Clinical Rheumatology

, Volume 33, Issue 10, pp 1509–1515 | Cite as

The effectiveness of balneotherapy in chronic low back pain

  • Şule Şahin Onat
  • Özlem Taşoğlu
  • Fulya Demircioğlu Güneri
  • Zuhal Özişler
  • Vildan Binay Safer
  • Neşe Özgirgin
Original Article


The aim of this study is to determine the effectiveness of balneotherapy plus physical therapy versus only physical therapy in patients with chronic low back pain. In this trial, 81 patients with low back pain were followed up in two groups. Patients in group I (n = 44) were treated with physical therapy alone. Patients in group II (n = 37) were treated with balneotherapy in addition to the same physical therapy protocol in group I. Patients in both groups were given a home-based standardized exercise program. The following parameters were measured: visual analog scale (0–10 cm), fingertip-to-floor distance (cm), Oswestry Disability Index, and Short Form 36 quality of life scale. First evaluations were done at the time of enrollment, and second evaluations were done after accomplishment of a 3-week treatment program. There were no significant differences between the two groups for the sociodemographic features. All of the measured parameters improved in both groups. However, improvements in pain, functionality, and quality of life scores were found to be superior in the balneotherapy plus physical therapy group. For the patients with chronic low back pain, balneotherapy plus physical therapy is more effective, compared to physical therapy alone.


Balneotherapy Chronic low back pain Physical therapy Quality of life 


One of the most common health problems in the industrialized world is low back pain (LBP) with a lifetime incidence of 60–80 % and annual incidence of 10–12 % [1, 2]. LBP persisting longer than 7–12 weeks is considered to be “chronic” [3]. Medical treatment, exercise therapy, physical therapy (PT), manual therapy, acupuncture, and balneotherapy (BT) are the most effective methods that are widely used in chronic LBP treatment [4].

BT or “therapy with spa water,” which can be defined as “bathing in thermal or mineral waters”, has been practiced for centuries in the management of chronic musculoskeletal diseases. These kinds of waters are derived from natural springs with a temperature of ≥20 °C and solute content of ≥1 g/L.

The well-known effects of BT in the treatment of musculoskeletal diseases are thermal, mechanical, and chemical effects. Thermal effect, which is the result of heat, acts via four ways: vasodilatation, gate control mechanism, elevation of beta-endorphin levels, and muscle relaxation. It has been shown that by causing a superficial vasodilation, heat application causes an increase in blood flow and reduces vascular spasm and stasis. As a result, nociceptive elements and free oxygen radicals are swept away [5]. Thermal stimuli also cause activation of gate control mechanism and elevation of beta-endorphin levels exerting a direct analgesic effect [6, 7]. Besides, heat can induce muscle relaxation and sedation too [5].

Mechanical effect can be described as hydro-mechanical stimuli of the mineralized water adapted to the body parts. It increases joint mobility and muscle tone [8]. In addition to this, body fluids change place from the extremities to the trunk causing hemodilution and diuresis. Immersion of the body parts in mineralized water for 1 h increases water excretion by about 50 % [5].

The last effect of BT mentioned above is a chemical effect. It is explained by absorption of the trace elements from the mineralized water through the skin, modulating the immune system. Chemical effects of BT are less clear than the thermal and mechanical effects. It is claimed that mineral elements accumulate in the various skin layers and turn out a deposit which releases mineral substances into the circulation incrementally to participate in systemic actions [5, 21].

BT is used for improving the range of joint movements, strengthening muscles, relieving muscle spasms, and enhancing functional mobility. Therefore, the patients’ suffering decreases [5, 9]. Some other treatments, such as PT, exercise, hydrotherapy and mud pack therapy, can also be used in combination with BT. Aside from its popularity, the number of studies about the effectiveness of balneotherapy in the treatment of chronic LBP is not sufficient [9, 10, 11, 12, 13, 14, 15].

Under the scrutiny of evidence-based medicine, our study was designed to determine the effectiveness of BT-combined PT versus PT alone in patients with chronic LBP.

Materials and methods


Eighty-one patients between ages 50 and 87 (71 females and 10 males), with LBP persisting longer than 12 weeks of duration, were included in our prospective study. All the study participants were given a written informed consent, and hospital ethical committee approval was obtained. The chronic LBP diagnosis was made via medical history, physical examination, and radiological findings. The patients whose clinical and radiological manifestations were consistent with chronic low back pain (except the ones with neurologic deficits) were included in the study. All the patients were hospitalized. Pretreatment workup included complete blood count, erythrocyte sedimentation rate (ESR) (mm/h), C-reactive protein (CRP) (mg/L), blood glucose, hepatic and renal function tests, urine analysis, and lumbar X-ray examinations (standing anterior–posterior and nonstanding lateral views). The patients were allowed to take their routine medications for systemic diseases. The same physician evaluated all of the patients before and after the treatment protocol. Also, daily control visits for both groups were hold, and the patients’ complaints were taken into consideration.

