The Change of Well-Being Associated with Spa Therapy

Abstract

The present exploratory study sought to examine the changes of well-being associated with 3 weeks of resort based spa therapy. This is a traditional form of health enhancement incorporating balneotherapy, physical therapies, and health education in an inpatient setting.
Subjects were spa patients (n = 153, mean age 58 years) with chronic pain and other age related complaints of moderately higher than normal prevalence. The well-being variables were vegetative complaints, pain, fatigue, positive and negative mood, and health satisfaction assessed at the beginning and end of spa treatment as well as 5 weeks and 12 months thereafter.
Well-being improved significantly in all variables during spa therapy, the improvement continuing with a slight deterioration at 5 weeks after the stay. After 12 months, vegetative complaints and fatigue had again reached pre-spa levels, whereas pain, positive and negative mood as well as health satisfaction remained improved. Both patients with high and low levels of pain increase their well-being, although pain patients showed greater improvements in some of the measures. Subjects not responding to spa therapy were older and showed less health satisfaction.
The results suggest that spa therapy may be a powerful tool in enhancing well-being in progressed middle aged adults with common health impairments.

Full text

Key Words
Balneotherapy ´ Well-being ´ Chronic pain ´ Mental health ´
Non-Responders
Summary
Objective: The present exploratory study sought to examine
the changes of well-being associated with 3 weeks of resort
based spa therapy. This is a traditional form of health en-
hancement incorporating balneotherapy, physical therapies,
and health education in an inpatient setting. Patients and
Method: Subjects were spa patients (n = 153, mean age
58 years) with chronic pain and other age related complaints
of moderately higher than normal prevalence. The well-being
variables were vegetative complaints, pain, fatigue, positive
and negative mood, and health satisfaction assessed at the
beginning and end of spa treatment as well as 5 weeks and
12 months thereafter. Results: Well-being improved signifi-
cantly in all variables during spa therapy, the improvement
continuing with a slight deterioration at 5 weeks after the
stay. After 12 months, vegetative complaints and fatigue had
again reached pre-spa levels, whereas pain, positive and ne-
gative mood as well as health satisfaction remained im-
proved. Both patients with high and low levels of pain in-
crease their well-being, although pain patients showed great-
er improvements in some of the measures. Subjects not
responding to spa therapy were older and showed less health
satisfaction. Conclusions: The results suggest that spa ther-
apy may be a powerful tool in enhancing well-being in pro-
gressed middle aged adults with common health impair-
ments.
SchluÈ sselwoÈrter
Balneotherapie ´ Wohlbefinden ´ Chronischer Schmerz ´
Seelische Gesundheit ´ Non-Responders
Zusammenfassung
VeraÈ nderungen des Wohlbefindens in Verbindung
mit einem Kuraufenthalt
Hintergrund und Fragestellung: Ziel der Studie war es, die
VeraÈ nderungen des Wohlbefindens waÈ hrend einer 3-woÈ chi-
gen Kur zu untersuchen. Die Kur ist eine traditionelle Form
der GesundheitsfoÈ rderung, die Balneotherapie, physik alische
Therapie und Gesundheitserziehung in einem stationaÈren
Setting beinhaltet. Methode: An der Studie nahmen n = 153
Kurpatienten (mittleres Alter 58 Jahre) mit chronischem
Schmerz und anderen altersentsprechenden Beschwerden
von etwas hoÈ herer PraÈ valenz als in der NormalbevoÈ lk erung
teil. Die Befindensmasse waren vegetative Beschwerden,
Schmerz, ErschoÈ pfung, positive und negative Stimmung so-
wie die Gesundheitszufriedenheit. Sie wurden am Anfang
und Ende der Kur sowie 5 Wochen und 12 Monate nach der
Kur erhoben. Ergebnisse: Das Wohlbefinden verbesserte sich
signifikant in allen Variablen waÈhrend der Kur, wobei die Ver-
besserung trotz geringfuÈgiger Abnahme auch 5 Wochen nach
der Kur zu verzeichnen war. Nach 12 Monaten erreichten ve-
getativen Beschwerden und ErschoÈ pfung wieder das Aus-
gangsniveau, wohingegen Schmerz, positive und negative
Stimmung sowie die Gesundheitszufriedenheit immer noch
verbessert waren. Sowohl Patienten mit hohem als auch ge-
ringem Schmerzausmass erhoÈ hten ihr Wohlbefinden, wenn-
gleich Schmerzpatienten in einigen Variablen eine groÈ ssere
VeraÈ nderung zeigten. Non-Responders waren aÈ lter und hat-
ten ein geringeres Mass an Gesundheitszufriedenheit.
