Balneotherapy for rheumatoid arthritis at the Dead Sea. Early combination disease-modifying antirheumatic drug therapy and tight disease control improve long-term radiologic outcome in patients with early rheumatoid arthritis: the 11-year results of the Finnish Rheumatoid Arthritis Combination Therapy trial Balneotherapy at the Dead Sea area for patients with psoriatic arthritis and concomitant fibromyalgia. Balneotherapy in medicine: A review Balneotherapy at the Dead Sea area for knee osteoarthritis. Treatment of Very Early Rheumatoid Arthritis With Symptomatic Therapy, Disease-Modifying Antirheumatic Drugs, or Biologic Agents Sulphur bath and mud pack treatment for rheumatoid arthritis at the Dead Sea area. Effect of spa therapy in Tiberias on patients with rheumatoid arthritis and osteoarthritis. Effect of spa therapy with saline balneotherapy on oxidant/antioxidant status in patients with rheumatoid arthritis: a single-blind randomized controlled trial Spa therapy adjunct to pharmacotherapy is beneficial in rheumatoid arthritis: a crossover randomized controlled trial A clinical study of Suogudan granule in the treatment of rheumatoid arthritis. Long-Term Outcomes of Patients With Recent-Onset Rheumatoid Arthritis After 10 Years of Tight Controlled Treatment Mud compress therapy for the hands of patients with rheumatoid arthritis Rehabilitation in rheumatoid arthritis: a critical review. Evaluation of the effect of balneotherapy in patients with osteoarthritis of the hands: a randomized controlled single-blind follow-up study A randomized and controlled trial of hydrotherapy in rheumatoid arthritis. A randomized controlled trial to evaluate the efficacy of community based physical therapy in the treatment of people with rheumatoid arthritis.
Thirty-six patients with active rheumatoid arthritis were treated for 12 days at the Ein Gedi Spa . The patients were allocated r and omly to four study groups . Group 1 ( n = 9 ) was treated with daily baths in the Dead Sea , group 2 ( n = 9 ) was treated with daily sulphur baths , group 3 ( n = 10 ) was treated with a combination of daily Dead Sea bathing and sulphur baths , and group 4 ( n = 8) served as a control group . All patients were assessed by a rheumatologist who was blinded to the treatment modalities and group allocation . Clinical parameters assessed included : duration of morning stiffness , 15 m walk time , grip strength , activities of daily living , patient 's assessment of disease severity , number of active joints , and the Ritchie articular index . Statistically significant improvement lasting up to 3 months was observed only in the three treatment groups Introduction Early treatment of rheumatoid arthritis ( RA ) has been shown to retard the development of joint damage for a period of up to 5 years . The aim of this study was to evaluate the radiologic progression beyond that time in patients with early RA initially treated with a combination of three disease-modifying antirheumatic drugs ( DMARDs ) or a single DMARD .  Methods A cohort of 199 patients with early active RA were initially r and omized to receive treatment with a combination of methotrexate , sulfasalazine , and hydroxychloroquine with prednisolone ( FIN-RACo ) , or treatment with a single DMARD ( initially , sulfasalazine ) with or without prednisolone ( SINGLE ) . After 2 years , the drug-treatment strategy became unrestricted , but still targeted remission . The radiographs of h and s and feet were analyzed by using the Larsen score at baseline , 2 , 5 , and 11 years , and the radiographs of large joints , at 11 years . Results Sixty-five patients in the FIN-RACo and 65 in the SINGLE group had radiographs of h and s and feet available at baseline and at 11 years . The mean change from baseline to 11 years in Larsen score was 17 ( 95 % CI , 12 to 26 ) in the FIN-RACo group and 27 ( 95 % CI , 22 to 33 ) in the SINGLE group ( P = 0.037 ) . In total , 87 % ( 95 % CI , 74 to 94 ) and 72 % ( 95 % CI , 58 to 84 ) of the patients in the FIN-RACo and the SINGLE treatment arms , respectively , had no erosive changes in large joints at 11 years . Conclusions Targeting to remission with tight clinical controls results in low radiologic progression in most RA patients . Patients treated initially with a combination of DMARDs have less long-term radiologic damage than do those treated initially with DMARD monotherapy . Trial registration Current Controlled Trials IS RCT N18445519 BACKGROUND Balneotherapy has been successfully used to treat various rheumatic diseases , but has only recently been evaluated for the treatment of fibromyalgia . Since no effective treatment exists for this common rheumatic disease , complementary methods of treatment have been attempted . OBJECTIVES To assess the effectiveness of balneotherapy at the Dead Sea area in the treatment of patients suffering from both fibromyalgia and psoriatic arthritis . METHODS Twenty-eight patients with psoriatic arthritis and fibromyalgia were treated with various modalities of balneotherapy at the Dead Sea area . Clinical indices assessed were duration of morning stiffness , number of active joints , a point count of 18 fibrositic tender points , and determination of the threshold of tenderness in nine fibrositic and in four control points using a dolorimeter . RESULTS The number of active joints was reduced from 18.4 + /- 10.9 to 9 + /- 8.2 ( P < 0.001 ) . The number of tender points was reduced from 12.6 + /- 2 to 7.1 + /- 5 in men ( P < 0.003 ) and from 13.1 + /- 2 to 7.5 + /- 3.7 in women ( P < 0.001 ) . A significant improvement was found in dolorimetric threshold readings after the treatment period in women ( P < 0.001 ) . No correlation was observed between the reduction in the number of active joints and the reduction in the number of tender points in the same patients ( r = 0.2 ) . CONCLUSIONS Balneotherapy at the Dead Sea area appears to produce a statistically significant substantial improvement in the number of active joints and tender points in both male and female patients with fibromyalgia and psoriatic arthritis . Further research is needed to eluci date the distinction between the benefits of staying at the Dead Sea area without balneotherapy and the effects of balneotherapy in the study population Bathing in water ( balneotherapy or spa therapy ) has been frequently and widely used in classical medicine as a cure for diseases . This paper review s the present literature on the use of balneotherapy in dermatologic , chronic musculoskeletal ( inflammatory and non-inflammatory ) , metabolic and psychological conditions . We performed a systematic review on related papers appearing in the Medline and Cochrane Library data base from 1966 to 2003 that included r and omized controlled and non-r and omized clinical trials using balneotherapy . We also determined to reflect where possible the chemical compositions of spas . The major dermatologic and musculoskeletal diseases that are frequently treated by balneotherapy with a remarkable rate of success are atopic dermatitis , psoriasis , rheumatoid arthritis ( RA ) , ankylosing spondylitis , osteoarthritis and low back pain . Moreover , the effects of spa therapy on several metabolic conditions are discussed . The mechanisms by which broad spectrums of diseases respond to spa therapy probably incorporate chemical , thermal and mechanical effects . The importance of balneotherapy either alone or as complement to other therapies should be considered after , or accompanying , orthodox medical treatments BACKGROUND Balneotherapy at the Dead Sea area has been applied in various inflammatory rheumatic diseases such as rheumatoid arthritis and psoriatic arthritis . The efficacy of balneotherapy at the Dead Sea area for the treatment of degenerative rheumatic diseases has not yet been formally evaluated . OBJECTIVE To evaluate the efficacy of balneotherapy at the Dead Sea area in patients suffering from osteoarthritis of the knees . METHODS Forty patients were r and omly allocated into four groups of 10 patients . Group I was treated by bathing in a sulphur pool , group 2 by bathing in the Dead Sea , group 3 by a combination of sulphur pool and bathing in the Dead Sea , and group 4 served as the control group receiving no balneotherapy . The duration of balneotherapy was 2 weeks . RESULTS Significant improvement as measured by the Lequesne index of severity of osteoarthritis was observed in all three treatment groups , but not in the control group . This improvement lasted up to 3 months of follow-up in patients in all three treatment groups . CONCLUSION Balneotherapy at the Dead Sea area has a beneficial effect on patients with osteoarthritis of the knees , an effect that lastas at least 3 months Context It remains unclear whether the optimal treatment strategy for early rheumatoid arthritis ( RA ) is to step care from nonsteroidal anti-inflammatory drugs and other symptomatic treatments to glucocorticoids and then to disease-modifying antirheumatic drugs ( DMARDs ) only after 1 year , or to use more aggressive therapy early after diagnosis . Contribution The investigators used available data to estimate the cost-effectiveness of initial treatment strategies for RA . Compared with stepped care , early DMARDs or early biologic agents seem to improve outcomes , but only DMARDs do so at a cost per year of life saved that society typically considers acceptable . Caution Assumptions were based on limited data on early RA treatment with DMARDs and biologics . The Editors The treatment of rheumatoid arthritis ( RA ) has changed dramatically in the past decade with the introduction of new biologic therapies , particularly tumor necrosis factor inhibitors . Growing evidence suggests a benefit of aggressive treatment very early in the course of the disease and the existence of a critical therapeutic window of opportunity within which antirheumatic therapy is more effective and has a more durable effect than later in the course of the disease ( 1 , 2 ) . Very early initiation of disease-modifying antirheumatic drug ( DMARD ) or biologic therapy has a demonstrated prolonged benefit on RA progression and may permanently modify the disease to a milder course ( 1 , 3 ) . Emerging data also suggest that if RA is detected and treated very early , long-term control or remission may be possible and continuing treatment may not be necessary ( 46 ) . Although antirheumatic therapy should be initiated as early as possible after disease onset , the optimal strategy has not been determined . Early treatment with  biologics  seems to be superior to treatment with conventional DMARDs  in terms of hard outcomes , such as radiographic structural joint damage , but not necessarily in terms of disease activity ( 7 ) . Biologics are generally prescribed only after therapy with 1 or more conventional DMARDs has failed . However , r and omized , controlled trials ( RCTs ) have demonstrated improved efficacy of biologics in early disease ( 811 ) , and the pharmaceutical industry promotes early initiation of biologic therapy for RA . Because early therapy may change the natural course of the disease ( 4 ) , biologics could be most useful in early RA ( 4 , 12 , 13 ) . Although evidence supports the cost-effectiveness of biologic therapy  in DMARD-resistant severe RA ( 14 , 15 ) , its long-term cost-effectiveness in very early RA is unknown . The diagnosis of RA can be problematic very early in the course of disease ( 16 ) . An early diagnosis carries the risk for prescribing expensive and potentially toxic drugs to patients who might have spontaneous remission . Patients may incur time lost from work because of