Exclusion criteria

Patients with the following conditions were excluded from the study: confirmed osteoporosis, structural scoliosis, grade ≥2 spondylolisthesis, neoplastic or inflammatory lesions as the underlying cause of chronic LBP, uncontrolled liver disease, heart failure, unstable hypertension, angina pectoris, respiratory insufficiency, uncontrolled endocrine diseases, other uncontrolled and unstable metabolic disorders, acute febrile infections, cutaneous suppuration, pregnancy, severe genitourinary disease, fecal or urinary incontinence, decompensated psychosis or neurosis, and lack of compliance.

Patients who had undergone spinal surgery or had received PT or BT during the previous year and patients who are receiving oral or local nonsteroidal anti-inflammatory drugs (NSAIDs) were also excluded.


The study comprised a 3-week intervention. Participants were assessed by the same physician before (baseline) and after the treatment (third week).


Participants were randomly assigned to groups I and II. Simple randomization was made by using a computer-generated table of random numbers. In the study, an independent researcher gave instructions to the patients for the questionnaires and did the outcome measurements. The patients in different groups were hospitalized in unconnected inpatient services and have never seen each other, so that interaction between the groups was prevented.


Patients in group I (n = 44) were treated with PT alone. Patients in group II (n = 37) were treated with BT in addition to the same PT protocol in group I. The water contains sodium bicarbonate, fluoride, and chlorine, and its total mineral solute content is 2,595 mg/L with an original temperature of 78 °C. Water quality, tested by the National Public Health and Medical Officer Service, did not reveal microbiological or chemical contaminants. For BT, mineral water was cooled to 38 °C.

Patients in both groups had a PT protocol for back region lasting 45 min for 5 days in a week with a total duration of 3 weeks. PT comprised hot pack (HP) for 20 min/day, transcutaneous electrical stimulation (TENS) (50–100 Hz) for 20 min/day, and ultrasonography (US) (frequency, 1 MHz; intensity, 1 W/cm2) for 5 min/day. Patients in group II were also treated with BT for 20 min/day in addition to PT. The BT sessions were performed at the same time of the day. All of the patients had bed rest for 2 h after treatment. Blood pressures and radial pulses of the patients were measured before and after the treatment.

A home-based standardized exercise program was given to all of the patients by an experienced physiotherapist. Patients in both groups were taught the following exercises: cat–camel exercises and posterior pelvic tilt exercises for strengthening the back and abdomen, bridge exercises for strengthening the hip and back, hyperextension exercises for mobilization and discus centration, and stretching exercises for lumbar and hip extensors. All of the patients were instructed about the aim and the confidence limits of the exercises. This exercise program was arranged as five sessions/week, during 3 weeks.

The patients were not allowed to use NSAIDs during the hospitalization.


The demographic data of the patients [age, sex, occupation, marital status, height (m), weight (kg), body mass index (BMI) (kg/m2)], presence of chronic diseases, and chronic drug use were recorded.

Pain intensity was measured by using (0–10 cm) visual analog scale (VAS). VAS scores were expressed in centimeters (zero point, no pain; endpoint, intolerable pain).

Functional disability was assessed by using the Oswestry Disability Index (ODI). This is an easily administered self-report which examines the patients’ perceived level of disability in 10 everyday activities of daily living (e.g., pain intensity, the changing status of pain, personal hygiene, lifting, walking, sitting, standing, sleeping, social activity, and traveling). The patients were asked to read the 10 questions and score them between 0 and 5. The obtained total score is between 0 and 50, and the result is expressed in percentage [16]. The test is considered a gold standard of low back functional outcome tools [17]. This form has validity and reliability in Turkish [18].

The range of mobility of the lumbar spine was estimated by the fingertip-to-floor distance. The patients were instructed to stay in an upright position on a horizontal straight line, with a distance of 30 cm between the medial malleoli and then try to touch their fingertips to the floor without knee angulation. In that position, the fingertip-to-floor distance was measured [19].

