Sulphur Thermal Water Improves Blood Lipids But Not Total Anti-oxidant Capacity in Knee Osteoarthritis Patients

Abstract

Objectives: Balneotherapy is known to alleviate pain in bone and joint diseases, and many blood parameters were shown to be modified upon thermal water therapy. In our study, we sought to investigate the effect of sulphur thermal water on blood lipids and total anti-oxidant capacity in patients suffering from knee osteoarthritis.
Interventions: Patients were selected according to the American College of Rheumatology criteria. Volunteers (13 women, aged 30 to 60 years old) underwent a thermal water cure session of 20 min daily during two weeks in a sulphur water pool of Moulay Yacoub spring.
Outcome measures: Patients have ha lipid laboratory tests and total anti-oxidant capacity measured before and after two weeks of thermal water treatment.
Results: In this study, we found that sulphur thermal water treatment reduced cholesterol, triglyceride and LDL in patients’ blood; instead, no change was found in their plasma total anti-oxidant capacity.
Conclusions: Balneotherapy sessions lead to lowering of blood lipid of patients suffering from knee osteoarthritis. The latter effect could be part of the mechanism of action of thermal water in decreasing disease activity in knee osteoarthritis. On the other hand, blood total anti-oxidant capacity, as measured by our method, does not seem to be of relevance in the pathology of our patients.

Full text

54
In the name of God
Shiraz E-Medical Journal
Vol. 13, No. 2, April 2012
http://semj.sums.ac.ir/vol13/apr2012/90034.htm
Sulphur Thermal Water Improves Blood Lipids But Not Total Anti-
oxidant Capacity in Knee Osteoarthritis Patients.
Errasfa. M *, Harzy.T **.
*Associate Professor of Pharmacology, Department of Pharmacology, Faculty of Medicine
and Pharmacy. Laboratoire de Recherches sur les Bases Moléculaires en Pathologie Hu-
maine et Outils Thérapeutiques, Fez, Morocco, ** Associate Professor of Rheumatology,
Rheumatology Unit, CHU Hassan II, Fez, Morocco.
Correspondence: Dr. M. Errasfa. Department of Pharmacology, Faculty of Medicine and Pharmacy. Km
2,2. Route de Sidi Harazem, Fez, Morocco. Telephone: +2125(35) 35619320, Fax: ++2125(35)
35619320,, E-mail: pharmacologiefmpf@yahoo.fr.
Received for Publication: December 15, 2011, Accepted for Publication: January 5, 2012.
Abstract:
Objectives: Balneotherapy is known to alleviate pain in bone and joint diseases, and many
blood parameters were shown to be modified upon thermal water therapy. In our study, we
sought to investigate the effect of sulphur thermal water on blood lipids and total anti-oxidant
capacity in patients suffering from knee osteoarthritis.
Interventions: Patients were selected according to the American College of Rheumatology
criteria. Volunteers (13 women, aged 30 to 60 years old) underwent a thermal water cure
session of 20 min daily during two weeks in a sulphur water pool of Moulay Yacoub spring.
Outcome measures: Patients have ha lipid laboratory tests and total anti-oxidant capacity
measured before and after two weeks of thermal water treatment.
Results: In this study, we found that sulphur thermal water treatment reduced cholesterol,
triglyceride and LDL in patients’ blood; instead, no change was found in their plasma total
anti-oxidant capacity.
Conclusions: Balneotherapy sessions lead to lowering of blood lipid of patients suffering from
knee osteoarthritis. The latter effect could be part of the mechanism of action of thermal
water in decreasing disease activity in knee osteoarthritis. On the other hand, blood total
anti-oxidant capacity, as measured by our method, does not seem to be of relevance in the
pathology of our patients.
Keywords: balneotherapy, knee osteoarthritis, blood lipids, anti-oxidant

