Comparison of Blood Pressure and Pulse Adaptations Between Younger and Older Patients During Balneotherapy With Physiotherapy

Abstract

Objective

This study aimed to investigate the blood pressure and pulse adaptation characteristics between younger and older patients with musculoskeletal disorders during acute and recovery responses at the first and 10th sessions of balneotherapy added to physiotherapy.

Methods

Forty-six participants (n = 22, between 18 and 35 years of age as young adults; n = 24, more than 65 years of age as older adults) with musculoskeletal disorders admitted to physiotherapy therapy sessions with balneotherapy were enrolled. The participants’ immersion time was 20 minutes each during 10 sessions occurring over the course of 2 weeks. Blood pressure and pulse were measured at the baseline and the 5th minute as acute responses, and at the baseline and the 30th minute as recovery responses during the first and 10th sessions.

Results

First, the group and session effect was examined. There was no significance in this part. Then, session main effect and group main effect were examined. The group main effect was significant, that is, a difference was found between groups independent of the session in terms of only pulse values (P < .001). There was no difference in sessions. The acute and recovery responses of the pulse at the first and 10th sessions of balneotherapy showed higher alterations in the young people compared with the older people (P < .008).

Conclusion

Greater pulse alterations at the acute and recovery phases of the first and 10th sessions were observed in young adults.

Introduction

Musculoskeletal disorders are one of the leading causes of disability and a major contributor to the global financial burden of disease. The rates of patients seeking treatment are about 39% and 45% in men and women, respectively.¹ Chronic musculoskeletal disorders increase as age gets older.²

There is an increasing interest in the treatment of these disorders. In general, combinations of pharmacologic and nonpharmacological methods are preferred. Hydrotherapy, the application using the principles of hydrostatics and hydrodynamics of water in different temperature and various forms, balneotherapy, described as bathing in natural mineral or thermal waters, and spa therapy, including other modalities such as massage, electrotherapy, and exercise besides immersion with thermal mineral water, are the leading methods among the nonpharmacological treatment options in many countries.^{3, 4, 5} Balneotherapy has been used as an alternative or additional therapy for a long time. Its therapeutic effect depends on the physical and chemical effects of thermal water.⁶ Balneotherapy practices involve a specific dose, in a particular term with repeated standard time and a certain method in various diseases, including inflammatory and noninflammatory musculoskeletal problems with or without cardiac problems that may coexist.^{7, 8, 9, 10}

Several studies showed that balneotherapy is effective in muscle relaxation by decreasing joint stiffness.^{11, 12, 13, 14} In addition, balneotherapy has a direct analgesic effect by increasing stress hormones like β-endorphin.^15,16 Moreover, it has been demonstrated that balneotherapy can affect hemodynamic parameters.^17,18 Blood pressure (BP) decrease and heart rate increase owing to peripheral vasodilatation have been reported.¹⁹ The venous return enhancement and cardiac after-load depression have been reported at 41°C during immersion.²⁰ Karagulle²¹ suggested that balneotherapy may not be recommended for older patients with heart diseases because of acute and intensive responses during immersion. Furthermore, a study from Japan emphasized that physiological reactions during balneotherapy immersion differ between older and young people.²² Chiba et al²³ declared that balneotherapy might be responsible for sudden death in the older population in Japan. It has been demonstrated that, during balneotherapy, venous return and heart rate increase while systolic blood pressure (SBP) decreases.²² Balneotherapy causes vascular relaxation, improving vascular function, and decreases peripheral resistance causing cardiac afterload.^{22, 23, 24}

There are some differences in the arterial wall between older and young people. The primary change is medial degeneration that causes stiffening in large elastic arteries. A longstanding arterial pulsation may affect the muscular structure and may cause elastin fibers to fatigue and fracture.^{22, 23, 24, 25} Various risk factors are highly frequent among older individuals, and this condition encourages the atherosclerotic process leading to intima-media thickening. Arterial stiffness occurs in a vicious cycle by aging.²⁵ It is well known the vascular structure changes by aging^{22, 23, 24, 25}; however, there is limited data about the effect of balneotherapy on cardiac responses in young compared with older patients with musculoskeletal problems.

