sleep                39.1 [+ or -] 25.9   37.80    12.57-55.93
  Social isolation     17.6 [+ or -] 28.5     0        0-22.53
  Physical mobility    17.8 [+ or -] 15.3   21.36      0-30.66
NPDS                   28.5 [+ or -] 18.3     24        14.39

Follow-up                     Three months posttreatment (3)
parameters                      (25th-75th) percentiles

                        Mean [+ or -] SD    Median    Min.-Max.

VAS                    32.0 [+ or -] 17.3     30        20-50
PatientVAS             23.4 [+ or -] 20.9     20        10-40
DrVAS                  18.3 [+ or -] 18.7     20        0-30
NHP
  Energy               40.3 [+ or -] 35.3   39.20       0-76
  Pain                 35.1 [+ or -] 29.9   29.23    10.49-59.69
  Emotional reaction   24.5 [+ or -] 27.3    9.76      0-46.19
  Sleep                35.8 [+ or -] 23.2   37.80    12.57-55.93
  Social isolation     17.6 [+ or -] 27.7     0        0-37.98
  Physical mobility    16.2 [+ or -] 15.8   11.20      0-21.91
NPDS                   24.0 [+ or -] 18.7     20        8-35

Follow-up                       Multiple comparisons for
parameters                         significant groups

                        p *

VAS                    <0.001        1-2, 1-3, 2-3
PatientVAS             <0.001           1-2, 1-3
DrVAS                  <0.001        1-2, 1-3, 2-3
NHP
  Energy               <0.001           1-2, 1-3
  Pain                 <0.001           1-2, 1-3
  Emotional reaction   <0.001           1-2, 1-3
  Sleep                0.003              1-3
  Social isolation     <0.001           1-2, 1-3
  Physical mobility    <0.001           1-2, 1-3
NPDS                   <0.001        1-2, 1-3, 2-3

SD: Standard deviation; Min.: Minimum; Max.: Maximum; * All p values
were less than 0.000001 except for Sleep; VAS: Visual analog scale;
PatientVAS: Patient's Global Assessment; DrVAS: Physician's Global
Assessment; NHP: Nottingham Health Profile; NPDS: Neck Pain and
Disability Scale.

Table 7. Comparison of mean change scores in follow-up parameters
measured at one week posttreatment based on pretreatment values in
both groups

                                      Spa therapy group
                                   (25th-75th) percentiles

Follow-up parameters    Mean [+ or -] SD     Median    Min.-Max.

VAS                    -29.7 [+ or -] 18.9    -30        -50 - -10
PatientVAS             -23.4 [+ or -] 25.8    -10        -40 - 0
DrVAS                  -25.7 [+ or -] 21.9    -20        -40 - -10
Nottingham Health
Profile
  Energy               -26.0 [+ or -] 33.0     0      -39.20 - 0
  Pain                 -28.7 [+ or -] 29.1   -22.16   -51.53 - 0
  Emotional reaction   -15.7 [+ or -] 20.6   -9.78    -27.94 - 0
  Sleep                -14.2 [+ or -] 27.5   -12.57   -28.67 - 0
  Social isolation     -13.8 [+ or -] 22.0     0      -22.53 - 0
  Physical mobility    -15.4 [+ or -] 16.6   -11.20   -31.29 - 0
  Neck Pain and        -26.7 [+ or -] 18.9    -22        -37 - -13
    Disability Scale

                                      Exercise therapy group
                                      (25th-75th) percentiles

Follow-up parameters    Mean [+ or -] SD     Median    Min.-Max.

