Spa therapy and rehabilitation of musculoskeletal pathologies: a proposal for best practice in Italy

Advances in modern Balneology: new evidence-based indications from recent studies

Balneotherapy (BT) is a therapeutic approach that utilizes various forms of water-based treatments to promote health and well-being. BT possesses a rich historical heritage and has garnered recognition from esteemed institutions such as the World Health Organization (WHO). Recent scientific research enables the identification of relevant diseases (obesity, metabolic diseases, sleep disorders, mental health conditions, Long-COVID-19, and cancer rehabilitation) that could potentially benefit from balneo-therapeutic treatments, thereby presenting new avenues of opportunity for SPA ("Salus per Aquam") medicine. These conditions exemplify the potential benefits of BT for ailments beyond the traditional scope of treatment associated with BT (most commonly osteoarthritis, fibromyalgia, rheumatic back pain, and chronic inflammatory respiratory or skin disorders). Overall, the current scientific evidence suggests that BT holds significant potential for enhancing both individual wellbeing and public health. However, further high-quality clinical trials are essential to corroborate these preliminary findings and to provide critical insights into the therapeutic benefits of BT, paving the way for its broader integration into healthcare practices and public health initiatives.

Balneotherapy using thermal mineral water baths and dermatological diseases: a systematic review

Balneotherapy includes practices and methods using medically and legally recognized mineral-medicinal waters, muds and natural gases from natural springs for therapeutic purposes. One of the most widely used method in balneotherapy is bathing with thermal mineral water. In the course of the years, scientific community has produced an increasing number of evidences that this practice is an effective method for treating signs and symptoms of several pathologies such as rheumatic, cardiovascular and dermatological diseases. This systematic review is aimed at evaluating the effect of balneotherapy with thermal water baths as a treatment to manage signs and symptoms of patients affected by all types of dermatological diseases. The systematic review was conducted according to the PRISMA Statement, and its protocol was registered on PROSPERO platform (CRD42022295913). The research was performed on the databases Pubmed, Scopus, Web of Science and Cochrane. We included clinical trials evaluating the effects of balneotherapy using thermal mineral water baths for managing dermatological diseases in humans, published in English and Italian language. Eight studies were included, seven of them enrolled adults affected by psoriasis and one studied atopic dermatitis patients. The common result of all the articles included was a clear improvement of signs and symptoms of psoriasis and eczematous diseases after use of thermal mineral water baths. These effects seem to be strictly related to physical and chemical properties of thermal water used for balneotherapy. However, studies in this field are still limited to support robust evidence of the effectiveness of balneotherapy using thermal mineral water baths and often their quality is low. Thus, new clinical studies need to be carried out, using more correct methods for conducting the studies and for processing statistical data.

Relying on the French territorial offer of thermal spa therapies to build a care pathway for long COVID-19 patients

BACKGROUND

Work on long COVID-19 has mainly focused on clinical care in hospitals. Thermal spa therapies represent a therapeutic offer outside of health care institutions that are nationally or even internationally attractive. Unlike local care (hospital care, general medicine, para-medical care), their integration in the care pathways of long COVID-19 patients seems little studied. The aim of this article is to determine what place french thermal spa therapies can take in the care pathway of long COVID-19 patients.

METHODS

Based on the case of France, we carry out a geographic mapping analysis of the potential care pathways for long COVID-19 patients by cross-referencing, over the period 2020-2022, the available official data on COVID-19 contamination, hospitalisations in intensive care units and the national offer of spa treatments. This first analysis allows us, by using the method for evaluating the attractiveness of an area defined by David Huff, to evaluate the accessibility of each French department to thermal spas.

RESULTS

Using dynamic geographical mapping, this study describes two essential criteria for the integration of the thermal spa therapies offer in the care pathways of long COVID-19 patients (attractiveness of spa areas and accessibility to thermal spas) and three fundamental elements for the success of these pathways (continuity of the care pathways; clinical collaborations; adaptation of the financing modalities to each patient). Using a spatial attractiveness method, we make this type of geographical analysis more dynamic by showing the extent to which a thermal spa is accessible to long COVID-19 patients.

CONCLUSION

Based on the example of the French spa offer, this study makes it possible to place the care pathways of long COVID-19 patients in a wider area (at least national), rather than limiting them to clinical and local management in a hospital setting. The identification and operationalization of two geographical criteria for integrating a type of treatment such as a spa cure into a care pathway contributes to a finer conceptualization of the construction of healthcare pathways.

The Impact of Hot Spring Hydrotherapy on Pain Perception and Dysfunction Severity in Patients with Chronic Low Back Pain: A Systematic Review and Meta-Analysis

Background

Chronic Low Back Pain (CLBP) is a prevalent global health issue, leading to prolonged discomfort and functional limitations. Hot spring hydrotherapy, which utilizes mineral-rich, warm spring water, offers a unique physical therapy that holds promise in alleviating CLBP symptoms.

Objective

This meta-analysis aims to assess the effectiveness of hot spring hydrotherapy in improving CLBP symptoms, encompassing pain intensity, functional disability, quality of life, and medication usage.

Methods

A systematic review and meta-analysis were conducted by searching relevant literature in multiple databases. Included studies compared hot spring hydrotherapy with control interventions or other treatments. Standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated for pain intensity, functional disability, medication usage, and quality of life.

Results

A total of 16 studies met the inclusion criteria, involving 1656 participants with chronic low back pain across various countries. The meta-analysis demonstrated that hot spring hydrotherapy was effective in reducing pain intensity (SMD = -0.901, 95% CI [-1.777, -0.025], P < 0.05) and improving functional disability (SMD = -3.236, 95% CI [-4.898, -1.575], P < 0.0001) in CLBP patients. Hot spring hydrotherapy also resulted in a significant reduction in medication usage (P < 0.05). Subgroup analysis showed that the effects of hot spring hydrotherapy were more pronounced in patients aged 60 and above, while no significant differences were observed in patients below 60 years of age, single hot Spring Hydrotherapy help improve patients' quality of life.

Conclusion

Hot spring hydrotherapy is an effective intervention for improving CLBP symptoms, including pain intensity, functional disability, and medication usage. It is particularly beneficial for CLBP patients aged 60 and above. These findings support the integration of hot spring hydrotherapy into the treatment approach for CLBP, although further research is needed to determine its efficacy in younger patients and to explore the underlying mechanisms of its therapeutic effects.

