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Effects of balneotherapy with exercise in patients with low back pain

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Available from: Kagan Ucok Retrieved on: 06 October 2015 Journal of Back and Musculoskeletal Rehabilitation 21 (2008) 263–272 263 IOS Press

Effects of balneotherapy with exercise in patients with low back pain

Reha Demirela,∗, Kagan Ucokb, Vural Kavuncuc, Omer Gecicid, Deniz Evcike, Umit Dundarc, Ozlem Solakc and Hakan Mollaoglub aDepartment of Public Health, Faculty of Medicine, Kocatepe University, Afyonkarahisar, Turkey bDepartment of Physiology, Faculty of Medicine, Kocatepe University, Afyonkarahisar, Turkey cDepartment of Physical Therapy and Rehabilitation, Faculty of Medicine, Kocatepe University, Afyonkarahisar, Turkey dDepartment of Psychiatry, Faculty of Medicine, Kocatepe University, Afyonkarahisar, Turkey eDepartment of Physical Therapy and Rehabilitation Faculty of Medicine, Ufuk University, Ankara, Turkey

Abstract. Low back pain (LBP) is an important clinical, social, and public health problem. Balneotherapy is a type of therapy by hot or warm waters containing minerals. The aim of this study was to investigate the effects of balneotherapy with exercise on pulmonary functions, aerobic exercise capacity, resting metabolic rate, body fat %, psychosocial condition and its efficiency on therapy in patients with LBP. Balneotherapy and exercise program were applied to group 1 (14 female, 9 male). Only an exercise program was applied to group 2 (13 female, 8 male). The measurements of maximal oxygen consumption, resting metabolic rate, pulmonary function tests, body fat %, Oswestry disability index, visual analog scale, quality of life measure, symptom checklist-90-revised, the hospital anxiety and depression scale, spine joint mobility tests from all participants were performed before and after the treatment. An improvement was found in pulmonary function test (maximal volunteer ventilation), aerobic exercise capacity, pain and disability scores, spine mobility (extension distance), quality of life, and all psychiatric symptoms (except anxiety) in group 1 following therapy period. Also some improvements were observed in body fat percentage, pulmonary function tests (forced vital capacity, forced expiratory volume in 1 second, forced expiratory flow at 25% to 75% vital capacity and peak expiratory flow), and other spine joint mobility tests before and after therapy in group 1, though they were not statistically significant. Balneotherapy with exercise could be alternative therapy methods in patients with LBP.

Keywords: Low back pain, balneotherapy, exercise, aerobic capacity, pulmonary function

1. Introduction LBP poses an economic burden to society, mainly in terms of the large number of work days lost (indirect Low back pain (LBP) is an important clinical, social costs) and less so by direct treatment costs [28]. Given and public health problem, affecting the populations the association of comorbidities and cost for patients worldwide [32]. LBP represents an important factor of with LBP, management approaches that are effective disabling chronic pain and low quality of life in the adult across chronic illnesses may prove to be beneficial for population, and a devastating problem of public health high cost patients identified with LBP [42]. because of its tremendous medical and social cost [25]. LBP is still one of the most common causes of sick- ness absence, long-term incapacity and early retire- ment, yet there is no absolute medical reason why this ∗Address for correspondence: Yrd. Doc.Dr. Reha Demirel, should be so [54]. The etiology of LBP is complex and A.K.U. Tip Fakultesi, Pembe Hastane, Halk Sagligi AD, Konya Cad- the causes are not clearly known; although some risk desi Karayollari Kavsagi, 03040, Afyonkarahisar, Turkey. Tel.: +90 272 2167901/151; Fax: +90 272 2172029; E-mail: rehademirel@ factors are implicated. For instance, trunk and lower yahoo.com. extremity loss of muscle mass and central obesity may