VAS                      -14 [+ or -] 13.8    -10        -20 - -10
PatientVAS             -11.7 [+ or -] 14.7    -20        -50 - 0
DrVAS                  -13.7 [+ or -] 14.2    -10        -20 - 0
Nottingham Health
Profile
  Energy               -15.0 [+ or -] 18.7     0      -36.80 - 0
  Pain                 -22.4 [+ or -] 21.8   -19.45   -40.31 - 0
  Emotional reaction   -18.1 [+ or -] 22.9   -9.76    -25.52 - 0
  Sleep                 -8.2 [+ or -] 20.1     0      -12.57 - 0
  Social isolation      -8.9 [+ or -] 14.3     0      -19.36 - 0
  Physical mobility    -11.9 [+ or -] 15.2   -9.93    -20.84 - 0
  Neck Pain and        -14.5 [+ or -] 8.7     -12        -19 - -9
    Disability Scale

Follow-up parameters    p *

VAS                    0.001
PatientVAS             0.225
DrVAS                  0.022
Nottingham Health
Profile
  Energy               0.210
  Pain                 0.586
  Emotional reaction   0.891
  Sleep                0.119
  Social isolation     0.634
  Physical mobility    0.304
  Neck Pain and        0.001
    Disability Scale

SD: Standard deviation; Min.: Minimum; Max.: Maximum; VAS: Visual
analog scale; * Mann-Whitney U test; PatientVAS: Patient's Global
Assessment; DrVAS: Physician's Global Assessment.

Table 8. Comparison of mean change scores in follow-up parameters
measured at three months posttreatment based on pretreatment values
in both groups

                                      Spa therapy group
                                  (25th-75th) percentiles

Follow-up parameters    Mean [+ or -] SD     Median     Min.-Max.

VAS                      -32 [+ or -] 18.6    -30        -50 - -20
PatientVAS             -24.9 [+ or -] 31.3    -20        -50 - 0
DrVAS                  -28.6 [+ or -] 24.5    -20        -50 - -10
Nottingham Health
Profile
  Energy               -22.3 [+ or -] 30.5     0      -39.20 - 0
  Pain                 -32.0 [+ or -] 26.1   -29.35   -49.46 - -9.99
  Emotional reaction   -14.5 [+ or -] 19.6   -10.69   -36.43 - 0
  Sleep                -15.2 [+ or -] 27.3   -12.57   -39.83 - 0
  Social isolation     -13.8 [+ or -] 23.0     0      -22.01 - 0
  Physical mobility    -16.2 [+ or -] 16.7   -20.50   -30.60 - 0
  Neck Pain and        -29.2 [+ or -] 19.8    -27        -36 - -15
    Disability Scale

                                   Exercise therapy group
                                  (25th-75th) percentiles

Follow-up parameters     Mean [+ or -] SD    Median    Min.-Max.

VAS                      -24 [+ or -] 16.5   -30         -30 - -10
PatientVAS             -19.1 [+ or -] 16.3   -20         -30 - 0
DrVAS                  -23.1 [+ or -] 16.0   -20         -40 - -10
Nottingham Health
Profile
  Energy               -18.9 [+ or -] 21.4   0        -39.20 - 0
  Pain                 -24.0 [+ or -] 21.8   -20.86   -44.26 - 0
  Emotional reaction   -20.3 [+ or -] 24.1   -13.99   -32.74 - 0
  Sleep                -11.5 [+ or -] 21.5   0        -22.37 - 0
  Social isolation      -8.9 [+ or -] 14.7   0        -19.36 - 0
  Physical mobility    -13.5 [+ or -] 15.2   -11.2    -21.77 - 0
  Neck Pain and        -19.1 [+ or -] 13.6   -17         -26 - -11
    Disability Scale

Follow-up parameters    p *

VAS                    0.096
PatientVAS             0.585
DrVAS                  0.387
Nottingham Health
Profile
  Energy               0.919
  Pain                 0.212
  Emotional reaction   0.414
  Sleep                0.241
  Social isolation     0.722
  Physical mobility    0.446
  Neck Pain and        0.024
    Disability Scale

SD: Standard deviation; Min.: Minimum; Max.: Maximum; VAS: Visual
analog scale; * Mann-Whitney U test; PatientVAS: Patient's Global
Assessment; DrVAS: Physician's Global Assessment.
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Title Annotation:ORIGINAL ARTICLE
Author:Turel, Aycan; Solak, Ozlem; Dundar, Umit; Toktas, Hasan; Demirdal, Umit Secil; Subasi, Volkan; Kavun
Publication:Turkish Journal of Rheumatology
Article Type:Clinical report
Date:Dec 1, 2015
Words:5821
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