treatment or drug-related toxicities or may die because of treatment ( 13 ) . In addition , early antirheumatic therapy increases treatment costs ; in particular , biologics cost up to 10 times more than conventional DMARDs . However , patients may benefit from early therapy , endure fewer disability days , have less productivity loss , require fewer days in the hospital , and need fewer subsequent joint replacements ( 13 ) . It is therefore important to consider the total long-term costs associated with various therapeutic strategies . Health policy analyses use the incremental cost effectiveness ratio ( ICER ) to compare a particular treatment or strategy with competing treatment strategies to inform the allocation of health care re sources ( 17 ) . To determine whether the increased costs of treatment strategies that involve biologics in very early RA are warranted by health gains , we assessed the cost-effectiveness of major therapeutic strategies by examining different scenarios based on emerging data . Methods Decision Model Structure Our base-case analysis considers adults with very early RA , operationally defined as symptoms of less than 3 months in duration a definition commonly used in the literature for very early RA ( 18 , 19 ) . The classification criteria for RA require that signs and symptoms be present for at least 6 weeks ( 20 ) , and studies of patients with early RA suggest a median duration of illness of 11 to 23 weeks at diagnosis ( 21 , 22 ) . However , RA can not be reliably diagnosed at an early stage in all patients with inflammatory polyarthritis . A significant proportion of patients with undifferentiated arthritis will have spontaneous remission or receive diagnoses of other conditions ( 23 , 24 ) . Evolving diagnostic techniques , such as biomarkers ( 25 ) or improved clinical prediction rules for identifying which patients who present with undifferentiated polyarthritis will progress to RA , enable individualized decisions about initiation of treatment with DMARDs ( 23 , 26 ) . We used an individual sampling model ( 27 ) to track the course of disease over time , with changes in important variables ( principally radiographic joint damage and functional disability ) at time points at which events ( toxicities , treatment initiation , treatment discontinuation , or death ) occur . We estimated the expected lifetime costs and benefits for U.S. patients , expressed as quality -adjusted life-years ( QALYs ) , from both a health care provider and a societal perspective . Our models explore 5 conceivable strategies , but we focus on the 3 most plausible and clinical ly relevant strategies for very early RA . Although these may vary in actual practice , we simplified the choices to model the problem . In the pyramid strategy , initial nonsteroidal anti-inflammatory drugs , patient education , joint protection and therapeutic exercise , pain management , and low-dose glucocorticoids are administered as needed , followed by DMARDs at 1 year for nonresponders . This is still the most common pattern of therapy because of delayed consultation and diagnosis ( 2830 ) . In the early DMARD strategy , conventional DMARDs ( such agents as leflunomide , sulfasalazine , hydroxychloroquine , or methotrexate ) are given within 12 weeks of symptom onset . Methotrexate is the current st and ard of care in U.S. rheumatology ( 30 ) and also has the most evidence for its effectiveness in very early RA ( 6 ) . The early biologic strategy involves very early use of biologics , defined as use of 3 sequential tumor necrosis factor inhibitors , in combination with methotrexate . In the first 2 strategies , patients initially receive conventional DMARDs ; those who do not respond to therapy with 3 conventional DMARDs , alone or in combination , then receive agents from the third strategy . We modified a published model ( 31 ) for this analysis . We tracked hypothetical patient cohorts through the model , one at a time , in 6-month cycles from symptom onset until death . The exact route a simulated patient takes through the model depends on the therapeutic strategy used and the patient 's disease characteristics ( type of disease progression , age , sex , education level , race , income , duration of disease , comorbid conditions , baseline and current Health Assessment Question naire [ HAQ ] Disability Index score , and type and number of previously received DMARDs ) . Figure 1 shows model pathways . Figure 1 . Model schematic . Patients can change disease state every 6 months , depending on the underlying disease type and the treatment strategy received . The time spent in a particular disease state determines the probability of transition and the ultimate outcome . DMARD = disease-modifying antirheumatic drug ;  HAQ = Health Assessment Question naire ; RA = rheumatoid arthritis . * See Appendix for discussion of this strategy . Appendix . Technical Appendix We assume that patients follow 1 of 3 disease courses : drug-free remission , a mild course with slow disease progression , or rapid disease progression . At presentation , we assume that a patient 's future course can not be predicted . The patients ' disease characteristics are representative of the U.S. population with RA ( 32 ) . The model synthesizes data from RCTs ( 33 ) ; the National Data Bank for Rheumatic Diseases ( NDB ) , a longitudinal data base of semi-annual , self-reported patient data ( 32 ) ; and other literature . Details on disease progression , treatment effect , estimates for QALYs , and costs are provided in the following sections . Table 1 ( 3445 ) describes input variables , and the Appendix details our methods . We used R project statistical software ( www.R-project.org ) for all decision analyses . Table 1 . Key Model Parameters and Assumptions Disease Progression We modeled the