Prospero Id

CRD42023430860.

Balneotherapy for osteoarthritis: a systematic review

This systematic review is aimed to evaluate the effects of balneotherapy with thermal mineral water for managing the symptoms and signs of osteoarthritis located at any anatomical site. The systematic review was conducted according to the PRISMA Statement. The following databases were consulted: PubMed, Scopus, Web of Science, Cochrane Library, DOAJ and PEDro. We included clinical trials evaluating the effects of balneotherapy as a treatment for patients with osteoarthritis, published in English and Italian language, led on human subjects. The protocol was registered in PROSPERO. Overall, 17 studies have been included in the review. All of these studies were performed on adults or elderly patients suffering from osteoarthritis localized to knees, hips, hands or lumbar spine. The treatment assessed was always the balneotherapy with thermal mineral water. The outcomes evaluated were pain, palpation/pressure sensibility, articular tenderness, functional ability, quality of life, mobility, deambulation, ability to climb stairs, medical objective and patients' subjective evaluation, superoxide dismutase enzyme activity, serum levels of interleukin-2 receptors. The results of all the included studies agree and demonstrated an improvement of all the symptoms and signs investigated. In particular, pain and quality of life were the main symptoms evaluated and both improved after the treatment with thermal water in all the studies included in the review. These effects can be attributed to physical and chemical-physical properties of thermal mineral water used. However, the quality of many studies resulted not so high due and, consequently, it is necessary to perform new clinical trial in this field using more correct methods for conducting the study and for processing statistical data.

The Potential Role of Spa Therapy in Managing Frailty in Rheumatic Patients: A Scoping Review

Frailty is not limited to the elderly, as patients with rheumatic diseases can also experience this condition. The present scoping review aimed to investigate the possibility of using the health resort setting as an alternative location for managing rheumatic patients with frailty. The research resulted in finding several in vitro, in vivo, and clinical studies, resulting in evidence supporting the effectiveness of spa treatments in reducing pain, improving function, and managing comorbidity in rheumatic diseases. Additionally, spa treatments were demonstrated to modulate the MAPK/ERK pathway and the NF-kB pathway's activation and to reduce proinflammatory molecules' secretion in rheumatic diseases, thus suggesting their potential effective role in the regulation of inflammaging in frailty. Moreover, the health resort setting may offer potential resources to reduce risk factors, such as drug consumption, inactivity, and disease severity, and may serve as a setting for developing prevention protocols for frailty. Future research should explore innovative approaches, such as exercise training and early diagnostics, for the overall management of frailty in rheumatic patients in the spa setting.

A Novel Approach to Assess Balneotherapy Effects on Musculoskeletal Diseases-An Open Interventional Trial Combining Physiological Indicators, Biomarkers, and Patients' Health Perception

The present study aimed to evaluate whether a 14-day period of balneotherapy influences the inflammatory status, health-related quality of life (QoL) and quality of sleep, underlying overall health state, and clinically relevant benefits of patients with musculoskeletal diseases (MD). The health-related QoL was evaluated using the following instruments: 5Q-5D-5L, EQ-VAS, EUROHIS-QOL, B-IPQ, and HAQ-DI. The quality of sleep was evaluated by a BaSIQS instrument. Circulating levels of IL-6 and C-reactive protein (CRP) were measured by ELISA and chemiluminescent microparticle immunoassay, respectively. The smartband, Xiaomi MI Band 4, was used for real-time sensing of physical activity and sleep quality. MD patients improved the health-related QoL measured by 5Q-5D-5L (p < 0.001), EQ-VAS (p < 0.001), EUROHIS-QOL (p = 0.017), B-IPQ (p < 0.001), and HAQ-DI (p = 0.019) after balneotherapy; the sleep quality was also improved (BaSIQS, p = 0.019). Serum concentrations of IL-6 were markedly decreased after the 14-day balneotherapy (p < 0.001). No statistically significant differences were observed regarding the physical activity and sleep quality data recorded by the smartband. Balneotherapy may be an effective alternative treatment in managing the health status of MD patients, with a decrease in inflammatory states, along with positive effects on pain reduction, patient's functionality, QoL, quality of sleep, and disability perception status.

Balneotherapy and Health-related Quality of Life in Adults with Knee Osteoarthritis: a Prospective Observational Study Into a Real Clinical Practice Condition

Aim: To analyze the influence of balneotherapy applied in conditions of real clinical practice in Fitero’s Thermal Station (Spain) on HRQoL in adults with KOA. Materials and Methods: This was a prospective observational study conducted under conditions of real clinical practice with a 9-month follow-up. The individuals were beneficiaries of the Spanish social thermalism programme. A total of 10 sessions were prescribed, individually, considering the clinical situation and preferences of each participant. In all cases, 10 bath sessions were administered, along with other techniques. The clinical assessments were conducted before initiating the balneotherapy and 1, 3, 6 and 9 months after. The main variable was HRQoL (Euroqol 5D-5L; WOMAC). The statistical analysis was performed by intention to treat. Results: The study included 71 users. At 6 months, improvements were found in the following dimensions of the WOMAC questionnaire: pain (24.47%), stiffness (30.75%) and functional capacity (26.66%) (p<0.05). Pain and anxiety/depression showed statistically significant differences in the EQ 5D-5L throughout the study. Conclusions: HRQoL in KOA would improve with the Balneotherapy, prevailing the effects for up to 6 months. The absence of adverse effects and the ease of completing the treatment provided by the Spanish social thermalism system make this treatment feasible.

Effects of hyaluronic acid injections on pain and functioning in patients affected by tendinopathies: A narrative review

BACKGROUND

Tendinopathies are overuse tendon injuries showing load-dependant pain, stiffness, weakness of movement in the affected area, and impairment in the movements. The scientific interest on the role of Hyaluronic Acid (HA) for the management of tendinopathies has been increased due to its anti-inflammatory and lubricative properties.

OBJECTIVE

To collect evidence regarding the effectiveness and safety of HA injections in reducing pain in patients affected by tendinopathies.

METHODS

A scientific literature search was conducted using the PubMed, Medline and PEDro electronic databases. The databases were searched since their inception until July 2021. The search was limited to English language articles. Different combinations of the terms and MeSH terms "tendinopathy", "tendinosis", "tendinitis", "hyaluronic acid", "hyaluronate", "infiltration", "hyaluronic injections", "viscosupplementation" connected with various boolean operators were used for other electronic databases.