Therefore, the aims of the present study were to investigate BP and pulse alteration differences between young and older adults during acute response and recovery at the first and 10th sessions of balneotherapy added to a physiotherapy program for musculoskeletal disorders and to determine adaptation between acute and recovery responses of BP and pulse of young and older people between the first and 10th sessions. The following hypotheses were investigated: (1) acute and recovery responses of BP and pulse at the first and 10th sessions of balneotherapy would be different between young and older adults; and (2) adaptations of the acute and recovery responses of BP and pulse in young people would be faster compared with those of older people.

Methods

Population Samples

The ethics committee of Yildirim Beyazit University approved this study (Confirmation No. 30). The current study was performed in compliance with the Declaration of Helsinki and was performed in a physical therapy and rehabilitation hospital. The patients agreed to participate in the study and signed an informed consent form.

Forty-six participants (between 18 and 35 years of age as younger adults and more than 65 years of age as older adults) with chronic musculoskeletal pain who were admitted to the hospital for physical therapy were enrolled. Volunteer participants with chronic musculoskeletal disorders with osteoarthritis, fibromyalgia syndrome, myofascial pain syndrome, rotator cuff tear, and intervertebral disc pathologies were included in the study. Medical disorders requiring medical regimes, fractures, infectious diseases, malignancies, hypertension, intensive cardiovascular diseases, hepatic and renal failure, bleeding diathesis, pregnancy, intolerance to heat, and skin disorders that may not allow balneotherapy immersion were accepted as exclusion criteria. Furthermore, participants who completed the therapy in less than 20 minutes and with fewer than 10 sessions were excluded.

All patients were assessed and diagnosed by the physician. As a routine procedure, laboratory tests were performed for patient examinations. These tests included acute phase reactants, hepatic and renal parameters, and complete blood count. Participants who fulfilled the study criteria were admitted.

Intervention

All patients received 10 sessions of balneotherapy immersion combined with conventional physiotherapy modalities. The modalities included Transcutaneous Electrical Nerve Stimulation and hot pack, and each modality was applied for 20 minutes for 10 sessions. The modalities were practiced on the related pain regions after each balneotherapy session. The diet programs of the participants were not changed. The participants did not perform any exercise program during the treatment. The exercise program was added after the 10th session of the therapy if needed. For the balneotherapy, the immersion was applied in semirecumbent position in pools rich in bicarbonate, sulfate, magnesium, and calcium minerals with a temperature range of 38°C to 40°C. Balneotherapy sessions were performed simultaneously every weekday (11:00-11:20 AM) for 20 minutes for 10 days.

Outcome Measures

All participants’ demographic and clinical features were recorded. The patient's age, sex, height, weight, smoking, alcohol consumption, and diagnosis data were recorded. Body mass index (BMI) was defined as the division of body weight in kilograms over height in meters squared (kg/m²).

Blood pressure was examined with a sphygmomanometer (Oncomed plus⁺, AS-B) on the same arm (right) in sitting position as SBP and diastolic blood pressure (DBP). Researchers measured pulse using the index and middle finger on the radial artery. All the measurements were taken by experienced physical therapists before (baseline), during (5th minute), and after balneotherapy (30th minute, out of the pool). To observe changes, measurements were performed during the first and 10th balneotherapy sessions. Differences between the baseline and the 5th-minute values were recorded as acute responses, and differences between baseline and the 30th-minute values were recorded as recovery responses.

Statistical Analyses

The G*Power package software program (version 3.0.10, Franz Faul, Universität Kiel, Germany) was used to detect the required sample size for this study. First, five participants from each group were randomly selected for the pilot study before the calculation of the sample size. And then, considering the pulse measurements of the pilot study, it was calculated that a sample consisting of 44 participants (22 per group) was needed to obtain 80% power with d = 0.79 effect size, α = 0.05 type I error.