course of the disease by using functional disability and radiographic evidence of structural joint damage . Functional disability , measured by the HAQ ( 46 ) , is a primary outcome in most RA clinical studies . Structural joint damage can be assessed by several radiographic scoring methods . We used the percentage of the maximum score of each measure to include all sources of information ( 39 ) . We applied the rate of disease progression to each disease course pattern . Because these rates are often unknown over an extended period , we first assumed that all patients present with a HAQ score of 1 and no radiographic damage . We then used the literature as a guide for the mean progression rates in each disease course . Finally , we calibrated the overall progression for all disease courses . We calibrated the HAQ with data from the NDB that show increases during early disease to an annual HAQ score progression of around 0.03 in patients with established disease , similar to previous estimates ( 47 ) . We assumed that radiographic damage increased linearly over time and calibrated it with rates of approximately 2 % per year ( 48 ) . We computed the relationship between radiographic damage and HAQ score . Estimates indicate that a 1percentage point change in radiographic progression is equivalent to a 0.04 change in HAQ score ( 38 ) . However , the effect of radiographic progression on functional disability in early phases of disease is only Forty patients with classical or definite rheumatoid arthritis in a stage of active disease were treated for two weeks at a spa hotel . The patients were divided into four groups of 10 . Group I was treated with daily mud packs , group II with daily hot sulphur baths , group III with a combination of mud packs and hot sulphur baths , and group IV served as a control group . The patients were assessed by a rheumatologist who was blinded to the treatment modalities . Statistically significant improvement for a period of up to three months was observed in the three treatment groups in most of the clinical indices . Improvement in the control group was minor in comparison and not statistically significant . No significant improvement was observed in any of the laboratory variables measured . Except for three mild cases of thermal reaction there were no side effects Forty-one patients with rheumatoid arthritis were treated for 2 weeks at a Tiberias spa hotel . R and omized into 2 groups , Group 1 received a combination of mineral baths and mud packs , and Group 2 had tap water baths only . Both groups had a significant but temporary improvement in Ritchie index . Group 1 showed a significant improvement in grip strength . No improvement was noticed in morning stiffness , 15 meter walk time and laboratory variables of disease activity in either group . Twelve patients with osteoarthritis ( OA ) received 2 weeks of treatment with mineral baths and mud packs . Statistically significant improvement for a period of 6 months was noticed in night pain , pain on passive motion , tenderness on palpation and in the index of severity of OA of the knee Oxidative stress has been shown to play a contributory role in the pathogenesis of rheumatoid arthritis ( RA ) . Recent studies have provided evidence for antioxidant properties of spa therapy . The purpose of this study is to investigate whether spa therapy with saline balneotherapy has any influence on the oxidant/antioxidant status in patients with RA and to assess clinical effects of spa therapy . In this investigator-blind r and omized controlled trial , we r and omly assigned 50 patients in a 1:1 ratio to spa therapy plus st and ard drug treatment ( spa group ) or st and ard drug treatment alone ( control group ) . Spa group followed a 2-week course of spa therapy regimen consisting of a total of 12 balneotherapy sessions in a thermal mineral water pool at 36–37 ° C for 20 min every day except Sunday . All clinical and biochemical parameters were assessed at baseline and after spa therapy ( 2 weeks ) . The clinical parameters were pain intensity , patient global assessment , physician global assessment , Health Assessment Question naire disability index ( HAQ-DI ) , Disease Activity Score for 28-joints based on erythrocyte sedimentation rate ( DAS28–4[ESR ] ) . Oxidative status parameters were malondialdehyde ( MDA ) , nonenzymatic superoxide radical scavenger activity ( NSSA ) , antioxidant potential ( AOP ) , and superoxide dismutase ( SOD ) . The NSSA levels were increased significantly in the spa group ( p = 0.003 ) but not in the control group ( p = 0.509 ) ; and there was a trend in favor of spa therapy for improvements in NSSA levels compared to control ( p = 0.091 ) . Significant clinical improvement was found in the spa group compared to the control in terms of patient global assessment ( p = 0.011 ) , physician global assessment ( p = 0.043 ) , function ( HAQ-DI ) ( p = 0.037 ) , disease activity ( DAS28–4[ESR ] ) ( 0.044 ) and swollen joint count ( 0.009 ) , and a trend toward improvement in pain scores  ( 0.057 ) . Spa therapy with saline balneotherapy  exerts antioxidant effect in patients with RA as reflected by the increase in NSSA levels after spa therapy ; whether this antioxidant effect contributes to the clinical improvements observed remains to be verified This study aims to investigate whether 2-week spa therapy , as an adjunct to usual pharmacological therapy , has any beneficial effect in patients with rheumatoid arthritis ( RA ) . In this single-blind crossover study , 50 patients were r and omly assigned in a 1:1 manner to receive usual pharmacological therapy plus 2-week spa therapy or usual pharmacological therapy alone ( period 1.6 months ) ; after a 9-month washout , patients were crossed over to the opposite assignment ( period 2.6 months ) . Spa therapy