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Monday, January 23, 2012

Paraffin Bath and Rheumatoid Arthritis

Introduction:

Paraffin baths are a form of thermotherapy that is used mainly on the hands and feet. The paraffin is a superficial heater and allows a depth of 1 cm of therapeutic heating. It is used for therapy because it has the therapeutic effects of decreasing pain and increasing soft-tissue extensibility. Paraffin baths can be used for treatment of rheumatoid arthritis (RA). There have been studies done to see if paraffin baths are an effective form of therapy for and should be used in the clinics. 

Research supporting use of paraffin bath:

In a review by Marks and Ayling (1995) on the effect of paraffin baths on treatment for RA, it was found that paraffin baths can be an effective treatment. They started by searching for studies on the CINHAL, MEDLINE, and EMBASE databases. The terms that were searched were rheumatoid arthritis, therapeutic use of heat, and therapeutic use of cold. There was also a manual search that was done to help locate additional literature that could be used. The studies found had to have the focus of the effect of paraffin was on the temperature of hand joints or the application of paraffin wax and its effect on RA. Clinical trials examining the effect paraffin wax has on hand tissue temperature, randomized controlled clinical trials examining the use of paraffin wax for treating RA, and basic studies were thoroughly assessed according to standardized criteria. Four randomized studies were found that met the search criteria. Three of the four studies found that after three to four weeks, the use of paraffin baths coincided with significant improvements in hand function for subjects with RA when exercised followed the paraffin treatment. Overall, the collected information pointed towards the conclusion that paraffin baths may have some benefits for the treatment of patient’s hands that have RA. It was noted in this review that data is limited and there can be no definite conclusions about the benefits of paraffin baths. 

In the research review Thermotherapy for treating Rheumatoid Arthritis by Welch V. et al., researchers looked at different types of thermotherapy and their effectiveness for treating rheumatoid arthritis. Interventions other than paraffin were hot pack, cold pack, faradic bath, and therapeutic ultrasound. Using objective measures such as pain rating, swelling, grip strength, ROM, medication intake, and hand function, they found statistically significant results favoring paraffin wax combined with exercise. Hot pack, cold pack, cryotherapy, and faradic baths were found to have no significant affect on the objective measures. Researchers found no negative effects for any of the types of thermotherapy. It was concluded in this review that thermotherapy, especially wax baths, may be used as palliative therapy and adjunct therapy along with therapeutic exercises.

In the research review Validation of the Comprehensive International Classification of
Functioning, Disability and Health Core Set for Rheumatoid Arthritis:
The Perspective of Physical Therapists by Inge Kirchberger et al., researchers looked at the ICF Core Set used by physical therapists for Rheumatoid Arthritis. PTs were surveyed about their intervention goals using a 3-round Delphi system. Eighty-two physical therapists from twelve countries participated in the study. Examiners concluded that the most relevant interventions for RA were thermotherapy, dynamic exercise and balance therapy, patient education, and electrical stimulation.

Research refuting use of paraffin bath/thermotherapy:

A study by Harris and Millard (1955) examined the effect of paraffin baths on RA. This study examined ninety patients with RA and divided them into three groups. Group one received no local treatment to the hands, group two received paraffin baths every day for three weeks for the hands, and the last group received paraffin baths every day for six weeks for the hands. No other local treatment was applied to the hands during the study, but each subject was undergoing a general physical rehabilitation program for RA. The subjects were examined two days prior to the beginning of treatment to allow for a base measurement then were examined each week for the duration of six weeks. Tenderness, swelling, and pain were measured on a scale of 0 to three in order of increasing severity. Grip, dexterity, and erythrocyte sedimentation rate (ESR) was also measured. The total overall impression was measured after the six week on a scale of -1 to 3 with -1 being worsened condition and 3 being major gains. It was found that the changes from week to week were so small that no useable information could be obtained. Each group had made similar subjective and objective progress after the first three weeks of the study. At the end of the sixth week it was found that groups one and three had similar slight progress for grip, swelling, and dexterity while the second group had worsened. Overall, the results show that the subjects did not receive any benefit from the paraffin baths.

Several studies conclude that paraffin bath therapy is not effective when used alone (i.e. when not paired with therapeutic exercise). One such study, whose purpose it was to create guidelines for thermotherapy interventions for adult patients with RA, was done by Ottawa Panel Members et al. This study lists nine goals for the management of RA: decrease pain, decrease joint swelling, decrease stiffness, correct or prevent joint deformity, increase ROM, increase muscle force/decrease weakness, improve mobility, reduce fatigue, and increase functional status. In the portion of this article pertaining to paraffin wax, they found no statistically significant difference for patients who had wax applied to the hand and wrist versus a control after one month. It was, however, shown that wax combined with exercise versus a control has clinically important benefits. So, the article concludes that paraffin wax, as a treatment alone, is ineffective.

The review Non-drug treatment (excluding surgery) in rheumatoid arthritis: Clinical practice guidelines by Romain Forestier et al. aimed to establish guidelines for physical therapy use in union with drug treatment in patients with RA. Researchers compiled reviews spanning from 1985-2006 from online databases (MEDLINE, EMBASE, CINAHL, Pascal, Cochrane, National Guideline Clearinghouse, HTA database, and PEDRO). “Each study was allocated an evidence level. The grade of a guideline depended on the evidence level of the studies. When no grade could be allocated, working group members attempted to reach ‘professional agreement’ on specific topics.” (Forestier, R…) The researchers found that heat treatment, as well as ultrasound, had a low level of evidence and concluded that the benefits were short-lasting and should not be used as primary treatment.


