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Effects of Spa Therapy on Pain and
Fatigue – Mechanisms and Assessment
Effets de la cure thermale sur la douleur et
la fatigue – mécanismes et principes
d´évaluation
Christoph Gutenbrunner
Professor Christoph Gutenbrunner, MD, PhD,
Department for Physical Medicine and Rehabilitation
Medical University Hanover
Carl-Neuberg-Str. 1
D-30625 Hannover
gutenbrunner.christoph@mh-hannover.de
Introduction
Chronic pain is defined by pain perception not (only) related to
a specific damage of tissue (chronification mechanisms related
to neuroplasticity as well as to psychological an vegetative functions)
Pain perception and pain thresholds are influenced by the
autonomous regulation (e.g. circadian variations of pain
intensity and thresholds)
Chronic fatigue is a non-specific symptom of exhaustion and
severe diseases (chronic overstrain, cancer, inflammatory diseases)
Fatigue is also related to disturbances of the autonomous
regulation (e.g. circadian rhythms)
Acute effects of
balneotherapy on pain
and pain-related functions
Rheumatoid arthritis (pain)
Design of the Study:
- Controlled study, cross-over-design
Patients:
- Patients suffering from rheumatoid arthritis (n=17)
Intervention:
- head-out water immersion, sulphuric water
(20 mg H2S/l, 36°C, 20 min)
- head-out water immersion, plain water (36°C, 20 min)
Main Outcome Parameter:
- pain (Visual Analogue Scale)
- microcirculation (Laser-Doppler-flow, forearm)
Rheumatoid arthritis (pain)
[cm]
6
Pain
5 (Visual analogue
scale)
4
3
2 Sulphur baths
* Tap water baths
** n=17
1
*=p<0,05
bath **=p<0,01
0
0 10 20 30 40 [min] 50 60
Fibromyalgia (pain and well being)
Design of the Study:
- Controlled study, cross-over-design
Patients:
- Patients with fibromyalgia (ACR-criteria) (n=17)
Intervention:
- head-out water immersion, sulphuric water
(20 mg/l, 36°C, 20 min, one arm excluded)
- cold-camber expositions (-76°C, 3 min,
one arm thermo-isolated)
- rest (20 min)
Main Outcome Parameters:
- pain intensity (visual analogue scale)
- overall well being (visual analogue scale)
Fibromyalgia (pain and well being)
[cm]
resting pain during pain during overall well- Visual
2 pain movements strain pain being
analogue
scale
1
Difference before - after
0
-1
*** Controls
-2 ***
*** ** Sulphur baths
***
*** *** Cryo chamber
***
*** je n=17
-3
* *=p<0,05
**=p<0,01
*** ***=p<0,001
-4
Low Back Pain (muscle tension)
Study design:
- Controlled study in cross-over design
Patients:
- 21 patients with cLBP lasting at least for 6 weeks
(10 men, 11 women, age: 47,3 ± 2,9 years)
Intervention:
- A single brine (6% NaCl, Solequelle Bad Münder) or
tap water plain bath (360C, 16 min), respectively
Outcome parameters:
- IEMG activity on defined muscles (M. erector spinae
cervicales et lumbales, M. trapezius, M. ext. carpi
radialis, M. rectus abdominis)
- Pain intensity (VAS)
- Subjective muscle tension (Chromatic Analogue Scale)
Low Back Pain (muscle tension)
p=0,000
4 (both groups)
Subjective
muscle tension
3
Scale
2
1
Tap water
Brine water
n=21
0
Before bath Bath After bath
(M1) (M2) (M3)
Difference of
0,0
subjective
muscle tension
-0,5
Scale
-1,0
-1,5
Difference Difference
M1-M2 M1-M3
Psychological variables (immersion)
Design of the Study:
- Controlled study, cross-over-design
Patients:
- Healthy subjects (n=20)
Intervention:
- isothermal head-out water immersion, tap water
(36°C, 20 min)
- rest (20 min)
Main Outcome Parameters:
- mood (Rating scale)
- overall well-being (VAS)
- depression, anxiety (pre-test for patient study)
Psychological variables (immersion)
2
Mood
(Differences)
n.s.