RESULTS

One hundred and one records were identified from the selected databases plus three additional papers identified by the authors through other sources. After removing duplicated papers and title/abstract screening, 19 studies were included in our review (eight papers on shoulder, three on elbow, four on hand, one on knee, and three on ankle).

CONCLUSION

The results showed that none of the studies report severe adverse effects and most of them support the use of HA injections in tendinopathies, with a special attention to pain reduction and functional assessment. Further studies are warranted to better investigate effects and methods of administration of HA in tendinopathies.

Publication activity in water treatments: Web of Science-based bibliometric analysis of the last two decades

We evaluated the quantity and quality of scientific publications linked with water treatments using the Web of Science (WoS) database. The WoS was searching by using the following terms "hydrotherapy," "balneotherapy," "spa therapy," "spa treatment," "creno-balneotherapy," "water treatments," and "aqua therapy," on February 10th, 2022. The recorded data were the total number of articles, year of articles, country of articles, journal, document type, index data, and citation data. Also, the studies performed with natural source mineral water were marked to make a further subgroup analysis through quality and quantity. We obtained 816 articles; 667 (81.74%) were original research articles, and 149 (18.26%) were review articles. A statistically significant and increasing trend was shown in the publication about water treatments (p < 0.01). About three-quarters of the trials were sourced from high-income countries. Italy (n = 98; 12.01%); Turkey (n = 75; 9.19%); Australia (n = 65; 7.97%); Brazil (n = 46; 5.64%); and France (n = 38; 4.66%) were the most productive countries. Calculating the number of articles per million population, Hungary (3.38), Australia (2.53), and Italy (1.64) ranked in the top three. According to 100 billion dollars GDP, the top three countries were Brazil (24.41), Hungary (21.15), and Turkey (10.41). In the average citation calculation, the Netherlands (60.84), Israel (29.86), and Australia (29.06) were in the top three. The International Journal of Biometeorology was the leading journal for publication trials about water treatments. In the subgroup analysis, we found the total number of studies performed with natural source mineral water and non-specified source water trials as 430 and 386, respectively. We also presented that the natural source and non-specified water trials had a statistically significant and increasing trend between 2000 and 2021 (p < 0.01 and p < 0.01, respectively). The trials performed with natural source water mainly were sourced from Italy (n = 79; 18.37%), Turkey (n = 61; 14.19%), France (n = 38; 8.84%), Poland (n = 30; 6.98%), and Hungary (n = 29; 6.74%), the trials performed with non-specified water were sourced from Australia (n = 61; 15.80%), Brazil (n = 46; 11.92%), USA (n = 27; 6.99%), Italy (n = 19; 4.92%), and England (n = 18; 4.66%). The top journal of the natural source water trials was the International Journal of Biometeorology (n = 65; 15.12%), and for the non-specified water trials, it was the International Journal of Sports Physiology (n = 12; 3.11%).Our study presented an increasing trend in trial publications regarding water treatments between 2000 and 2021. Most of the trials were from high and upper-middle-income countries. We suggest that by demonstrating global productivity worldwide, our results can create more scientific attention on this topic and may promote the quantity and quality of the trials.

Clinical Impact of Balneotherapy and Therapeutic Exercise in Rheumatic Diseases: A Lexical Analysis and Scoping Review

To review the evidence regarding the clinical effect of spa therapy for rheumatic diseases, with particular attention given to association protocols between balneotherapy and rehabilitation interventions, and to support the literature research and studies’ selection with lexical analysis. Methods: A lexical analysis was performed considering a list of words representing diseases and outcome measures linked to the theme studied in our review. Then, two independent researchers conducted a literature search on PubMed using the string employed for lexical analysis, including Randomized Controlled Trials regarding spa therapy’s clinical effects on patients affected by rheumatic diseases published in the last 30 years. After the exclusion of works that did not meet the eligibility criteria, 14 studies were included in the final scoping review. Results: Spa therapy has shown a favourable effect on pain, function and quality of life in patients with Osteoarthritis, Fibromyalgia and Rheumatoid Arthritis. Different treatment modalities and types of water have demonstrated beneficial long-term clinical improvement. Furthermore, the association between thermal therapy and rehabilitation treatments has shown better clinical outcomes, probably due to the synergistic effect between the peculiar properties of the thermal waters and the therapeutic exercise program, if conducted in the same context. Conclusions: The combination of balneotherapy and rehabilitative interventions seems to be effective in ameliorating several outcomes in patients with rheumatic diseases. However, due to the wide variety of methodologies and interventions employed, these findings need to be further investigated. The lexical analysis should represent an auxiliary support for an extensive evaluation of scientific literature.

YouTube as a source of information for water treatments

The purpose of the study was to investigate the quality and reliability of YouTube videos as a source of information in water treatments. We searched videos on YouTube ( www.youtube.com ) using the following keywords: "health resort medicine," "spa treatment," "spa therapy," "hydrotherapy," "thermal medicine," "balneology," and "balneotherapy" on June 17th, 2021. The global quality scale (GQS) was used to evaluate the quality of the videos. The assessment of reliability was evaluated using the modified DISCERN tool. Some other video parameters and sources of the videos were also recorded. One hundred twenty-one (121) videos were analyzed. The most common video source was advertisement (46.3%). GQS and modified DISCERN median scores were generally low. They were superior for "hydrotherapy" and "balneotherapy" and were also higher in videos uploaded by health-related persons or organizations (physicians, health-related professionals, and health-related websites). A statistically significant positive correlation was found between investigated parameters (like view ratio, number of likes, video power index, video length) and GQS. Only video length was correlated with modified DISCERN for investigated parameters. The median video power index scores were statistically higher for "spa therapy" and "spa treatment." The YouTube content linked with water treatments has poor quality and reliability most of time. The hydrotherapy and balneotherapy keywords have the best quality and reliability.We think that designers of water treatment videos should involve health professionals more often so that the content of their video will better explain the details of medical conditions or interventions.The scientific experts should ensure a consensus in terminology to straighten the awareness of water treatments for patients and physicians.

