title: Both serum receptors of tumor necrosis factor are influenced by mud pack treatment in osteoarthrotic patients. Anti-inflammatory effect as a mechanism of effectiveness underlying the clinical benefits of pelotherapy in osteoarthritis patients: regulation of the altered inflammatory and stress feedback response A study on the efficacy of treatment with mud packs and baths with Sillene mineral water (Chianciano Spa Italy) in patients suffering from knee osteoarthritis Therapy With Mud Compresses for Knee Osteoarthritis: Comparison of Natural Mud Preparations With Mineral-Depleted Mud Effect of balneotherapy on temporospatial gait characteristics of patients with osteoarthritis of the knee Spa therapy in the treatment of knee osteoarthritis: a large randomised multicentre trial Bath thermal waters in the treatment of knee osteoarthritis: a randomized controlled clinical trial. Balneotherapy in elderly patients: effect on pain from degenerative knee and spine conditions and on quality of life. Mud bath therapy influences nitric oxide, myeloperoxidase and glutathione peroxidase serum levels in arthritic patients. Therapeutic effect of spa therapy and short wave therapy in knee osteoarthritis: a randomized, single blind, controlled trial Evaluation of the effect of Lake Hévíz thermal mineral water in patients with osteoarthritis of the knee: a randomized, controlled, single-blind, follow-up study. The therapeutic effects of Cserkeszölö thermal water in osteoarthritis of the knee: a double blind, controlled, follow-up study Evaluation of clinically relevant changes in patient reported outcomes in knee and hip osteoarthritis: the minimal clinically important improvement. Cytokine levels in osteoarthrosis patients undergoing mud bath therapy. A 10-day course of SPA therapy is beneficial for people with severe knee osteoarthritis Short- and Long-Term Effects of Spa Therapy in Knee Osteoarthritis Circulating levels of adiponectin, resistin, and visfatin after mud-bath therapy in patients with bilateral knee osteoarthritis
abstract: Several authors have demonstrated the pivotal role of proinflammatory cytokines in inducing progressive cartilage degradation and secondary inflammation of the synovial membrane in osteoarthritis ( OA ) . It has recently been established that tumor necrosis factor (TNF)-alpha plays a well-defined role in the pathophysiology of inflammatory joint diseases and that binding to circulating soluble TNF-alpha receptors can inactivate it . We investigated the influence of mud pack treatment , which is able to diminish TNF-alpha serum values , on specific TNF receptor ( sTNF-R ) levels . Thirty-six patients with OA were enrolled and r and omized into two groups . Group A underwent mud pack treatment and group B underwent thermal bath treatment .  A group of 20 healthy untreated subjects was used as a control . Blood sample s were collected at baseline and after treatment , and assays of sTNF-R55 and sTNF-R75 were performed in both groups . We found small changes in sTNF-Rs serum values but these were not statistically significant . sTNF-R55 serum values decreased by 0.4 % after the therapy in group A , while in group B the decrease was -17.7 % . sTNF-R75 was reduced by -21.17 % in group A and by -10.6 % in group B. In conclusion , through its thermic and ant/inflammatory activity mud pack treatment shows complex interaction with the most common factors of inflammatory and cartilage degradation . Our results suggest that the thermic component of this natural treatment is mainly involved in modulating inflammatory reaction and cartilage damage through binding of the circulating TNF , which controls the activation of the cells responsible for the production of proinflammatory cytokines The purpose of the present investigation was to evaluate whether an anti-inflammatory effect together with an improvement of the regulation of the interaction between the inflammatory and stress responses underlies the clinical benefits of pelotherapy in osteoarthritis ( OA ) patients . This study evaluated the effects of a 10-day cycle of pelotherapy at the spa centre ‘ El Raposo ’ ( Spain ) in a group of 21 OA patients diagnosed with primary knee OA . Clinical assessment s included pain intensity using a visual analog scale ; pain , stiffness and physical function using the Western Ontario and McMaster Universities Arthritis Index ; and health-related quality of life using the EuroQol-5D question naire . Serum inflammatory cytokine levels ( IL-1β , TNF-α , IL-8 , IL-6 , IL-10 and TGF-β ) were evaluated using the Bio-Plex ® Luminex ® system . Circulating neuroendocrine-stress biomarkers , such as cortisol and extracellular 72 kDa heat shock protein ( eHsp72 ) , were measured by ELISA . After the cycle of mud therapy , OA patients improved the knee flexion angle and OA-related pain , stiffness and physical function , and they reported a better health-related quality of life . Serum concentrations of IL-1β , TNF-α , IL-8 , IL-6 and TGF-β , as well as eHsp72 , were markedly decreased . Besides , systemic levels of cortisol increased significantly . These results confirm that the clinical benefits of mud therapy may well be mediated , at least in part , by its systemic anti-inflammatory effects and neuroendocrine-immune regulation in OA patients . Thus , mud therapy could be an effective alternative treatment in the management of OA Mud-bath therapy plays a primary role in the treatment and prevention of  osteoarthritis  that has been recognised since antiquity . Numerous studies have demonstrated its clinical benefits and its effects on inflammatory mediators ( interleukins ) , the immune system , cenesthesic factors ( endorphins ) , and the diencephalic – pituitary – adrenal axis . This study was conducted to assess the efficacy of mud-bath therapy with mineral water from the Sillene Spring at Italy ’s Chianciano Spa in patients with osteoarthritis of the knee . Patients ( n = 61 ) were divided into two groups . Group A underwent three cycles of mud-based spa therapy over a year ’s time , whereas group B did not . Clinical conditions , visual analogue scale pain ratings , and Lequesne indexes of the two groups were compared . We also compared these same parameters in the patients of the two groups that were following the therapy with drugs and in the patients of the group A before and after spa treatment . The percentage of patients with no symptoms or mild symptoms was higher in group A than in group B. Within group A , this percentage was higher after treatment than before spa therapy . Even in the comparison between the patients of the two groups that were following the therapy with drug , the results was that in group A the percentage of patients with no symptoms or mild symptoms was higher than in group B. Statistical analyses based on various tests revealed that almost all these differences were highly significant . No adverse effects were observed in any of the patients in group A. In conclusion , the mud-bath therapy performed at Chianciano Spa with Sillene Spring water remarkably improved the clinical conditions of patients with knee arthritis and significantly reduces the frequency and severity of symptoms and the disability they cause Mud pack therapy is an alternative mode of treatment for rheumatic diseases . It is based on the application of heated mud packs to the entire body or to specific areas , such as over joints . The aim of the current study was to evaluate the efficacy of treatment with mud compresses at patients ’ homes for osteoarthritis of the knee . Fifty-eight patients with osteoarthritis of the knee were enrolled in a prospect i ve , double-blinded , controlled study . Forty patients were treated with natural mineral-rich mud compresses and 18 patients were treated with mineral-depleted mud compresses . Mud compresses were applied 5 times each week during 3 weeks for a total of 15 treatments . Patients were assessed at baseline , at completion of the 3-week treatment period , and twice after the conclusion of the treatment period — after 1 month and after 3 months . The main outcome measures were the Lequesne Index of severity of knee osteoarthritis , patient self- assessment of pain , and severity of knee pain on a visual analog scale . A reduction of 20 % or more in the pain scores was considered clinical ly significant . In the group treated with natural mud compresses , a significant reduction in knee pain was observed at all assessment s. Similarly , improvement in the Lequesne Index was seen at the end of therapy and a month after treatment . In the control group , given mineral-depleted mud compresses , no significant change in knee pain was seen at any assessment . Improvement in the Lequesne Index was seen 1 and 3 months after completion of the therapy , but not at the end of therapy . Seventy-two percent of the patients in the treatment group had an improvement of > 20 % in self- assessment of knee pain , compared with 33 % in the control group ( p = 0.005).The data suggest that treatment with mud compresses , but only in