1 p<0,05
Score
0
isothermal bath
rest
-1 n=20
2,0
Overall
p<0,05
well being
1,5
(Differences)
Visual Analogue Scale
p<0,05
1,0
0,5
0,0
before - bath before - after
Conclusion (1)
Relevant effects of spa treatment on pain are
- increase of pain thresholds (sulphur baths)
- decrease of pain in rheumatoid arthritis (sulphur baths)
- decrease of pain in fibromyalgia (sulphur baths)
- decrease of muscle tension and pain in low back pain
(thermo-neutral immersion)
- improvement of well being in healthy subjects and
patients with fibromyalgia (thermo-neutral immersion,
sulphur baths)
Mechanisms of long-term
effects of balneotherapy:
functional adaptation
Introduction
Spa treatment is prescribed mostly in chronic conditions
(chronic generalised pain, metabolic syndrome and other)
Spa treatment is performed during limited periods of time
(two to six weeks)
The time interval between treatment periods amounts to
months or even years (12 months to four years)
Therefore long-term effects are crucial
- disease activity
- health behaviour
Adaptation physiology
Autonomous adaptation of the cerebral cortex
duration
(learning, change of behaviour)
Trophoblastic adaptation and plasticity
(growth, increase of functional capacity)
Functional adaptation
(increase of economy of regulatory processes)
Habituation
(set point shift, increase of tolerance)
Neural inhibition
(e.g. of the spinal irradiation)
Autonomous local adaptation
(e.g. increase of tissue tolerance)
Adaptive normalisation
Systolic
blood
pressure
Hypertension
(n=8)
Normal blood
pressure (n=80)
Low blood
pressure (n=16)
Days of treatment
Adaptive normalisation
Increase
Target value
Normalisation
Change of blood pressure (linear
of the systolic
regression) days 4-28
blood pressure
Decrease
Normal range
From Gutenbrunner
& Ruppel (1992)
Initial values (classes of 10 mmHg)
days 1-3
Conclusions (2)
Functional adaptive processes evoked by balneological
stimuli may lead to adaptive normalisations of functions
controlled by the autonomous regulation system
- e.g. cardio-respiratory, metabolic, digestive or immune
functions
Adaptive normalisation is formally characterised by
- convergence of functional parameters
- aiming at normal values
- coincidence of normal values with functional optima
Functional adaptation may influence
- pain sensitivity
- muscle tension
- overall well being
- fatigue
Clinical trials on the
efficacy of balneotherapy
on pain and fatigue
Autonomous regulation (Hildebrandt 1998)
Design of the Study:
- Follow-up study during spa treatment
Patients:
- Patients with autonomous dysregulation and fatigue
Intervention:
- complex spa treatment (incl. training; all patients)
- hydrotherapy (n = 1,925)
- CO2-baths (n = 1,414)
Main Outcome Parameters:
- vegetative symptoms
- quality of sleep
- tiredness
- mood
Autonomous regulation (Hildebrandt 1998)
Mean frequencies [%] Hydrotherapy CO2-balneotherapy
Well being Well being
Complaints
Complaints
Restlessness
Restlessness
Sleep disturbances
Sleep disturbances
Tiredness
Mean vote [%]
Tiredness
Bad mood Bad mood
dreams
dreams
Feeling of sickness Feeling of sickness
days days
Patients with Breast Cancer
Design of the Study:
- Follow-up study during and after rehabilitation in a
health resort
Patients:
- Patients with breast cancer (n = 71)
Intervention:
- complex rehabilitation programme
- pool exercise
- physical therapies according to individual needs
Main Outcome Parameters:
- psychological symptoms (incl. anxiety and depression)
- functional state (IRES = Indicators of Rehab Status; Gerdes
& Jäckel)
Patients with Breast Cancer
Complaints [v. Zerssen]
***
Depression [ADS-L]
