The Benefits of Taking the Waters

From Age-Old Practices to Today

By Shirley Vanderbilt

Originally published in Massage & Bodywork magazine, August/September 2003.

For centuries, Europeans have flocked to spas for medicinal purposes. With roots dating back to ancient times, “taking the waters” is a traditional integrative approach, utilizing the benefits of balneotherapies such as thermal and salt water soaks and mud applications. In addition, spas offer physiotherapies including various forms of massage, CO2 applications (naturally carbonated tub baths or immersion in chambers), dietary regimens and health education. Although generations of healers over thousands of years have touted the medicinal benefits of spa treatments for general well-being and pain relief, scientific research documenting these effects is fairly recent.1,2

According to Gerhard Strauss-Blasche and his research team at the University of Vienna, Austria, the first scientific literature on spa therapy began appearing, primarily in German journals, during the 1960s. Over several decades, investigators have been attempting to unravel the “whys” and “hows” of specific spa effects and have found some encouraging results in the process.3

In an article published in the Israeli Journal of Medical Science, the author notes 10 previous years of controlled studies “demonstrated that treatments provided at the Dead Sea have a positive effect on patients with inflammatory arthritides such as rheumatoid and psoriatic arthritis, and on non-inflammatory arthritides such as osteoarthritis.” Mud packs and Dead Sea salts dissolved in regular bath water are also reported to be effective, “although to a lesser degree than when applied at the Dead Sea area itself.”4

A group of Italian scientists found a link between the therapeutic application of thermal mud and subsequent increased beta-endorphin and decreased stress hormone levels, suggesting a possibility that reduction of inflammation and pain could result in lowered stress.5 Other studies have shown improvement of low back pain (Guillemin et al., 1994; Constant et al., 1995 and 1998), with effects sometimes lasting up to one year.6

Strauss-Blasche et al., in three recently published studies, have added significantly to this fund of knowledge. The first of these, an examination of the overall effects of spa therapy on well-being, gives us a basic understanding of the traditional European spa approach and an observation on how this integration of treatments impacts the body/mind function. Strauss-Blasche’s two subsequent projects explore the contribution of individual spa therapies for reduction of chronic pain and variation of this effect by season.

Health and Well-being

In their 2000 article on well-being, Strauss-Blasche et al. write that spa therapy— especially as it is used in central Europe — is considered a medical approach for treatment of non life-threatening chronic disorders. But they also point out, “Next to the treatment of the specific disorder, the second generally acknowledged aim of spa therapy is to increase and sustain well-being.” Regardless of specific therapies implemented by the resort, there are several constants inherent in the spa experience: An extended stay of three to four weeks, a prescribed daily routine and a focus on “health rather than illness, as balneotherapy tends to improve health by ‘training’ physiological systems rather than by external correction of dysfunction.”7

In this study, 153 subjects undergoing spa therapy at the Bad Tatzmannsdorf resort in Austria were recruited to test short- and long-term effects of treatment on their well-being. With ages ranging from 33 to 85 (mean of 58), the group of subjects presented with a variety of complaints including non-inflammatory chronic back pain (88 percent) and joint pain (93 percent). Although authors note a higher level of health problems in this group than in a comparable normal population of the same age, none were considered overtly disabled.8

During their 21-day stay, participants followed individual treatment protocols consisting primarily of mud and CO2 applications (82 percent and 81 percent, respectively), massage (95 percent), exercise therapy (65 percent), and, to a smaller extent, electrotherapy and other applications including relaxation training. Among the variables assessed through standard questionnaires were physical complaints (general pain, vegetative complaints and fatigue), negative and positive mood, health satisfaction and intensity of back and joint pain. These measures were taken at days one and 20 of therapy, and again at five weeks and 12 months post-therapy.9

Study results indicated an immediate and significant general improvement in physical and emotional well-being from beginning to end of spa treatment. Although some decline of these measured values was noted during the five-week post-therapy period, at 12 months there continued to be positive effect in pain level, mood and health satisfaction. This led the team to conclude, “Spa therapy may be a powerful tool in enhancing well-being in progressed middle-aged adults with common health ailments.”10

It’s All Relative — Or Not

Spa therapy has been shown to be effective for relief of chronic pain, but exactly which therapies are significant in this treatment? Is it the combination of treatments or are some therapies more effective than others? The Austrian team points out that just being in the spa environment, away from the stresses of normal life, is likely to have therapeutic effect. It is also known that resort-based balneotherapies are more effective than those administered on an outpatient basis. This result is likely based on the cumulative physiological reactions that take place in the stress-free environment of an extended spa stay.11

