Phytothermotherapy in fibromyalgia and osteoarthritis

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Review article

Phytothermotherapy in fibromyalgia and osteoarthritis: Between tradition and modern medicine Sara Tenti a , Patrizia Manica b , Mauro Galeazzi a , Antonella Fioravanti a,∗ a

Rheumatology Unit, Department of Clinical Medicine and Immunological Sciences, University of Siena, Italy b Thermal Resort of Garniga Terme, Italy Received 18 September 2012; received in revised form 11 December 2012; accepted 17 December 2012

Abstract Introduction: Phytothermotherapy (PTT) is a singular treatment consisting in immersing oneself in pools of fermenting alpine grass, to exploit its heat and rich aromatic components. The efficacy of PTT in rheumatic diseases (RD) is bolstered by ancient tradition. However, there is a marked lack of clinical validation of its efficacy and tolerability in current literature. The objective of this review was to summarize the actually available knowledges on possible effects of PTT in RD. Methodology: We conducted a search of the literature in May 2012. Medline was searched using the term “phytothermotherapy” and “hay baths” in combination with “rheumatic diseases”, “fibromyalgia syndrome”, “osteoarthritis”. Results: We identified one article reporting the clinical effects of PTT in 56 patients with fibromyalgia syndrome (FMS) and 3 trials describing the results of PTT in osteoarthritis (OA). The available data demonstrate that PTT is efficacy in decreasing pain and disability and improving function in patients with FMS and OA. Furthermore, the tolerability of PTT is excellent. The actual mechanism of action of PTT is yet not completely known, although it’s probably due to different combined mechanical, physical and chemical effects. Discussion: PTT could represent a useful aid in the treatment of FMS and OA. However, further studies on a larger number of patients are needed to provide more precise therapeutic guidelines on the modalities of use of PTT. Additionally, there is a need for further botanical investigations and researches on the mechanisms of actions of PTT. © 2013 Published by Elsevier GmbH. Keywords: Phytothermotherapy; Rheumatic diseases; Osteoarthritis; Fibromyalgia syndrome; Fresh grass; Fermenting grasses

Introduction Phytothermotherapy (PTT) is a singular treatment consisting in immersing oneself in pools of fermenting alpine grass, to exploit its heat and rich aromatic components. The traditional expression “hay baths”, corresponding to the German “Heybaeder”, is actually inappropriate, because in reality for PTT only fresh grass, or frozen grass to avoid desiccation, is used. The traditional name, although substantially incorrect, undoubtedly derives from the fact that this procedure was originally linked to haymaking practices. The expressions “grass baths” or more simply “phytothermotherapy” seem, thus, more accurate [1].

∗

Corresponding author at: Rheumatology Unit, University of Siena, Policlinico “Le Scotte”, Viale Bracci 1, 53100 Siena, Italy. Tel.: +39 0577 233345; fax: +39 0577 40450. E-mail address: [email protected] (A. Fioravanti).

PTT represents a popular treatment for many rheumatic disease (RD); the main indications for PTT include osteoarthritis (OA) and other degenerative joint diseases, extra-articular rheumatisms, both generalized, fibromyalgia syndrome (FMS), or localized forms [1]. The efficacy of PTT in RD is bolstered by ancient tradition. However, despite its long history and popularity, there is a marked lack of clinical validation of its efficacy and tolerability in current literature. In an era of evidence based medicine, it is necessary to ask what real medical and scientific value this therapy have. The objective of this review is to summarize the currently available information on possible effects of PTT in RD. We also provide some suggestions for further development in this area. Historical background Bathing in fermenting mountain grass for alleviation of “joint pains” is a rather ancient practice traditionally carried out in

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Please cite this article in press as: Tenti S, et al. Phytothermotherapy in fibromyalgia and osteoarthritis: Between tradition and modern medicine. Eur J Integr Med (2013), http://dx.doi.org/10.1016/j.eujim.2012.12.002