Schlussfolgerungen: Die Ergebnisse weisen darauf hin, dass
Kur ein wirksames Instrument zur Verbesserung des Wohlbe-
findens von Erwachsenen mit gaÈ ngigen Gesundheitsbeein-
traÈ chtigungen dar stellen koÈ nnte.
Ó2000 S. Karger GmbH, Freiburg
Fax +49761 452 0714 Accessible online at:
E-mail Information@Karger.de www.karger.com/journals/fkm
www.karger.com
Dr. Gerhard Strauss-Blasche
Institut fuÈr Physiologie
UniversitaÈt Wien
Schwarzspanierstrasse 17, A-1090 Wien (Austria)
Tel. +43 1 4277-62112, Fax -62199
E-mail gerhard.strauss-blasche@univie.ac.at
Originalarbeit ´ Original Article
Forsch KomplementaÈrmed Klass Naturheilkd 2000;7:269±274
The Change of Well-Being Associated
with Spa Therapy
G. Strauss-Blasche
a,b
C. Ekmekcioglu
a,b
N. Klammer
b
W. Marktl
a,b
a
Department of Physiology, University of Vienna, Austria
b
Ludwig Boltzmann Institute for Biological Rhythm Research, Bad Tatzmannsdorf, Austria

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Introduction
In recent years, well-being and its determinants [1±3] and conse-
quences [4, 5] have become an increasing issue in health research.
Although personality factors explain a part of the variance of well-
being [1], ways to improve general well-being are of constant inter-
est [6±9]. One of these methods is the tradition of spa therapy, a
medical intervention for the treatment of non-life-threatening
chronic disorders of various kinds, used especially in central Eu-
ropean countries [10].
In Austria, for example, 163,000 patients, that is approximately
2.3% of the population, received spa therapy reimbursed by the
general health insurance in the year 1998 [11]; in France about
250,000 patients, that is approximately 0.5% of the population
have spa treatment per year [12]; in Germany, 9,530,000 people,
that is about 12% of the population visited a spa in 1997 [13]. New
possibilities of intervention could be opened if it can be shown that
spa therapy is associated with an enhancement of physical and
mental well-being, which also would promote the understanding of
processes determining mental health.
In Europe, spa therapy generally encompasses balneotherapeutic
(e.g. the use of natural remedies like mud applications, thermal
water, salt water etc.) as well as physiotherapeutic applications. In
addition, other treatments such as dietary measures or health edu-
cation are often employed [14]. Next to the treatment of the specif-
ic disorder the second generally acknowledged aim of spa therapy
is to increase and sustain well-being. Although spa resorts differ in
the natural therapies used, the setting of spa therapy tends to be
constant. Firstly, patients stay at a spa for 3±4 weeks, mostly in a re-
sort-like setting in a non-urban environment, thereby being away
from work and from their families. Secondly, the patient has a pre-
scribed daily routine consisting of fixed sleeping and waking hours,
meals and several therapeutic applications as well as free time.
Thirdly, the focus of spa therapy is health rather than illness, as bal-
neotherapy tends to improve health by `training' physiological sys-
tems rather than by external correction of dysfunction [15].