SPSS Statistics version 21.0 (IBM, Armonk, NY) was used to conduct data analysis. To summarize data, the mean ± standard deviation, frequency (percent) was given for continuous and categorical variables, respectively. The independent-sample t test was used to compare groups for age and BMI values. The χ² test or Fisher exact test was used to compare groups for categorical variables. The multivariate mixed factorial analysis of variance (two-factor mixed multivariate analysis of variance, or MANOVA) was applied to investigate whether multivariate effect across the interaction between within-subject effect (sessions, sessions and groups) and between-subject (groups) factors on acute/recovery response of DBP, SBP, and pulse values is significant or not. The family-wise error was taken as 0.05. The Bonferroni correction applied according to the number of comparisons was indicated under the relevant tables. For further comparisons, the independent sample t test for comparisons between the first and 10th sessions in each group and paired sample t test for comparisons between groups in each session was used with Bonferroni correction

Results

Fifty-five individuals participated in the study. The study was completed with 46 individuals. The flowchart listing the inclusion and exclusion criteria was presented in Figure 1. There was no adverse effect of the balneotherapy-added physiotherapy program for the participants.

Fig. 1.

Flowchart diagram of the participants.

At baseline, there were no significant differences between groups regarding demographics and clinical features including sex, smoking, and alcohol consumption (P > .05), except for age and BMI (P < .05) (Table 1).

Table 1.

Demographic and Physical Characteristics of the Participants

Characteristic	Young Group (n = 22)	Older Group (n = 24)	P Value
Age (y), mean ± SD	28.63 ± 5.42	65.33 ± 0.76	<.001a,b
Body mass index (kg/m²), mean ± SD	25.46 ± 3.46	31.68 ± 4.13	<.001a,b
Sex, n (%)
Male	10 (45.5)	7 (29.2)	.253c
Female	12 (54.5)	17 (70.8)
Smoking, n (%)
Yes	5 (22.7)	1 (4.2)	.090d
No	17 (77.3)	23 (95.8)
Alcohol consumption, n (%)
Yes	0 (0.0)	1 (4.2)	>.999d
No	22 (100.0)	23 (95.8)

SD, standard deviation.

^aP < .05.

^bIndependent sample t test.

^cχ² test.

^dFisher exact test.

First, the group and session effect was examined. There was no significance in this part. Then, session main effect and group main effect were examined. The group main effect was significant, that is, a difference was found between groups independent of the session in terms of only pulse values (P < .001, Table 2). There was no difference in sessions.

Table 2.

The Multivariate and Univariate Effect of the Main and Interaction

Response	Factor	Multivariate Tests (Wilk's Lambda)	Univariate Tests
		P Valuea	P Valueb
			SBP (mmHg)	DBP (mmHg)	Pulse (beats/min)
Acute (Δ0-5 min)	Groups	<.001	.589	.208	<.001
	Sessions	.497	.657	.301	.194
	Groups and sessions	.746	.657	.431	.904
Recovery (Δ0-30 min)	Groups	<.001	.812	.051	<.001
	Sessions	.355	.110	.370	.479
	Groups and sessions	.367	.169	.129	.828

DBP, diastolic blood pressure; SBP, systolic blood pressure; Δ0-5 min, the difference between 0 and 5 minutes; Δ0-30 min, the difference between 0 and 30 minutes.

^aThe family-wise alpha is 0.05.

^bThe Bonferroni corrected alpha is 0.017 (0.05/3).

At the first and 10th sessions of balneotherapy, the acute and recovery responses of the pulse increased in the young group compared with the older group (P < .008; Table 3). No significant differences were found regarding the responses of SBP and DBP between the groups (Table 3).

Table 3.