ISSN 1053-8127/08/$17.00  2008 – IOS Press and the authors. All rights reserved 264 R. Demirel et al. / Effects of balneotherapy with exercise in patients with low back pain be risk factors for chronic LBP [47]. Primary targets Hospital at AKU. The patients who were referred to for treatment of LBP should be an increase in physi- Physical Medicine and Rehabilitation Clinic and diag- cal fitness and the self-management of the problem by nosed with a mechanical LBP were enrolled. the patient [7]. Clinical belief holds that patients with Initially a total of 60 patients were planned to enroll chronic LBP have low fitness levels because of inactiv- for this study. However, only a total of 54 patients par- ity because of pain [57]. The relation between physi- ticipated for the study during the first phase of planned cal fitness and LBP have been explored by examining period of investigation, and only a total of 44 of them such measures of physical fitness including flexibility, to the second assessment phase. aerobic capacity, strength, muscle endurance, and body The patients were divided into two groups (group 1 composition [50]. and group 2) randomly with toss-up method. Bal- Balneotherapy is a therapy type by hot or warm wa- ters containing minerals and having physical and chem- neotherapy and exercise program were applied to the ical characteristics which is applied as and it group 1, only exercise program was applied to the n = generates mechanical, chemical and physical effects group 2. In Group 1 ( 23), there was 14 female, 9 when it is applied. Thermo-mineral waters occurring male patients, whereas in Group 2 (n = 21) there was by natural circulation reach certain temperature level 13 female, and 8 male patients. underground and contain dissolved minerals and ma- terials to some extent in them as well as having spe- 2.2. Subjects cial chemical composition [22]. Thermo-mineral wa- ters arise from underground to the surface either spon- taneously or via artificial methods by drilling. The study was approved by the local IRB (School of Balneotherapy has been used empirically in treating Medicine Medical Ethics Committee). All participants various musculoskeletal disorders since many years. gave their informed consent before participation. All The therapeutic value of thermal spring water has been patients had radiological and routine laboratory exam- linked to its composition, mineral concentration and ination before the study. the temperature [15,55]. Several studies suggest a ben- Inclusion criteria were as follows: having mechan- eficial effect of balneotherapy on degenerative and in- ical LBP for at least 3 months and having no exercise flammatory joint diseases, as well as offering an adju- risk. vant therapy in the treatment of various chronic health Exclusion criteria were the followings: major mus- conditions [15,55]. Afyonkarahisar is one of the culoskeletal problems and previous spinal operation, centers in Turkey and there are many balneotherapy having inflammatory LBP and , having ele- units and the natural spring waters with varying prop- vated acute phase reactant and red flag findings for erties [11]. LBP, acute infection, pregnancy for women, liver dis- Exercises aim to improve lung function and mus- eases, epilepsy and other neurological illnesses, psy- cle performance. Resistance exercise training pre- chiatric, metabolic (hyper/hypothyroidism, etc.), and vents lower-back pain and affects resting metabolic rate (RMR) and body fat positively [56]. cardiovascular disorders, use of drugs affecting basal Obviously, to improve body functions is important metabolism, diabetes mellitus and other systemic dis- for successful treatment. Therefore, we intended to eases. clarify the effects of balneotherapy and exercise on LBP together with body functions in patients with LBP. 2.3. Balneotherapy The study aimed to investigate the effects of bal- neotherapy with exercise on respiratory functions, aer- obic exercise capacity, basal metabolism, body fat % Balneotherapy was continued for 3 weeks (except and psychosocial condition in patients with mechanical weekends), a total of 15 sessions, each of which took low back pain and its efficiency on therapy. 20–25 minutes. Balneotherapy was performed with natural spring water which contains sodium, bicar- bonate, sulfate, calcium, magnesium, iron, aluminum, 2. Methods chlorine, metasilicate and its temperature was about ◦ 2.1. Study design 36–38 C. Patients were instructed to take bath in mineral water This study was performed in the Physical Medicine pool as their whole bodies up to the head being sunken and Rehabilitation Clinic of Research and Application in the water. R. Demirel et al. / Effects of balneotherapy with exercise in patients with low back pain 265

