Balneotherapy for chronic venous insufficiency

Physical exercise for the treatment of non-ulcerated chronic venous insufficiency

BACKGROUND

Chronic venous insufficiency (CVI) is a condition related to chronic venous disease that may progress to venous leg ulceration and impair quality of life of those affected. Treatments such as physical exercise may be useful to reduce CVI symptoms. This is an update of an earlier Cochrane Review.

OBJECTIVES

To evaluate the benefits and harms of physical exercise programmes for the treatment of individuals with non-ulcerated CVI.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 28 March 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing exercise programmes with no exercise in people with non-ulcerated CVI.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were intensity of disease signs and symptoms, ejection fraction, venous refilling time, and incidence of venous leg ulcer. Our secondary outcomes were quality of life, exercise capacity, muscle strength, incidence of surgical intervention, and ankle joint mobility. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included five RCTs involving 146 participants. The studies compared a physical exercise group with a control group that did not perform a structured exercise programme. The exercise protocols differed between studies. We assessed three studies to be at an overall unclear risk of bias, one study at overall high risk of bias, and one study at overall low risk of bias. We were not able to combine data in meta-analysis as studies did not report all outcomes, and different methods were used to measure and report outcomes. Two studies reported intensity of CVI disease signs and symptoms using a validated scale. There was no clear difference in signs and symptoms between groups in baseline to six months after treatment (Venous Clinical Severity Score mean difference (MD) -0.38, 95% confidence interval (CI) -3.02 to 2.26; 28 participants, 1 study; very low-certainty evidence), and we are uncertain if exercise alters the intensity of signs and symptoms eight weeks after treatment (MD -4.07, 95% CI -6.53 to -1.61; 21 participants, 1 study; very low-certainty evidence). There was no clear difference in ejection fraction between groups from baseline to six months follow-up (MD 4.88, 95% CI -1.82 to 11.58; 28 participants, 1 study; very low-certainty evidence). Three studies reported on venous refilling time. We are uncertain if there is an improvement in venous refilling time between groups for baseline to six-month changes (MD 10.70 seconds, 95% CI 8.86 to 12.54; 23 participants, 1 study; very low-certainty evidence) or baseline to eight-week change (MD 9.15 seconds, 95% CI 5.53 to 12.77 for right side; MD 7.25 seconds, 95% CI 5.23 to 9.27 for left side; 21 participants, 1 study; very low-certainty evidence). There was no clear difference in venous refilling index for baseline to six-month changes (MD 0.57 mL/min, 95% CI -0.96 to 2.10; 28 participants, 1 study; very low-certainty evidence). No included studies reported the incidence of venous leg ulcers. One study reported health-related quality of life using validated instruments (Venous Insufficiency Epidemiological and Economic Study (VEINES) and 36-item Short Form Health Survey (SF-36), physical component score (PCS) and mental component score (MCS)). We are uncertain if exercise alters baseline to six-month changes in health-related quality of life between groups (VEINES-QOL: MD 4.60, 95% CI 0.78 to 8.42; SF-36 PCS: MD 5.40, 95% CI 0.63 to 10.17; SF-36 MCS: MD 0.40, 95% CI -3.85 to 4.65; 40 participants, 1 study; all very low-certainty evidence). Another study used the Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-20), and we are uncertain if exercise alters baseline to eight-week changes in health-related quality of life between groups (MD 39.36, 95% CI 30.18 to 48.54; 21 participants, 1 study; very low-certainty evidence). One study reported no differences between groups without presenting data. There was no clear difference between groups in exercise capacity measured as time on treadmill (baseline to six-month changes) (MD -0.53 minutes, 95% CI -5.25 to 4.19; 35 participants, 1 study; very low-certainty evidence). We are uncertain if exercise improves exercise capacity as assessed by the 6-minute walking test (MD 77.74 metres, 95% CI 58.93 to 96.55; 21 participants, 1 study; very low-certainty evidence). Muscle strength was measured using dynamometry or using heel lifts counts. We are uncertain if exercise increases peak torque/body weight (120 revolutions per minute) (changes from baseline to six months MD 3.10 ft-lb, 95% CI 0.98 to 5.22; 29 participants, 1 study; very low-certainty evidence). There was no clear difference between groups in baseline to eight-week change in strength measured by a hand dynamometer (MD 12.24 lb, 95% CI -7.61 to 32.09 for the right side; MD 11.25, 95% CI -14.10 to 36.60 for the left side; 21 participants, 1 study; very low-certainty evidence). We are uncertain if there is an increase in heel lifts (n) (baseline to six-month changes) between groups (MD 7.70, 95% CI 0.94 to 14.46; 39 participants, 1 study; very low-certainty evidence). There was no clear difference between groups in ankle mobility measured during dynamometry (baseline to six-month change MD -1.40 degrees, 95% CI -4.77 to 1.97; 29 participants, 1 study; very low-certainty evidence). We are uncertain if exercise increases plantar flexion measured by a goniometer (baseline to eight-week change MD 12.13 degrees, 95% CI 8.28 to 15.98 for right leg; MD 10.95 degrees, 95% CI 7.93 to 13.97 for left leg; 21 participants, 1 study; very low-certainty evidence). In all cases, we downgraded the certainty of evidence due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to assess the benefits and harms of physical exercise in people with chronic venous disease. Future research into the effect of physical exercise should consider types of exercise protocols (intensity, frequency, and time), sample size, blinding, and homogeneity according to the severity of disease.

