OUTCOME-RESEARCH in Thermalism OUTCOME-RESEARCH in Thermalism Nuevos retos en medicina Nuevos retos en medicina The New Challenge of Medicine The New Challenge of Medicine Helmut G. Pratzel, MD, PhD President of the International Society of Medical Hydrology and Climatology (I.S.M.H.)
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OUTCOME-RESEARCH in Thermalism Nuevos retos en medicina The New Challenge of Medicine Helmut G. Pratzel, MD, PhD President of the International Society.
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OUTCOME-RESEARCH in Thermalism OUTCOME-RESEARCH in Thermalism
Nuevos retos en medicinaNuevos retos en medicinaThe New Challenge of MedicineThe New Challenge of Medicine
Helmut G. Pratzel, MD, PhD
President of the International Society of Medical Hydrology and Climatology (I.S.M.H.)
Situación y competencia térapéuticaSituación y competencia térapéutica
Sano
Agotado
Enfermedades crónicas
Enfermedades agudas
Caso de emergenciaM
éd
ico d
e f
am
ilia
Hospital
Vacaciones de salud
en spa
en spa Tra-
tamiento
Criterios de excelencia de las curas hydrotermales Criterios de excelencia de las curas hydrotermales y de los lugares del termalismo dentro de las y de los lugares del termalismo dentro de las
grandes opciones terapeuticasgrandes opciones terapeuticas
Spas and Health Resorts Rank within Health Care Systems Criteria of Efficient
Treatments
Long time experience Long time experience by many patientsby many patients
Controlled trialsControlled trialsby few patientsby few patients
¿Equivalencia de resultados clínicos?
Clinical Trial Protocol Clinical Trial Protocol by the Guidelines for Good Clinical Practice (GCP) of by the Guidelines for Good Clinical Practice (GCP) of
the European Communitythe European Community
Trial objectives and purpose
Trial design
Randomisation, Blinding
Selection and withdrawal of subjects inclusion and exclusion
Tres grados de la investigación son Tres grados de la investigación son importantesimportantes
Efecto del tratamiento médico durante la curaResultados médicos y socio-médicos a largo
plazo Diferencia entre los gastos y el efecto
MeasurementMeasurement of pressure painof pressure pain thresholdthreshold
Pressure Areas
1. M. levator scapulae1. M. levator scapulae2. M. supraspinatus2. M. supraspinatus3. M. teres minor3. M. teres minor4. M. deltoideus4. M. deltoideus5. M. glutaeus maximus5. M. glutaeus maximus6. M. glutaeus medius6. M. glutaeus medius7. M. bizeps femoris7. M. bizeps femoris8. M. semimembranosus8. M. semimembranosus
Pressure pain threshold by Sulphur bath seriesPressure pain threshold by Sulphur bath series
Period of inspectionPeriod of inspection Period of inspectionPeriod of inspection
Subjective pain feelingSubjective pain feelingRheumatoide Arthritis (Radon trial Bad Brambach 1997)Rheumatoide Arthritis (Radon trial Bad Brambach 1997)
1st value1st valueCO2CO2
Radon+ CO2Radon+ CO2
mm VAS
N = 30 N = 30/27N = 28/30
Differences to 1st value and 95%-Confidence interval
Imp
rove
men
t
Moving test by KeitelMoving test by Keitel
To bend the fingers Motility of hand joins and
arms Stand up from lying Active straddle of legs from
lying Stand up from a stool
• Standing on toes and heel
• Knee-crooking
• Standing on one foot
• Outside Rotation of the hit join
• Mobility of legs and feet
• Walking
• Climbing stairs
Moving Test by KeitelMoving Test by KeitelRheumatoide Arthritis (Radon trial Bad Brambach Rheumatoide Arthritis (Radon trial Bad Brambach
19971997))
-8
-6
-4
-2
0
2
4
6
8
end oftreatment
3 month later 6 month later
CO2CO2
Radon+CO2Radon+CO2
N = 30 N = 28/30 N = 30/29
SktDifferenzen zum Ausgangswert und 95%-Konfidenzintervall
Imp
rove
men
t
1st value1st value
Measurement of Patient Outcome - MOPOMeasurement of Patient Outcome - MOPO Physical handicap and psychosocial Consequences by Rheumatoid ArthritisPhysical handicap and psychosocial Consequences by Rheumatoid Arthritis
Mobility Physical activity Skill Activities at home Activities in daily life Social activities Pain Depression Anxiety
Assessment included:
Measurement of Patient Outcome Measurement of Patient Outcome (MOPO)(MOPO)Rheumatoide Arthritis (Radon trial Bad Brambach 1997)Rheumatoide Arthritis (Radon trial Bad Brambach 1997)
-0,8
-0,6
-0,4
-0,2
0
0,2
0,4
0,6
0,8
3 month later 6 month later
Radon+CO2Radon+CO2
CO2CO2
Differenzen zum Ausgangswert und 95%-Konfidenzintervall
upper extremity DASHlower extremity WOMACBack NASSmore Regions HAQ
Sangha O et.al. Rheumatol 56:322-333, 1997
Disease AssessmentsDisease Assessments
Rheumatoide A. HAQ Bechterew BASFI Narrow spinal channel LSS-Inst. Osteoarthrosis WOMAC
German translation by Sangha O et.al. Rheumatol 56:322-333, 1997
BASFI für Morbus Bechterew BASFI für Morbus Bechterew (Ankylosing Spondylitis)(Ankylosing Spondylitis)
Ohne Hilfe und Hilfsmittel Socken und Strümpfe anziehen Ohne Hilfe von der Hüfte aus nach vorn beugen um einen
Kugelschreiber vom Boden aufzuheben Ohne Hilfe etwas von einem Regal nehmen Von einem Wohnzimmerstuhl ohne Armlehne aufstehen ohne
dabei die Hände oder eine andere Hilfe zu benutzen Ohne Hilfe vom Boden aufstehen, wenn Sie auf dem Rücken
liegen
German translation by Sangha O et.al. Rheumatol 56:322-333, 1997
BASFI für Morbus Bechterew BASFI für Morbus Bechterew (Ankylosing Spondylitis)(Ankylosing Spondylitis)
Ohne Schmerzen 10 Minuten stehen ohne sich anzulehnen Ohne Benutzung eines Geländers oder Gehhilfen 12-15
Treppenstufen steigen. 1 Fuß pro Stufe Über die Schulter schauen ohne dabei den Körper abzudrehen. Körperlich anstrengende Tätigkeiten verrichten (z.B.