2.4. Exercise programs BW formula for calculation of body density for women was: Group 1 and 2 patients performed same exercise pro- Body density = 1.06234–0.00068 (subscapular gram for 3 weeks under surveillance by a physiother- skinfold)–0.00039 (triceps skinfold)–0.00025 (thigh apist who doesn’t know the patients’ group (if they skinfold) belong to group 1 or 2). Body fat percentage was calculated from body den- Each exercise program included the following ones: sity with Siri formula, which is [37]: Williams flexion exercise, spinal stabilization exercise, Body fat percentage = (4.95/body density–4.5)*100 McKenzie extension exercise, abdominal strength ex- 2.5.2. Aerobic exercise capacity ercise, and spinal stretching exercise [5,41]. These ex- Measuring aerobic exercise capacity was preferred ercises were applied 10 times for each session and sub- for patients with LBP because aerobic capacity is af- jects took a rest for 2 minutes between each exercise. fected not only by exercise therapy but also by daily physical activity of patients. VO2max measurements 2.5. Tests and measurements were carried out using Astrand exercise protocol. Pri- or to implementation of exercise test, the assessment Following the physical examination of the all par- of exercise risk for subjects were carried out accord- ticipants in the study, they were subjected to the fol- ing to American College of Sports Medicine criteria lowing tests and questionnaires: Oswestry Disability and only appropriate subjects were enrolled for the As- Index (ODI), Visual Analog Scale (VAS), Quality of trand test [4]. The tests were performed in the same Life Measure (SF36), Symptom Checklist-90-Revised order and conditions by the same person. The subjects (SCL-90-R) and The Hospital Anxiety and Depression were taken into the laboratory in convenient clothes. Scale (HAD), Spine Joint Mobility Tests. Spine Joint The subjects were instructed to avoid food intake two Mobility Tests were carried out as described previous- hours before the test, and taking beverages or foods ly [35,39]. containing caffeine or alcohol. The Astrand test was Also, for all participants test of respiratory functions, performed on a computerized cycle ergometer (Monark an exercise test, basal metabolism levels and subcuta- 839E, Monark Exercise AB, Sweden). The heart rate neous fat measurements were done in the lab of the De- was monitored with chest belt telemetry system (Po- partment of Physiology. Prior to the measurements, all lar CR2032, CE0682, Monark Exercise AB, Sweden). patients were informed about tests and measurements. The subjects were asked to perform a 6-min submaxi- The measurements of subcutaneous fat thicknesses, mal exercise test reaching a steady state heart rate. The maximal oxygen consumption (VO2max), RMR and VO2max was determined from heart rate and workload pulmonary function tests (PFTs) were performed in by Astrand test [31]. the laboratory of the Department of Physiology. Once 2.5.3. Resting metabolic rate the therapy period is finished, all measurements were RMR was measured with portable indirect calorime- repeated once more. The devices were calibrated prior ter (BodyGem, HealtheTech Inc., USA) as follows: to each test. The subjects were instructed to avoid food intake for 12 hours, not smoke for 2 hours and not perform exercise 2.5.1. Body fat percentage for 24 hours before the test. The tests were performed The skinfold thicknesses were measured by the same at the same hours (08:30 am–10:30 am) of the day. Af- using skinfold caliper (Holtain, Holtain Ltd., ter resting for 15 minutes, the measurements were ap- UK). Abdomen, triceps, thigh and subscapular skinfold plied to the subjects in laboratory that was silent, light- thickness measurements were done twice. When the less and at room temperature. The subjects were put differences between the two measurements were more on mouthpiece and nose clip, seated and instructed not than 5%, the measurements were repeated and the sec- to move arms and legs during the measurement. They ond measurements were used. Body densities were hold the device during the measurement and were sup- calculated with the Behnke Wilmore (BW) formula for ported their arm on the armrest of the chair. RMR was both men and women [37]. measured indirectly in 5 to 10 minutes with a metabol- BW formula for calculation of body density for men ic sensor in the device by analysis of respired gases was: (O2). BodyGem uses standard metabolic formulas in Body density = 1.08543–0.00086 (abdomen which oxygen consumption per day is used to calculate skinfold)–0.0004 (thigh skinfold) RMR [36]. 266 R. Demirel et al. / Effects of balneotherapy with exercise in patients with low back pain

Table 1 Body weight, body mass index (BMI) and body fat percentage before and after therapy of groups Before therapy After therapy P Body weight (kg) Group 1 76.8 ± 10.8 76.3 ± 11.1 0.186 Group 2 77.4 ± 12.5 77.2 ± 11.9 0.353 BMI (kg/m2) Group 1 28.7 ± 4.1 28.6 ± 4.3 0.467 Group 2 29.1 ± 5.5 29.2 ± 5.5 0.802 Body fat (%) Group 1 26.1 ± 8.7 25.6 ± 7.9 0.160 Group 2 27.3 ± 11.5 25.9 ± 10.4 0.004 All values represent means ± standard deviation.