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some areas of northeast Italy and Austria. There is some evidence that already at the beginning of the XIX century peasants from some areas of those regions, after a whole day spent in haymaking, during the evening used to lay down on a bed of freshly cut grass and wake up in the morning feeling perfectly refreshed and in great shape [2]. Throughout the second half of the 19th century, such popular practice gradually begun to assume the features of an accepted medical practice. In 1871, dr. Lersh from Aachen in one of his writings on PTT, observed that “grass baths” were used not only by peasants, but also by all people suffering of “joint pain” [3]. Actually this treatment is used and studied to treating RD especially in the area of Monte Bondone, a mountain above Trento (Italy). Phytothermotherapy: the method In the original method [3] the herbs used for the PTT come from mountains meadows which are situated at altitudes between 1200 and 1500 m. The grass is a special composite blend of different herbs, encompassing, among others, woundwort, Arnica montana (European Arnica, Mountain Tobacco, Leopard’s Bane), Achillea millefolium (Yarrow), Alchemilla vulgaris (Bear’s foot, Ladies Mantle), Plantago media (Plantain), Thymus serpyllum (Thyme), Taraxacum alpinum (Blow ball, Lion’s tooth), Vaccinium myrtillus (Blueberry), Gentiana lutea (Gentian) [4]. Harvesting at the mentioned altitudes not only guarantees a peculiar floral mix, but also avoids finding insects such as tics and other parasites, virtually inexistent over 1200 m above sea level. The grass, mowed, collected and transported down to the valley, is then placed in 50 cm thick vats, where, left to ferment, develops heat due to its own metabolic activity as well as that of the associated microbial flora. After 1–2 days, the deeper layers reach temperatures of 60 ◦ C or more; which is maintained throughout the whole thermal treatment. The patient immerses in the warm bath and is covered with a 10–20 cm thick layer of grass, every day for 20 min. After each bath, the patient lays on a reaction couch, wrapped in a woollen

blanket, for 30–45 min. The reaction is characterized by profuse sweating which gradually diminishes in 3–4 h. A complete cycle of PTT lasts 10 days, with a 1 day interval halfway through the cure. Such a break is necessary to prevent a possible reaction called “thermal crisis” and characterized by asthenia, migraines, insomnia, malaise, increased joint pain, which can manifest after the third or fourth bath [1,5]. The method described above is used also today to treat RD. Methodology A short review was conducted by searching the literature in May 2012. We searched the PubMed and Scopus (the period examined was 1980–2012) for clinical trials, examining the effect of PTT in RD. Medline was searched using the term “phytothermotherapy” and “hay baths” in combination with “rheumatic diseases”, “fibromyalgia syndrome”, “osteoarthritis”. We included only papers published in English or Italian languages and in a peer-reviewed journals. Diagnosis of knee and hip OA and of FMS met ACR criteria [7,15,16]. Results Clinical studies in rheumatic diseases We identified one article reporting the effects of PTT in 56 patients with FMS and 3 trials describing the results of PTT in OA (Table 1). In a recent study Fioravanti et al. [6] have evaluated the efficacy and tolerability of a cycle of PTT through a single-blind, controlled, randomized clinical trial in patients with primary FMS who are poor responders to a pharmacological treatment administered for at least 3 months. Fifty-six females with primary FMS who met the ACR criteria [7] and were aged between 33 and 67 years were included in the study. The patients were randomly allocated to two groups: 30 were submitted to PTT (group

Table 1 Clinical trials on PTT in FMS and OA. Authors

Disease

Trial design

Sample size

Intervention

Main outcomes

Follow-up

Results

Fioravanti et al. [6]

FMS

SB-RCT

56

G I: PTT G II: Ambulatory care

FIQ; TPC; HAQ; AIMS1

24 weeks

27

PTT

VAS; morning stiffness; grip strength; patient general assessment Lequesne index; drug consumption

24 weeks

Persistent improvement at 24 weeks of all evaluation parameters Persistent improvement of all parameters at 24 weeks

Miori et al. [1]

OA

Open study

Miori et al. [12]

OA

Observational study

142

Fioravanti et al. [14]

OA

SB-RCT

218

VAS; HAQ; Lequesne index; RMQ; drug consumption

12 weeks

G I: PTT G II: Ambulatory care G III: FKT G I: PTT

48 weeks

Persistent improvements of Lequesne index at 48 weeks in groups I and II Persistent improvement of VAS at 12 weeks in group I

Abbreviations: FMS, fibromyalgia syndrome; SB-RCT, single-blind-randomized clinical trial; PTT, phytothermotherapy; FIQ, Fibromyalgia Impact Questionnaire; TPC, Tender Points Counts; HAQ, Health Assessment Questionnaire; AIMS1, Arthritis Impact Measurement Scales; OA, osteoarthritis; VAS, Visual Analogue Scale; FKT, physio-kinesitherapy; RMQ, Rolland Morris Questionnaire.