program included a daily saline balneotherapy session at 36–37 ° C for 20 min except Sundays . The clinical outcomes were evaluated at baseline , after spa therapy ( 2 weeks ) and 3 and 6 months after the spa therapy in both period and were pain ( Visual Analogue Scale ( VAS ) ) , patient and physician global assessment s ( VAS ) , Health Assessment Question naire ( HAQ ) , and Disease Activity Score ( DAS28 ) . Spa therapy was superior to control therapy in improving all the assessed clinical outcomes at the end of the spa therapy . This superiority persisted significantly in physician global assessment ( p = 0.010 ) and with a trend in favor of spa group in patient global assessment ( p = 0.058 ) , function ( p = 0.092 ) , and disease activity ( p = 0.098 ) at 3 months . Statistically significant improvements were found in spa therapy compared to control in disease activity ( p = 0.006 ) and patient ( p = 0.020 ) and physician global ( p = 0.011 ) assessment s , and a trend toward improvements in pain ( p = 0.069 ) and swollen joints ( p = 0.070 ) at 6 months . A 2-week spa therapy adjunct to usual pharmacological therapy provided beneficial clinical effects compared to usual pharmacological therapy alone , in RA patients treated with traditional disease-modifying antirheumatic drugs . These beneficial effects may last for 6 months OBJECTIVE To study the clinical efficacy of Suogudan Granule ( SGDG ) in the treatment of rheumatoid arthritis ( RA ) . METHODS Ninety patients with RA were r and omly divided into the treated group and the control group . The treated group was administered orally with SGDG 6 g each time , thrice a day , while the control group with the combined therapy of Fenbid Capsules 0.3 g each time , twice a day and Tripterygium tablet 20 mg each time , thrice a day . The treatment course for both groups was 6 weeks . The changes of clinical symptoms and signs , and laboratory indices such as erythrocyte sedimentation rate ( ESR ) , rheumatoid factor ( RF ) , antistreptolysin O ( ASO ) , routine examination of blood and urine , liver and kidney function , etc . before and after treatment were observed . RESULTS ( 1 ) The total effective rate in the treated group ( 88.0 % ) was obviously higher than that in the control group ( 67.5 % ) with significant difference ( P < 0.05 ) . ( 2 ) The improvement in arthralgia , joint swelling , time of morning stiffness , 15-meter walking , analgesia initiation and persistence in the treated group was better than that in the control group ( P < 0.05 , P < 0.01 ) , but there was no obvious difference in improvement of joint tenderness , range of joint motion , grip strength , and initiating detumescence time ( P > 0.05 ) . ( 3 ) The improvement in ESR and RF in the treated group was better than that in the control group with significant difference ( P < 0.05 ) . The negative-conversion rate of ASO in the treated group was also higher than that in the control group ( P < 0.01 ) . ( 4 ) No evident abnormality in blood , urine , liver or kidney function was found in either group . CONCLUSION SGDG is effective and safe for the treatment of RA Context A treat-to-target strategy , or treatment to achieve low disease activity , has been associated with improved outcomes among patients with early active rheumatoid arthritis ( RA ) . Long-term data on this approach are lacking . Contribution This r and omized , controlled trial compared 4 treat-to-target strategies for early active RA over 10 years . Most patients had persistently reduced disease activity scores , improved functional status , and limited joint damage during follow-up . They had survival similar to that of the general Dutch population . Caution The trial lacked a nontargeted treatment strategy . Implication Potential outcomes of a treat-to-target approach for early RA include sustained clinical improvement , drug-free remission , and normalized survival . Suppression of inflammation in patients with rheumatoid arthritis ( RA ) is associated with clinical improvement and prevention of radiographic joint damage . Rapid suppression can be achieved with initial combination therapy , including synthetic disease-modifying antirheumatic drugs and corticosteroids or a tumor necrosis factor- inhibitor ( 17 ) . In addition , tightly controlled targeted treatment ( that is , frequent measurements of disease activity with treatment adjustments aim ing to achieve a predefined target ) results in better outcomes than routine care ( 8 , 9 ) . The BeSt ( Beh and elStrategien in reumatode artritis ) study integrated a treat-to-target concept to achieve low disease activity ( defined as a disease activity score [ DAS ] 2.4 ) with a comparison of 4 dynamic treatment strategies . Patients with early active RA were r and omly assigned to sequential monotherapy , step-up combination therapy , or initial combination therapy with either prednisone or an antitumor necrosis factor- agent ( infliximab ) . Based on measurements of disease activity every 3 months , the medication dosage was increased when the DAS was higher than 2.4 and tapered if DAS was persistently 2.4 or less . The study compared the clinical , radiographic , and toxicity outcomes of these strategies over time . We report on these outcomes among participants during 10-year follow-up and compare their survival with that of the general population . Methods Design Overview The r and omized , multicenter , assessor-blinded BeSt study ( 2 ) was design ed by Dutch rheumatologists to determine in which order available antirheumatic medication could best be used to treat patients with newly diagnosed RA , aim ing at low disease activity over 10 years . The original study protocol and amendments for study extension after 2 and 5 years ( Supplements 1 through 3 ) were approved by the medical ethics committees