In our study, quality of life was assessed by using Short Form 36 (SF-36) quality of life scale which was developed by Ware [20]. The Turkish validation was performed by Koçyiğit et al. [21]. It consists of 36 items and aims to measure the following eight parameters: physical function (PF) (10 items), social function (SF) (2 items), physical role difficulties (PRD) (4 items), mental status role (MSR) (3 items), mental health (MH) (5 items), vitality/energy (V/E) (4 items), pain (2 items), and general perception of health (GH) (5 items). The subscores of these eight parameters are calculated separately between 0 and 100. In this scale, a score of 0 indicates the worst, and a score of 100 indicates the best health status. The scores of the two main components which were named as physical score (PS) and mental score (MS) were also evaluated [20].

Statistical analysis

All statistical calculations were done by the supervision of the staff biostatistician by using the SPSS 20.0 program. Definitive statistics were applied in the analyses. The chi-square test or Fisher’s exact chi-square test was used to compare the distribution of categoric variables in groups I and II. “Independent Student’s t test” was performed for the comparison of continuous variables in groups I and II. Normal distribution of results was tested using Kolmogorov–Smirnov test. Statistical tests were applied in order to answer the following questions:
  1. 1.

    Is there any significant difference between pre- and posttreatment results within each group? “Paired Student’s t test” was used for this comparison.

  2. 2.

    Is there any significant difference between the change in post- and pretreatment measurement results between the groups? Independent Student’s t test was used for this comparison. Significance level was set at p = 0.05.



A total of 81 patients with chronic LBP whose ages range between 50 and 87 were included in this study. Mean age of the patients was 67.09 ± 8.29. Forty-four (54.3 %) of the patients were in the PT group (group I), whereas 37 (45.7 %) of the patients were in the BT plus PT group (group II). Mean age of the patients in groups I and II was 66.81 ± 9.77 and 67.43 ± 6.20, respectively, and there was no statistically significant difference between the groups (p = 0.742). The comparison of demographic characteristics of the groups (sex, marital status, occupation, alcohol consumption, and cigarette smoking) was shown in Table 1. Furthermore, the comparison of the mean value of the number of comorbid conditions, number of chronic drugs used, height, weight, body mass index, duration of LBP, pretreatment day and night VAS scores, fingertip-to-floor distance, and ODI scores was also shown in Table 1. As shown on the tables, there were no statistically significant differences between the two groups in any of these parameters (p > 0.05).
Table 1

The comparison of baseline characteristics and clinical parameters of the groups


Group I, n = 44 (%a)

Group II, n = 37 (%a)


Mean ± SD

Mean ± SD



37 (84.1)

27 (73)



7 (15.9)

10 (27)

Marital status


36 (81.8)

35 (94.6)



8 (18.2)

2 (5.4)


 Active working

10 (22.7)

12 (32.4)


 Not active working

32 (77.3)

25 (67.6)

Cigarette smoking


12 (27.3)

5 (13.5)



32 (72.7)

32 (86.5)

Alcohol consumption

 Social drinker

1 (2.3)

0 (0)



43 (97.7)

37 (100)

Number of comorbid conditions

1.75 ± 0.89

1.48 ± 0.98


Number of drugs used chronically

2.56 ± 1.42

2.43 ± 1.83



1.56 ± 0.060

1.57 ± 0.065



75.52 ± 9.28

74.43 ± 10.22


Body mass index

30.83 ± 3.49

29.78 ± 3.47


Duration of low back pain

7.02 ± 7.30

8.31 ± 10.95


Pretreatment daytime VAS

8.40 ± 1.04

8.21 ± 1.08


Pretreatment night VAS

6.15 ± 1.80

6.67 ± 1.73


Pretreatment fingertip to floor distance

21.36 ± 6.93

19.64 ± 10.20


Pretreatment ODI

27.79 ± 3.80

28.56 ± 6.78


n number of patients per group

aPercentage of patients per group

bThe chi-square test

cFisher’s exact chi-square test; p < 0.05 is considered as statistically significant

dIndependent Student’s t test; p < 0.05 is considered as statistically significant

The results of the assessments (pre- and posttreatment VAS, fingertip-to-floor distance, ODI, SF-36) were compared within the two groups and shown in Table 2. As a result, in comparison to baseline, a statistically significant improvement was observed on all variables for both groups (except MSR and MS variables of SF-36 in group I) (p < 0.05).
Table 2

The comparison of pre- and posttreatment results for pain level (VAS), fingertip-to-floor distance, ODI, and SF-36 quality of life scale within each group


Group I (n = 44 (%a), mean ± SD)

Group II (n = 37 (%a), mean ± SD)







