Current issues of ACP Journal Club are published in Annals of Internal Medicine


Spa therapy was effective for low-back pain

ACP J Club. 1994 July-Aug;121:14. doi:10.7326/ACPJC-1994-121-1-014

Source Citation

Guillemin F, Constant F, Collin JF, Boulange M. Short and long-term effect of spa therapy in chronic low back pain. Br J Rheumatol. 1994 Feb;33:148-51.



To assess the short- and long-term effectiveness of spa therapy in patients with chronic low-back pain.


9-month randomized controlled trial.


Spa resort in eastern France.


104 patients (mean age 58 y, 61% women) who had low-back pain for ≥ 2 years and an erythrocyte sedimentation rate of < 30 mm/h and who resided within 30 km of the resort were referred by 10 area general practitioners. Exclusion criteria were sciatica, lumbar disc herniation, previous back surgery, any inflammatory disease likely to affect the spine, any concurrent chronic disease, or any spa treatment within the past year. 98 patients completed the study.


Patients were randomly allocated to a treatment group (n = 52) in which they received immediate spa therapy or to a control group (n = 52) in which spa therapy was postponed for 9 months. Spa therapy consisted of 15-minute, underwater, high-pressure showers at a water temperature of 36°C , and 3-minute showers at varying pressures and temperatures 6 days per week for 3 weeks. For the remainder of the study, patients in both groups received routine ambulatory care from their general practitioners that included pain management with various drugs and excluded massage and physiotherapy. Patients were assessed 3 times during the study period by an independent physician who was blinded to the patients' treatment group.

Main outcome measures

Pain intensity was assessed by a 0- to 100-mm visual analog scale (VAS), daily duration of pain, finger-floor distance, lumbar stiffness measured by the Schober index, degree of disability measured by the Waddell disability self-reported index, and drug consumption.

Main results

At short-term examination (26 days from baseline), patients in the treatment group had improved in all outcome measures compared with patients in the control group (P < 0.001 for all comparisons) (Table). At long-term examination (9 months from baseline), patients in the treatment group continued to improve in all but one outcome measure (P < 0.01 for daily duration of pain, pain VAS, finger-floor distance, lumbar stiffness, and drug consumption); the groups did not differ for Waddell disability score (Table).


Short-term results showed that spa therapy was effective in improving symptoms, disability, and drug use in patients with low-back pain. Long-term evaluation showed improvement in all measures except disability status.

Source of funding: Not stated.

For article reprint: F. Guillemin, Ecole de Santé Publique, Faculté de Médecine, BP184, 54505 Vandoeuvre-les-Nancy, France. FAX 33-83-592-690.

Table. Spa therapy vs control for low-back pain at 26 days and 9 months*

Outcomes at 26 d Spa therapy Control Difference (95% CI)
Daily duration of pain (h) -3.6 -0.3 3.3 (2.04 to 4.56)
Pain on visual analogue score (mm) -32.2 -0.2 32 (24.1 to 39.9)
Finger-floor distance (cm) -4.2 1.7 5.9 (4.09 to 7.71)
Schober index (mm) 5.8 -3.5 9.3 (7.3 to 11.3)
Waddell index score -1.19 -0.005 1.18 (0.63 to 1.74)
Outcomes at 9 mo
Daily duration of pain (h) -3.9 1.3 5.2 (3.93 to 6.47)
Pain on visual analogue score (mm) -34.4 7.1 41.5 (34.1 to 48.9)
Finger-floor distance (cm) -4.9 3.4 8.3 (6.47 to 10.1)
Schober index (mm) 7.0 -5.0 12.0 (10 to 14)
Waddell index score 0.09 0.18 0.09 (-0.79 to 0.97)†

*Values are means. CI calculated from data in article.
†Not significant.


For millennia, the people of Europe and Asia have sought comfort and healing in mineral and thermal baths. In America, Hot Springs in Arkansas, Warm Springs in Georgia, and Saratoga Springs in New York were sought out by luminaries into the early decades of this century before being eclipsed by another ethos. Europe, however, maintains the tradition, as does Japan where onsen provide serenity to this day.

Spa medicine, or balneology, was first practiced in Europe in the 18th century and still flourishes in many countries. Weeks of medically supervised "taking the waters" seems so appropriate an option that it is underwritten by national health insurance schemes, including Sécurité Sociale in France. For the French people, a spa is not the application of modalities, the way we view a "rehabilitation service." The French spa is good for the terrain, for the harmony of the body (1). In the study by Guillemin and colleagues, the 104 volunteers coping with regional low-back pain and life at age 60 years viewed their time at the spa in this context. Regardless of the "informed consent," the control group was asked to postpone feeling better about themselves and their back pain. And so they did. For the French people, no scientific way to test their vaunted spas exists; no adequate control group can be found. Likewise, for the American people, no method to generate cogent scientific data exists to show that introducing balneology is cost-effective; we would have to control for cynicism and prejudice regarding the experimental group. Vive la différence.

Nortin M. Hadler, MD
University of North Carolina Medical SchoolChapel Hill, North Carolina, USA


1. Payer L. Medicine & Culture. New York: Henry Holt;1988:35-73.