Previous studies have shown that spa therapy is generally asso-
ciated with an improvement of well-being [16±18]. Also, chronic
low back pain is decreased through spa therapy [19, 12]. But little
is known about the differential changes of the various aspects of
well-being associated with spa therapy nor of the duration and sta-
bility of these changes. Furthermore, the issue of non-responders
to spa therapy has not been considered thus far. Also, it is unclear
whether pain patients benefit from spa therapy more than non-
pain patients. These issues are addressed in the present paper.
Patients and Method
Patients
Subjects were volunteer spa patients undergoing balneotherapy.
153 subjects with a mean age of 58.4 ±10.1 (youngest 33 years, old-
est 85 years; 69% female, 31% male) participated in the study after
giving written consent. They were that part of a larger sample of
subjects which had responded to the follow-up questionnaire
12 months after the end of spa treatment. The sample did not differ
from the approximately 40% of the subjects who had not re-
sponded to this questionnaire in any of the dependent variables at
time 1. Regarding the diagnosis of the present sample (overlapping
categories), 88% of the subjects had non-inflammatory chronic
back pain, 93% additionally had pain in one or more joints, 30%
had hypertension, 6% had diabetes, 7% had coronary heart disease
and 5% had chronic obstructive pulmonary disease. 9% of the sub-
jects received pain medication. Regarding their occupational sta-
tus, 60% of the subjects were working, whereas 40% were retired.
Variables
The dependent variables were measured with several standardized
German questionnaires. `General pain', `vegetative complaints'
(encompassing abdominal and cardiovascular complaints) and fa-
tigue were assessed with the scale for physical complaints (`Giess-
ener Beschwerdebogen', [20]). `Negative mood' and `positive
mood' were assessed with the quality-of-life questionnaire (`Profil
der LebensqualitaÈt bei Chronischkranken', [21]), the prior incor-
porating items referring to anxiety, anger, and depression and the
latter items referring to joy, energy, relaxation, and optimism.
Health satisfaction was measured with the life-satisfaction ques-
tionnaire (`Fragebogen zur Lebenzufriedenheit', [22]) using the
scale `satisfaction with one's health'. The intensities of back and
joint pain were measured with 5-point Likert scales.
Procedure
All subjects stayed at the spa resort `Bad Tatzmannsdorf' in Aus-
tria for 21 days and received spa therapy during that time. The
therapies administered were mud applications received by 82% of
the subjects, CO
2
applications received by 81%, various forms of
massages received by 95%, exercise therapy received by 65%, as
well as electrotherapeutic and other applications (relaxation train-
ing, inhalations etc.) received by 39% and 31%, respectively. The
dependent measures were taken on day 2 (time 1) and day 20
(time 2) of spa therapy, 5 weeks after the end of spa therapy
(time 3), and 12 months after the end of spa therapy (time 4).
Statistics
To test the short- and long-term changes of well-being associated
with spa treatment, an ANOVA (analysis of variance) for repeated
measures was calculated over the 4 times of measurement. To
further test differences between the baseline value and the conse-
cutive post spa values, t tests for paired samples were applied.
To test the effects of gender on the change of well-being an analy-
sis of covariance was conducted. The change of each of the 6 de-
pendent variables from time 1 to time 3 was analyzed with gender
as the main factor and the pre-spa levels of well-being as covariant
to control for initial gender differences. As all main effects were
far from being significant (smallest p >0.25), it can be concluded
that gender did not have a significant effect on the change of well-
being. Therefore, all further analyses were calculated for the whole
group.

Forsch KomplementaÈrmed Klass Naturheilkd
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271
To study the individual change of well-being, the percentage of
subjects whose well-being had improved versus deteriorated be-
tween successive observations was calculated for each dependent
variable. This analysis should give insight into the stability of the
individual improvements.
To investigate whether patients with high and low pain intensities
at the onset of spa therapy show different reactions to treatment,
an analysis of variance for repeated measures was calculated. As
dependent variables, the well-being measures at time 1 and time 3
were used. As independent variable, a median split of the sum of
pain intensities from back and joint pain was used.