Daytime VAS

8.40 ± 1.04

5.90 ± 1.21


8.21 ± 1.08

2.54 ± 1.44


Night VAS

6.15 ± 1.80

4.02 ± 1.84


6.67 ± 1.73

1.97 ± 1.23


The fingertip-to-floor distance

21.36 ± 6.93

24.18 ± 6.78


19.64 ± 10.20

10.81 ± 9.01



27.79 ± 3.80

16.95 ± 3.89


28.56 ± 6.78

11.43 ± 4.24


SF-36 quality of life scale’s subgroup


32.83 ± 1.31

46.12 ± 10.76


21.32 ± 5.73

48.47 ± 7.35



51.39 ± 9.94

54.27 ± 6.51


45.14 ± 13.34

56.08 ± 0.67



31.78 ± 5.07

44.96 ± 5.53


33.85 ± 6.13

50.41 ± 3.91



31.52 ± 4.34

37.87 ± 5.30


38.15 ± 5.91

43.96 ± 4.70



45.19 ± 4.11

48.70 ± 5.71


48.29 ± 3.82

50.66 ± 4.85



34.06 ± 6.33

45.47 ± 5.75


34.84 ± 8.12

48.48 ± 6.32



50.11 ± 11.07

52.27 ± 8.16


43.91 ± 14.55

55.32 ± 0.16



37.83 ± 3.65

41.47 ± 4.82


38.83 ± 5.98

45.08 ± 5.52



33.13 ± 6.48

44.72 ± 7.50


29.11 ± 7.11

48.46 ± 4.40



45.40 ± 4.81

46.55 ± 4.11


47.20 ± 4.67

49.49 ± 4.11


n number of patients per group, VAS visual analog scale, ODI Oswestry Disability Index, PF physical function, PRD physical role difficulties, GH general perception of health, V/E vitality/energy, SF social function, MSR mental status role, MH mental health, PS physical score, MS mental score

aPercentage of patients per group

bPaired Student’s t test; p < 0.05 is considered as statistically significant


For two groups, the changes in post- and pretreatment outcome scores within each group were measured for the following parameters: daytime and night VAS (0–10 cm), fingertip-to-floor distance, ODI, and SF-36 as shown in Table 3. After statistical analyses, it has been found that, compared to group I, group II is significantly superior for the daytime and night VAS, ODI, PF, PRD, pain, MSR, MS, and PS subgroups of SF-36 (p < 0.05). There was no statistically significant difference between the two groups by means of the change in post- and pretreatment outcome scores for fingertip-to-floor distance and SF and V/E subgroups’ scores of SF-36 (p > 0.05).
Table 3

The comparison of the changes in pre- and posttreatment mean outcome scores on daytime and night VAS, fingertip-to-floor distance, ODI, and SF-36 quality of life scale’s subgroups


Group I, n = 44 (%a)

Group II, n = 37 (%a)


Mean ± SD

Mean ± SD

The change of daytime VAS

2.51 ± 1.26

5.64 ± 1.41


The change of night VAS

2.11 ± 0.78

4.64 ± 1.68


The change of fingertip-to-floor distance

7.18 ± 3.57

8.78 ± 4.16


The change of ODI

10.65 ± 2.45

16.86 ± 6.53


The change of PF

12.97 ± 6.61

25.72 ± 9.07


The change of PRD

2.72 ± 6.80

10.81 ± 13.25


The change of pain

13.59 ± 6.49

16.70 ± 6.17


The change of V/E

4.27 ± 5.32

3.02 ± 2.70


The change of SF

11.31 ± 5.76

13.81 ± 7.71


The change of MSR

2.77 ± 5.37

8.29 ± 10.46


The change of MH

3.63 ± 3.89

7.86 ± 4.54


The change of PS

11.72 ± 4.07

18.70 ± 7.47


The change of MS

3.84 ± 2.54

6.16 ± 3.40


n number of patients per group, VAS visual analog scale, PF physical function, PRD physical role difficulties, GH general perception of health, V/E vitality/energy, SF social function, MSR mental status role, MH mental health, PS physical score, MS mental score

aPercentage of patients per group

bIndependent Student’s t test; p < 0.05 is considered as statistically significant



According to our results, both PT and BT plus PT are effective in the treatment of chronic LBP, while BT plus PT is significantly superior to only PT in improving pain, disability, and most parameters about quality of life. In our study, the improvements on pain, physical function, and quality of life variables obtained in both treatment groups may be explained by the thermal effects, whereas mechanical and thermal effects may be responsible for the superiority of group II over group I.