2.5.4. Pulmonary function tests significant difference before therapy in terms of body PFTs were measured with a spirometer (Spirolab, weight (p = 0.855) and BMI (p = 0.739) between two SDI Diagnostics, USA). The subjects performed a prac- groups. There was no significant difference after ther- tice for adaptation to the spirometer before PFTs. A apy in terms of body weight (p = 0.795) and BMI (p = forced expiratory maneuver was performed. After 0.272) between groups. The fat percentage was found wearing a nose clip subjects were instructed to inhale lower after therapy than the one before therapy in the completely before inserting the mouthpiece, then ex- group 2 (Table 1). hale forcefully into the spirometer for as much as they An increase was found in VO2max levels in group 1 could. Forced vital capacity (FVC), forced expiratory following the therapy period, but, there was no dif- volume in 1 second (FEV1), forced expiratory flow at ference in group 2. Following the therapy period, an 25% to 75% vital capacity (FEF25−75), peak expiratory increase in RMR was observed in group 2 (Table 2). flow (PEF) were measured, FEV1/FVC ratio was de- FEV1/FVC and FEF25−75 values were lower after termined. Maximal voluntary ventilation (MVV) was therapy than the ones before therapy in group 2, where- measured using another spirometry maneuver. Sub- as MVV value was higher after therapy than the one jects were asked to exhale maximal volume during 12 before therapy in group 1 (Table 3). seconds of forced breathing into the spirometer and Table 4 shows the mean values for HAD, SCL-90-R MVV was calculated for one minute. Acceptability and and SF 36 scores before and after therapy of groups. reproducibility criteria of American Thoracic Society A decrease was observed in depression scores after were applied to all patients [1]. therapy for both in group 1 and group 2 (Table 4). The average decreases in depression scores after therapy 2.6. Statically analyses were −2.3 ± 2.7 and −1.1 ± 1.8 for group 1 and group 2 respectively. However, these differences were All parametric results were expressed as mean ± not statistically significant (p = 0.119). standard deviation for each group. Shapiro-Wilks test A decrease was observed in SCL-90-R scores after was performed to check the normality of the data be- therapy for both in group 1 and group 2 (Table 4). The fore running tests. The results were evaluated statisti- average decreases in depression scores after therapy cally using paired samples t-test, independent samples were −1.2 ± 2.6 and −2.3 ± 2.7 for group 1 and t-test, Wilcoxon signed-ranks test, Mann-Whitney U group 2 respectively. However, these differences were test and chi-square test. A p-value less than 0.05 were not statistically significant (p = 0.185). considered to be statistically significant. An increase was observed in quality of life com- ponents scores after therapy for both in group 1 and group 2 (Table 4). The average increases in physical 3. Results component scores after therapy were 3.4 ± 6.7and 4.8 ± 6.1 for group 1 and group 2 respectively. However, There was no statistical significance in terms of gen- these differences were not statistically significant (p = der in group 1 (14 female, 9 male) and group 2 (13 0.469). The average increases in mental component female, 8 male) (p = 0.944). Mean illness durations scores after therapy were 4.9 ± 7.9and 5.2 ± 7.3 for and smoking in group 1 (81.4 ± 69.0 month and 13.8 ± group 1 and group 2 respectively. However, these dif- 11.9 packed-year) and in group 2 (72.0 ± 61.0 month ferences were not statistically significant (p = 0.904). and 16.9 ± 8.6 packed-year) were also not different Table 5 shows the mean values for VAS and ODI (p = 0.571 and p = 0.541, respectively). There was no scores before and after therapy of groups. A decrease R. Demirel et al. / Effects of balneotherapy with exercise in patients with low back pain 267

Table 2 Maximal oxygen consumption (VO2max) and resting metabolic rate (RMR) before and after therapy of groups Before therapy After therapy P VO2max(L/min) Group 1 1.69 ± 0.42 1.86 ± 0.39 0.049 Group 2 2.09 ± 0.46 1.96 ± 0.46 0.084 RMR (kcal/day) Group 1 1584.8 ± 343.8 1535.7 ± 284.1 0.253 Group 2 1492.9 ± 262.9 1653.8 ± 265.4 0.04 All values represent means ± standard deviation L: Liter