The response to spa therapy was defined as the relative change of
general complaints (a sum score of the 3 complaint measures) from
the beginning of therapy to 5 weeks after therapy. The relative
change was chosen because the change score was significantly corre-
lated with its baseline value (r = 0.32 for general complaints), indi-
cating that subjects with more complaints reduce their complaints
more than subjects with less complaints. The relative change was cal-
culated by dividing the change score by its baseline value, thereby
eliminating the effect of the level of initial complaints.
Results
Short- and Long-Term Effects
The change of well-being associated with spa therapy is illustrated in
figure 1, the statistics are listed in table 1. Vegetative complaints,
general pain, fatigue and negative mood decreased significantly
from the beginning to the end of the 3-week stay at the spa
(p <0.001). A reciprocal pattern occurred for positive mood and
health satisfaction (p <0.001). 5 weeks after spa treatment, all 6
well-being variables were still significantly improved compared to
the beginning of the treatment (p <0.001), although a deterioration
of different magnitude occurred. Vegetative complaints had deterio-
rated the most, regaining 52% of their pre-spa level, followed by
negative mood, positive mood, health satisfaction and general pain,
regaining 46, 45, 36 and 29% of their pre-spa level, respectively. Fa-
tigue showed the smallest deterioration from its post-spa level to fol-
low-up at 5 weeks, only regaining 15% of its pre-spa level.
12 months after spa therapy, the level of vegetative complaints and
fatigue were not significantly different from their pre-spa level.
General pain and negative mood were significantly lower, positive
mood and health satisfaction were significantly higher as compared
to pre-spa levels. In regard to their pre-spa level, negative mood
had regained 66%, health satisfaction 61%, positive mood 55%,
and general pain 54%, respectively.
Dynamics of Change
Table 2 illustrates the percentage of positive and negative changes
of well-being between successive observations. The most frequent
positive change between time 1 and time 2 occurred for general
pain, 87% of the subject showing a decrease in pain. The least fre-
quent positive change occurred for fatigue, only 52% of patients
decreasing their level of fatigue. 50±63% of the subjects well-being
deteriorated from the end of spa to 5 weeks after the spa, whereas
23±42% of the subjects improved their well-being. The most fre-
quent improvement was found for health satisfaction (42%), the
least frequent for vegetative complaints (23%). From 5 to
12 months after the spa treatment, the well-being of 49±56% of the
subjects deteriorated further. Improvements were seen in 29±40%,
whereby the greatest improvement was found for health satisfac-
tion (40%) and the smallest improvement for general pain (29%).
Moderating Effects of Pain
The change of well-being from time 1 to time 3 for patients with
high and low levels of pain is illustrated in figure 2. Patients with
The Change of Well-Being Associated
with Spa Therapy
Fig. 1. Means and standard errors of the 6 measures of well-being at the be-
ginning and end of spa therapy and at 5 weeks and 12 months follow-up. The
displayed value of health satisfaction is 1/3 of the original value.
Table 1. F and t statistics for the change of well-being associated with spa therapy (time 1 = pre-spa; time 2 = post-spa; time 3 = follow-up at 5 weeks;
time 4 = follow-up at 12 months)
ANOVA for
repeated measures
t tests
time 1±2 time 1±3 time 1±4
Fp tp tp tp
Vegetative complaints 27.7 0.000 9.3 0.000 4.5 0.000 0.6 0.55
General pain 61.0 0.000 13.8 0.000 9.0 0.000 5.8 0.000
Fatigue 5.9 0.001 3.3 0.001 3.0 0.003 1.1 0.29
Negative mood 54.5 0.000 12.8 0.000 6.1 0.000 4.1 0.000
Positive mood 37.2 0.000 10.6 0.000 5.5 0.000 4.9 0.000
Health satisfaction 26.0 0.000 9.7 0.000 4.9 0.000 3.1 0.002

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high pain intensities had a poorer well-being in all measures com-
pared to patients with low pain intensities (multivariate F = 7.6;
p = 0.000). The difference between high and low pain patients in
regard to their change of well-being was less pronounced (multi-
variate F = 2.0; p = 0.07). Subjects with high initial pain levels did
show a greater decrease in general pain and negative mood as well
as a greater increase in health satisfaction, but differences in the
change of vegetative complaints, fatigue or positive mood were not
found. Overall, both high- as well as low-pain patients showed a
significant improvement of well-being (multivariate F = 16.1;
p = 0.000).