krankengymnastische Übungen, Gartenarbeit oder Sport) Zu Hause oder bei der Arbeit den ganzen Tag aktiv sein.
German translation by Sangha O et.al. Rheumatol 56:322-333, 1997
BASFI für Morbus BechterewBASFI für Morbus Bechterew((Bath Ankylosing Spondylitis Functional Index)Bath Ankylosing Spondylitis Functional Index)
Easy Unimportant
Each question 11 positions !
Ruof J et al, Z. Rheumatol 58:218-225 (1999)
Mineral water for bathingMineral water for bathingMineral water for bathingMineral water for bathingChemical quality can be used only in bath tubs
– Without any disinfections of water– With minimal concentrations of following substances
In pools only physical quality can be used– With disinfections (chlorine)– Temperature must be more than 30 °C
IndicationsIndications Sulphured water in bath tubs in rheumatology Radon water in bath tubs and Radon-gas-baths or Radon-mines CO2 water in bath tubs and CO2-gas-baths
Brine water in bath tubs Brine water in pools for kinesitherapy Thermo-neutral baths (35 °C) Cold baths (<32 °C) Cold-warm changing baths Hot baths (>39 °C)
IndicationsIndicationsSulphured-Water in bath tubs in RheumatologySulphured-Water in bath tubs in Rheumatology
IndicationsIndicationsCOCO22-Water in bath tubs and CO-Water in bath tubs and CO22-Gas-baths-Gas-baths
Disorder of microcirculation of the skin Trophic ulcera of the skin, venous ulcera Decubitus Peripheral arterial occlusive disease in any stage Functional disorder of vascularity Polyneuropathy (Malum perforans) Cerebral disorders of microcirculation Arterial hypertension Algodystrophy (M. Sudeck)
IndicationsIndicationsBrine-Water in bath tubsBrine-Water in bath tubs
Psoriasis vulgaris
+ UV-B-irradiation
Neurodermitis
+ UV-A-irradiation
IndicationsIndicationsBrine-Water in pools for kinesitherapyBrine-Water in pools for kinesitherapy
Degenerative joint diseaseSpondylarthrosisOsteoporosisPosttraumatic and postoperative
Dehydration by increase of capillary re-absorption and diuresis– Rheumatic diseases– Posttraumatic und postoperative state– Oedema
Training vegetative-hormonal functions like blood volume, blood pressure and electrolyte regulation– Convalescence– Disorder of heart-circulation-regulation– Psycho-vegetative syndrome
Thermic stimuli for training of vegetative-hormonal functions– Convalescence– Psycho-vegetative syndrome– Disorder of heart-circulation-regulation– Metabolic disorders
Bath effects Bath effects Indications hot baths (>39 °C)Indications hot baths (>39 °C)
Muscle relaxationIncrease of distensibility of connective tissue
structures Analgesic Antiphlogistic by hyperthermia
– Rheumatic diseases– Chronic-inflammatory diseases of the urogenital
system– Posttraumatic und postoperative state
Risks of bathingRisks of bathing
By immerse:increased cardiac preload result in a decompensation riskPrecaution by disorders of heart rhythm and Angina pectoris
By get out:Collapse riskPrecaution by venous diseases andorthostatic irregularity
During bathing:Loading of respiratory and lung function Precaution by respiratory insufficiency
Controles de calidad (DIN ISO 9001ff)Controles de calidad (DIN ISO 9001ff)
de la ejecución de los métodos terapéuticos
de los remedios naturales usados
de la prescripción
de los resultados terapéuticos
Quality of Health Resort MedicineQuality of Health Resort Medicine
• Quality control of
•Mineral waters
•Air and climate
•Treatment strategies
• Quality assurance by
•Technical systems
•Protection of resources
•Definition of performance standards
ConclusiónConclusiónPacientes con enfermedades crónicas
dependen de los ofrecimientos de las estaciones balnearias
En Europa no conocemos métodos mejores para esos pacientes
End of End of SlidesSlides
International Congress on International Congress on Natural Spa Therapy of the Natural Spa Therapy of the