of all participating hospitals . All patients gave written informed consent . Supplement . Data Supplement Setting and Participants The study enrolled 508 patients aged 18 years or older with early active RA according to the revised 1987 American College of Rheumatology criteria for RA ( 10 ) , with symptom duration of fewer than 2 years . They were recruited in 18 nonuniversity and 2 university hospitals in the Netherl and s between 2000 and 2002 . Exclusion criteria encompassed contraindications to the antirheumatic medications used in the study protocol ( Appendix 1 ) ( 2 , 11 ) . R and omization and Interventions Patients were allocated to 1 of 4 dynamic treatment strategies by variable block r and omization , stratified by center : strategy 1 , sequential monotherapy ; strategy 2 , step-up combination therapy ( both starting with methotrexate monotherapy ) ; strategy 3 ; initial combination therapy with methotrexate , sulfasalazine , and prednisone ; and strategy 4 , initial combination therapy with methotrexate and infliximab . For all strategies , subsequent treatment adjustments were specified in the study protocol for patients with an inadequate response ( Appendix Figure 1 ) . Over 10 years , treatment response was measured every 3 months using the DAS ( 12 ) based on a swollen joint count in 44 joints , a tender joint count in 53 joints ( Ritchie articular index ) ( 13 ) , erythrocyte sedimentation rate , and patient 's assessment of global health on a visual analogue scale ( 0 to 100 mm ) ( 12 ) . A DAS of 2.4 or less , indicating low disease activity ( 14 ) , was set as the treatment goal . Treatment was intensified ( medication changed or dosage increased , according to the treatment strategy ) at each study visit that the DAS was greater than 2.4 ( Appendix Figure 1 ) . In case of a continued good response ( DAS 2.4 for 6 months ) , dosage was tapered to a maintenance dose ( if DAS remained < 1.6 for 6 months ; defined as remission ) ( 15 ) and eventually discontinued ( defined as drug-free remission [ DFR ] ) ( Appendix 2 ) . Appendix Figure 1 . Flow diagram of treatment steps per strategy . The figure shows the required treatment intensification steps for each strategy as long as the DAS remained > 2.4 when measured every 3 mo . In all 4 strategies , patients may progress from one treatment step to the next at different times , depending on individual DAS results determined at observation every 3 mo . Patients receiving infliximab ( who receive their dose every 8 wk ) had additional DAS measurements 1 wk before each infusion . These measurements dictated if the next dose needed to be increased . Doses started at 3 mg/kg of body weight . If the DAS was greater than 2.4 , the dose was increased in a stepwise manner to 6 mg/kg , then 7.5 mg/kg , and finally 10 mg/kg ( always rounded to the nearest hundredth ) . The dosage could be tapered if DAS calculations determined every 3 mo were 2.4 or less for at least 6 mo consecutively . Medication dosages were as follows : azathioprine , 2 mg/kg to 3 mg/kg per day ; cyclosporine A , 2.5 mg/kg per day ; methylprednisolone , 3 doses of 120 mg in weeks 1 , 4 , and 8 ; gold , 50 mg/wk ; hydroxychloroquine , 200 mg/d ; infliximab , dose as indicated every 8 wk ; leflunomide , 20 mg/d ; methotrexate , dose as indicated every week ; prednisone , 7.5 mg/d unless indicated otherwise ; sulfasalazine , 2000 mg/d .  DAS= disease activity score . Outcomes and Follow-up The patients were clinical ly assessed every 3 months at study visits during the 10-year follow-up . Functional status , laboratory tests , and adverse events ( AEs ) were assessed . Functional ability was measured using the Health Assessment Question naire ( HAQ ) ( range , 0 [ best ] to 3 [ worst ] ) ( 16 ) . Conventional radiography of h and s and feet were performed annually to assess joint damage progression . All radiographs from baseline to year 10 were scored by 2 independent blinded readers using the modified Sharpvan der Heijde score ( SHS ) ( range 0 [ best ] to 448 [ worst ] ) ( 17 ) in 1 session in r and om order . The intraclass correlation coefficient between the 2 readers was 0.96 ( 95 % CI , 0.95 to 0.97 ) . The mean score of the 2 readers was used for the analysis . The AEs , either reported during visits or apparent in continued laboratory assessment s every 3 months , and serious AEs ( SAEs ) , which also included death during follow-up , were recorded during the trial . For patients who dropped out of the study , life and death status from inclusion to year 10 was obtained from the hospital ( where they enrolled ) , general practitioner , or municipality of the patient 's residence . Those who emigrated and could not be traced thereafter were censored from the date of emigration ( n= 6 ) . One patient could not be located after loss to follow-up and was also censored from the last moment of contact . Survival data of the general Dutch population were acquired from Statistics Netherl and s. Statistical Analysis For each analysis , patients were analyzed in their allocated treatment strategy at baseline , regardless of the number of treatment steps during follow-up . Time to dropout was compared among the treatment strategies with the log-rank test . The HAQ score , low disease activity , remission rate , DFR , SHS , and initial treatment step at year 10 ( intention-to-treat and completer analyses ) were reported separately for each strategy . After multiple imputation of the DAS , the percentages of low disease activity ( DAS 2.4 ) and remission ( DAS < 1.6 ) at year 10 were estimated and compared among the strategies . The imputation model included terms for observed DAS , HAQ score , r and omization strategy , age , sex , anticitrullinated peptide antibody , rheumatoid factor , SHS , and treatment step ; 10 data sets were