their natural form , temporarily relieves pain in patients with osteoarthritis of the knees . We believe that treatment with mud compresses might augment conventional medical therapy in these patients Effects of balneotherapy on gait properties of patients with osteoarthritis of the knee were investigated prospect ively . A total of 30 patients with knee osteoarthritis received balneotherapy consisting of two daily thermomineral water baths for 2 weeks . Patients were evaluated using gait analysis and clinical scores , both within 2 weeks , before and after spa treatment . Patients were walking faster in their control analyses ( 0.81 ± 0.21 to 0.89 ± 0.19 m/s ; P = 0.017 ) , with a shorter mean stance time ( 63.0 ± 3.3 to 61.8 ± 2.5 % stride ; P = 0.007 ) , an increased cadence ( 96 ± 13.1 to 100 ± 11.9 steps/min ; P = 0.094 ) and stride length ( 996 ± 174 to 1,058 ± 142 mm ; P = 0.017 ) . Balneotherapy also result ed in a significant decrease in Lequesne knee osteoarthritis index ( 12.1 ± 3.7 to 10.0 ± 3.3 points ; P = 0.003 ) , VAS for pain ( 58 ± 25 to 33 ± 15 ; P = 0.0001 ) , VAS for patients ’ ( 56 ± 24 to 29 ± 19 ; P < 0.001 ) and investigator ’s global assessment ( 55 ± 20 to 26 ± 15 ; P < 0.0001 ) and WOMAC score ( 2.1 ± 0.7 to 1.6 ± 0.8 ; P = 0.0004 ) . Balneotherapy has positive effects on gait properties and clinical health quality parameters of patients with knee osteoarthritis in short-term evaluations Objective To determine whether spa therapy , plus home exercises and usual medical treatment provides any benefit over exercises and usual treatment , in the management of knee osteoarthritis . Methods Large multicentre r and omised prospect i ve clinical trial of patients with knee osteoarthritis according to the American College of Rheumatology criteria , attending French spa resorts as out patients between June 2006 and April 2007 . Zelen r and omisation was used so patients were ignorant of the other group and spa personnel were not told which patients were participating . The main endpoint criteria were patient self-assessed . All patients continued usual treatments and performed daily st and ardised home exercises . The spa therapy group also received 18 days of spa therapy ( massages , showers , mud and pool sessions ) . Main Endpoint The number of patients achieving minimal clinical ly important improvement ( MCII ) at 6 months , defined as ≥19.9 mm on the visual analogue pain scale and /or ≥9.1 points in a normalised Western Ontario and McMaster Universities osteoarthritis index function score and no knee surgery . Results The intention to treat analysis included 187 controls and 195 spa therapy patients . At 6 months , 99/195 ( 50.8 % ) spa group patients had MCII and 68/187 ( 36.4 % ) controls ( χ2=8.05 ; df=1 ; p=0.005 ) . However , no improvement in quality of life ( Short Form 36 ) or patient acceptable symptom state was observed at 6 months . Conclusion For patients with knee osteoarthritis a 3-week course of spa therapy together with home exercises and usual pharmacological treatments offers benefit after 6 months compared with exercises and usual treatment alone , and is well tolerated . Trial registration number NCT00348777 BACKGROUND Osteoarthritis is a degenerative disease associated with pain , reduced range of motion , and impaired function . Balneotherapy or bathing in thermal or mineral waters is used as a non-invasive treatment for various rheumatic diseases . AIM To evaluate the effectiveness of hot sulfurous and non-sulfurous waters in the treatment of  knee osteoarthritis  . DESIGN A r and omized , assessor-blind , controlled trial . SETTING A spa resort . POPULATION One hundred and forty patients of both genders , mean age of 64.8±8.9 years , with knee osteoarthritis and chronic knee pain . METHODS Patients were r and omized into three groups : the sulfurous water ( SW ) group ( N.=47 ) , non-sulfurous water ( NSW ) group ( N.=50 ) , or control group ( N.