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I) at the thermal resort of Garnica Terme (Trento, Italy) and the other 26 were considered as controls (group II). Group I patients were submitted to 10 generalized daily immersions of 20 min each in warm (50–58 ◦ C) grass. The grass used was grown 1200–1500 m above sea level, on Monte Bondone (Trento, Italy). The cycle comprised of 10 baths, with a day of rest after the fifth bath. Group II continued the pharmacological treatment alone. Patients were evaluated using the following: Fibromyalgia Impact Questionnaire (FIQ) [8], comprising 20 questions distributed into 10 items (functional capacity, well-being, absence from work, work capacity, pain, fatigue, morning stiffness, sleep, anxiety and depression) [9], that detects and measures functional disability and health status; Tender Points Count (determined by digital pressure), Health Assessment Questionnaire (HAQ) [10] that consists in 41 questions, including 20 activities of daily living items and 21 items about aids and devices to measure the success or failure of treatment intervention; Arthritis Impact Measurement Scales (AIMS1) [11] that captures areas of mobility, activities of daily living, shopping, and domestic activities, and also includes hand and fine motor use. These parameters were assessed at baseline, after 10 days, then after 12 and 24 weeks. Data at baseline demonstrated that the clinical pictures were similar in the two groups of patients and no significant differences were observed in the evaluation parameters. Patients submitted to PTT showed visible and significant improvement of all evaluation parameters at the end of the treatment, which persisted during the follow-up period. The favourable effects extended to several domains, including pain, fatigue, general health and physical functioning. No significant differences were found for the control group. Regarding the tolerability, none of the patients presented side effects. In conclusion, this study presented PTT as a useful aid alongside the usual pharmacological and physio-kinesitherapy (FKT) in FMS patients. To verify the efficacy of PTT in OA, Miori et al. [1] performed an open study on 27 patients (15 of them with a generalized OA form). The following clinical features were considered: pain in affected joints evaluated by Visual Analogue Scale (VAS), presence of global subjective improvement (or lack of it) immediately and 6 months after treatment, degree of global functional impairment, stiffness duration, handgrip strength. The mean score at the affected joints (on the VAS) was 2.51 ± 0.71 before and 1.83 ± 0.89 after treatment (p < 0.001), with improvement in 68% of patients. Morning stiffness was reduced from 38.9 ± 30.5 to 17.5 ± 17.2 min (p < 0.05), with improvement in 57% of patients. Grip strength measure went from 136 ± 59.7 to 147 ± 51 mmHg (p < 0.01), with improvement in 77% of patients. Patient general assessment demonstrated an improvement in 72% of cases immediately after treatment, and in 80% after 6 months. Tolerability was high in 23 out of 25 patients, nobody was taken off treatment because of side effects, in two cases a 1 day interval due to asthenia was introduced. In an other observational study, Miori et al. [12] reported the long term efficacy of one cycle of PTT in a group of patients affected by gonarthrosis, in comparison with the outcome of a conventional medical treatment and FKT. 142 patients with primary knee OA were included in the study: 54 patients (group A) were treated with a single course of PTT, 58 patients (group B)

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continued with their usual outpatient care, and 30 patients (group C) were treated with a course of FKT. For each group of consecutively treated patients the authors evaluated the Lequesne algo-functional index [13], a validated, disease-specific questionnaire addressing in a single index knee pain (5 questions scored on a 0–2 scale, with 0 indicating absent and 2 indicating severe), function limitation (4 questions, same scale), and maximum distance walked (1 question scored on a 0–6 distance scale, with 0 indicating ability to walk unlimited distances and 6 indicating ability to walk 30 mm, for at least 3 months prior to inclusion in the study. Patients were randomly allocated into two groups: group I (109 patients) were submitted to PTT at the thermal centre of Garniga Terme and group II (109 patients) as control group, continued regular outpatient care (exercises, non-steroidal anti-inflammatory drugs (NSAIDs) and/or analgesics). Group I patients were submitted to ten generalized daily immersions of 20 min each in warm (50–58 ◦ C) hay. Patients in both groups were advised to note daily in a diary the consumption of analgesic and NSAIDs. Patients were assessed at baseline, after 2 weeks and 3 months from the beginning of the study and were evaluated by VAS for pain intensity, HAQ, Lequesne index for hip and knee OA, Rolland Morris Questionnaire (RMQ) for lumbar spine OA (an important tool to assess function of patients with low back pain) [18] and symptomatic drug consumption. In patients treated with PTT the authors observed a significant improvement of VAS, at the end of the treatment and 3 months later, and in the HAQ index after 15 days. Furthermore, a significant reduction of NSAIDs consumption was reported in the group I. In the control group no significant differences were noted, compared to the basal time. The analyses performed separately for each subgroup of OA localization showed that the best results were evident in lumbar spine OA patients who presented significant improvement in RMQ score and HAQ index. Concerning tolerability, in the group treated with PTT 10% of patients presented side effects due to treatment, but these were of low intensity and did not interrupt the therapy. In conclusion, this study shows the beneficial effects of a cycle of PTT in patients with OA of the hip, knee, or lumbar spine.