Balneotherapy for chronic venous insufficiency

BACKGROUND

Chronic venous insufficiency (CVI) is a progressive and common disease that affects the superficial and deep venous systems of the lower limbs. CVI is characterised by valvular incompetence, reflux, venous obstruction or a combination of these symptoms, with consequent distal venous hypertension. Clinical manifestations of CVI include oedema, pain, skin changes, ulcerations and dilated skin veins in the lower limbs. It places a large financial burden on health systems. There is a wide variety of treatment options for CVI, ranging from surgery and medication to compression and physiotherapy. Balneotherapy (treatments involving water) may be a relatively cheap and efficient way to deliver physiotherapy to people with CVI. This is an update of a review first published in 2019.

OBJECTIVES

To assess the effectiveness and safety of balneotherapy for the treatment of people with chronic venous insufficiency.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 June 2022.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials comparing balneotherapy to no treatment or other types of treatment for CVI. We also included studies that used a combination of treatments.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. disease severity, 2. health-related quality of life (HRQoL) and 3.

ADVERSE EFFECTS

Our secondary outcomes were 1. pain, 2. oedema, 3. leg ulcer incidence and 4. skin pigmentation changes. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included nine randomised controlled trials involving 1126 participants with CVI. Seven studies evaluated balneotherapy versus no treatment, one study evaluated balneotherapy versus a phlebotonic drug (melilotus officinalis), and one study evaluated balneotherapy versus dryland exercises. We downgraded our certainty in the evidence due to a lack of blinding of participants and investigators, participant-reported outcomes and imprecision. Balneotherapy versus no treatment Balneotherapy compared to no treatment probably results in slightly improved disease severity signs and symptoms scores as assessed by the Venous Clinical Severity Score (VCSS; mean difference (MD) -1.75, 95% confidence interval (CI) -3.02 to -0.49; 3 studies, 671 participants; moderate-certainty evidence). Balneotherapy compared to no treatment may improve HRQoL as assessed by the Chronic Venous Insufficiency Quality of Life Questionnaire 2 (CIVIQ2) at three months, but we are very uncertain about the results (MD -10.46, 95% CI -19.21 to -1.71; 2 studies, 153 participants; very low-certainty evidence). The intervention may improve HRQoL at 12 months (MD -4.48, 95% CI -8.61 to -0.36; 2 studies, 417 participants; low-certainty evidence). It is unclear if the intervention has an effect at six months (MD -2.99, 95% CI -6.53 to 0.56; 2 studies, 436 participants; low-certainty evidence) or nine months (MD -6.40, 95% CI -13.84 to 1.04; 1 study, 59 participants; very low-certainty evidence). Balneotherapy compared with no treatment may have little or no effect on the occurrence of adverse effects. The main adverse effects were thromboembolic events (odds radio (OR) 0.35, 95% CI 0.09 to 1.42; 3 studies, 584 participants; low-certainty evidence), erysipelas (OR 2.58, 95% CI 0.65 to 10.22; 2 studies, 519 participants; low-certainty evidence) and palpitations (OR 0.33, 95% CI 0.01 to 8.52; 1 study, 59 participants; low-certainty evidence). No studies reported any serious adverse effects. Balneotherapy compared with no treatment may improve pain scores slightly at three months (MD -1.12, 95% CI -1.35 to -0.88; 2 studies, 354 participants; low-certainty evidence); and six months (MD -1.02, 95% CI -1.25 to -0.78; 2 studies, 352 participants; low-certainty evidence). Balneotherapy compared with no treatment may have little or no effect on oedema (measured by leg circumference) at 24 days to three months, but we are very uncertain about the results (standardised mean difference (SMD) 0.32 cm, 95% CI -0.70 to 1.34; 3 studies, 369 participants; very low-certainty evidence). Balneotherapy compared with no treatment may have little or no effect on the incidence of leg ulcers at 12 months, but we are very uncertain about the results (OR 1.06, 95% CI 0.27 to 4.14; 2 studies, 449 participants; very low-certainty evidence). Balneotherapy compared with no treatment may slightly reduce skin pigmentation changes as measured by the pigmentation index at 12 months (MD -3.60, 95% CI -5.95 to -1.25; 1 study, 59 participants; low-certainty evidence). Balneotherapy versus melilotus officinalis For the comparison balneotherapy versus a phlebotonic drug (melilotus officinalis), there was little or no difference in pain symptoms (OR 0.29, 95% CI 0.03 to 2.87; 1 study, 35 participants; very low-certainty evidence) or oedema (OR 0.21, 95% CI 0.02 to 2.27; 1 study, 35 participants; very low-certainty evidence), but we are very uncertain about the results. The study reported no other outcomes of interest. Balneotherapy versus dryland exercise For the comparison balneotherapy versus dryland exercise, evidence from one study showed that balneotherapy may improve HRQoL as assessed by the Varicose Vein Symptom Questionnaire (VVSymQ), but we are very uncertain about the results (MD -3.00, 95% CI -3.80 to -2.20; 34 participants, very low-certainty evidence). Balneotherapy compared with dryland exercises may reduce oedema (leg volume) after five sessions of treatment (right leg: MD -840.70, 95% CI -1053.26 to -628.14; left leg: MD -767.50, 95% CI -910.07 to -624.93; 1 study, 34 participants, low-certainty evidence). The study reported no other outcomes of interest.