=43 ) who received no treatment . Patients were not blinded to treatment allocation . Treatment groups received 30 individual thermal baths ( three 20-minute baths a week for 10 weeks ) at 37 - 39 ° C . The outcome measures were pain ( visual analog scale , VAS ) , physical function ( Western Ontario and McMaster Universities Osteoarthritis Index , WOMAC ; Lequesne Algofunctional Index , LAFI ; Stanford Health Assessment Question naire , HAQ ) , and use of pain medication . Patients were assessed before treatment ( T1 ) , at treatment endpoint ( T2 ) , and two months post-intervention ( T3 ) . Intra- and intergroup comparisons were performed at a significance level of 0.05 ( P<0.05 ) . RESULTS A significant decrease in VAS pain scores ( pain during movement , at rest , and at night ) and use of pain medication , and improvement in WOMAC , LAFI and HAQ scores were observed from baseline to T2 and T3 within treatment groups ( P<0.001 ) , and between controls and both treatment groups at T2 and T3 ( P<0.001 ) . No significant differences in these variables were observed between treatment groups at T2 , but patients in the SW group reported less pain and better functional status than those in the NSW group at T3 , showing a lasting effect of sulfurous water baths . CONCLUSIONS Both therapeutic methods were effective in the treatment of knee osteoarthritis ; however , sulfurous baths yielded longer-lasting effects than non-sulfurous water baths . CLINICAL REHABILITATION IMPACT Baths in thermal waters , especially those in sulfurous waters , are effective in reducing pain and improving physical function in patients with knee osteoarthritis BACKGROUND Balneotherapy is an established treatment modality for musculoskeletal disease , but few studies have examined the efficacy of spa therapy in elderly patients with degenerative spine and joint diseases . OBJECTIVES To assess the effects of balneotherapy on chronic musculoskeletal pain , functional capacity , and quality of life in elderly patients with osteoarthritis of the knee or with chronic low back pain . METHODS The 81 patients in the study group underwent a 1 day course of 30 minute daily baths in mineral water . Changes were evaluated in the following parameters : pain intensity , functional capacity , quality of life , use of non-steroidal anti-inflammatory or analgesic drugs , subjective disease severity perceived by the patients , investigator-rated disease severity , and severity of pain perceived by the patients . We analyzed the results of 76 subjects as 5 did not complete the study . RESULTS Compared to baseline , all monitored parameters were significantly improved by balneotherapy in both investigated groups . Moreover , the favorable effect was prolonged for 3 months after treatment . CONCLUSIONS This study showed that balneotherapy is an effective treatment modality in elderly patients with osteoarthritis of the knee or with chronic low back pain , and its benefits last for at least 3 months after treatment Nitric oxide ( NO ) has recently been proposed as an important mediator in inflammatory phases and in loss of cartilage . In inflammatory arthritis NO levels are correlated with disease activity and articular cartilage is able to produce large amounts of NO with the appropriate inducing factors such as cytokines and /or endotoxin . Neutrophils also play an important role in inflammatory reactions and the level of myeloperoxidase , a constituent of neutrophil granules , is related to the intensity of the inflammation . Because there is evidence that suggests that mud packs influence the main cytokines involved in cartilage damage , we tried to determine whether NO and myeloperoxidase are involved in the mechanisms of action of mud bath treatment .  We enrolled 37 subjects and r and omly assigned them to two groups : 19 patients underwent mud bath treatment ( group A )  while 18 patients underwent bath treatment alone .  Blood sample s were obtained before and after the treatment cycles to assay serum levels of NO , myeloperoxidase ( MPO ) and glutathione (GSH)-peroxidase . The results showed a statistically significant decrease in NO and myeloperoxidase serum values in groups A and B , while GSH-peroxidase was not significantly increase in either of the groups ; no correlation was found between NO , myeloperoxidase and GSH-peroxidase serum values .  Mud bath treatment can exert beneficial effects on cartilage homeostasis and inflammatory reactions , influencing NO and decreasing myeloperoxidase serum values . The increase in GSH-peroxidase was not correlated with the reduction of other biochemical markers , suggesting that mud bath treatment has different mechanisms of action Spa therapy and short wave therapy are two of the most commonly used non-pharmacological approaches for  osteoarthritis .  