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Efficiency of physiotherapy cures

Efficiency survey of complex physiotherapy cures at spa hotels for patients with coxarthrosis

Dr István Fluck, Dr József Szakonyi, Dr Márta Mogyorósi,
Dr Miklós Weigl, Dr Péter Horváth and their contributors

In relation to the effectiveness of treatments with medicinal water, several high-standard publications by Hungarian authors – easily meeting the requirements of “evidence-based medicine” – have been published in recent years in Hungarian and foreign scientific reviews. (1,2, 3, 4,5) 
Several important publications have also dealt with the complex treatment of locomotive disorders. (6, 7, 8, 9)

According to the domestic and Central European medical approach, complex treatments which apply the entire arsenal of physiotherapy are much more effective than monotherapy. There are therefore no health resorts or institutions in Hungary treating diseases with the exclusive application of a single – no matter how effective – local curative factor. There are, for example, no mud or irrigation health institutions where every disorder is treated with mud packs, or by rinsing all bodily orifices with medicinal water (e.g. in the event of lesions of the accessory nasal cavities or gastro-intestines, or gynaecological diseases).

We deemed it expedient to investigate the status of patients participating in two and three-week cures at domestic spa hotels (spa guests) upon arrival and departure, and to ascertain their subjective complaints and their opinions relating to the efficiency of the treatments.

We involved the spa guests of Danubius Health Spa Resort Hotel Margitsziget, Hotel Helia, the spa operating in the same building as Danubius Hotel Gellért, the Spa Hotels Hévíz and Aqua, and the Spa Hotels in Sárvár and Bük in the survey.

+Danubius Zrt: Dr Katalin Lónyai, Dr Ferenc Németh, Dr Bernadett Horváth, Dr Attila Gász, Dr Zsuzsanna Laczkó, Dr Márta Kőrösfalvi
Budapest Spas Zrt: Dr Kornélia Lányi, Dr Andrea Szabó, Dr Andrea Ürögi

The data of 94 patients with coxarthrosis were computer-processed in total. The patients were treated between December 2007 and May 2008 at the above-mentioned institutions.
Every patient received every treatment necessary for his/her condition and his/her complaints (spa treatments, hydrotherapeutic procedures, mud treatments, medicinal gymnastics, electrotherapy, etc.).
Spa treatments were performed using certified medicinal water at all locations.
From the outset, we excluded from the survey patients who had undergone operations involving hip or knee-joint prosthesis, as well as those restricted in their motion due to their cardiac condition or spinal complaints.

We compiled the assessment form based on the documentation recommendations that   Csermely (10) proposed for the qualification of medicinal water.

The forms were completed during the first medical examination and on the last treatment day; they were always completed by the same person.

The patients came from eight countries:

HOME COUNTRY WOMEN MEN TOTAL
Grand Total: 59 35 94
Germany 32 25 57
Hungary 12 3 15
Austria 7 3 10
Switzerland 3 2 5
Russia 3 0 3
USA 1 1 2
Australia 0 1 1
Israel 1 0 1

German citizens traditionally have made up a decisive majority of patients receiving complex treatment, although their number has decreased in recent years in the absolute sense due to the restrictions of domestic insurance subsidies, as well as the economic recession.

The proportion of men (35 people) to women (59 people) represents the typical ratio split of spa guests, since, according to general experience, women take more care of their health than men and are also willing to spend money on it.

There was little difference between the average age of men and women (men: 67.3 years, women: 67.5 years).
The highest average age was found in patients at the two hotels in Hévíz (men: 70.14 years, women: 70.43 years).
At the Budapest hotels, the average age of men was 62.5 years and the average age of women 65.7 years; this proportion was almost identical at the hotels in Sárvár and Bük as well.

Of the 94 patients examined, 58 received a three-week treatment and 36 received a two-week treatment. The three-week cure was primarily taken by the Germans (20 women and 13 men) and the Hungarians. The latter group all received a three-week treatment.
Contrary to our expectations, we found no significant discrepancy between the therapeutic results of those having participated in a two-week or three-week cure, thus we – on assessment – merged the two groups.
There was also no significant difference between the results achieved amongst the respective establishments. This fact confirmed our conviction that improvement was independent of the spa hotel where the patients received treatment.

18% of men and 32% of women had a bilateral hip process. Unfortunately, we could only rely on physical examinations, measurable data (walking time, distance of pace, etc.) and the patients’ complaints when completing the forms, because most of the patients did not bring an X-ray photograph or medical report with them.


During the assessment, we compared the data of the respective examined parameters both prior to and subsequent to complex treatment.

We recorded alterations in five sorts of pain sensations, based on the patients’ subjective opinions.