Responders and Non-Responders
Differences between responders and non-responders to spa ther-
apy are listed in table 2. If not otherwise indicated, the measures
displayed are pre-spa levels. Non-responders are older than me-
dium- and especially high-responders. Differences in sex, the fre-
quency of pain medication, the body mass index or negative mood
were not found. High- and non-responders also did not differ in
pain or general complaints, but medium-responders showed more
pain and general complaints than the other two groups. There was
a tendency for high-responders to have higher positive mood and
health satisfaction than low-responders.
Responders and non-responders showed differences in the stability
of effects. Whereas all groups reduced general complaints on a
short-term basis, non-responders' general complaints increased
again at follow-up after 5 weeks, whereas high-responders' com-
plaints continued to decrease. Significant differences in regard to
complaints between non- and medium-responders on the one hand
and high-responders on the other hand could be observed at all
3 post-treatment measures (table 3).
Discussion
The aim of the present study was to investigate the change of phy-
sical and psychological well-being during and after 3 weeks of spa
Table 2. Percentage of subjects showing an improvement (+) versus deterio-
ration (±) of well-being in the specified variable between successive observa-
tions (time 1 = pre-spa; time 2 = post-spa; time 3 = follow-up at 5 weeks;
time 4 = follow-up at 12 months)
time 1±2 time 2±3 time 3±4
+± +± +±
Vegetative complaints 74.5 10.3 23.4 53.8 31.7 52.4
General pain 87.1 4.8 27.9 59.9 29.3 55.8
Fatigue 52.1 29.3 32.9 50.0 34.3 50.0
Negative mood 85.7 8.2 23.1 63.3 32.0 53.1
Positive mood 76.2 11.3 26.5 53.0 35.8 49.0
Health satisfaction 79.1 15.7 41.8 54.2 39.9 52.9
Fig. 2. The change of the 6 well-being measures from the beginning of treat-
ment (t1) to follow-up at 5 weeks (t3) for patients with high and low levels of
pain. The probabilities are based on F statistics (group´time) and pertain to
differences in change. The displayed value of health satisfaction is 1/3 of the
original value.
Table 3. Means, standard deviations, F statistics and Scheffe post-hoc test for non-, medium-, and high-responders to spa therapy in regard to the change of
general complaints
Response Significance
p
Scheffe
none (n = 43) medium (n = 53) high (n = 52)
mean SD mean SD mean SD
Age, years 60.9 11.2 58.6 8.3 55.3 10.3 0.02 0±2
Sex (% male) 37 25 35 n.s. ±
BMI 26.8 4.0 27.8 4.7 26.5 4.2 n. s. ±
Pain medication, SU 12 0.32 11 0.32 0.2 0.14 n. s. ±
General pain, SU 10.7 3.8 13.3 4.6 10.8 4.2 0.003 0±1; 1±2
Negative mood, SU 11.7 6.1 11.5 6.7 9.4 6.3 n. s. ±
Positive mood, SU 6.5 2.6 6.9 2.8 7.8 3.2 0.08 ±
Health satisfaction, SU 24.6 7.6 23.4 6.8 28.2 8.8 0.007 1±2
General complaints, SU
time 1 24.5 12.2 30.2 15.3 23.3 12.2 0.02 1±2
time 2 19.6 10.1 20.9 10.6 12.7 10.4 0.0002 1±2; 0±2
time 3 28.9 12.0 24.5 13.1 10.4 7.7 0.0000 1±2; 0±2
time 4 26.9 10.5 27.7 16.1 17.3 10.2 0.0002 1±2; 0±2
n. s. = Not significant; SU = scale units.