The aim of this study was to assess their efficacy in comparison to conventional therapy in patients with osteoarthritis of the knee in a single blind , r and omized , controlled trial . Seventy-four out patients were enrolled ; 30 patients were treated with a combination of daily local mud packs and arsenical ferruginous mineral bath water from the thermal resort of Levico Terme ( Trento , Italy ) for 3 weeks ; 24 patients were treated with short wave therapy for the same period and 20 patients continued regular , routine ambulatory care . Patients were assessed at baseline , upon completion of the 3-week treatment period , and 12 weeks later . Spa therapy and short wave therapy both demonstrated effective symptomatic treatment in osteoarthritis of the knee at the end of the treatment , but only the spa therapy was shown to have efficacy persistent over time . Our study demonstrated the superiority of arsenical ferruginous spa therapy compared to short wave therapy in the treatment of osteoarthritis of the knee , probably in relationship to the specific effects of the minerals in this water BACKGROUND Osteoarthritis is the most frequent joint disease and is a leading cause of pain and locomotor disability in elderly people . The treatment of osteoarthritis includes non-pharmacological , pharmacological , and surgical therapies . Silver level evidence has been found concerning balneotherapy in osteoarthritis . AIM OF THE STUDY The aim of this study was to evaluate how Lake Hévíz thermal mineral water therapy influences pain , knee function , and quality of life in patients with knee osteoarthritis , compared to the control group . STUDY DESIGN r and omized , controlled , single-blind , follow-up study . SETTING Spa Hévíz and St. And rew Hospital for Rheumatic Diseases POPULATION This study included 77 out patients between 45 and 75 years of age with mild to moderate osteoarthritis of the knee meeting the American College of Rheumatology classification criteria . METHODS Patients were r and omized into two groups . In group I ( n = 38 ) , subjects bathed in Lake Hévíz and in group II ( N.=39 ) , patients were treated in a pool full of tap water . Water temperature was 34 ° C for both groups . Participants underwent 30-minute therapy sessions , five times a week for three weeks . Outcome measures were pain visual analogue scale scores , active flexion degree , knee circumference , stair-climb time , Western Ontario and McMaster Universities osteoarthritis index ( WOMAC ) , and EuroQoL Group 5-Dimension Self-Report Question naire score ( EQ-5D ) . Study parameters were recorded at baseline , immediately after treatment , and after 15 weeks . RESULTS Comparison of the two groups revealed a statistically significant difference in pain visual analogue scale scores ( P<0.01 ) , active flexion degree ( P<0.01 ) , physical function components of WOMAC ( P<0.05 ) , and EQ-5D scores ( P<0.05 ) even after 15 weeks . CONCLUSIONS Balneotherapy  improved pain , function as well as the quality of life in patients with knee osteoarthritis . CLINICAL REHABILITATION IMPACT Balneotherapy is a potentially useful treatment modality for patients with knee osteoarthritis Abstract . The effects of thermal water from Cserkeszölö in Hungary were appraised in a r and omised , double blind study conducted on 58 patients with osteoarthritis of the knee .  Balneotherapy was delivered as a 15-day course of 30-min daily sessions performed with thermal water ( active treatment ) or tap water of similar colour and odour ( placebo treatment ) . The musculoskeletal status of participants was evaluated at baseline , at the end of the balneotherapy course , and 3 months later . Study endpoints ( initial pain , range of motion , tenderness on palpation , stair climbing , physicians ' opinion and subjective rating by patients , and ambulation ) were assessed using visual analogue scales and symptom scores . Both groups improved ; however , the magnitude of improvement was significantly greater in patients treated with thermal water from Cserkeszölö BACKGROUND In clinical trials , at the group level , results are usually reported as mean and st and ard deviation of the change in score , which is not meaningful for most readers . OBJECTIVE To determine the minimal clinical ly important improvement ( MCII ) of pain , patient 's global assessment of disease activity , and functional impairment in patients with knee and hip osteoarthritis ( OA ) . METHODS A prospect i ve multicentre 4 week cohort study involving 1362 out patients with knee or hip OA was carried out . Data on assessment of pain and patient 's global assessment , measured on visual analogue scales , and functional impairment , measured on the Western Ontario McMaster Universities Osteoarthritis Index ( WOMAC ) function subscale , were collected at baseline and final