In the literature, controlled studies investigating the clinical efficacy of BT in chronic LBP are few in number and have contradictory results [10, 11, 12, 13, 14, 15]. In a study performed by Constant et al. [15], the efficacy of spa therapy plus analgesic therapy was compared with that of analgesic therapy alone. The remarkable improvement in pain and functional disability after 3 weeks and the decreased analgesic use after 6 months were observed in the spa group [15]. In a similar trial, 50 patients were followed up with spa plus analgesic therapy, while 52 were followed up with analgesics alone. VAS score, lumbar spinal mobility, functional disability, and analgesic use were evaluated three times: pretreatment, posttreatment, and posttreatment ninth month. At the posttreatment visit, spa group showed significant improvements in all of the parameters. The improvements persisted until posttreatment ninth month except for functional disability [22]. Konrad et al. [14] administered balneotherapy, underwater traction bath, and underwater massage to 158 patients in three different groups for 4 weeks in their randomized prospective controlled trial. They evaluated the patients twice, first at the end of the therapy period and second at 12 months from the beginning. Although they observed a significant decline in the pain scores of all three groups, spinal motion and straight leg raising test evaluations did not reveal any significant difference between the groups. There was no significant difference between the decreases in the pain scores of three groups [14]. Balogh et al. [12] assessed balneotherapy (mineral water with sulfide) and hydrotherapy with tap water for 15 days in two groups of 30 patients. The patients were evaluated at baseline, at the end of the 15 days of treatment period, and at the end of the third month regarding VAS score, spinal mobility, and ODI. Balneotherapy group showed improvement in all of the parameters except functional disability after the 15-day therapy program, and these improvements sustained at the third month visit, whereas hydrotherapy group only showed improvement in intensity of pain after 15-day therapy program [12]. Kulisch et al. [13] also compared balneotherapy and hydrotherapy with tap water and measured pain severity, spinal mobility, quality of life, and functional disability before treatment, at the end of the 3-week therapy interval, and after 15 weeks. They reported a statistically significant improvement in all of the parameters of the balneotherapy group at the end of the 3-week therapy interval, persisting at 15 weeks. On the other hand, hydrotherapy group only showed an improvement in pain and quality of life parameters [13]. A similar study comparing balneotherapy and tap water by Tefner et al. revealed similar results too [11]. A meta-analysis performed to assess the effectiveness of spa therapy and balneotherapy concluded that there was some evidence to suggest that each provided a greater reduction in VAS pain score than no treatment [9].

Kesiktaş et al. [10] studied the effectiveness of BT and PT in patients suffering from chronic LBP. They divided 60 patients into two groups: group I (n = 30) received PT plus exercise, while group II (n = 30) received BT plus exercise. The performed assessments were VAS at rest and movement, paracetamol dose, manual muscle tests for lumbar muscles, modified Schober’s test, ODI, and SF-36. They reported significant improvements in both groups with a statistically significant preponderance of group II in most of the parameters like in our study [10].

In our study, group II had an improvement in each of the parameters of quality of life compared to baseline, whereas for group I, no improvements were detected on MSR and MS subgroups of quality of life. This may be contributed to the deprivation of the sedative effect of balneotherapy in group I. In addition, we found a statistically significant improvement in SF and V/E of SF-36 in both groups, but there was no any significant difference by means of the improvements of these parameters between the groups. This may be explained with the fact that all patients in both groups were inpatient. Nevertheless, all of the other quality of life parameters were found to be superior in favor of group II. Therefore, we may suggest that BT plus PT improves quality of life much more than only PT in patients with chronic LBP.

On the other hand, although the fingertip-to-floor distance showed an improvement in both groups, there is no statistically significant difference between the groups. This can be explained with the technical incompetence of the measurements.

Our study, consistent with the literature, demonstrates the beneficial effect of balneotherapy in pain, disability, and quality of life.

In conclusion, while PT is an effective treatment modality for chronic LBP, BT plus PT may be more effective to improve severity of pain, functional disability, and quality of life. In the light of the reported effects of BT on patients with chronic LBP, we may conclude that BT could be considered as an effective alternative treatment modality in the clinical management of LBP. In spite of this, studies with a larger scale and better methodological quality are needed to investigate its whole aspects. Results of our study may stimulate further researches also about the biochemical effects of balneotherapy with longer follow-up periods and larger patient groups.


While one of the limitations of this study is the small number of patients, the most important one is the lack of follow-up period.





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Copyright information

© Clinical Rheumatology 2014

Authors and Affiliations

  • Şule Şahin Onat
    • 1
    • 2
  • Özlem Taşoğlu
    • 1
    • 2
  • Fulya Demircioğlu Güneri
    • 1
    • 2
  • Zuhal Özişler
    • 1
    • 2
  • Vildan Binay Safer
    • 1
    • 2
  • Neşe Özgirgin
    • 1
    • 2
  1. 1.Ankara Physical Therapy and Rehabilitation Training and Research HospitalAnkaraTurkey
  2. 2.AnkaraTurkey

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