Comparison of the effectiveness of peloid therapy and kinesio taping in tennis elbow patients: a single-blind controlled study

This study aimed to compare the peloid therapy and kinesio tape treatments in chronic lateral epicondylitis. While home exercise program and cold application were applied to the control group, peloid therapy (5 days a week for 3 weeks at 45 °C for 30 min each day, a total of 15 treatment days) was applied in addition to the first group, and kinesio taping (6 treatment days 2 times a week) was applied to the second group. Patients were evaluated with visual analog scale (VAS), grip strength with Jamar hydraulic dynamometer, Arm, Shoulder, and Hand Disabilities (DASH), quality of life in Short Form-36 (SF-36), and Patient-Rated Forearm Evaluation Questionnaire (PRFEQ) was recorded before treatment, after treatment (third week), and 1 month after the end of treatment. In this study, 156 patients with chronic lateral epicondylitis were included. In the follow-up of the patients, there was a statistically significant improvement in the hand grip strength, DASH, PRFEQ, VAS, and SF-36 scores in the 1st month follow-up after the treatment compared to the pre-treatment control in all groups (p < 0.001). At the end of the treatment, the hand grip strength (p = 0.002), DASH (p < 0.001), PRFEQ pain (p < 0.001) and function (p = 0.007), SF-36 physical health (p = 0.002) scores were statistically significant in the peloid therapy group compared to the control group. At the 1st month after the end of treatment, hand grip strength, VAS, DASH, PRFEQ pain, function, daily activities, and SF-36 physical health scores (all of p < 0.001) were statistically significant in the peloid treatment group compared to the control group. Peloid treatment was found to be more effective than kinesio taping in SF-36 physical health (p = 0.007) and PRFEQ pain (p = 0.003) scores in the 1st month follow-up after treatment. Peloid therapy in addition to exercise seems more effective in chronic lateral epicondylitis. Randomized controlled long-term studies are needed.ClinicalTrials ID: NCT04687943.

The Efficacy of Instrumental Physical Therapy through Extracorporeal Shock Wave Therapy in the Treatment of Plantar Fasciitis: An Umbrella Review

(1) Background: Plantar fasciitis (PF) is the most common cause of heel pain in adults. Extracorporeal shockwave therapy (ESWT) is a minimally invasive treatments commonly used for treating PF. Our aim is to provide a complete overview of which treatments have been compared to ESWT, with a focus on the modalities that have been used. (2) Methods: A thorough search of the literature was performed on Medline via Pubmed, Cochrane Database of Systematic Reviews (CDSR) of the Cochrane Library and Physiotherapy Evidence Databases (PEDro) up to 18 November 2021. In the study were included only systematic reviews and meta-analysis in English language, published from 2010 to date. (3) Results: A total of 14 systematic reviews and meta-analysis were included in the umbrella review. A total of eight studies compared the efficacy of ESWT treatment with placebo, three studies compared ESWT with another therapy (two studies compared ESWT and corticosteroids, one study ESWT and ultrasound therapy), and three studies had more than one comparison. (4) Conclusions: When compared to placebo, ESWT demonstrated to be effective. More randomized trials with specific comparisons between different types and intensity of SW are needed to obtain more precise information on SW effectiveness.

Efficacy of Radiofrequency as Therapy and Diagnostic Support in the Management of Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Radiofrequency (RF) is a minimally invasive procedure used to interrupt or alter nociceptive pathways for treating musculoskeletal pain. It seems a useful tool to relieve chronic pain syndromes, even if, to date, solid evidence is still needed about the effectiveness of this therapy. By this systematic review and meta-analysis, we aimed to evaluate the efficacy of RF in treating musculoskeletal pain. PubMed, Medline, Cochrane, and PEDro databases were searched to identify randomized controlled trials (RCTs) presenting the following: patients with chronic musculoskeletal pain as participants; RF as intervention; placebo, anesthetic injection, corticosteroid injection, prolotherapy, conservative treatment, physiotherapy, and transcutaneous electrical nerve stimulation as comparisons; and pain and functioning as outcomes. Continuous random-effect models with standardized mean difference (SMD) were used to compare the clinical outcomes. Overall, 26 RCTs were eligible and included in the systematic review. All of them analyzed the efficacy of RF in four different regions: cervical and lumbar spine, knee, sacroiliac (SI) joint, shoulder. The outcomes measures were pain, disability, and quality of life. A medium and large effect in favor of the RF treatment group (SMD < 0) was found for the shoulder according to the Visual Analogical Scale and for the SI joint according to the Oswestry Disability Index. A small effect in favor of the RF treatment group (SMD > 0) was found for the spine according to the 36-item Short Form Survey. Non-significant SMD was found for the other outcomes. RF represents a promising therapy for the treatment of chronic musculoskeletal pain, especially when other approaches are ineffective or not practicable. Further studies are warranted to better deepen the effectiveness of RF for pain and joint function for each anatomical region of common application.

The Challenge in Combining Pelotherapy and Electrotherapy (Iontophoresis) in One Single Therapeutic Modality

Pelotherapy and electrotherapy are therapeutic methodologies with proven success in physical medicine and rehabilitation (PMR) and dermatology fields. The main purpose of these therapeutic modalities is to reduce pain, accelerate wound healing, alleviate muscle spasms, and improve mobility, and muscle tone. Their main challenge is in the passage of some ionic species through the skin barrier. The use of drugs, such as diclofenac, corticosteroids or steroids, has gained widespread efficacy recognition in physical therapy and the therapeutic action of these drugs is widely studied in experimental and clinical trials. Unlike pharmaceutical and cosmetic clays, peloids are not subject to any prior quality control or subject to any specific European regulation. The dermal absorption values are an integral part of the risk assessment process for peloids. This work explores the converging points between these two transdermal drug delivery systems (TDDS) and the presentation of methodologies to achieve peloid safety compliance, especially concerning the potential and degree of toxicity arising from ion exchange and trace elements. TDDS is applied to the pharmaceuticals industry and drug is the generic term for the active substances released into skin tissues. The transdermal delivery of drugs or clay components with therapeutic properties is limited due to the excellent barrier function of the stratum corneum. The transdermal drug delivery of pelotherapy is enhanced by temperature and electrically by iontophoresis. The low voltage of iontophoresis and sweat phenomena with pore dilation driven by pelotherapy allows the use of the same pathways: hair follicles and sweat pore. The therapeutic integration of iontophoresis and pelotherapy focused on patient benefits and low safety-related risk may contribute to the outstanding physiological performance of pelotherapy, specifically, in the way the essential elements and exchange cations pass through the skin barrier. The validation of an innovative iontophoretic systems applied to pelotherapy can also promote future challenges in the obtaining of the ideal therapeutic control of peloids and the clinical validation of results with physiological efficacy recognition.