AUTHORS' CONCLUSIONS

For the comparison balneotherapy versus no treatment, we identified moderate-certainty evidence that the intervention improves disease severity signs and symptoms scores slightly, low-certainty evidence that it improves pain and skin pigmentation changes, and very low-certainty evidence that it improves HRQoL. Balneotherapy compared with no treatment made little or no difference to adverse effects, oedema or incidence of leg ulcers. Evidence comparing balneotherapy with other interventions was very limited. To ensure adequate comparison between trials, future trials should standardise measurements of outcomes (e.g. disease severity signs and symptoms score, HRQoL, pain and oedema) and follow-up time points.

Effectiveness of Vascular Balneotherapy in the Treatment of Chronic Venous Disease (CVD)

Aim: Inside the “Antica Querciolaia” Thermal Station, located in the municipality of Rapolano Terme (Siena), there is a well, called “Well 5 – Cold Bath”, from which gushes a homeothermic alkaline bicarbonate-sulphate mineral water, considered suitable for thermal use with venous vascular address. The main endpoint of the study was to demonstrate the effects of vascular balneotherapy with thermal mineral water on classical symptoms, such as edema and quality of life of patients with chronic venous disease in the lower limbs, while the secondary endpoint was to verify the efficacy and tolerability of vascular balneotherapy carried out in predefined vascular paths and with a standardized protocol. Materials and Methods: In the double-blind, randomized controlled study, 60 patients with chronic venous disease of the lower limbs were enrolled in the first three stages of the CEAP classification. The patients were divided into two equivalent groups: “Balneotherapy Group”, treated with baths in thermal mineral water from “Well 5 – Cold Bath” and venoactive drug therapy and “Control Group” which only took drug therapy in an equivalent dose and duration. Results: The results of the study show a clear improvement of the “Balneotherapy Group” compared to the “Control Group” in the treatment of chronic venous disease of the lower limbs, concerning both the primary and secondary endpoints set by the study. Conclusions: Our findings show the undoubted efficacy and excellent tolerability of vascular balneotherapy in the treatment of chronic venous disease of the lower limbs.

Systematic review of adapted physical activity and therapeutic education of patients with chronic venous disease

BACKGROUND

Chronic venous disease (CVD), comprising impaired lower limb venous return, will lead to chronic distal venous pressure overload manifested by various clinical signs and symptoms and resulting in diminished quality of life. The CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) classification of CVD distinguishes six stages (C0-C6) using clinical, etiologic, anatomic, and pathophysiologic parameters. In the present study, we analyzed the effects of adapted physical activity (APA) and patient-oriented therapeutic education (PTE) programs on the clinical signs, symptoms, and quality of life of patients with CVD.