Table 3 Pulmonary function tests (PFTs) before and after therapy of groups PFTs Before therapy After therapy p FVC (L) Group 1 3.68 ± 0.99 3.75 ± 1.05 0.638 Group 2 3.59 ± 0.86 3.59 ± 0.83 0.903 FEV1(L) Group 1 3.23 ± 0.78 3.26 ± 0.90 0.106 Group 2 3.10 ± 0.67 3.09 ± 0.60 0.715 FEV1/ FVC (%) Group 1 0.87 ± 0.04 0.87 ± 0.07 0.837 Group 2 0.87 ± 0.06 0.86 ± 0.06 0.049 FEF25−75(L) Group 1 3.83 ± 1.01 3.90 ± 1.02 0.426 Group 2 3.70 ± 0.81 3.49 ± 0.83 0.015 PEF (L) Group 1 7.22 ± 2.42 7.76 ± 2.03 0.08 Group 2 7.01 ± 1.93 7.24 ± 1.76 0.14 MVV (L) Group 1 125.9 ± 33.7 132.7 ± 37.3 0.035 Group 2 125.7 ± 33.5 129.7 ± 32.8 0.192 All values represent means ± standard deviation L: Liter

Table 4 The hospital anxiety and depression scale (HAD), symptom checklist revised (SCL- 90-R) and quality of life quality of life measure (SF 36) scores before and after therapy of groups Before therapy After therapy P HAD (Anxiety) Group 1 7.7 ± 3.9 7.0 ± 4.2 0.314 Group 2 6.3 ± 2.6 6.7 ± 2.1 0.576 HAD (Depression) Group 1 7.3 ± 3.8 5.0 ± 3.5 0.02 Group 2 5.9 ± 2.9 4.7 ± 2.7 0.013 SCL-90-R Group 1 8.9 ± 5.5 7.7 ± 4.5 0.033 Group 2 9.5 ± 4.9 7.2 ± 4.2 0.001 SF 36 (Physical component) Group 1 49.5 ± 9.9 52.8 ± 11.0 0.024 Group 2 48.8 ± 9.4 53.6 ± 9.9 0.002 SF 36 (Mental component) Group 1 44.4 ± 10.7 49.4 ± 9.9 0.014 Group 2 43.6 ± 5.6 48.8 ± 6.9 0.004 All values represent means ± standard deviation was observed in rest, mobility and nocturnal VAS after these differences were not statistically significant (p = therapy for both in group 1 and group 2 (Table 5). The 0.896). average decreases in rest VAS scores after therapy were A decrease was observed in ODI scores after therapy −2.2 ± 2.9 and −1.8 ± 2.7 for group 1 and group 2 re- for both in group 1 and group 2 (Table 5). The average spectively. However, these differences were not statis- decreases in rest VAS scores after therapy were −9.6 ± tically significant (p = 0.712). The average decreases 13.4 and −6.2 ± 10.2 for group 1 and group 2 respec- in mobility VAS scores after therapy were −2.7 ± 2.3 tively. However, these differences were not statistically and −2.7 ± 2.2 for group 1 and group 2 respectively. significant (p = 0.356). However, these differences were not statistically signif- Table 6 shows the mean values for spine joint mo- icant (p = 0.974). The average decreases in nocturnal bility before and after therapy of groups. An increase VAS scores after therapy were −2.9 ± 2.6 and −2.8 was observed in extension distance after therapy for ± 2.7 for group 1 and group 2 respectively. However, both in group 1 and group 2 (Table 6). The average 268 R. Demirel et al. / Effects of balneotherapy with exercise in patients with low back pain

Table 5 Visual analog scale (VAS) and Oswestry disability index (ODI) scores before and after therapy of groups Before therapy After therapy P VAS (Rest) Group 1 3.0 ± 2.9 0.8 ± 1.6 0.003 Group 2 4.8 ± 3.5 2.9 ± 2.9 0.01 VAS (Mobility) Group 1 6.1 ± 2.1 3.4 ± 2.2 < 0.001 Group 2 7.3 ± 1.6 4.5 ± 2.7 < 0.001 VAS (Nocturnal) Group 1 4.5 ± 3.2 1.5 ± 1.9 < 0.001 Group 2 5.3 ± 2.9 2.4 ± 2.9 0.001 ODI(%) Group 1 27.2 ± 16.4 17.7 ± 13.4 0.002 Group 2 28.1 ± 13.8 21.9 ± 12.4 0.011