The effectiveness of balneotherapy and thermal aquatic exercise in postoperative persistent lumbar pain syndrome

In our study, we aimed to investigate the effectiveness of balneotherapy and aquatic exercises in patients with postoperative chronic low back pain. Forty-three patients over the age of 18 who had been operated on for herniated disc and who had at least 6 months of back and/or leg pain were included in the study. The patients have been distributed randomly into 2 groups prior to the treatment. The program comprising aquatic exercises distributed into 5 days a week for 2 weeks and 20 min (min) a day, in a 33 °C spa pool was applied to the first group. After the first group's treatment was completed, a program consisting of walking out of the pool and strengthening and stretching exercises for the hip, abdominal, back, and waist muscles was distributed into 5 days a week for 2 weeks for a total duration of 20 min per day was applied to both groups. The patients subjected to the study were evaluated before treatment, after treatment (2nd week), and at 1st and 6th months after treatment. The Visual Analogue Scale, Modified Schober Test, Finger-to-Floor Distance, Sorensen Test, Progressive Iso-inertial Lifting Evaluation, Rolland Morris Disability Index, Leeds Disability Scale, Beck Depression Inventory, Nottingham Health Profile, and Short Form 36 Health Survey parameters were evaluated. We detected a significant improvement in all parameters except for the Sorensen test, in both groups. We observed that the changes in VAS, Sorensen, NHP, and SF 36 tests in the aquatic exercise group were significantly better than those in the non-aquatic exercise group.

Italian and Japanese public attention toward balneotherapy in the COVID-19 era

Italian and Japanese public widely use balneotherapy. The population interest in balneotherapy in coronavirus disease-2019 (COVID-19) era should be investigated. Therefore, we aimed to exploit Google Trends analysis, as a measure of peoples' interest in balneotherapy, in two countries, Italy and Japan. In this infodemiology study, Google Trends was queried for the lay terms widely used by the Italian population to refer to the balneotherapy setting (terme + termale) and by the Japanese to refer to the bathing place and balneotherapy facilities ( + スパ). The internet searches in 2020 were compared to overlapping time spans in 2016-2019 and were correlated with new confirmed cases/deaths. This study demonstrated that from February 23 to June 20, 2020, and from October 4 to December 26, 2020, the internet searches of the Italian words corresponding to balneotherapy were statistically significantly decreased; however, the internet searches were not significantly different in June 21 to October 3, 2020, compared to overlapping time spans in 2016-2019 in Italy. The study also showed that from March 15 to September 5, 2020, and from November 29 to December 26, 2020, the internet searches of the Japanese words corresponding to balneotherapy were statistically significantly decreased; however, the internet searches were significantly increased in September 13 to November 7, 2020, and were not significantly different in November 8 to 28, 2020, compared to overlapping time spans in 2016-2019 in Japan. There were significant negative correlations between the relative search volume and number of new cases (rho=-0.634; p<0.001)/deaths (rho=-0.856; p<0.001) in Italy and the number of new deaths (rho=-0.348; p=0.012) in Japan. Population interest in balneotherapy has changed in the COVID-19 era both in Italy and Japan. During the early stage of pandemic (March to June), the interest was lower. After this early stage, the interest showed a recovery in both countries. In Italy, the population interest reached to its prior levels in late June through early October, with a peak in August. In Japan, the recovery exceeded the prior 4-year levels in mid-September through early November. Then, both countries demonstrated a decline in interest: began in early October in Italy and late November in Japan. This information would allow us to understand/address the population response in the pandemic in respect of the balneotherapy and would guide the preparedness of healthcare providers and planners both in this pandemic and future similar situations.

Spa therapy interventions for post respiratory rehabilitation in COVID-19 subjects: does the review of recent evidence suggest a role?

Pulmonary rehabilitation is essential in post-COVID subjects, reporting respiratory impairment after the discharge from the hospital. Because the number of patients with respiratory outcomes is high and there are few facilities available, we wonder if a spa setting could represent a valid out-of-hospital alternative. We aim to explore recent evidence related to respiratory rehabilitation in the spa environment to understand if it can represent an appropriate setting for respiratory rehabilitation interventions in post-COVID subjects. Studies were found by screening PubMed, MEDLINE, and Google Scholar databases from 2011 up to February 2021. Studies were eligible if they were reviews, randomized controlled trials (RCTs), or clinical trials, investigating respiratory interventions in the spa environment. Recent evidence has shown that inhalations and mineral-rich water immersions are effective in fighting and preventing multiple chronic respiratory tract diseases. Therefore, these treatments could also be applied to post-COVID patients with medium long-term respiratory outcomes.

The Influence of Rehabilitation on Quality of Life in Breast Cancer Survivors: A Clinical Study

Background: Breast cancer survivors report negative impacts of cancer, augmented by specific vulnerabilities to body changes, negative self-assessment, and quality-of-life concerns. The main objective of our work was to test the effect of a rehabilitation program on breast cancer patients by evaluating the change in their physical well-being during an outpatient rehabilitation setting and, subsequently, in a home rehabilitation setting, considering the individual personality profile. Methods: Patients who underwent total mastectomy with breast prostheses or tissue expanders were enrolled. Outcome assessments (Pain, Quality of Life, Personality traits for the Minnesota Multiphasic Personality Inventory-2) before treatment (T0), at the end of the rehabilitative treatment (T1 = 10 sessions 2/week, one hour/each), and after two months of follow-up (T2) were performed. Results: The data of 38 included patients were analyzed. The quadratic trend of the Visual Analogue Scale can be explained by the fact that patients have a strong reduction in the perceived pain immediately after rehabilitation in the clinic. This reduction remains constant for the home period of the rehabilitation. The personality profiles of all the participants were substantially valid. Only three patients obtained scores higher than 65 points. Conclusions: The study evidenced that in the initial phase of the rehabilitation, psychological traits such as anxiety, depression, and preoccupation could have a strong association especially with the autonomous functions and the perceived physical symptoms. However, during the therapeutic process, this association decreased and these decrements were higher when patients performed their rehabilitation at home, in a more familiar and comfortable setting.