**
Fear [STAI]
**
Anxiousness [STAI]
***
Health status [EORTC]
**
IRES total score (x10)
**
Somatic status [IRES] (x10)
*
Begin
Funktional status [IRES] (x10)
End
*** * = p<0,05
Psychosocial status [IRES] (x10) ** = p<0,01
*** = p<0,001
n = 71
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
Score
Patients with Breast Cancer
9
Functional state
(n = 21)
8 * * *
*
7
6 Initial value (M1)
1,0
0,8 Effect size
0,6
0,4
0,2
0,0
M1 M2b M3 M4 M5
Autonomic functions
Design of the Study:
- Prospective controlled with long-term follow-up
(1 year)
Patients:
- Patients with autonomous dysregulation and fatigue
Intervention:
- study group: complex spa treatment,
esp. hydrotherapy and training (n = 48)
- control group: care by the family doctor (n = 54)
Main Outcome Parameters:
- blood pressure
- lung function
- pressure-frequency-product (under strain)
Autonomic functions
1,0
0,5 Difference of
pressure-frequency-
Difference of PFP
0,0
product
-0,5
during ergometry
-1,0
-1,5
p<0,01
p<0,05
-2,0
0,8
Effect size
0,6
Effect size
0,4
Intervention (n=48)
0,2
Controls (n=54)
Daten from Baier (unpublished)
0,0
before-after before-1 y later before-after before-1 y later
Cervico-bracial pain
Design of the Study:
- Follow-up study before, during and after
rehabilitation in a health resort
Patients:
- Patients with functional or degenerative cervico-
brachial pain (n = 149)
- exclusion criteria: radiculopathia, medullopathia
Intervention:
- complex rehabilitation programme
- physical therapies according to individual needs
Main Outcome Parameters:
- local pain and pain irradiation
- sleep disturbances (caused by pain)
Cervico-bracial pain
Catamnesis
[U]
2,8 Intensity of
pain of the
2,6 cervical spine
2,4
Score
2,2
2,0
1,8 p<0,001
(Rep.-Mes.-ANOVA)
Tr n=149
1,6
[%]
90 Cervico-
brachial
80 pain irradiation
**
Percent
70
**
**
***
60 ***
2
Chi -test of the post-
50 treatment course:
** = p<0,01
*** = p<0,001
40 Tr n=149
80
[%]
Sleep
70
disturbances
60
caused by
pain
Percent
50
40 *** ***
*** ***
***
30
2
Chi -test of the post-
20
treatment course:
*** = p<0,001
10 Tr n=149
0 1 3 6 Months 9 12
Fibromyalgia
Design of the Study:
- Prospective controlled study, pilot study
Patients:
- Patients suffering from fibromyalgia (ACR-criteria;
n=32; up to now)
Intervention:
- serial head-out water immersion, sulphuric water
(20 mg/l, 36°C, 20 min, three weeks , 2-3 times a week)
- serial head-out water immersion, tap water
(36°C, 20 min, three weeks , 2-3 times a week)
Main Outcome Parameters:
- Lautenschläger pain score
- thermal pain thresholds (forearm, bilateral)
- physical complaints (questionnaire)
Fibromyalgia
[Score]
15
12 H2S-baths Lautenschläger
(iso-thermal)
10 pain score
Difference from initial value
5
0
n.s.
-5
p<0,001
-10
-15 Sulphur baths
(n=19)
Tap water baths
-20 (n=13)
0 1 2 3 4
Months after begin of treatment
Institut
für
Balneologie
und
nnov
er
Fibromyalgia
Medizinische Klimatologie schule Ha
ch
he Ho
inisc
Mediz
[Score]
55
Treatment period Fibromyalgia
50 Impact
Questionnaire
(FIQ)
45
n.s.
40 n.s.
35 p<0,05 p<0,05
Thermal pool baths
p<0,001 (n=16)
30
No baths
(n=13)
(Dönmez et al. 2005)
25
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Months after start of treatment
Meta-analysis
Meta-analysis
From Pittler et al. 2006
Conclusions (3)
Complex spa treatments induce functional adaptive processes
with relevant effects on
- vegetative functions
- sleep quality and fatigue (even in cancer patients)
Long-term effects are shown in
- cervico-brachial pain
- low back pain
- fibromyalgia
Meta-ananlyses show at least some evidence in
- rheumatoid arthritis
- low back pain