(PT: prior to treatment; ST: subsequent to treatment)

PT AT REST PT PCS ST AT REST ST PCS
none 49  none 63
mild 25  mild 25
medium 16  medium 6
strong 4 strong 0
PT UPON MOTION PT PCS ST UPON MOTION ST PCS
none 1  none 14
mild 29  mild 46
medium 39  medium 33
strong 25 strong 1
PT UPON START-UP PT PCS ST UPON START-UP ST PCS
none 4  none 9
mild 21  mild 47
medium 38  medium 34
strong 31 strong 4
PT UP THE STAIRS PT PCS ST UP THE STAIRS ST PCS
none 6  none 9
mild 24  mild 52
medium 36  medium 30
strong 28 strong 3
PT DOWN THE STAIRS PT PCS ST DOWN THE STAIRS ST PCS
none 12  none 18
mild 33  mild 54
medium 31  medium 22
strong 18 strong 0

It is interesting to observe that pain registered at the start, both prior to and subsequent to treatment, lasted a lot longer in the case of the men than the women. However, the assessments show significant improvements for both genders.

Average duration of pain at the start (in seconds)

Gender Avarage PT Avarage ST
Men 550 333
Women 180 71
All 317 167



Significance – Men:
H0: the value of pain at the start is identical prior to and subsequent to treatment.
H1: the value of pain at the start is not identical prior to or subsequent to treatment.



Significance – level: p = 0.05
Degree of freedom: f = n – 1 = 30 – 1 = 29
tp = 2.042

t > tp

We reject H0. The difference is significant.

Significance – Women:
H0: the value of pain at the start is identical prior to and subsequent to treatment.
We reject H0. The difference is significant.


Significance – level: p = 0.05
Degree of freedom: f = n – 1 = 53 – 1 = 52
tp = 2.009

t > tp

We reject H0. The difference is significant.

We obtained a similarly favourable result while assessing with the visual analogue scale (VAS). (In eight cases, the patients indicated “0” pain upon conclusion of the treatment.)

Average of visual analogue scale (VAS):


Gender Avarage PT Avarage ST
Men 48 28
Women 54 31
All 52 30



Significance – Men:
H0: the VAS value is identical prior to or subsequent to the treatment.
H1: the VAS value is not identical prior to or subsequent to the treatment.


Significance – level: p = 0.05
Degree of freedom: f = n – 1 = 34 – 1 = 33
tp = 2.030

t > tp

We reject H0. The difference is significant.

Significance – Women
H0: the VAS value is identical prior to or subsequent to the treatment.
H1: the VAS value is not identical prior to or subsequent to the treatment.


Significance – level: p = 0.05
Degree of freedom: f = n – 1 = 59 – 1 = 58
tp = 2.000

t > tp

We reject H0. The difference is significant.



Survey of the maximum distance of pace (cm) brought the following result:

Gender Avarage PT Avarage ST
Men 42 46
Women 41 44
All 41 45



Maximum distance of pace - Significance – Men:
H0: the value of maximum distance of pace is identical prior to and subsequent to treatment.
H1:  the value of maximum distance of pace is not identical prior to or subsequent to treatment.


Significance – level: p = 0.05
Degree of freedom: f = n – 1 = 35 – 1 = 34
tp = 2.030

t > tp
We reject H0. The difference is significant.


Significance – Women:
H0: the value of maximum distance of pace is identical prior to or subsequent to treatment.
H1: the value of maximum distance of pace is not identical prior to or subsequent to treatment.


Significance – level: p = 0.05
Degree of freedom: f = n – 1 = 59 – 1 = 58
tp = 2.000

t > tp
We reject H0. The difference is significant.


Walking time both on flat ground (25 metres) and up and down 20 stairs showed improvement. Such improvement was most marked on flat ground, with lesser (although still significant) improvement in the case of walking the stairs.


On 25m of flat ground: Men t=5.16   tp=2.030   t>tp
  Women t=7.45   tp=2.000   t>tp
Up 20 stairs: Men t=6.14   tp=2.030   t>tp
  Women t=7.45   tp=2.000   t>tp
Down 20 stairs: Men t=6.99   tp=2.030   t>tp
  Women t=6.80   tp=2.000   t>tp

Gender Walking time on 25m of flat ground PT (sec) Walking time on 25m of flat ground ST (sec)
Men 46 41
Women 47 40
All 47 40

Gender Walking time up 20 stairs PT (sec) Walking time up 20 stairs ST (sec)
Men 47 41
Women 52 43
All 50 42

Gender Walking time down 20 stairs PT (sec) Walking time down 20 stairs ST (sec)
Men 55 40
Women 47 41
All 50 41





The patients’ ability to walk essentially improved upon ascending and descending the stairs. (We did not examine men and women separately.)