Public interest in spa therapy during the COVID-19 pandemic: analysis of Google Trends data among Turkey

In Turkey, spas are widely used and preferred by patients who are seeking relief from their disability and pain. The spa therapy program is partly reimbursed by the national health insurance system. The objective of the present study was to leverage Google Trends to elucidate the public interest in spas in Turkey during the COVID-19 pandemic. Google Trends was queried to analyze search trends within Turkey for the Turkish term representing a spa (i.e., kaplıca) from January 01, 2016, to September 30, 2020. The relative search volume of "kaplıca" was statistically significantly decreased in the March 15-May 30, 2020 (- 73.04%; p < 0.001); May 31-July 25, 2020 (- 41.38%; p < 0.001); and July 26-September 19, 2020 (- 29.98%; p < 0.001) periods compared to similar periods of preceding 4 years (2016-2019). After June 1, 2020, the relative search volume was shown to have a moderate recovery, without reaching the level of 2016-2019. Public interest in spas showed an initial sharp decline between mid-March and May, with a moderate increase during the June-August period. This finding might be indicative of public preference in undertaking spa therapy during the COVID-19 period. In Turkey, spas might be used to increase places providing rehabilitation for both non-COVID-19 patients and survivors of COVID-19 with long-term symptoms during the pandemic.

New Viscoelastic Hydrogel Hymovis MO.RE. Single Intra-articular Injection for the Treatment of Knee Osteoarthritis in Sportsmen: Safety and Efficacy Study Results

Viscosupplementation by hyaluronic acid (HA) is recommended for non-surgical management of knee osteoarthritis (OA). This study investigated the efficacy and safety of a single i.a. (32 mg/4 ml) Hymovis MO.RE. injection, a new HA derivative hydrogel, for the treatment of adult regular sports players affected by knee OA arising from overuse injuries. Patients were prospectively enrolled if regularly practicing sports and diagnosed with Kellgren-Lawrence grade I-III OA. They received a single Hymovis MO.RE. intra-articular (i.a.) injection and were evaluated 30, 90, 180, and 360 days thereafter. The assessment involved measuring changes in knee function, pain, the activity of daily living (ADL), and quality of life (QOL) by using the Knee injury and Osteoarthritis Outcome Score (KOOS), GAIT analysis, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores for knee pain (WOMAC A) and function (WOMAC C), and a visual analogue scale (VAS) pain score. The study involved thirty-one patients, 23 women and eight men, whose median age was 49. KOOS function subscore, as well as GAIT cadence and velocity, showed a statistically significant increase at each time-point after injection (p < 0.0001). WOMAC, KOOS pain, symptoms, ADL, and QOL scores also significantly improved at all control visits. No severe adverse events or treatment-related events were detected. A single Hymovis MO.RE. (32 mg/4 ml) intra-articular injection provides a rapid, lasting, and safe response in regular sports players affected by knee OA, possibly representing a viable therapeutic option for this demanding patient subgroup. Further investigations are necessary to confirm these findings.

Effects of age, gender, frailty and falls on spatiotemporal gait parameters: a retrospective cohort study

BACKGROUND

Many studies have explored spatial and temporal gait parameters in the elderly, and showed that frailty status, fall history, age, and gender may individually strongly influence these parameters. However, it appears necessary to investigate the confounding factors more deeply in order to better know the specific role of each of these factors impacting the evolution of gait with the increase of age.

AIM

The aim of the present study was to determine the influence of frailty status, fall history, age and gender on spatiotemporal gait parameters. We hypothesized that frailty was the factor that most influence gait parameters.

SETTING

This is a monocentric retrospective study performed at Nice University Hospital Center on older out-patients.

POPULATION

Older adults were included in the study. This study explored for the first time how frailty status, age, gender and history of falls impact the multiple spatiotemporal parameters of gait using linear mixed models (LMM).

RESULTS

479 older adults (360 women and 119 men; 213 non-frail, 228 pre-frail and 38 frail; aged from 65 to 94 years; 403 non-fallers and 73 fallers). Frailty status explained fully: i) the gait speed; ii) the cadence: iii) the initial double contact: DS1; iv) the percentage of the single support phase v) the final double contact: DS2; v) the percentage of the swing phase of the gait cycle.

CONCLUSIONS

The results of this study allow a deeper understanding of the confounding factors since LMM highlighted the importance of frailty status for explaining all the spatiotemporal gait parameters.

CLINICAL REHABILITATION IMPACT

These results showed that to improve gait, clinical intervention should focus on reducing frailty status. It is also interesting to note that a history of falls explains none of the spatiotemporal gait parameters which suggests that it may be possible to improve gait in all frail subjects irrespective of their history of falls.

Integration of focal vibration and intra-articular oxygen-ozone therapy in rehabilitation of painful knee osteoarthritis

OBJECTIVE

To examine the pain-reducing effects of intra-articular oxygen-ozone (O₂O₃) injections and mechanical focal vibration (mFV) versus O₂O₃ injections alone in patients with knee osteoarthritis.

METHODS

Patients with chronic pain (>6 weeks) due to knee osteoarthritis (II-III on the Kellgren-Lawrence scale) were consecutively enrolled and divided into two groups: O₂O₃ (n = 25) and O₂O₃-mFV (n = 24). The visual analog scale (VAS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Medical Research Council (MRC) Manual Muscle Testing scale were administered at baseline (before treatment), after 3 weeks of treatment, and 1 month after the end of treatment. Patients received three once-weekly intra-articular injections of O₂O₃ into the knee (20 mL O₃, 20 μg/mL). The O₂O₃-mFV group also underwent nine sessions of mFV (three sessions per week).

RESULTS

The VAS score, KOOS, and MRC score were significantly better in the O₂O₃-mFV than O₂O₃ group. The within-group analysis showed that all scores improved over time compared with baseline and were maintained even 1 month after treatment. No adverse events occurred.

CONCLUSION

An integrated rehabilitation protocol involving O₂O₃ injections and mFV for 3 weeks reduces pain, increases autonomy in daily life activities, and strengthens the quadriceps femoris.

Robotic rehabilitation for end-effector device and botulinum toxin in upper limb rehabilitation in chronic post-stroke patients: an integrated rehabilitative approach

BACKGROUND

Determine the effects of an integrated rehabilitation protocol, including botulinum toxin and conventional rehabilitation exercise plus end-effector (EE) robotic training for functional recovery of the upper limb (UL) compared to training with the robot alone in post-chronic stroke patients with mild to severe spasticity, compared to training with the robot alone.

