J Jpn Soc Balneol Climatol Phys Med (2015) 78 (3) 271

Thalassotherapy in Diabetic Polyneuropathy: a Study in Pomorie,

Antoaneta GROZEVA, Mimi STOICHEVA

Abstract Background: Diabetes mellitus and its complications are a source of considerable morbidity and mortality, with important medical and social implications. The aim of our study was to establish the efficacy of combined application of seawater, Pomorie therapeutic mud and lye in diabetic polyneuropathy rehabilitation. Materials and methods: The study was carried out during the 2011 and 2012 summer seasons in 43 patients (18 male and 25 female) with diabetic polyneuropathy from Germany, and Bulgaria. The average age was 62±2.15 years and the average duration of diabetes was 16±3.4 years. All patients underwent combined treatment with mud baths (temp 37℃, duration 15- 20min, 10 applications) and 10 lye electrophoresis procedures to the lower limbs, and sea water baths. The visual analogue scale (VAS) was used before and after the course of treatment to objectively measure the pain and parasthesiae of the lower limbs. Results: Following a 2 week treatment course there was significant improvement in the clinical symptoms of diabetic polyneuropathy. 90% of patients reported improvement in pain, with VAS decreasing from 4.85±0.31 to 2.75±0.24, p<0.05. There was also a decrease in lower limb parasthesiae in 95% of patients, with VAS decreasing from 5.61±0.65 to 3.26±0.31, p<0.05. Conclusion: The clnical symptoms and quality of life of patients with diabetic polyneuropathy imroved significantly following combined treatment with Pomorie natural resources as a result of the trophic and pain-reducing properties of therapeutic mud, lye and sea water. We support the combined application of these treatments in the rehabilitation of patients with diabetic polyneuropathy.

Keywords: thalassotherapy, diabetic polyneuropathy, therapeutic mud, lye

I INTRODUCTION Bulgaria has century-old tradtitions in spa treatment based on its exceptional natural resources, including pleasant continental climate, beautiful natural environment and numerous mineral water springs and therapeutic mud deposits. The Bulgarian coast is 378km long and offers many opportunities for the combined application of all elements of thalassotherapy. Of particular importance is the pleasant temperate climate, the calm and safe sea with low salinity and endless beaches. An important factor for the development of rehabilitation and balneology on the Black Sea coast is the abudance of mineral water springs and therapeutic

（Received: September, 1, 2014, Accepted: November, 11, 2014） Medical College, Professor Assen Zlatarov University , Bulgaria 272 A. GROZEVA et al. mud with excellent physical and chemical properties. One of the commonest complications of diabetes, leading to poor quality of life and disablity is diabetic neuropathy. The urgent need to address this problem is evident from predictions that the number of patients with diabetes worldwide is set to increase to 300 million by the year 2025. Diabetes mellitus and its complications present an exceptional challenge not only to medical and social services, but also to world economies. The therapeutic and economic effectiveness of peloid therapy is proven in a number of conditions. The combined application of the three basic spa assets present in Pomorie (seawater, lake water and lye) presents an opportunity for increased effectiveness, based on their rich ion composition (Table 1). Peloid therapy has proven effect in peripheral nerve conditions1）, 2）. A number of Bulgarian authors have conducted experimental and clinical studies with therapeutic mud, establing evidence for benefit. Gaicheva et al1） studied effeciveness of therapeutic mud in infants with obstetric brachial plexus injuries and demonstrated a positive contribution to rehabilitation. The authors show a beneficial effect on the circulation in the paralysed limb immediately after the application of therapeutic mud. A study by Koujumdjieva2） also demonstrated improvement in the nerve regenerative process in rats with experimentally induced trauma of the sciatic nerve with application of Varna therapeutic mud. The study also followed up 82 patients with tramatic injuries to peripheral nerves who received mud therapy and found acceleration in the rehabilitation process. The effect of Pomorie therapeutic mud in patients with diabetes and diabetes complications

Table 1 Composition of Pomorie seawater, lake water and lye. Thalassotherapy in Diabetic Polyneuropathy 273 has been studied by Grozeva and Krusteva3） in 28 patients who received mud-lye baths. This study demonstrated lowered blood glucose measurements, and improvement in the symptoms from blood vessel disease and polyneuropathy. In a study by Koleva4）, a beneficial effect was observed from the inclusion of Varna therapeutic mud applications and lye compresses in the combination treatment of patients with diabetic polyneuropathy. The aim of our study was to examine the effects of the combined application of Pomorie mud, lye and seawater in rehabilitation of diabetic polyneuropathy.