55
Introduction:
Knee osteoarthritis (OA) is one of the
most common forms of arthritis. Knee OA
affects more than 10 % of people over
55 years of age, mostly women.(1) Rec-
ommendations of EULARS (Europeans
League again Rheumatism) pointed out
to several forms of treatment for the re-
lief of pain in knee OA.(2) Among non
pharmacological treatment, balneothera-
py is widely accepted as a good remedy
for the relief of symptoms and pain in
knee OA.(3,4,5,6) In a previous part of the
present study, we also have confirmed
the clinical improvement (pain score and
walking distance) of knee OA patients
who practice balneotherapy in a sulphur
thermal pool.(7) Beside the clinical benefit
of balneotherapy, researchers have fo-
cused on biochemical mechanisms and
possible pain-related molecules, that
could be modulated in patients upon
thermal water treatment of OA.(8,9,10) It is
believed that Oxidative stress resulting
from either an over production of oxygen
free radicals or from an imbalance in the
capacity of defense mechanisms could
play an important role in OA.(11) Because
blood lipids represent a target of oxygen
free radical, they were studied in many
balneotherapy clinical trials, which have
demonstrated indeed, that blood lipids
can be modulated by balneotherapy in-
terventions.(12,13,14) In the present study,
we sought to investigate the effect of
bathing in a sulphur water pool on blood
lipids of patients suffering from knee OA,
and also to assess their total anti-oxidant
capacity. Our results confirm that blood
lipids can be modified by balneotherapy
in knee OA patients.
Material & Methods:
Patients: 13 patients, all women, aged 30
to 60 years old (48,84 ± 7,11 years )
were selected among a list of 34 pa-
tients, all, having signs of knee OA ac-
cording to radiologic exam and examina-
tion by a team of rheumatologists. Pa-
tients enrolled in this study have had
knee OA evolution for a mean period of
time of 47, 23 ± 37,73 months. Inclu-
sion of patients in the study was carried
out according to American College of
Rheumatology (ACR)’s criteria. Inclusion
criteria were: Fulfilling the ACR criteria
for knee, Pain characteristic of knee joint
OA for at least three months, no limita-
tions of motion of the joint and outpa-
tients with no severe disability. Exclusion
criteria were: Patients with severe inter-
nal cardiovascular and peripheral vascu-
lar diseases, presence of any common
contra indication for hot thermal water
cure, any pharmacologic treatment
change or intra-articular infiltration dur-
ing the last three months. Patients were
told not to take any special medication
nor vitamins during the study, but they
could keep taking their regular analgesic
or non steroidal anti-inflammatory drugs.
Volunteers were enrolled in the study
after having signed a written consent and
having received information about the
purpose of the study during a meeting
with the team of researchers. The study
was approved by a local ethic committee.
Balneotherapy: For daily treatment with
thermal water, patients were taken every
morning by bus from the city of Fez to
the thermal balneotherapy resort of Mou-
lay Yacoub (15 Kms far from Fez). Ther-
mal cure consisted on a hot spring pool
session of 20 min daily, (not Monday)

56
during two weeks. Temperature of water
was 38-39.5 °C.
Lipids analyses: Among other blood ana-
lyses, blood lipid analyses were per-
formed according to standard laboratory
methods and were carried out at the uni-
versity hospital Hassan II of Fez.
Total anti-oxidant capacity (TAC) of
blood: TAC was evaluated in plasma
samples of patients using a commercial
kit according to its manufacturer (Merck-
Boeringer). Blood plasma of each patient
was obtained following centrifugation of
heparinised blood samples. TAC assay
was performed as indicated by the manu-
facturer, at the department of pharma-
cology of the faculty of medicine of Fez.
Water composition of Moulay Yacoub’s
spring is as follows (in mg/ml): Ca2+ ;
1200, Mg2+ ; 277, Na+ ; 9600, K+ ;
660, Fe2+; 1.2,. Anions: Cl- ; 17200,
SO42- ; 34.8, PO42- ; 1.6, SiO3- ; 36,
HCO3-; 238 and sulphurs ; 32. pH: 6.5.
Statistical analysis: Data are expressed
as mean ± S.D (Standard Deviation).
Quantitative variables were compared
using paired Student t-test.
Results:
Following two weeks of balneotherapy at
Moulay yacoub’s spring, and among sev-
eral biochemical blood parameters ana-
lyzed in our patients, blood lipids were
the most affected parameters in this
study. Interestingly, although blood lipids
were in the normal range for all patients,
data analyses (Table 1) showed that
upon balneotherapy sessions, there have
been a significant decrease (more than
25%) in plasma triglycerides concentra-
tion, as well as a slight but significant
decrease of LDL and total cholesterol
concentrations. Instead, a slight, but not
significant increase of HDL concentrations
was found in patients at the end of bal-
neotherapy cure. Plasma TAC analysis in
patients did not show any significant
change upon balneotherapy sessions
(Table 2).
TABLE 1: Plasma lipid levels (g/l) of patients before and after balneotherapy.
Before treatment
After treatment
Triglycerides 1.28 ± 0.49 0.95 ± 0.41 p < 0.001
LDL Cholesterol 1.14 ± 0.32 1.04 ± 0.26 p < 0.049
HDL Cholesterol 0.44 ± 0.09 0.50 ± 0.15 p < 0.072
Total Cholesterol 1.86 ± 0.28 1.74 ± 0.32 p < 0.015
TABLE 2: Plasma Total Anti-oxidant Capacity (mM) of patients before and after balneothe-
rapy.
Before treatment After treatment
Total Anti-oxidant Capacity 2.54 ± 0.52 2.38 ± 0.42 p < 0.363
Discussion:
SPA therapy is mentioned in the EULARS
2003 report (4) as a possible choice of
treatment of pain in knee osteoarthritis
patients. In order to unravel the mechan-
ism of action of thermal water and how it
acts in the body, many clinical studies
have focused on biochemical regulations
that take place in the blood. Blood lipids