imputed ( Supplement 4 ) . The imputation method assumed the missing values to be missing at r and om . Sensitivity analyses using controlled imputation methods ( 18 ) tested the robustness of this assumption against violations ( Supplement 4 ) . The HAQ score was analyzed over time using a linear mixed model , taking into account repeated measurements , with a Toeplitz covariance type under the assumption of equally spaced visits ( scheduled every 3 months ) . This model included time as a continuous variable , treatment , and a time-by-treatment interaction term . Sensitivity analyses were also performed for this outcome ( Supplement 4 ) . Radiographic progression at 10 years ( defined as an increase in SHS from baseline to year 10 ) was observed in patients who completed the study using a cumulative probability plot . Radiographic progression over time was analyzed by using a weighted generalized estimating equation ( GEE ) with a negative binomial working distribution , AR1 ( that is , autoregressive ) working correlation , and robust estimation of SEs . This analysis is valid under the missing-at-r and om assumption and was chosen because of the skewed nature of the SHS ( 18 ) . Weights per patient per year were found by using a logistic regression that modeled the inverse probability of a patient having radiographic data available at that measurement time ( Supplement 5 ) . Survival in the study population was compared with the general population ( matched by sex , age , and calendar year ) using the st and ardized mortality ratio : ( observed deathsexpected deaths ) ( 19 ) . KaplanMeier curves and the log-rank test were used to compare survival among the treatment strategies . Cox regression analysis was used to identify Objective The aim of this study was to evaluate the efficacy of home treatment with mud compresses for the h and s of patients with rheumatoid arthritis ( RA ) . Methods Forty-five patients suffering from RA were enrolled in a double-blind , r and omized , controlled study . Twenty-two were treated with true mud compresses ( treatment group ) and 23 were treated with attenuated mud compresses ( control group ) . The compresses were applied in the patients ’ homes five times a week during a 3-week period . Patients were assessed four times : at baseline , upon completion of the 3-week treatment period , 1 month after the treatment , and 3 months after conclusion of the treatment period . Positive response was defined as reductions of 30 % or more in the number of tender and swollen joints , 20 % or more in physician global assessment of disease activity , and 20 % or more in patient global assessment of the severity of joint pain . Results In the treatment group , significant reductions in the number of swollen and tender joints and patients ’ global assessment s of pain severity was observed at all post-treatment assessment s. Significant improvement in the scores of physician global assessment was seen at the end of therapy and 1 month later . In the control group , no improvement in the number of swollen and tender joints or physician global assessment was found in any post-treatment evaluation . However , a significant reduction in patient global assessment of joint pain severity was reported at the end of therapy and 3 months after concluding treatment . Conclusion Treatment with mud compresses relieves pain affecting the h and s and reduces the number of swollen and tender joints in the h and s of patients suffering from RA . This treatment can augment conventional medical therapy in these patients This article considers the evidence for effectiveness and timing of rehabilitation  for people with rheumatoid arthritis ( RA ) . The Cochrane Library , DARE , Medline , Embase , CINAHL and AMED were search ed to identify systematic review s and r and omized controlled trials evaluating rehabilitation interventions for people with rheumatoid arthritis . Many trials identified had method ological limitations ( e.g. short follow-up periods , small sample sizes ) . Evidence to date is that symptomatic relief results from thermotherapy , laser therapy , acupuncture and assistive devices . In the short-term , comprehensive occupational therapy ( in established rheumatoid arthritis ) , orthoses , and mind-body approaches can help maintain function . Over at least a one-year period , the following are effective in reducing pain and maintaining function :  patient education and joint protection training using behavioural approaches ; dynamic exercise therapy , h and exercises and hydrotherapy ; and cognitive-behavioural therapy ( in people with poorer psychological status ) . Many trials have recruited people with moderate to severe , established RA and relatively little is known about the long-term effectiveness of early rehabilitation , although this is becoming much more common in practice . Despite the increased availability of guidelines and systematic review s , most conclude there is insufficient evidence for many areas of rheumatology rehabilitation . Further well- design ed clinical trials are needed recruiting people with early disease using patient-centred outcomes Objective : To evaluate the effectiveness of thermal mineral water compared with magnetotherapy without balneotherapy as control , in the treatment of h and osteoarthritis . Design : R and omized controlled single-blind follow-up study . Setting : Rheumatology specialist clinic of Gunaras Health Spa . Subjects : Patients between 50 and 70 years of age with h and osteoarthritis , r and omly assigned into three groups . Interventions : The subjects in the first two groups bathed in thermal mineral water of two different temperatures ( 36 ° C and 38 ° C ) for three weeks five times a week for 20 minutes a day and received magnetotherapy to their h and s three times weekly . The