II MATERIALS AND METHODS The study was conducted during the 2011 and 2012 summer seasons in patients from Germany, Russia and Bulgaria with musculo-skeletal conditions and diabetic polyneuropathy. A total of 43 patients were recruited (18 men and 25 women), with diabetic polyneuropathy and duration of diabetes 16±3.4 years and average age 62±2.15 years. Seven patients had insulin- dependent (Type 1) diabetes and 35 patients had non-insulin dependent (Type 2) diabetes. The characteristics of the pateints are summarised in Table 2. All patients underwent combination treatment for 14 days with therapeutic mud, lye and sea baths. The therapeutic mud treatment included 10 sessions of immersion in bath at 37℃ for 15-20 minutes. The lye was applied by electrophoresis to the lower limbs, 10-15A, for 15-20 minutes, 10 procedures. The patients had daily sea baths. The visual analogue scale (VAS) was used at the start and end of treatment to record pain and paraesthesiae in the lower limbs. Fasting blood glucose levels were recorded at the start and at the end of the treatment period.

III RESULTS Following 14 days of therapy, the clinical symptoms of diabetic polyneuropathy were significantly reduced. The pain diminished in 90% of patients, demonstrated by the VAS score decreasing from 4.85±0.31 to 2.75±0.24, p<0.05. There was also a reduction in paraesthesiae in the lower limbs in 95% of patients, with VAS scores decreasing from 5.61±0.65 to 3.26±0.31, p<0.05 (Figure 1). Fasting blood glucose levels reduced from 8.34 mmol/L to 6.27 mmol/L, p<0.05.

Table 2 Characteristics of the 43 study patients 274 A. GROZEVA et al.

Fig. 1 Visual analogue scale (VAS) scores for pain (a) and paraesthesiae (b) before and after treatment in patients with diabetic polyneuropathy, demonstrating a reduction in VAS for pain from 4.85 ± 0.31 to 2.75 ± 0.24, and in VAS for paraesthesiae from 5.61 ± 0.65 to 3.26 ± 0.31.

IV DISCUSSION The results from our study are consistent with other published studies into the effects of Thalassotherapy in Diabetic Polyneuropathy 275 peloid therapy, lye thereapy and preformed factors in patients with peripheral nerve conditions and diabetic polyneuropathy1）, 2）, 4）. The observed reduction in pain in patients with diabetic polyneuropathy who underwent rehabilitation combining different treatment modalities can be explained by several mechanisms of action of peloid therapy, lye electrophoresis and seabaths. Peloid therapy has proven vasodilating and trophic tissue effect. This accelerates metabolism of biochemical substrates which mediate pain (prostaglandins, histamines and others). Application of thermal baths results in an increase in β-endorphins which have an analgesic effect5）. The organic component in the water extract from Pomorie mud also has proven effect in activating α2-adreno and D2- dopamine receptors on nerve cells6）. The activation of α2 ‒ adrenoreceptors suppresses the release of noradrenaline, resulting in vasodilation, improved tissue metabolism and suppression of pain impulses, which explains the clinical improvement. We also observed an improvement in glycaemic control, a finding recently demonstrated in another study7）.

V CONCLUSION The combined application of Pomorie mud, lye and seawater resulted in significant symptom improvement and improved quality of life in patients with diabetic polyneuropathy. We recommend the combined application of these therapies in the rehabilitation in patients with diabetes and diabetic polyneuropathy.

Conflict of Interest No potential conflicts of interest were disclosed.

References 5）Cozzi F, Lazzorin I, Todesco S, Cima L. 1）Gacheva J., Marinkev M, Bliznakov V. Effect Hypothalamic pituitary-adernal axis dysregula- of therapeutic mud applications on blood vessel tion in healthy subjects undergoing mud bath autonomic reactivity in infants with obstetric application. Arthritis Rheum 1995 38: 724-725. brachial plexus injury. NKFR bulletin, 1979, 6）Grozeva A., Beer A.M., Zagorchev P., Lukanow 2-3: 43-51. (In Bulgarian) J. Action of water extract from Pomorie mud 2）Koujumdjieva M. Clinical and experimental on the spontaneous contractile activity of smooth- studies of the effect of Varna therapeutic mud muscle strips of guinea pig stomach. Physikalis- on traumatic peripheral nerve injuries. PhD che Medizin, Rehabilitatiosmedizin, Kurort- dissertation 1980 (In Bulgarian). medizin 2005, 5 (In German). 3）Grozeva A, Krusteva D. Effect of mud thera- 7）Fioravanti A, Anmczyk P, Pascarelli NA, py on diabetes. Physical medicine, rehabilitation, Giannitti C, Urso K, Tolodziecki M, Ponikowska health, 2004, 1: 17 (In Bulgarian). I. Clinical and biochemical effects of 3-week 4）Koleva I. Physical factors in the prophylaxis, program of diet combined with spa therapy in therapy and rehabilitaion of patients with dia- obese and diabetic patients: a pilot study. Int J betes and diabetic polyneuropathy. PhD disser- Biometeorol 2014 Sep 7 (epub ahead of print). tation 2004 (In Bulgarian).