In a subsequent article, the Austrian research team investigated the relative contribution, within a multi-modal spa regimen, of individual therapies on relief of chronic pain. The authors concluded that overall effects of spa therapy on pain and mental health cannot be accounted for solely by the individual balneotherapies and physical treatments, but that other factors related to the therapy as a whole must be contributing to the positive outcomes.12

For this study, 151 subjects, all participating in a three-week stay at the Bad Tatzmannsdorf resort, were selected based on strong intensity of back pain with chronicity of at least one year. Strong joint pain was also present for 80 percent of the group. Subjects ranged in age from mid-30s to mid-80s, the majority being female (n=109).13

Therapy was individualized to subjects according to health status, prescribed benefit and personal choice, creating a study limitation in that no randomized assignment occurred. The most frequently used treatments were massage, CO2 applications and mud packs or baths (approximately 90 percent of patients), with less frequent use of exercise, electrotherapy and spinal traction. It should be noted that a thermal water environment was used for spinal traction, at times for exercise therapy and for jet massage. Measurements of pain intensity and well-being (general pain, negative mood, health satisfaction and pain intensity) were administered at the beginning and end of the three-week therapy period along with a physical examination. Additional measurements were taken six weeks post-therapy.14

“The most prominent finding,” researchers note, “is that each therapeutic application accounts for only a small percentage of overall treatment outcome.” Passive therapies such as mud baths and massage appear to have a greater, although inconsistent, short-term benefit while active therapies (exercise) positively affect well-being both on a short-term and medium-term basis. Although most of the treatments used are known to have some effect within the context of spa therapy, “the bulk of improvement could not be explained by the number and type of individual” treatments received. These results reflect findings in other studies involving chronic conditions and may have to do with factors such as placebo effect, the general physiological and psychological changes inherent to the structured protocol of spa therapy and the similarity of the balneotherapies (water immersion and/or hyperthermia).15

Despite these conclusions, some specific attributes of treatments were evident. Mud applications and exercise positively affected mood. A surprising finding was the negative relationship of number of massages and CO2 applications to the subjects’ estimation of health satisfaction. The high expectations of those receiving more frequent massage, authors note, may have resulted in them re-evaluating and lowering their responses (less favorable) on questionnaires. Exercise and, to a lesser extent, spinal traction showed positive medium-term effects on reduction of back pain. In general, conditions improved the most in those subjects receiving more mud baths, exercise and spinal traction, regardless of frequency of application.16

Seasons Vary

If spa therapy is to be seen as an integrative approach in which the total effect is greater than the sum of its parts, then perhaps other elements, such as seasonal variation, also impact the outcome. Strauss-Blasche et al. sought to investigate this factor, noting that although such literature exists, the studies were inadequate and did not include patients with chronic pain. The Austrian team published their results in 2002, following a two-year study of subjects with non-inflammatory chronic pain disorders of various types and locations. These participants were also guests at Bad Tatzmannsdorf resort, receiving balneotherapies for a period of three weeks. Of the 387 subjects, 268 were female and ages ranged from 31 to 90.17

Treatments included mud baths (82 percent), CO2 applications (81 percent), various forms of massage (95 percent), exercise (65 percent) and, to a lesser degree, electrotherapy, relaxation training, spinal traction and others. At the beginning and end of the subjects’ stay and again at six weeks post-therapy, measurements of dependent variables were taken to assess physical complaints of general pain and fatigue, positive and negative mood (quality of life), and pain intensity.18

Although data were collected over a two-year period to “compensate for possible effects of a single-year cycle,” the independent variable (time of year when balneotherapy was received) was “collapsed into a 12-month span and into quarters.” Before determining the seasonal variation effect, investigators analyzed overall change in measurements of dependent variables. They found substantial improvement in pain, mood and fatigue, as has been indicated in other studies, and, authors say, “The amount of improvement varied with season.”19

Patients treated between April and June experienced the greatest short-term reduction in pain, with the smallest improvement occurring between January and March, and July and August. Seasonal variation was more pronounced for medium-term improvement between October and November, with greater stability in general improvement between September and November and least between January and March for back pain and also July and August for joint pain. Improvement in positive mood showed greatest improvement between April and June, but there appeared to be no substantial seasonal variation for negative mood and fatigue.20

The study team offers several possible explanations for this seasonal variation. The positive mood generally associated with spring could affect improvement during this time, especially as positive mood is known to affect pain sensitivity. But this does not account for pain improvement noted in the fall. Additionally, the moderate environmental temperature of spring and fall are associated with increased outdoor activity. However, pain and mood improvement were shown to have a greater peak in spring. They also note variations may be related to change of season, rather than differences between season. Concluding that time of year of application impacts the efficacy of spa therapy, the authors propose consideration of this effect on application of other related treatments for pain, including physical therapy, rehabilitation and alternative therapies.21