METHODS

In this prospective, observational case-control study, stroke patients were allocated into 2 groups: robot group (RG, patients who underwent robotic treatment with EE) and robot-toxin group (RTG, patients who in addition have carried out the injection of botulinum toxin for UL recovery). All patients were assessed by Fugl-Meyer Assessment (FMA), Motricity Index (MI), modified Ashworth scale (MAS), numeric rating scale (NRS), Box and Block Test (BBT), Frenchay Arm Test (FAT), and Barthel Index (BI) at baseline (T0), T1 (end of treatment), and T2 (3 months of follow-up).

RESULTS

Forty-four patients were included and analyzed (21RG; 23RTG). From the analysis between groups, the results suggested how there was a statistically significant difference in favor of RTG, specifically ΔT0-T1 and ΔT0-T2 for B&B p = 0.009 and p = 0.035; ΔT0-T1 and ΔT0-T2 for FAT with p = 0.016 and p = 0.031; ΔT0-T1 for MAS shoulder p = 0.016; ΔT0-T1 and ΔT0-T2 with p = 0.010 and p = 0.005 for MAS elbow; and ΔT0-T1 and ΔT0-T2 with p = 0.001 and p = 0.013 for MAS wrist.

CONCLUSION

Our results suggest, in line with the literature, a good efficacy in the reduction of spasticity and in the improvement of the function of the UL, with the reduction of pain, adopting a rehabilitation protocol integrated with BoTN, robot-assisted training, and traditional physiotherapy.

Public interest in musculoskeletal symptoms and disorders during the COVID-19 pandemic : Infodemiology study

Objective

The goal was to assess public interest in a wide range of musculoskeletal symptoms and disorders during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

We searched Google Trends for 118 search queries within the United States. We compared two timeframes of 2020 (March 15–July 4 and July 5–October 31) to similar timeframes over the four prior years (2016–2019).

Results

In the early pandemic, March 15–July 4, a statistically significant decrease in relative search volume of the majority of queries (60%) was detected, with a significant increase in only 2 queries (i.e. myalgia and toe swelling). In the phase July through October, a statistically significant decrease was detected in only 22% of search queries; there was no difference for 60% of search queries between 2020 and 2016–2019 suggesting a return to their prior levels for most of search queries. Interestingly, the search volume of 18% of search queries (i.e. fatigue, joint pain, muscle pain, myalgia, spondylosis, radiculopathy, myelopathy, neck pain, neck strain, lower back strain, sciatica, shoulder pain, frozen shoulder, elbow pain, lateral epicondylitis, wrist pain, carpal tunnel, hand pain, finger pain, trigger finger, and Morton’s neuroma) was significantly increased compared with the four prior years.

Conclusion

Public interest focused on COVID-19 and sought online information for COVID-19 symptoms in the early pandemic. In the period July through October, there was an upward trend in musculoskeletal symptoms and some colloquial terms/well-known musculoskeletal conditions coupled with a downward trend in general musculoskeletal disorder terms and certain specific diagnoses. This information may help rheumatologists understand public interest in musculoskeletal symptoms and disorders and address the needs of patients to mitigate the negative impact of the pandemic on outcomes.

Supplementary Information

The online version of this article (10.1007/s00393-021-00989-2) includes Table 1. Article and supplementary material are available at www.springermedizin.de. Please enter the title of the article in the search field, the supplementary material can be found under “Ergänzende Inhalte”.

Oxygen-Ozone Therapy in the Rehabilitation Field: State of the Art on Mechanisms of Action, Safety and Effectiveness in Patients with Musculoskeletal Disorders

In recent years, the interest in oxygen–ozone (O₂O₃) therapy application has considerably increased in the field of rehabilitation. Despite its widespread use in common clinical practice, the biochemical effects of O₂O₃ are still far from being understood, although its chemical properties seem to play a pivotal role in exerting its positive effects on different pathological conditions. Indeed, the effectiveness of O₂O₃ therapy might be partly due to the moderate oxidative stress produced by O₃ interactions with biological components. O₂O₃ therapy is widely used as an adjuvant therapeutic option in several pathological conditions characterized by chronic inflammatory processes and immune over-activation, and most musculoskeletal disorders share these pathophysiological processes. The present comprehensive review depicts the state-of-the-art on the mechanisms of action, safety and effectiveness of O₂O₃ therapy in the complex scenario of the management of musculoskeletal disorders. Taken together, our findings suggest that O₂O₃ therapy seems to reduce pain and improve functioning in patients affected by low back pain and knee osteoarthritis, as reported by several studies in the literature. However, to date, further studies are warranted to clearly investigate the therapeutic effects of this promising therapy on other musculoskeletal disorders in the field of rehabilitation.

The effect of thermal mineral waters on pain relief, physical function and quality of life in patients with osteoarthritis: A systematic review and meta-analysis

BACKGROUND

To evaluate the effectiveness and safety of thermal mineral waters therapy for pain relief, and functional improvement, and quality of life (QoL) in patients with osteoarthritis (OA).

METHODS

Cochrane Library, Web of science, EMBASE, ClinicalTrials.gov and PubMed were systematically searched for randomized controlled trials. Study inclusion criteria included assessment of the visual analog scale and Western Ontario and McMaster Universities scores and the lequesne index to evaluate the effects of thermal mineral waters on pain relief and functional improvement. Also, studies that used the European quality of life 5-dimension scale and health assessment questionnaire to assess the impact of thermal mineral waters therapy on improving QoL were included.

RESULTS

Sixteen studies were included. A meta-analysis showed that thermal mineral waters therapy could significantly reduce pain as measured visual analog scale and Western Ontario and McMaster Universities assessments (P < .001). Thermal mineral waters significantly reduced the lequesne index (P < .001) and improved joint function. Finally, compared with a control group, European quality of life 5-dimension scale and health assessment questionnaire improved significantly in patients with OA receiving thermal mineral waters therapy (P  < .05). There is no evidence that thermal mineral waters is unsafe for treating OA.

CONCLUSION

Thermal mineral waters therapy is a safe way to relieve pain, improve physical functions, and QoL in patients with OA.