METHODS

Our analysis, in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) recommendations, included a search of PubMed, CINAHL and LiSSa databases, using a single search equation.

RESULTS

A total of 21 studies were selected for analysis. The analysis revealed first, that patients at stage C0 to C5 had had access to an APA program. This therapy alleviated the clinical signs and symptoms and improved the patients' quality of life. The beneficial effects of APA were greater in the programs that had included aquatic activities than in the program that were exclusively dry-land programs. Second, patients at stage C6 had predominantly followed a PTE program. This therapy showed beneficial effects on the clinical signs and symptoms. However, the quality of life had rarely been assessed.

CONCLUSIONS

At present, APA and PTE programs comprise useful and complementary therapeutic options for the care of patients with CVD. Two of the studies included in our review had evaluated the effects of combining these two approaches, notably in the context of balneotherapy, and reported promising results.

Sleep and spa therapies: What is the role of balneotherapy associated with exercise? A systematic review

Balneotherapy and exercise are potential factors influencing sleep through several physiological pathways and relaxing effects. This review aims to assess whether balneotherapy can improve sleep quality in concomitance or not with exercise. The research was conducted on Medline, Scopus, PubMed, Web of Science, and Cochrane Library databases. The current review followed PRISMA reporting guidelines and involves twenty-one articles grouped into four sections based on the characteristics of the balneotherapy protocol: 1.a Balneotherapy–thermal water immersion alone (five studies); 1.b Balneotherapy–thermal water immersion with other spa treatments (six studies); 2.a Balneotherapy and physical exercise–balneotherapy and out-of-the-pool physical exercise (eight studies); 2.b Balneotherapy and physical exercise–balneotherapy and in-pool physical exercise (three studies). Apart from healthy or sub-healthy subjects, patients recruited in the studies were affected by fibromyalgia, ankylosing spondylitis, osteoarthritis, musculoskeletal pain, subacute supraspinatus tendinopathy, and mental disorders. Duration, number of sessions, and study protocols are very different from each other. Only one study objectively evaluated sleep, whereas the others used subjective sleep assessment methods. Eight studies considered sleep as a primary outcome and ten as secondary. Sixteen out of twenty-one studies described improvements in self-perceived sleep quality. Thus, balneotherapy associated with other spa treatments and physical exercise seems to be effective in improving self-perceived sleep quality. However, the miscellany of treatments makes it difficult to discern the isolated effects of balneotherapy and physical exercise. Future studies should consider using an objective sleep assessment method and describing the pathways and physiological mechanisms that could provoke sleep changes during balneotherapy treatments.

Clinical efficacy of medical hydrology: an umbrella review

The aim of this research was to summarize available scientific evidence on the efficacy of medical hydrology for the management of any health condition. The search was conducted on 26th March 2021, in the following databases: Medline (via PubMed), EMBASE, Web of Science, Cochrane Library, and Google Scholar. All relevant literature reviews investigating the clinical efficacy of interventions characterized by the use of natural mineral waters and muds were included. The quality of studies was assessed with the "AMSTAR 2" tool. After article screening, 49 reviews were included in this work. Overall, retrieved scientific evidence suggests that spa therapy is beneficial for patients affected by some specific musculoskeletal conditions, with improvements potentially lasting up to 9 months. Moreover, balneotherapy can be an integrative support for the management of chronic venous insufficiency and some inflammatory skin diseases like psoriasis. The role of spa therapy in rehabilitation appears relevant as well. More limited, although interesting evidence exists for inhalation and hydropinic therapies. Globally, retrieved evidence suggests that, besides individual wellbeing, medical hydrology can be useful for public health. In particular, higher-quality studies seem to support the integrative use of spa-related interventions for conditions like osteoarthritis, fibromyalgia, low back pain of rheumatic origin, and chronic venous insufficiency. However, the body of evidence has some limitations and further clinical trials should be designed for each relevant application to consolidate and expand acquired knowledge.