visits . Patients assessed their response to treatment on a five point Likert scale at the final visit . An anchoring method based on the patient 's opinion was used . The MCII was estimated in a subgroup of 814 patients ( 603 with knee OA , 211 with hip OA ) . RESULTS For knee and hip OA , MCII for absolute ( and relative ) changes were , respectively , ( a ) -19.9 mm ( -40.8 % ) and -15.3 mm ( -32.0 % ) for pain ; ( b ) -18.3 mm ( -39.0 % ) and -15.2 mm ( -32.6 % ) for patient 's global assessment ; ( c ) -9.1 ( -26.0 % ) and -7.9 ( -21.1 % ) for WOMAC function subscale score . The MCII is affected by the initial degree of severity of the symptoms but not by age , disease duration , or sex . CONCLUSION Using criteria such as MCII in clinical trials would provide meaningful information which would help in interpreting the results by expressing them as a proportion of improved patients Osteoarthritis is an important rheumatic condition characterized by the progressive destruction of cartilage . The pathophysiologic phenomena leading to the pathologic changes in the joint appear to result from biomechanical factors and activation of final common pathways of tissue damage influencing chondrocyte homeostasis and a functional program . Several cytokines and growth factors are reported to be responsible for inflammation and cartilage degradation . Among these , IL-1 and TNF alpha have been suggested as important in promoting cartilage inflammation and tissue destruction , while IGF I has a protective influence on cartilage structure . Chondrocytes and their metabolism have gained interest as targets of drug intervention ; the results of this study confirm that mud bath therapy is also able to influence chondrocyte activities . Our data suggest that mud bath therapy influences cytokines related to osteoarthrosis pathomechanism and maintenance , and encourage further investigations to evaluate possible synergism between pharmacological treatment and mud bath therapy The objective of this study was to test if spa therapy can play a role in the management of severe knee osteoarthritis ( OA ) . Twenty patients with radiologically and clinical ly severe knee OA were r and omly assigned into spa and drug therapy groups . Spa group ( n = 10 ) traveled to a spa town and stayed at a hotel for a 10-day spa therapy course . They followed a balneotherapy regimen including thermal pool baths at 37 ° C for 20 min two times daily . Drug therapy group ( n = 10 ) stayed at home and followed their individually prescribed drug therapy ( NSAIDs and paracetamol ) . Patients were assessed at baseline ( week 0 ) , after spa therapy at 2 weeks ( week 2 ) and during follow-up period at 12 ( week 12 ) and 24 ( week 24 ) weeks by a blinded investigator . Patients assessed with Lequesne algofunctional index ( LAFI ) , pain ( visual analogue scale , VAS ) , patient ’s and investigator ’s global evaluation ( VAS ) , ten-stairs stepping up and down time , 15 m walking time and three times squatting up and down time . Significant improvement in pain and LAFI scores were found at week 2 , week 12 and week 24 in the spa therapy group compared to baseline . Comparing the two group differences , spa therapy was superior to drug therapy in pain reduction and in physician ’s global assessment at all time points . This superiority was also found in LAFI scores and patients ’ global assessment s at week 12 and week 24 . A 10-day course of spa therapy may be beneficial in short- and medium-term up to 24 weeks by reducing pain and improving functional status and overall well-being in patients with severe knee OA and may be considered as an effective therapeutic tool for such patients in countries like Turkey where it is widely available and ( at least partly ) reimbursed Fioravanti A , Iacoponi F , Bellisai B , Cantarini L , Galeazzi M : Short- and long-term effects of spa therapy in knee osteoarthritis . Objective : To assess both the short- and long-term effectiveness of spa therapy in patients with primary knee osteoarthritis in a prospect i ve , r and omized , single-blinded , controlled trial . Design : Eighty out patients were enrolled in this study ; 40 patients were treated with a combination of daily local mud packs and bicarbonate-sulfate mineral bath water from the spa center of Rapolano Terme ( Siena , Italy ) for 2 wks , and 40 patients continued regular , routine ambulatory care . Patients were assessed at baseline time ; after 2 wks ; after 3 , 6 , and 9 mos after the beginning of the study and were evaluated by