Descriptive Statistics and Comparisons of Blood Pressure and Pulse Alterations of the Groups at the First and 10th Sessions for Acute and Recovery Responses

		Acute responses (Δ0-5 min)			Recovery responses (Δ0-30 min)
Variable	Group	First Session Mean ± SD	10th Session Mean ± SD	P Valuea	First Session Mean ± SD	10th Session Mean ± SD	P Valuea
SBP (mmHg)	Young	0.45 ± 7.70	1.36 ± 6.21	.257	5.68 ± 10.15	0.22 ± 9.57	.022
	Older	0.00 ± 2.94	0.00 ± 8.34	>.999	3.75 ± 9.23	3.33 ± 12.04	.883
	P valueb	.797	.531	.657c	.505	.336	.169c
DBP (mmHg)	Young	1.36 ± 13.64	1.82 ± 8.39	.874	4.09 ± 12.96	–0.68 ± 11.26	.152
	Older	2.50 ± 6.07	5.83 ± 7.17	.162	5.83 ± 7.75	7.08 ± 9.08	.588
	P valueb	.722	.090	.431c	.588	.014	.129c
Pulse (beats/min)	Young	–17.36 ± 14.17	–19.32 ± 13.06	.414	–14.09 ± 13.87	–13.23 ± 10.81	.778
	Older	–4.21 ± 6.90	–5.83 ± 4.56	.277	–3.75 ± 7.13	–2.13 ± 7.77	.392
	P valueb	<.001	<.001	.904c	.004	<.001	.828c

DBP, diastolic blood pressure; SBP, systolic blood pressure; SD, standard deviation; Δ0-5 min, the difference between 0 and 5 minutes; Δ0-30 min, the difference between 0 and 30 minutes.

^aThe paired t test with the Bonferroni corrected alpha is 0.008 (0.05/6).

^bThe independent sample t test with the Bonferroni corrected alpha is 0.008 (0.05/6).

^cThe interaction effect from univariate analysis with the Bonferroni corrected alpha is 0.017 (0.05/3).

Discussion

In the present study, it was found that pulse response was different in young adults compared with older adults with chronic musculoskeletal pain during 10-day balneotherapy sessions added to a physiotherapy program. It was observed that the acute and recovery responses of the pulse at the first and 10th sessions of balneotherapy added to physiotherapy altered more in young people compared with older people.

The cardiovascular effect of balneotherapy has been demonstrated in previous studies.^{18,24, 25, 26, 27} It has been suggested that hot springs increase venous return and heart rate and decrease SBP.^18,24,27 Umay et al²⁷ studied BP and pulse changes in patients with osteoarthritis comparing normotensive and hypertensive. They reported a significant decrease in both SBP and DBP and an increase in pulse measurement in each group. Sas et al¹⁸ reported significant improvement in cardiopulmonary responses in musculoskeletal patients and the BP decreased and the pulse increased after the first session and after the 10th session. In this study, SBP and DBP decreased and pulse increased regardless of age. A study performed in healthy pilots indicated favorable outcomes in isovolumetric contraction time and left ventricular ejection time decline.²⁸ In this study, echocardiographic measurements were not performed, but changes in BP and pulse by age were compared. The present study presented a significant increase in pulse in young people.

A smoky atmosphere rich in minerals and gases like carbon dioxide contributing to sedation and systemic vasodilatation plays a role in SBP reduction.²⁹ However, BP changes have not been investigated. It has been showed that balneotherapy leads people to feel better by removing stress.²⁹ Nagasawa et al²² demonstrated differences in autonomic activity and hemodynamics comparing older and young patients. They claimed that BP in the young decreased, although the older individuals had a slight decrease in BP at 4 minutes after immersion. Furthermore, it has been noted that in the young group pulse increased, whereas in the older group pulse increased abruptly at the beginning of hot bath immersion followed by a decline. Whereas heart rate variability was suppressed in young patients, no changes were observed in the older patients. They emphasized that it was difficult to maintain homeostasis in the older patients during immersion.²² Our results confirmed that the acute and recovery responses of the pulse at the first and 10^th sessions of balneotherapy added to physiotherapy increased in the young compared with the older individuals. However, we did not perform an electrocardiogram and did not analyze heart rate variability.

