Thermal Medicine: Therapeutic and Preventive Evidence on Fibromyalgia

Mini Review

A systematic literature search was conducted through March 2021 (Medline via Pubmed), using the keywords balneotherapy, mudtherapy, fibromyalgia, in order to assess the effectiveness of different forms of Thermal Medicine (TM) in the management of fibromyalgia syndrome (FMS). There were 20 Randomized Controlled Trials (RCTs) and 13 Systematic Reviews. The last Systematic Review was in April 2013, so we reviewed the 6 RCT’s since Aril 2013.

FMS is an idiopathic, common and complex syndrome, defined as long lasting, widespread and symmetrical non-articular musculoskeletal pain with generalized tender points at specific anatomical sites [1]. FMS main symptom is pain, however, it can, also be combined with other functional symptoms, such as fatigue and sleep disturbances. [2]. Unfortunately, there is no clear evidence on FMS’s etiology, and as a result, different therapeutic methods are based on several possible pathogenic mechanisms [3]. propose that FMS’s inflammatory process can be mediated by cytokines, proteases and inflammation mediators, while Clauw et al. (2011) and Kaltsas G, et al. [4] suggest that FMS is caused by pathophysiological changes on hypothalamo-pituitary-adrenal axis, autonomic nervous system, cytokines, hormones and neurotransmitters, which lead to lower biological amines’ levels and increase of the excretion of substance P.

TM is a complimentary therapeutic method that consists of Balneothetapy (BT), internal washes, drinking therapy, inhalation therapy, mud therapy (MT), thalassotherapy and cave therapy. The basic therapeutic elements, on which TM is based, are inorganic elements and nonmetals (Cl-, SO₄², HCO₃-, S, Br, I, F, NH₃,NO₃ -, NO₂-,PO₄³-, H₂PO₄-,HPO₄²-,CO₂, O₂ , N₂, H₂, Se), microminerals (Na⁺, K⁺, Ca²⁺, Mg²⁺, Fe²⁺, Fe³⁺, Cu, Co, Zn, Ni, Mn, Li⁺, Al, Ba, Sr²⁺, Pb, As, B) and noble gases (Rn, He, Ne, Ar, Kr) [5].

Hot thermal baths are thought to improve various FMS symptoms. Studies have shown that TM decreases pain moderately and improve the patients’ Health-Related Quality of Life (HRQoL) [6-8], while it, also, has a small effect on mood [6]. TM might even be considered as a first-line treatment together with patient education and aerobic exercise [9]. The mechanism of action of this approach is still a matter of discussion, but probably involves hormonal, inflammatory and cognitive-emotional factors [10].

Different pathophysiological mechanisms are suggested to explain the therapeutic results of BT and MT on FMS patients. First of all, mechanical factor (buoyancy and aquatic resistance) relieves body from pain, due to the absence of gravity on joints and secondly, thermal factor (heat) affects nerve endings and provokes muscle relaxation [10]. Sukenik S et al. [11] described the antiinflammatory effects of sulphurous thermal water. Ardiç F et al. [12] proposed that BT therapeutic result on FMS is based on the decrease of IL-1, PGE2, and LTB4. Furthermore, Ardiç F et al. [10] & Sukenik S et al. [13] suggest that increased plasma endorphin and cortisol levels, as well as the decrease of IL-1, IL-6, PGE2, LTB4, TNF-alpha are responsible of the therapeutic effect of BT on FMS.

Sulfur (S) is one of the main therapeutic elements of TM. It is structural element of proteins, hormones, enzymes, amino acids, muscles, skin, and bones, it promotes nervous system function and insulin production, and it provides anti-inflammatory, antitoxic, antiallergic, bactericidal and parasiticidal activity. Hydrogen sulfide (H2S) acts in inhalation and drinking therapy, as well as BT [14]. Sulphurous thermal water seems to reduce IL-2 and IFNγ production (Ghersetich, 1996). Furthermore, Bellometti S et al. [15] has demonstrated that MT relieves pain and provokes muscle relaxation through an increase of β-endorphin plasma levels Bender T et al. [16]. Prior systematic reviews and meta-analyses concerning BT in FMS have covered the literature up to April 2013 [6] and found moderate evidence of a medium-to-large effect on pain and trigger-points-count (TBC) for BT, a medium effect on HRQoL, and no significant effect on depressive symptoms. Since 2015, Fioravanti A, Koçyiğit BF, Pérez-Fernández MR [7,17,18] published results about BT and its efficacy on FMS and [19-21] published results about BT and MT and their efficacy of FMS.

Koçyiğit BF et al. [17] compared the effect of a 21-sessions program (5days/week) on 66 patients, Fioravanti A et al. [7] evaluated the results of a 2-week program to those 3 and 6 months later (follow-up) and Pérez-Fernández MR et al. [18] compared the results of a 14-session/month program. All of them used Visual Analogue Scale (VAS), Tender Point Count (TPC), Fibromylagia Impact Questioning Total score (FIQ-Total), and Modified Fatigue Impact Scale (MFIS) for the evaluation of the patients. They concluded that BT eliminated pain, reduced the number of tender points and fatigue, both short- and long- term.

Bazzichi L et al. [19] compared the effect of a 2-week program (6 days/week) on 41 FM patients, Bağdatli AO et al. [20] studied the effect of a 2-week program (20min/day) on 70 patients and Ablin JN et al. [21] studied the effects of BT and MT on FMS in intermittent treatment program (2/week, 5 weeks) and continuous treatment program (5/weeks, 2 weeks). In all RCT, the results showed that symptoms have been alleviated, especially pain, while there was no difference between intermittent and continuous treatment. Studies show that TM alleviates symptoms on patients with FMS, specifically it eliminates pain, reduces the number of tender points, decreases fatigue, both short- and long-term. However, more RCTs are required in order to ensure the efficacy of TM on FMS [22-32].

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