57
were shown to be improved by be bal-
neotherapy. A study on degenerative
musculoskeletal disease has shown that
balneotherapy decreased cholesterol and
triglyceride levels in patients.(12) Another
study has shown that SPA therapy was
associated with a decrease of cholesterol,
HDL and LDL levels, with no effect on
triglycerides nor on cholesterol/HDL ra-
tio.(13) Although our study have some
limits in term of number of patients
enrolled in the study, or the absence of a
control group of patients that did not un-
dergo balneotherapy, the statistical com-
parisons of blood lipids of our patients
clearly indicate that their lipid profile has
improved upon two weeks balneothera-
py. At present, the relevance of balneo-
therapy in lowering blood lipids in muscu-
loskeletal diseases is not clear yet, but
lipids could represent a target of thermal
water cure, where lowering certain lipids
could have a beneficial role in these dis-
eases. Our current results on blood lipids
and those of other studies (12,13) demon-
strate that balneotherapy is able to mod-
ulate lipid metabolism of OA patients. In
recent years, many studies have focused
on molecules that could be modulated
upon balneotherapy, such as those be-
longing to free radical-generating path-
ways and anti-oxidant systems, cytokines
and some lipid mediators.(8,9,10,11,12) All of
these molecules could be linked to pain
generation in musculoskeletal diseases.
An attractive idea was whether balneo-
therapy could have some protection
against molecular oxidation that usually
occurs in chronic diseases such as OA(11),
thus, by enhancing the anti-oxidant po-
tential of the body. Indeed, total blood
anti-oxidant capacity is considered as a
parameter of immune defense, whose
low level may be associated with certain
chronic pathologies. In our study, plasma
TAC of patients was not modified upon
balneotherapy sessions. We believe that
the assay of TAC may not be specific
enough to draw any conclusion about the
real anti-oxidant capacity of the blood,
because many molecules could have a
non specific anti-oxidant property, such
as uric acid, so as the interpretation of
the result could be misleading. Instead,
measurement of each anti-oxidant mole-
cule separately could give a real anti-
oxidant status of blood, which could be
correlated to the clinical outcome. In a
similar clinical study (14), and based on
superoxide dismutase activity and perox-
ides concentrations in patients’s blood,
the authors have concluded that oxida-
tive stress could be reduced by sulphur
bath therapy. Another study concluded
instead, that TAC was reduced upon bal-
neotherapy.(12) In conclusion, our study
confirms the data of other similar studies
(12,13) on lowering blood lipids upon bal-
neotherapy sessions, and this effect
could be of relevance for patients suffer-
ing from knee OA. Instead, blood TAC
should be investigated further, by ana-
lyzing separately the level of blood anti-
oxidant molecules as well as the products
of oxidative stress in patients. Our re-
sults on lowering blood lipids upon bal-
neotherapy should encourage to investi-
gating such an effect in hyperlipidemic
patients as well.
Conclusion:
Our study showed that knee osteoarthri-
tis patients have had an improvement of

58
blood lipids upon balneotherapy in sul-
phur water.
Acknowlegements:
The authors would like to thank Ms. L.
Bouxid for excellent technical assistance,
and Dr Ghani and Dr Akasbi for partici-
pating in examining patients, and Mr.
Faisal Belhassani as well as Dr. Raouf
Belefqih (local spa physician) for their
support. Transportation of patients and
TAC analysis were made possible by help
from the University of Sidi Mohamed Ben
Abdellah.
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