third group received only magnetotherapy . Outcome measures : Visual analogue scale scores , h and grip strength , pinchgrip strength , the number of swollen and tender joints of the h and , the duration of morning joint stiffness , Health Assessment Question naire , and Short Form-36 question naire . The study parameters were administered at baseline , immediately after treatment and after 13 weeks . Results : The study included 63 patients . Statistically significant improvement was observed in several studied parameters after the treatment and during the follow-up study in the thermal water groups versus the control group . The 38 ° C thermal water treatment significantly improved the pinch strength of the right h and ( 0.6 ( 95 % confidence interval ( CI ) 0.2 to 1.1 ) vs. 0.03 ( 95 % CI −0.3 to 0.4 ) , P < 0.05 ) and the Health Assessment Question naire parameters ( −0.4 ( 95 % CI −0.6 to −0.2 ) vs. −0.1 ( 95 % CI −0.2 to 0.1 ) , P < 0.01 ) even in the long term . Conclusions : Balneotherapy combined with magnetotherapy  improved the pain and function as well as the quality of life in patients with h and osteoarthritis OBJECTIVE The aim of this study was to evaluate the therapeutic effects of hydrotherapy which combines elements of warm water immersion and exercise . It was predicted that hydrotherapy would result in a greater therapeutic benefit than either of these components separately . METHODS One hundred thirty-nine patients with chronic rheumatoid arthritis were r and omly assigned to hydrotherapy , seated immersion , l and exercise , or progressive relaxation . Patients attended 30-minute sessions twice weekly for 4 weeks . Physical and psychological measures were completed before and after intervention , and at a 3-month followup . RESULTS All patients improved physically and emotionally , as assessed by the Arthritis Impact Measurement Scales 2 question naire . Belief that pain was controlled by chance happenings decreased , signifying improvement . In addition , hydrotherapy patients showed significantly greater improvement in joint tenderness and in knee range of movement ( women only ) . At followup , hydrotherapy patients maintained the improvement in emotional and psychological state . CONCLUSIONS Although all patients experienced some benefit , hydrotherapy produced the greatest improvements . This study , therefore , provides some justification for the continued use of hydrotherapy OBJECTIVE To evaluate the short term efficacy of a community based physical therapy ( PT ) program for people with rheumatoid arthritis ( RA ) through a single blind r and omized controlled trial . METHODS Adults with active RA were referred by their physician for community based PT . Participants were r and omized to either an  immediate intervention group [ experimental group ( EG ) ] or a wait list control group  ( CG ) . The intervention was a st and ardized program of education and exercise consisting of at least 4 visits or 3 h of PT over 6 weeks . Baseline , 6 , and 12 week assessment s were by a blinded independent assessor . The primary outcome instrument was the Stanford Arthritis Self-Efficacy Scale ( SES ) and secondary outcome measures included the ACREU Rheumatoid Arthritis Knowledge Question naire ( KQ ) and visual analog scale for pain ( VAS ) . Duration of morning stiffness , grip strength , and tender joint count were also collected at each assessment . Outcome analysis was conducted using analysis of variance . RESULTS Of 150 eligible and r and omized participants , 127 completed the study according to protocol . Baseline analysis showed no differences between the EG and CG for demographics , disease status , or other characteristics . At the 6 week assessment , primary outcome analysis for those who completed the protocol identified a mean change ( improvement ) of 13.5 % in the EG and 5.8 % in the CG , representing a 7.7 % difference in change scores between the 2 groups [ F(1,121 ) = 6.03 ; p = 0.015 ] . A statistically significant difference in change scores was also identified for the KQ [ F(1,120 ) = 6.67 ; p = 0.011 ] , but not for the VAS . Disease status measures did not change , except for duration of morning stiffness , which improved by 68.8 min in the EG and 8.3 min in the CG ( F(1,121 ) = 4.50 ; p = 0.036 ] . CONCLUSION Four hours of a community based PT intervention delivered over 6 weeks significantly improved self-efficacy , disease management knowledge and morning stiffness in people with RA
We found no statistically significant differences in pain on the McGill Question naire or in physical disability ( very low level of evidence ) between balneotherapy and the other interventions .
Overall evidence is insufficient to show that balneotherapy is more effective than no treatment , that one type of bath is more effective than another or that one type of bath is more effective than mudpacks , exercise or relaxation therapy
BACKGROUND No cure for rheumatoid arthritis ( RA ) is known at present , so treatment often focuses on management of symptoms such as pain , stiffness and mobility .
Treatment options include pharmacological interventions , physical therapy treatments and balneotherapy .
Balneotherapy is defined as bathing in natural mineral or thermal waters ( e.g. mineral baths , sulphur baths , Dead Sea baths ) , using mudpacks or doing both .
Despite its popularity , reported scientific evidence for the effectiveness or efficacy of balneotherapy is sparse .
This review , which evaluates the effects of balneotherapy in patients with RA , is an up date of a Cochrane review first published in 2003 and up date d in 2008 .
OBJECTIVES To perform a systematic review on the benefits and harms of balneotherapy in patients with RA in terms of pain , improvement , disability , tender joints , swollen joints and adverse events .