Table 6 Spine joint mobility before and after therapy of groups Before therapy After therapy P Flexion (cm) Group 1 58.6 ± 9.8 59.2 ± 10.1 0.666 Group 2 58.4 ± 16.5 62.2 ± 8.0 0.061 Extension (cm) Group 1 14.9 ± 4.8 18.0 ± 3.2 0.013 Group 2 12.8 ± 4.2 15.6 ± 3.9 0.011 Right lateral flexion (cm) Group 1 13.5 ± 4.2 15.9 ± 5.3 0.057 Group 2 13.7 ± 5.1 17.6 ± 4.2 0.001 Left lateral flexion (cm) Group 1 13.9 ± 3.6 15.2 ± 4.3 0.243 Group 2 12.6 ± 5.5 16.0 ± 6.0 0.001 Lomber Schober (cm) Group 1 14.8 ± 0.9 15.1 ± 0.75 0.119 Group 2 15.5 ± 0.75 15.6 ± 0.76 0.452 Fingertip to floor distance (cm) Group 1 4.2 ± 5.2 2.7 ± 3.6 0.070 Group 2 6.0 ± 5.0 3.1 ± 4.2 0.001 increases in physical component scores after therapy ical and psychosocial dimensions [21]. We aimed to were 3.1 ± 5.2 cm and 2.9 ± 4.5 cm for group 1 and investigate the effects of balneotherapy on some body group 2 respectively. However, these differences were functions and its efficiency on therapy. We found that not statistically significant (p = 0.878). aerobic exercise capacity and MVV were higher after therapy than before therapy in group 1. Also, pain and disability (VAS, ODI), spine mobility (extension 4. Discussion distance), quality of life and the most of psychiatric symptoms were found to be improved in group 1. LBP is one of the most prevalent musculoskeletal LBP is a multifactorial disorder with many possi- disorders affecting a large proportion of the population ble etiologies [32]. Individual risk factors are heredity, during their lifetime [2]. LBP has lifetime prevalence age, sex, posture, height, weight, smoking, physical fit- of 60–85% [32]. Incidence of recurrent or chronic LBP ness and physical activities [32]. Risk factors could be at 3 months, 6 months, and 12 months ranges from 35% important for treatment of the patients with LBP. Toda to 79% [32]. LBP are essentially a manageable health et al. claimed that trunk and lower extremity loss of problem [54]. Disability implies interference with dai- muscle mass and central obesity might be risk factors ly activities and impairment implies loss of physical for chronic LBP [47]. Han et al. found that there are function [53]. A significant disruption of daily activ- no significant interactions between waist and height, or ities including sex and sleep has been reported [16]. waist to hip ratio and body mass index on LBP symp- LBP is a major public health problem and because of toms [18]. Celan and Turk studied 122 male bus drivers disability and incapacity, patient’s daily life and their and claimed that nutritional status,body build, constitu- psychological, economic and work status might be dif- tion and muscular development are not associated with ficult. They might lose quality of life, productivity, so- the incidence of LBP [6]. Brox et al. claimed that de- cial status and happiness. Filho et al. claimed that per- conditioning was more related to psychophysical mea- formance and disability were more consistent in evalu- sures of abdominal and back muscle endurance than ating LBP [14]. And to evaluate the efficiency of ther- to cardiovascular fitness in patients with sub-acute or apeutic approaches in low back pain we need reliable chronic LBP [3]. Saur et al. found that physical capac- information concerning patient health status in its phys- ity (cardiovascular endurance) in disabled patients with R. Demirel et al. / Effects of balneotherapy with exercise in patients with low back pain 269