Visual Analog Scale for spontaneous pain , Lequesne index , Western Ontario and McMaster Universities Index for gonarthrosis , Arthritis Impact Measurement Scale-1 , and symptomatic drug consumption . Results : We observed a significant improvement of all evaluated parameters at the end of the cycle of spa therapy , which persisted throughout the whole of the follow-up period , whereas in the control group no significant differences were noted . This symptomatic effect was confirmed by the significant reduction of symptomatic drug consumption . Tolerability of spa therapy seemed to be good , with light and transitory side effects . Conclusions : The results from our study confirm that the beneficial effects of spa therapy in patients with knee osteoarthritis lasts over time , with positive effects on the painful symptomatology and a significant improvement on functional capacities .  Spa therapy can represent a useful backup to pharmacologic treatment of knee osteoarthritis or a valid alternative for patients who do not tolerate pharmacologic treatments Adipocytokines , including adiponectin , resistin , and visfatin may play an important role in the pathophysiology of osteoarthritis ( OA ) .  Spa therapy is one of the most commonly used non-pharmacological approaches for OA , but its mechanisms of action are not completely known . The aim of the present study was to assess whether a cycle of mud-bath therapy ( MBT ) influences the serum levels of adiponectin , resistin , and visfatin in patients with knee OA . As part of a prospect i ve r and omized , single blind-controlled trial evaluating the efficacy of MBT in knee OA , we included in this study 95 out patients . One group ( n = 49 ) received a cycle of MBT at the spa center of Chianciano Terme ( Italy ) in addition to the usual treatment , and one group ( control group ; n = 46 )  continued their regular care routine alone . Patients were assessed at basal time and at the end of the study ( 15 days ) for clinical and biochemical parameters . Clinical assessment s included spontaneous pain on a visual analog scale ( VAS ) score and the Western Ontario and McMaster Universities index ( WOMAC ) subscores for knee OA evaluated as total pain score ( W-TPS ) , total stiffness score ( W-TSS ) , and total physical function score ( W-TPFS ) . Adiponectin , resistin and visfatin serum levels were assessed by enzyme immunoassay methods . At the end of the mud-bath therapy , serum adiponectin levels showed a significant decrease ( p < 0.001 ) , while no significant modifications were found in the control group at day 15 . Serum resistin showed a significant decrease ( p < 0.0001 ) in the MBT group at the end of the study and a significant increase in the control patients ( p < 0.001 ) . No significant modifications of visfatin were found in MBT . Furthermore , we tested the relationships between demographic and clinical parameters and adipocytokine concentrations measured in the MBT group at basal and at the end of the study . In conclusion , the present study shows that a cycle of MBT can modify serum levels of adiponectin and resistin but not the circulating levels of visfatin . In view of the recent evidence s about the involvement of adiponectin and resistin in the pathogenesis and progression of OA , the decrease of these adipokines after mud-bath therapy may play a protective role in the course of the disease . However , it remains to be clarified which of the mechanisms of action of MBT may have determined the changes in serum levels of adiponectin and resistin that we observed
target: Among all the studies , the most relevant indexes used to measure effectiveness of spa therapy were improved including VAS , Lequesne , and WOMAC Score .
  Conclusions The mud-pack therapy , balneotherapy , mud-bath therapy , and spa therapy have proved to be effective in the treatment and in the secondary prevention of knee osteoarthritis , by reducing pain , nonsteroidal anti-inflammatory drug consumption , and functional limitation and improving quality of life of affected patients
background: Background Osteoarthritis ( OA ) is the most common musculoskeletal disease in the world .
  OA is the result of an inflammatory and degenerative process affecting the entire joint .
  Osteoarthritis , especially involving the knee , has a relevant socioeconomic impact in terms of drugs , hospital admissions , work absences , and temporary or permanent invalidity .
  Therapy of knee osteoarthritis is based on pharmacological and nonpharmacological measures .