Physiotherapeutic evaluation and intervention proposal on a patient with post-chikungunya chronic arthritis

BACKGROUND

Chikungunya fever is an arboviral disease characterized by a high morbidity rate related to intense and persistent arthralgia, causing a decrease in both quality of life (QoL) and productivity. This study aimed to report functional evaluation and multimodal physiotherapeutic intervention on a patient with post-chikungunya chronic arthritis (PCCA).

CASE PRESENTATION

Woman, 47 years old, resident of the municipality of Belém, state of Pará, northern Brazil, with clinical diagnosis of chikungunya fever marked by fever, swelling, pain in the joints of the hands and feet, and headache. The physiotherapeutic treatment started three months after the diagnosis and consisted of 24 sessions composed of electrotherapy, thermotherapy, and kinesiotherapy resources. The patient progressed from an initial status of intense pain in several joints to low pain in a single joint and showed improvement in all domains of QoL, mainly in limitations by physical and emotional aspects and functional capacity.

CONCLUSIONS

This case report details a proposal of multimodal physiotherapeutic intervention for a patient with functional impairments due to PCCA, suggesting that the use of physiotherapeutic resources may help this process and bring some assistance to those affected by the disease.

Mud therapy and rehabilitation - scientific relevance in the last six years (2015 – 2020) Systematic literature review and meta-analysis based on the PRISMA paradigm

Abstract Background. Balneotherapy is a stimulation - adaptation treatment method applied in the forms of bathing, drinking, and inhalation cures performed with natural therapeutic factors, a method which is acting in three main ways: thermally, mechanically, and chemically. Mud or peloids are natural therapeutic factors formed by natural processes under the influence of biological and geological phenomena, which in a finely dissolved state and mixed with water (mud) are used in medical practice in the form of baths or local procedures. Objective. This systematic review aims to rigorously select related articles and identify within their content, the main possible uses of therapeutic mud and physiological mechanisms, to see the main region of scientific interest for pelotherapy, and to discuss the value of mud therapy in rehabilitation medicine. Methods. The working method is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched for open-access articles published in English, between January 2015 and December 2020, from the following databases: Cochrane, Elsevier, NCBI/PubMed, NCBI/PMC, PEDro, and ISI Web of Knowledge/Science (the latter was also used to identify ISI indexed articles). The contextually searched syntax used was ”Pelotherapy/Peloidotherapy/Mud-therapy/ /Fango-therapy AND Rehabilitation”. The selected articles were analyzed in detail regarding pathologies addressed by mud therapy and country scientific relevance for this therapeutic method. The meta-analysis proceeded was designated to estimate the prevalence of various pathologies in the use of mud therapy. Results. Our search identified, first, 394 articles. Based on the successive filtering stages and, respectively, on the classification criteria of the Physiotherapy Evidence Database (PEDro), we finally identified/retained and analyzed 68 articles. Although, in principle, a rigorous method – and we have followed the PRISMA type paradigm – there still might be some missing works of our related article selection. On the other hand, to augment/ consolidate our documentation base, we have used also 40 papers freely found in the literature, and even – aiming, too, at an as exhaustive knowledge underpinning as possible – derogatively, we have also considered some articles which, probably being very new, couldn't yet have reached the PEDro threshold score we have settled. Conclusions. This paper overviews the current state-of-the-art knowledge in the approach of peloidotherapy in rehabilitation, with a focal point on the therapeutic properties of peloids. Keywords: mud-therapy, pelotherapy, peloidotherapy, fango therapy, rehabilitation, balneotherapy, natural therapeutic factors,

Comparison of a Novel Muscle Training Device with Conventional Rehabilitation Training in Motor Dysfunction of Lower Limb Patients: A Pilot Study

BACKGROUND

Postoperative functional training for fracture or osteoarthritis is mainly focused on functional self-exercise, which aims to recover the function of the lower limbs.

PURPOSE

To compare the function and life quality recovery in patients with fracture or arthritis treated with novel muscle training device (NMT) or conventional rehabilitation training (CRT) following surgery.

PATIENTS AND METHODS

A total of 32 fracture patients were randomly divided into the NMT or the CRT groups. The evaluation was performed on the first and 7th day after surgery. The outcome measurements included the incidence of foot drop, Deep Vein Thrombosis and pressure ulcers, Hospital for Special Surgery knee score (HSS scores), pain scores for the Visual Analogue Scale (Pain scores for VAS), Zung self-rating anxiety scale (SAS), Pittsburgh sleep quality index (PSQI) and the Barthel Index score.

RESULTS

The comparison of the change scores between the two groups indicated significant differences on day 7 following surgery in the Barthel Index score (P<0.01). The Pain scores for VAS between the two groups indicated a significant difference (P<0.05, U=20.0). The HSS scores between the two groups indicated a significant difference (P<0.05, U=19.0). The HSS scores exhibited a highly significant difference in the NMT group (P<0.01). The Mann-Whitney test was used to analyze the various components of the HSS scores. The comparison of the change scores on the function between the two groups indicated a significant difference (P<0.05). The Range of Motion difference between groups exhibited highly significant differences (P<0.01).

CONCLUSION

The novel muscle training device positively influenced the decrease in pain score, which resulted in a range increase of knee joint movement and a significant overall improvement in motion.

Proposal of Value for Customer of Spas: Expectations of Spa Patients and Tourist in Polish Spas

Literature on the trends of health tourism development has proven that it is becoming one of the most important tourism activities. With the growing popularity of this form of tourism, the structure of the needs of tourists and spa patients is simultaneously changing. This article presents the results of self-research carried out in Polish spa resorts based on a sample of 753 patients and spa tourists. The purpose of the research carried out was the development of a value proposition for the client of a spa enterprise as an element of a business model. At the same time, this paper points to the need to base spa activity on the values of sustainable development through key spa resources in the form of a therapeutic climate and natural raw materials applied in spa therapy. The key values for patients and spa tourists are the improvement of health with natural therapeutic resources, recreation in a place with a healing climate, achieving the effect of the treatment, the development of cultural activities, the possibility of taking care of a child during treatment, and the introduction of a psychologist and leisure animator. The mentioned features may become the basis for building a business model of spa enterprises to adapt the value propositions of a client in their business models to the needs demonstrated by the beneficiaries of these values. The problem raised in the article requires a simultaneous consideration of the principles of sustainable development in relation to the natural resources used in spa therapy.