Main Therapeutic Uses of Some Moroccan Hot Springs' Waters

Morocco has an important groundwater reserve, especially in the Atlas domain, corresponding to its largest water reservoir. This reserve comes from rainwater infiltrated into rocks and sediments to give rise to mineralized waters feeding many springs and having curative properties, which confer each spa-specific therapeutic indications, based on the medicinal properties of its waters. All over the world, mineral waters of thermal springs have interesting therapeutic uses to cure some diseases; unfortunately, such potential is underexploited in Morocco. This narrative review deals with the distribution of thermal springs in Morocco, the classification of their thermal waters, and their health effects, with the aim to enhance them. For this purpose, previous studies' results on different aspects of thermal waters were searched in the most famous scientific databases, by using targeted specific keywords. Literature has shown that Morocco contains several thermal springs, scattered throughout the Middle Atlas, in the South, and in the Rif, which are regarded as waters of high therapeutic quality, whose thermal cures are often recommended to people suffering from rheumatism and locomotor system's diseases, skin diseases such as eczema and psoriasis, cardiovascular diseases, overweight, or respiratory troubles. However, apart from the unique and real thermal station of Moulay Yacoub, the other thermal springs are exploited in an empirical and artisanal way, mainly by a local population. So, as hydrotherapy constitutes a good choice of natural therapy using water components as a complement or alternative to conventional treatments, a better understanding of the thermal springs' distribution in Morocco, their thermal waters' classification, and their potential health effects may enable their valorization through a better use of their waters.

Overview of Systematic Reviews with Meta-Analysis Based on Randomized Controlled Trials of Balneotherapy and Spa Therapy from 2000 to 2019

Background

The objectives of this review were to summarize systematic reviews with meta-analysis of balneotherapy (BT) and spa therapy (ST) based on randomized controlled trials, and to provide a perspective for future research.

Methods

Eligible studies were systematic reviews based on randomized controlled trials with meta-analysis that included at least one group treated with BT or ST. We searched the following databases for articles published in English from the year 2000 to 20 November 2019: Cochrane Database Systematic Review, MEDLINE, CINAHL, Web of Science, and Ichushi-Web.

Results

Eighteen studies met all inclusion criteria. Based on the International Classification of Diseases (ICD)-11, among these 18 studies, 8 (44%) were about “#15 Diseases of the musculoskeletal system or connective tissue”, 5 (28%) were about “#21 Symptoms, signs or clinical findings, not elsewhere classified”, 4 (22%) were about “#11 Diseases of the circulatory system”, and 1 study (6%) was about “#8 Diseases of the nervous system”. Both BT and ST provided significant pain relief and improved quality of life in chronic diseases of the musculoskeletal system and connective tissues. Additionally, BT and ST with exercise under water improved physical fitness and function in patients across diseases.

Conclusion

Researchers need to conduct studies on the treatment of many kinds of potential diseases using the keywords of pain relief and QoL. In addition, depending on patients’ symptoms, physical fitness, and disabilities, performing exercise under water may improve treatment effects on physical function and fitness.

Association of Daily Home-Based Hot Water Bathing and Glycemic Control in Ambulatory Japanese Patients with Type 2 Diabetes Mellitus During the COVID-19 Pandemic: A Multicenter Cross-Sectional Study

PURPOSE

To clarify the relationship between daily hot water bathing (HWB) at home and glycemic control in middle-aged and elderly ambulatory patients with type 2 diabetes mellitus (T2DM).

METHODS

We defined hemoglobin A1c (HbA1c) as the main outcome. We set 7.0% based on the mean value of the dependent variable as the cut-off point for analysis. Frequency of HWB was an explanatory variable. A two-sample t-test was used to compare between groups with continuous variables. Multiple logistic regression analysis was performed for frequency, adjusted age, sex, BMI, T2DM duration (Model 1), and other confounding factors (Model 2). Odds ratio (OR) and 95% confidence interval (95% CI) were calculated.

RESULTS

Among 838 patients, there was a significant difference (p<0.001) in age between males (n=528, 62.8±8.7 years) and females (n=310, 65.0±8.1 years). In Model 1, compared with participants who used HWB more than seven times a week, those with poorly controlled HbA1c were significantly associated with low frequency of HWB: four to six times a week (OR 1.32, 95% CI 0.87-1.99) and less than three times a week (OR 1.43, 95% CI 0.98-2.10); p-value for overall trend was 0.041. In Model 2, p-value for overall trend was 0.138.

CONCLUSION

A higher frequency of HWB was moderately associated with a decreased risk of poor glycemic control in middle-aged and elderly ambulatory patients with T2DM.