LBP is substantially reduced in comparison to persons might not be changed in exercise only group. Also we who do not suffer from back pain [43]. Consequently, found that exercise therapy is effective in group 1, but many possible causes were investigated as risk factors VO2max has not changed after therapy because of the in patients with LBP. In this respect, our study also fact that daily physical activity level might not have might enlighten this issue on the basis of some body increased. functions improved with balneotherapy and exercise in RMR measured at basal conditions is the compo- patients with LBP. nent of expenditure that explains the largest pro- We measured aerobic capacity with Astrand test in portion (70–80%) of an individual’s total daily ener- the patients with LBP. Macsween showed the reliability gy expenditure [17,52]. The BodyGem provides valid and validity of the Astrand test for deriving VO 2max and reliable measurements of RMR [33]. BodyGem from submaximal exercise data [31]. The reliability gives accurate and reproducible oxygen consumption was found to be acceptable for Astrand test, as evalu- and RMR measurements for nonobese and obese, male ated by the critical difference in patients with chronic and female individuals [36]. Liou et al. stated that LBP and healthy individuals [24]. Smeets et al. per- RMR obtained using the BodyGem has a high degree formed a modified Astrand submaximal cycling test of reproducibility and an acceptable validity compared in 108 chronic LBP patients, calculated VO2max, and to the Deltatrac Metabolic Monitor in Taiwanese wom- compared with normative data [46]. Both men and en [30]. In this study, RMR increased significantly af- women with chronic LBP patients had significant low- ter treatment in group 2, but not in group 1 (Table 2). er VO2max than the healthy referents [46]. van der Resistance training reduces body fat, increase basal Velde and Mierau stated that the percentile rank of aer- metabolic rate, improve functional capacity, and relieve obic capacity for the patients with LBP was statistically LBP [27]. Exercise is a factor that increases RMR [17]. significant and lower than those measures for the con- Total muscle mass and muscle metabolism can be en- trols [50]. It was also found that anaerobic power and larged by regular exercise programs. That is why ex- anaerobic capacity which are more sensitive to disabil- ercise might increase RMR in group 2. However, in ity than aerobic capacity were lower in patients with group 1, in which RMR also expected to be elevated, chronic LBP than healthy controls [48]. McQuade et al. this was not the case. This could be because of the evaluated ninety-six persons with chronic LBP with a fact that balneotherapy might have a restricting effect battery of physical disability measures and basic phys- on RMR. Balneotherapy activates the parasympathetic ical fitness tests [34]. They found that greater overall system [44]. Parasympathetic system decreases many physical fitness was significantly correlated with less functions of body organs and systems, so an increase in physical dysfunction [34]. Nevertheless, some studies RMR might have prevented in group 1. Body fat per- found opposite results about VO2max as follows: Fil- centage was decreased in group 2 after treatment and ho et al. claimed that aerobic capacity might not be this finding is appropriate with increased RMR. Other a primary concern for patients with LBP [14]. Hurri factors such as nutrition might have played a role in de- et al. found that there were no significant changes in creased body fat percentage in group 2 after treatment. the VO2max in any of the intervention in patients with Body weight, BMI and body fat percentage not stati- chronic LBP [20]. In current study, we compared aero- cally different before and after therapy in group 1. This bic capacity pre and post treatment in patients with LBP results show that body composition was not affected (Table 2). It might be claimed that VO2max increased from balneotherapy with exercise in patients with LBP. significantly after treatment because of improvement Pulmonary function tests; MVV was increased in of group 1 patients with balneotherapy and exercise. group 1 after treatment (Table 3). This result might VO2max might be elevated in group 1 because of in- have resulted from increased respiratory muscles per- creased physical activity level which depends on the formance in group 1 and are relevant to increased improvement in pain, disability, quality of life and oth- VO2max. FEV1/FVC and FEF25−75 measurements of er symptoms. These results support above studies [34, PFTs were decreased in group 2 after treatment and 46,50] that they found a relation between aerobic ca- these might be because of the negative or unexpected pacity and illness. On the other hand, VO2max has not effects of exercise on pulmonary function as exercise changed significantly in group 2 following the treat- may induce bronchospasm for some people [49]. How- ment; since usually it was aimed better flexibility, mus- ever, balneotherapy containing hot water might remove cular strength, and co-ordination with exercise pro- this negative effect in group 1. Nevertheless, it was the gram in patients with LBP. Therefore, aerobic capacity fact that all PFTs did not exceed normal limits before 270 R. Demirel et al. / Effects of balneotherapy with exercise in patients with low back pain and