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Tolerability Studies performed on the behaviour of a series of physiological parameters (arterial blood pressure monitored through time, cardiac frequency, biohumoral parameters, body temperature measured during the baths) [19,20], and careful monitoring for possible onset of side effects, mainly in patients presenting co-morbidities and of advanced age, have demonstrated the excellent tolerability of PTT. Few cutaneous papules, usually non itchy, frequently appear, resolving themselves spontaneously in a few days simply continuing with the cure. 10% of patients may suffer a worsening of the joint pain symptomatology immediately after completing the entire baths cycle; however this does not entail a reduction of the benefits seen during medium- and long-term follow-up. Exclusion criteria are basically limited to those patients with non stabilized ischaemic cardiopathies, decompensated nephropathies, cardiopathies and hepatopathies, neoplasms (within the 5th year), skin pathologies involving a continuous cutaneous lesion, acute inflammatory processes, active phlebitis or phlebothrombosis. Patients presenting articular forms in a phase of evident inflammatory activity also need to be excluded, as well as patients with known personal history of allergies, “hay” fever, pollen allergies or food intolerances [19,20]. Presence of arthroprosthesis or varicose phlebopaties of the lower extremities are not considered a contraindication. Mechanisms of action As for other thermal therapies, the actual mechanism of action of PTT is yet not completely known, although it’s probably ascribable to a series of different combined mechanical, physical, chemical and physio-chemical effects [21,22]. Such mechanisms may be distinguished in aspecific, common to hot baths in general, and specific, dependent upon the composition of the particular herbs used [4]. While the former are well known, the latter are difficult to identify and assess. It has been reported that hot stimuli produces analgesia on nerve endings by increasing the pain threshold. It causes relief of muscle spasms through the gamma fibres of muscle spindles and activates the descending pain inhibitory system. According to the “gate theory”, pain relief may be due to the temperature and hydrostatic pressure of water on the skin [23]. Moreover, thermal stimulation increases the extensibility of collagen-rich tissues, such as tendons, fasciae and articular capsules, which may improve the range of joint motion [21]. These effects of PTT on muscle tone, joint mobility and pain intensity may be effective in all the RD characterized by painful symptoms and prolonged muscle tension. The baths’ high temperatures induce rapid superficial hyperaemia together with an initial deep decongestion, followed by active hyperaemia of the deep tissues, including periarticular tissues (capsules, ligaments). The most important outcomes caused by the hyperaemia and by the increase in the circulation speed are represented by the elimination of the inflammatory mediators, the reduction in muscle tone, and tissue oedema. In particular, it has been demonstrated by measuring limbs circumference, by bioimpedance analysis and by measuring skin