Conclusion:

According to current literature, paraffin bath is a supported form of thermotherapy for treatment of RA. The amount of research available on this topic was limited, indicating that more research on the topic would be beneficial.


Summaries provided by Chelsea K., Kelci M., and Shannon L.

References:

Prentice, W. E. (2011). Therapeutic modalities in rehabilitation, fourth edition. McGraw-Hill Companies.

Kirchberger I., Glaessel A., Stuckl G., Cleza A. (2007). Validation of the comprehensive international classification of functioning, disability and health core set for rheumatoid arthritis: The perspective of physical therapists . (Vol. 87, pp. 368-384). American Physical Therapy Association. Retrieved from http://www.physther.net/content/87/4/368.full

Marks, R., & Ayling, J. (1995). Efficacy of Paraffin Wax Baths for Rheumatoid Arthritis. Physiotherapy, 190-201.

Welch V, Brosseau L, Casimiro L, Judd M, Shea B, Tugwell P, Wells GA. Thermotherapy for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD002826. DOI: 10.1002/14651858.CD002826.

Harris, R., & Millard, J. B. (1955). Paraffin-wax baths in the treatment of rheumatoid arthritis. Annals of the rheumatic diseases, 14(3), 278-82. 
Members, O. P., O. M. Members, et al. (2004). "Ottawa Panel Evidence-Based Clinical Practice Guidelines for Electrotherapy and Thermotherapy Interventions in the Management of Rheumatoid Arthritis in Adults." Physical Therapy 84(11): 1016-1043.

Forestier, R., André-Vert, J., Guillez, P., Coudeyre, E., Lefevre-Colau, M.-M., Combe, B., & Mayoux-Benhamou, M.-A. (2009). Non-drug treatment (excluding surgery) in rheumatoid arthritis: Clinical practice guidelines. Joint Bone Spine, 76(6), 691-698. doi: 10.1016/j.jbspin.2009.01.017

5 comments:

  1. Paraffin Bath and Osteoarthritis:

    According to Myrer et. al, the positive effects of the paraffin bath have been known since 1920. Thus, his team decided to look into the effects of paraffin bath versus the effects of paraffin bath with a topical analgesic infused in it.

    For this study, 40 participants were randomly assigned to a PO (paraffin only treatment) or a PTA (paraffin with topical analgesic treatment). The researchers used the VAS (visual analog scale) to assess participant’s pain both at rest and with movement because OA pain tends to differ with activity. Then they used the FIHOA table to assess participant’s hand function. The two assessments (pain and hand function) were administered on visit one and after the participant’s 12th visit.

    Both groups reported a significant improvement in their “current level of pain” 15 minutes post treatment on both visit one and visit 12. Thus, researchers determined that the improvement in pain was due to the thermal effects of the paraffin bath and not due to the presence or absence of a topical analgesic in the bath.

    Thus, overall paraffin baths have positive effects on patients with OA. However, the researchers admitted the little research available on this topic. Further research would be helpful for this topic.

    Citation:
    Myrer, J. W., Johnson, A. W., Mitchell, U. H., Measom, G. J., & Fellingham, G. W. (n.d.). Topical analgesic added to paraffin enhances paraffin bath treatment of individuals with hand osteoarthritis. (2011). Disability and Rehabilitation , 33(6), 467-474. doi. 10.3109/09638288.2010.498552


    Bilateral hand osteoarthritis participants (F=50; M=6; mean age ~ 59 years) were split into a paraffin bath therapy group (n=29) and no therapy group (n=27). All participants were educated about joint-protection techniques and paracetamol intake was recorded in drug diary. Paraffin treatment was performed 5 times per week for 3 weeks. At 50°C, both hands were dipped 10 consecutive times (dipped, dry 2-3s, redipped), wrap in plastic bag and towel, and then removed after 15 minutes.

    Outcome measures were recorded at baseline, 3 weeks, and 12 weeks. Pain at rest and during ADLs was measured by a visual analog scale. The Australian Canadian Osteoarthritis Hand Index (AUSCAN) and the Dreiser Functional Index (DFI) evaluated subjective functional level. Other measures included range of motion (ROM), grip and pinch strength, and painful and tender joint counts.

    Between groups differences at 3 and 12 weeks showed improvement in the paraffin group in resting pain (p=.01, p=.003) in addition to at 12 weeks a decrease in number of painful and tender points (p=0.01, p=0.02 respectfully). AUSCAN’s dimension of stiffness significantly changed in the paraffin group at 3 weeks and 12 weeks. Bilateral clinch and lateral pinch strength significantly declined in the control group from baseline to 12 weeks. Absolute bilateral grip strength was significantly different between paraffin group and control group at 12 weeks (Right hand p=.01; Left hand p=.01).

    This study shows paraffin bath therapy reduces pain and stiffness parameters, but there was no significant effect in functional dimensions of the AUSCAN and DFI. Both groups continue outpatient therapy exercises in conjunction with study protocol, although the study did not describe concurrent exercises. Some lasting concerns about this study include using a small sample size, lacking criterion norms to compare results, whether participants will adhere to an abundant amount of paraffin bath therapy in the clinical setting.

    Citation:
    Dilek, B., Gozum, M., Sahin, E., Baydar, M., Ergor, G., El, O., Bircan, C., & Gulbahar, S. (2013). Efficacy of paraffin bath therapy in hand osteoarthritis: a single-blinded randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 94, 642-649.

    Submission by Rachel August & Ali Pistora

    ReplyDelete
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