A study from Japan investigated participants’ biodynamic changes in a hot bath in both summer and winter.²³ In the study, they reported that older patients with arrhythmia needed enhanced myocardial oxygen. Furthermore, they suggested that some patients in the older group showed dangerous cardiac alterations. They claimed that these changes may have resulted in the loss of consciousness and unexpected sudden death in the winter season. Besides, the existence of coronary stenosis or weakness can be affected by cold season, hydrostatic pressure, and especially hot bath immersion.²³ It has been suggested that head-out mist bathing, as in the Japanese traditional style, reduced the risk of development of marked changes in the core temperature and hemodynamics.³⁰ Monitoring patients with myocardial infarction was suggested because of the possibility of a cardiac event during immersion in the hot bath.³¹ In the present study, patients with coronary syndrome and severe cardiac diseases were not enrolled in the study and seasonal changes were not noted. Another study investigated BP changes in young hypertensive patients treated with atenolol and diltiazem during and after a sauna bath. They reported that diltiazem has little effect on hemodynamics during heat stress. Beta-blocking agents increase heart rate during heat stress.³² It was shown that balneotherapy suppressed parasympathetic activity in the young group, but not in the older group. In the present study, we excluded any medical disorders requiring medical regimes.

It was suggested that the temperature range between 20°C and 27°C was safe for older people, and 27°C may be beneficial in lowering BP.³¹ In the present study, the temperature of the hot spring was 36°C to 42°C for both older and young patients. Because we want to measure the BP and pulse differences in the older individuals at the same temperature and standard procedure, the pool temperature was the same.

Unubol et al³³ investigated QT intervals and electrocardiographic changes in healthy volunteers and they reported no changes in QT intervals and a decrease in R-R intervals. It was demonstrated that balneotherapy improved cardiac rhythm and function of the left ventricle in patients with myocardial infarction.³⁴ It has been reported that autonomic nervous activity improved by Waon therapy in patients with chronic heart failure.³⁵ It was reported that balneotherapy immersion improved mood, fatigue, and chronic pain, decreased serum lipid levels, and supported the oxidative system.³⁶ The decrease in the peripheral resistance resulted in a significant decrease in DBP.³⁷ In the present study, the changes of the SBP and the DBP responses were not significant in young and older groups.

Limitations

First of all, seasonal variations were not taken into consideration. Second, electrophysiological measurements were not assessed. Although the present study involves the largest number of people in the literature that compare BP and heart rate in older and young people, further study is needed to confirm the results. Third, balneotherapy added to physiotherapy was applied to patients with musculoskeletal pain in this study. Because the present study was performed in a physiotherapy and rehabilitation hospital, we did not overlook the physiotherapy modalities. Therefore, it is difficult to know if the balneotherapy was related to the changes observed because there was no control group. However, the study was planned as a cross-sectional study and aimed to investigate BP and pulse alteration differences between young and older adults during acute response and recovery at the first and 10th sessions of balneotherapy added to physiotherapy, and to determine adaptation between acute and recovery responses of BP and pulse of young and older people between the first and 10th sessions. It could be taken into consideration in further study. Another limitation was the BMI differences among age groups, which can affect BP directly.³⁸

Conclusion

A major finding of this study was that greater pulse alterations at the acute and recovery phases of the first and 10th sessions were observed in young adults compared with older adults. As a result of these findings, it should be taken into account that there was a remarkable rise in pulse in the young and older individuals during balneotherapy added to physiotherapy. Seasonal conditions and pills, especially beta-blocking agents, should also be considered. Although attention is given to older patients for cardiac risk, it should be considered that younger patients may also be at risk for cardiac events.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): S.S., D.O.K., S.T.C.

Design (planned the methods to generate the results): S.S., D.O.K., S.T.C.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): S.S., D.O.K., S.T.C.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): S.S., D.O.K., S.T.C.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): D.O.K., S.T.C.

Literature search (performed the literature search): S.S.

Writing (responsible for writing a substantive part of the manuscript): S.S., D.O.K., S.T.C.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): S.S., D.O.K., S.T.C.

Practical Applications.

• •Greater pulse alterations at the acute and recovery phases of the first and 10th sessions were observed in young adults compared with older adults during balneotherapy added to physiotherapy.
• •The changes of the systolic blood pressure and the diastolic blood pressure responses were not significant in young and older groups during balneotherapy added to physiotherapy.
• •Although attention is often given to older patients for cardiac risk, it should also be considered that younger patients may be at risk for cardiac events during balneotherapy.

Alt-text: Unlabelled box