  Prior to treatment
  With both feet With one foot
  Holding on to something     Not holding on to anything Holding on to something     Not holding on to anything
Upstairs 41 18 32 3
Downstairs 33 29 30 2
  Subsequent to treatment
  With both feet  With one foot 
  Holding on to something   Not holding on to anything Holding on to something Not holding on to anything
Upstairs 45 25 20 4
Downstairs 29 42 17 6

We detected improvement of a similar degree for of those requiring a walking aid in the street or at home. Of the eight patients walking with an aid at home, two were able to give it up; of the 27 people using a stick or an elbow-crutch, four were able to abandon the aid altogether.


  Prior to treatment Subsequent to treatment
  With aid Without aid With aid Without aid
At home 8 86 6 88
In the street 27 67 23 71

Many of the patients took non-steroid antiphlogistics regularly, primarily diclofenac derivatives. No one was taking steroids regularly among the patients examined. By the end of the treatment period, the number of those able to reduce their dose of non-steroids was significant. Moreover, in a few cases, they could even eliminate it (for men, 4 out of 20, and for women, 10 out of 38).

Upon conclusion of the treatment, we asked the patients to judge their condition pre- and post-treatment. Of the 94 patients, one person mentioned a deterioration, 30 deemed their condition practically unchanged, 20 reported a medium improvement, 31 a definitely significant amelioration, and five reported an excellent result.
It is equally important to emphasise that every overseas patient declared he/she would be happy to return to Hungary for a repeated complex cure.



Acknowledgement


The authors express their thanks to Mr Tamás Varga, contributor of IT Management of Danubius Hotels Nyrt, for his assistance in data processing and for conducting the significant calculations.

Efficiency survey of complex physiotherapy cures at spa hotels for patients with coxarthrosis

Dr István Fluck, Dr József Szakonyi, Dr Márta Mogyorósi,
Dr Miklós Weigl, Dr Péter Horváth and their contributors+

Summary


The authors performed a multi-centric survey at six spa hotels belonging to Danubius Hotels Inc., as well as at the spa operating in the same building as Danubius Hotel Gellért. They studied the therapeutic results of complex cures lasting two or three weeks on 94 patients with coxarthrosis.
The survey compared the condition of patients both prior to and subsequent to the treatment. For a clear majority of patients, an improvement  manifested itself both objectively and subjectively.
Statistical calculations were carried out on quantifiable parameters, confirming a significant improvement in every case.

+Danubius Zrt: Dr Katalin Lónyai, Dr Ferenc Németh, Dr Bernadett Horváth, Dr Attila Gász, Dr Zsuzsanna Laczkó, Dr Márta Kőrösfalvi
Budapest Spas Zrt: Dr Kornélia Lányi, Dr Andrea Szabó, Dr Andrea Ürögi

Literature


  1. Báthori, G., Merétey, K., Korda, J., Gasztonyi, Gy., Görgényi, F., Böhm, U., Bálint, G.: Double-blind examination: The effect of the Kiskunhalas thermal water on patients with RA. Hungarian Rheumatology, 1981, 22, 30-36.
  2. Barta, A., Varjú, T., Papp, T., Berecz, I.: Double-blind examination on the clinical testing of the Nyíregyháza thermal water. Hungarian Rheumatology, 1988, 29, 19-33.
  3. Szűcs, L., Ratkó, I., Leskó, T., Szoór, I., Genti, Gy., Bálint, G.: Double-blind trial on the effectiveness of the Püspökladány thermal water on arthrosis of the knee-joints. J. R. Soc. Health, 1989, 109, 7-9.
  4. Konrád, K., Tátrai, T., Hunka, A., Vereckei, E., Korondi, I.: Controlled trial of balneotherapy in treatment of low-back pain. Ann. Rheum. Dis., 1992, 51, 820-822.
  5. Kovács, I., Bender, T.: The therapeutic effects of Cserkeszőlő thermal water in osteoarthritis of the knee: a double-blind controlled, follow-up study. Rheumatol. Int. 2002, 21, 218-221.
  6. Bálint, G. Bender, T., Szabó, E.: Spa treatment in arthritis J. Rheumatol., 1993, 20, 1623-1625.
  7. Bálint, G., Szebenyi, B.: Non-pharmacological therapies in osteoarthritis. Balliers Clin. Rheum. 1997, 11, 795-815.
  8. Bender, T., Géher, P., Bálint, G.: Non-pharmacological treatment of musculosceletal disease. Clin. J. Pain., 2001, 17, 278.
  9. Bender, T., Karagülle, Z., Bálint, G. P., Gutenbrunner, C., Bálint, P. V., Sukenik, S.: Hydrotherapy, balneotherapy and spa treatment in pain management. Rheum. Int. 2005, 25, 15-26.
  10. Csermely, M.: Spas and Medicinal Waters, White Golden Book Publishing House, Budapest 2002, 15-26.

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