after treatment in both groups, and also some of muscle nerve endings. Beta-endorphin releasing and them not statistically were different before and after washing out the pain mediators by peripheral vasodi- treatment. This situation implies that PFTs were not latation also play a role in producing analgesia [29]. affected strongly from exercise and balneotherapy in Extension distance was increased after therapy in both LBP patients. groups (Table 6). But other spine joint mobility tests Shutov and Panasiuk stated that pain relieved and not significantly changed in group 1 after therapy as re- psychovegetative status improved in patients with LBP ported above [26]. Because balneotherapy center was can be treated with balneopelotherapy [45]. In this outside of the city center, group 1 patients might have study, an improvement was observed in quality of life affected negatively by cold weather. and the majority of psychiatric symptoms except anx- Exercise is safe for individuals with back pain, be- iety in both groups (Table 4). Anxiety was not re- cause it does not increase the risk of future back in- moved after therapy in both groups; this state might be juries or work absence [41]. Fitness programmes com- expected in patients with LBP since anxiety is minor prise exercises for flexibility, aerobics, coordination, symptom than depression. Balneotherapy activates the muscular strength and endurance [28]. Exercise can parasympathetic system and accordingly increased ac- be useful for improving impairments in function that cumulation of acetylcholine in the central nervous sys- are frequently present in patients with chronic LBP, in- tem may be a factor of its sedative effect [44]. During cluding reduced back flexibility, strength and cardio- balneotherapy, releasing of beta-endorphin plays a role vascular endurance [41]. There is modest evidence to in producing sedation [29]. However, improvements in suggest that the regular performance of exercise may the symptoms of LBP, decreasing stress level and feel- directly reduce back pain intensity [8]. Similarly, in ing well might have a positive effect on psychological our study, in agreement with above reports, exercise status of patient with LBP. Furthermore, this psycho- treatment had an improvement shown by questionnaires logic improvement might lead to success in patients’ (VAS, ODI, HAD-depression, SCL-90-R, SF36) and social life. spine joint mobility tests (extension, right and left later- There is encouraging evidence suggesting that bal- al flexion, lomber Schober, fingertip to floor distance) neotherapy may be effective for treating patients with (Tables 4, 5 and 6). It also increased RMR and de- LBP [38]. The data from the systematic reviews and creased body fat percentage in group 2 (Tables 1 and meta-analysis suggest significant differential effects in 2). Therefore, exercise therapy which is cheap and easy favor of balneotherapy for reducing low back pain [23, appears to be effective at relieving pain and improving 40]. Balogh et al. demonstrated that balneotherapy it- some body functions in patients with LBP [8,19]. self can alleviate LBP, by the analgesic efficacy (VAS) LBP is one of the most frequent symptoms and its and improvement of mobility (flexion-extension and ro- chronicity causes considerable socioeconomic costs in tation of the spine and Schober’s index) accomplished many countries [21]. Patients with LBP are a signifi- by the use of mineral water is significantly superior to cant concern for both health care professionals and em- that afforded by with tap water [2]. On ployers [9]. Physical and mental health co-morbidities the other hand Konrad et al. treated 35 patients with and measures of analgesic use were associated with LBP for 4 weeks and they found that pain score (VAS) chronicity, healthcare utilization and costs [42]. In its was significantly reduced but no significant change oc- various forms, LBP is a devastating individual, social, curred in spinal motion (flexion, extension and lateral and economic burden with costs estimated at $20 billion flexion) tests [26]. Evaluations of ODI for Low Back per year annually in the United States, and about 10% of Pain: The score 0-20 % is minimal disability; 21–40 % that amount per year in the United Kingdom [26]. The is medium disability; 41-60 % is serious disability; 61– 29.4% of workers who perceive to have LBP,which lim- 80 % is handicapped [12,13]. In current study, group 1 its their daily activities substantially is, however a point was in medium disability before therapy, but the same of concern for this specific industry [51]. Galukande group was in minimal disability after therapy (Table 5). et al. show that back pain was a significant cause of In this study, VAS (rest, mobility and nocturnal) scores disability particularly affecting the productive middle decreased significantly after therapy in both groups (Ta- years of adult life [16]. This has social and econom- ble 5). These results show that balneotherapy is an ic implications, as well as economic loss to the work- effective treatment for LBP as reported above [2,26, er, employer and society. The ultimate effects of LBP 38]. The common action mechanism of balneotherapy are that the individual’s ability for competitive employ- is to increase pain threshold by affecting sensory and ment and opportunity are lessened [16]. Importance R. 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