moisture, that, by the end of the PTT treatment there is a marked reduction in tissue oedema [20]. Furthermore, thermal stress provokes a series of neuroendocrine reactions. In particular, the heat stimulates the release of adrenocorticotropic hormone (ACTH), cortisol, prolactin and growth hormone (GH), although it does not alter the circadian rhythm of these hormones [24]. The effect of thermal stress on the hypothalamus-pituitary-adrenal axis seems to be particularly important for the antiedemigenous and anti-inflammatory actions of corticosteroids, as well as for the frequent alteration of the axis during some RD [25]. The increase in beta-endorphin demonstrated to occur with various spa therapy techniques [26–29] has an analgesic and anti-spastic effect that is particularly important in patients for whom pain is the prevalent symptom. This increase in beta-endorphin is probably the key factor in the mechanism of individual tolerance to thermal baths. The effects described make it possible to break the vicious circle of pain-muscle contraction-altered joint dynamics-pain that characterizes many chronic arthropathies. Furthermore, recent studies have shown after various spa therapy techniques, a reduction of circulating levels of Prostaglandin E2 (PGE2 ) and Leukotriene B4 (LTB4 ), important mediators of inflammation and pain, in patients suffering from OA or FMS [30,31]. Moreover, in patients with OA, PTT induces an increase of blood levels of Heat Shock Protein (HSP) such as HSP 70 [32]. In cell cultures of chondrocytes and in animal models of arthritis, Hsp70 has been shown to provide protection from cellular injuries and apoptosis [33]. Specific effects of PTT may be due to the active ingredients (essential oils, terpenes and other aromatic substances) contained in the fermenting grass, which, favoured by vasodilatation, enter the body during the bath [34]. However, at moment the specific actions are not fully understood. Other specific factors may also contribute to the clinical improvement observed after PTT, including the change in environment, pleasant scenery/surroundings, the absence of work duties, physical and mental relaxation, the non-competitive atmosphere with similarly suffering companions, and physical therapy. These spa benefits are especially important in studies evaluating the effects of PTT compared with no treatment or another treatment [21,22,35,36]. Discussion The aim of this review was to summarize the currently available information on clinical effects of PTT in RD. The results of clinical trials on PTT suggest a positive effect in decreasing OA and FMS symptoms and ameliorating quality of life. The studies assessed the medium-to-long-term effect found that the clinical efficacy of PTT lasted for 3–6 months. Moreover, PTT seems to be well tolerated, with slight and transitory side effects. On the other hand it’s important to underline that in literature there is a great lack of studies in the field of PTT and RD. Furthermore, some aspects of these studies are disputable and could be a source of bias; for example only two of the studies reported are randomized and none has a double-blind design because of the difficulty of creating a placebo with the same characteristics




as the treatment. Because of the lack of double-blinded studies, the placebo effect cannot be excluded and may contribute to confound results. Comparisons of the studies was difficult: only one study on PTT and FMS was conducted and in the OA trials the baseline characteristics of the patients were heterogeneous, the methods used for assessment of efficacy varied and the patients were assessed at different times after PTT. Furthermore, the mechanisms of action of PTT are not fully understood and one of the critical points is the controversial problem of the absorption of the active ingredients (essential oils, terpenes and other aromatic substances) contained in the fermenting grass, i.e. the demonstration of specific effects other than those linked to the simple action of heat. Unfortunately few studies have been conducted on this topic and little is known about the specific effects of various fermenting grass, so further botanical investigations and researches on the mechanisms of actions of PTT are necessary. Conclusions PTT could represent a useful aid in the treatment of some RD such as FMS and OA. This therapy could also represent a viable alternative for all those patients who cannot tolerate conventional pharmacological treatments or are at risks of serious side effects. The value of this therapeutic approach largely depends on the respect of some basic general rules, such as a correct diagnosis and characterization of the evolutionary phase of the disease, the accurate assessment of the patient’s general health status to exclude potential contraindications, and a good knowledge of the therapeutic medium utilized, including its indications and possible side-effects. Given the positive preliminary results of PTT in the treatment of patients with FMS and OA, further clinical investigations on larger populations and different RD are highly recommended, to widen the indications of this treatment modality and reduce the impact of drug toxicity and side effects. Conflict of interest All authors declare no conflict or competing financial interests. References [1] Miori R, Contu C, Marzano A, Fedrizzi A, Bambara LM. Critical evaluation of phytothermotherapy (“hay baths”) in degenerative arthropathies. Clinica Terapeutica 1994;144:31–42. [2] Atzwanger H. Das Voelser Heubad. Der Schlern 1936;17:75–9 [in Italian]. [3] Lersh BM. Polymorphe Balneologie, eine Abhandlung über Sandbäder, Schlamm- und Moorbäder, Kiefernadelbäder und manche andere weniger gebräuchliche Arten von Bädern.: Eine Abhandlung über Sandbäder, Schlamm- und Moorbäder, Kiefernadelbäder und manche andere weniger gebräuchliche Arten von Bädern. Enke: Erlangen; 1871. [4] Talamucci P, Piemontese S, Coser P. Risultati preliminari sulle modalità di utilizzazione e di conservazione dell’erba dei pascoli del Monte Bondone a fini terapici (“bagni di fieno”). Report Centro di Ecologia Alpina 1995;1:1–20.

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