Professional Documents
Culture Documents
DOI 10.1007/s00296-004-0487-4
O R I GI N A L A R T IC L E
Received: 23 December 2003 / Accepted: 3 May 2004 / Published online: 15 July 2004
Springer-Verlag 2004
Introduction
The use of water for medical treatment is probably as
old as mankind. Until the middle of the last century, spa
treatment, including hydrotherapy and balneotherapy,
remained popular; but this went into decline, especially
in the Anglo-Saxon world, with the development of
eective analgesics. However, no analgesic, regardless
of potency, is capable of eliminating pain, and reports of
life-threatening adverse reactions to the use of these
drugs led to a renewal of interest in spa therapy.
Confusion persists regarding hydrotherapy and balneotherapy. The former employs simply water, while the
latter uses natural thermal mineral water. Spa therapy
employs a number of dierent treatment modalities,
including hydrotherapy and balneotherapy, and creates
a special therapeutic atmosphere of its own through the
change in environment and lifestyle.
Because of methodologic diculties and lack of
research funding, the eects of water treatments in pain
relief have rarely been subjected to rigorous assessment
by randomised, controlled trials. However, the few
which have been done indicate that pain can be relieved
in inammatory and noninammatory rheumatic diseases, chronic low back pain, and bromyalgia. Pain
relief in several trials has lasted 3 to 9 months.
The placebo eect of spa therapy certainly plays an
important role. The mechanisms of action of water
treatmentsespecially the special eects claimed for
natural mineral watersremain largely unknown.
Human life has certainly been full of physical and psychologic pain ever since Adam and Eve were driven from
the Garden of Eden [1]. Pleasure, it is well known,
reduces pain [2]. In postindustrial societies, chronic pain
syndromes appear to be on the ascendant, owing to
unpleasant psychologic and mechanical factors [3, 4].
After a short historical review, this study discusses
evidence of the pain-relieving eects of hydrotherapy,
balneotherapy, and spa treatment. It is important to
appreciate the dierence between these three modalities.
221
Hydrotherapy
According to the law of Archimedes, some exercises in
water are made easier, while others such as walking are
more dicult [15]. Pain may be relieved due to the eects
of pressure and temperature on nerve endings [16] and as
a result of muscle relaxation [12]. Recently, Geytenbeek
Balneotherapy
Balneotherapy uses natural thermal mineral waters. The
denitions of these waters is based on the sum of the
cations of Na, K, Ca, and Mg and the anions of SO4, Cl,
and HCO3 exceeding 1 g/l [9, 21]. The amounts of NH3,
NO, and NO2 must be negligible, and the waters must be
bacteria-free. Some elements, such as iodine, require
contents of 1 mg/l or more. It was presumed that most
mineral ingredients would be absorbed through the skin,
which is an active immune organ and may play an
important role in the mechanism, but to date this has
not been conrmed [22].
The adjective thermal requires that the natural
spring or welled water is 20C or higher. Balneotherapy
alone is dicult to study, since it is usually part of total
spa therapy. However, it has been possible to compare
the eects of balneotherapy with those of warm tap
water in double-blind trials in osteoarthritis of the knees
[23, 24] and in rheumatoid arthritis [25]. In other controlled but not double-blind trials, ambulatory balneotherapy was tried in local patients for chronic low back
pain [26, 27, 28] and bromyalgia [29]. In this way, the
eect of a spa atmosphere was excluded.
Spa therapy
The word spa comes from the name of a Belgian town
where a thermal spring was discovered in the fourteenth
century [14]. The problem in assessing the value of spa
therapy is its complexity. Patients receive treatment not
only with thermal mineral water but also other modalities such as massage, electrotherapy, and exercise. Spa
treatment usually consists of a health holiday lasting
some 23 weeks. The placebo eect is therefore consid-
222
Mechanisms of action
Hydrotherapy
Buoyancy, immersion, resistance, and temperature all
play important roles. According to the gate theory, the
pain relief may be due to the pressure and temperature
of water on the skin [16]. Water immersion induced an
increase in methionine-encephalin plasma levels and,
conversely, suppressed plasma b-endorphin, corticotropin, and prolactin levels [43]. Muscle relaxation [12, 13]
and reduced joint swelling [18, 19, 20] may also play a
role. Signicant improvements in mood and tension may
contribute to the results [20]. Reilly and Bird found that
group therapy in a community swimming pool was more
eective than individual treatment in the pool of a
hospital. This was probably due to concentrating on
health improvement and well being, instead of disease,
and to encouraging social interaction [44].
Balneotherapy
One might expect that minerals are absorbed through
the skin with balneotherapy or application of mud
packs, but there is little evidence of this [19]. Shani et al.
[45] in Israel noted, however, increased serum concentrations of bromine, rubidium, calcium, and zinc in
psoriatic patients after bathing in the Dead Sea. Whether these chemicals have any biologic eect is not
known. There are data, however, that sulphur can be
absorbed through the skin and may have an analgesic
eect [46, 47, 48]. Gutenbrunner et al. found that sulphur baths reduced pressure-induced, temperatureinduced, and spontaneous pain in both normal subjects
and patients with rheumatoid arthritis [48]. In Freunds
adjuvant-induced chronic arthritis of rats, swelling was
Conclusions
It is our belief that hydrotherapy, balneotherapy, and
spa resort treatment should be considered separate
entities, similar to the classication of simple, nonsteroidal anti-inammatory, and opioid analgesics or to
dierent classes of antidepressants. Further, properly
designed, controlled, clinical trials are required in various arthritic and rheumatic diseases and other conditions which continue to be treated in spas. There are
major diculties in conducting such studies, especially
223
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