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273
therapy in a heterogeneous sample of chronic pain patients. The
patients primary complaint was back pain, but only few received
pain medication, implying that pain was not disabling for most pa-
tients. Prevalence of low back pain in the general population over
a period of 1 month is about 30±40%, higher rates being observed
in the 40±60-year age group [23]. This implies that the patient
group studied had approximately a 2 fold higher rate of back pain
than the general population. Subjects also had other chronic dis-
eases of a slightly higher prevalence than the general population,
such as hypertension (30%) or diabetes (6%), the prevalence rates
being 20% for essential hypertension [24] and 1±3% for diabetes
[25]. In all, the subjects of this study had slightly more health prob-
lems than an comparable age group of the normal population, but
were not overtly disabled.
It was found that well-being generally improved from the begin-
ning to the end of spa therapy, the improvement deteriorating over
time but still being present in some of the variables 12 months after
the end of treatment. On a short-term basis, that is from baseline
to the end of treatment, vegetative complaints, general pain, fa-
tigue, positive and negative mood as well as health satisfaction im-
proved significantly. This is consistent with other studies showing a
short-term positive effect of balneotherapy on physical complaints
[16, 17, 26], vegetative complaints [10], pain [12], and emotional
well-being [16, 27] for a variety of disorders.
In terms of the number of subjects improving their well-being on
this short-term basis, 75±90% of the subjects showed improve-
ments in all measures except fatigue, which decreased only in 50%
of the subjects. The reason for this latter finding could be the fact
that balneotherapy is a physically demanding procedure which in-
duces tiredness in patients as has been shown elsewhere [18].On
the other hand, the above finding indicates that 10±25% of the sub-
jects failed to improve on a short-term basis. This, and the sponta-
neous improvement of well-being between the end of therapy and
follow-up at 5 weeks, may in part be due to what is known as the
`cure reaction', a temporary deterioration of well-being due to the
impact of treatment, followed by a delayed recovery [28].
5 weeks after the end of spa treatment, well-being generally re-
mained significantly improved in comparison to the pre-spa levels,
although some measures had regressed towards their initial value.
Negative and positive mood and vegetative complaints deterio-
rated faster than health satisfaction, fatigue, and general pain, indi-
cating that mood-related aspects of well-being are less stable than
physical complaints or health satisfaction. 12 months after the stay
at the spa, vegetative complaints and fatigue had again reached
pre spa levels. Negative and positive mood as well as health satis-
faction and general pain still were significantly improved as com-
pared to their initial pre-spa levels. The most stable spa-related
changes could be observed for general pain, having regained only
about 50% of its initial value. This latter result is comparable to
the findings of other studies on the long-term effect of spa treat-
ment on chronic pain [19, 12].
The failure of the measures of mood related well-being to regain
pre-spa levels may in part be due to the greater number of sponta-
neous improvements occurring in these measures after spa treat-
ment compared to the measures of physical well-being. This and
the above mentioned finding suggests that emotional well-being
might be more subject to spontaneous and situational change than
physical complaints, which is in agreement with other research
findings [29, 30].
To investigate whether all patients show a similar response to spa
therapy, a responder/non-responder analysis was conducted in re-
gard to the improvement of physical complaints. A group of non-
responders was identified. Although all patients reduced their
complaints on a short-term basis, non-responders could not sustain
their improvements, showing a marked increase of complaints to
5 weeks post treatment, whereas high-responders showed a further
decrease. These differences were still displayed 12 months after
spa therapy. In regard to biological characteristics, responders were
younger than non-responders, other differences not being appar-
ent. In regard to their psychological characteristics, high respond-
ers tended to have a more positive mood and greater health satis-
faction than non-responders, while at the same time displaying
comparable levels of pain and other complaints. A possible inter-
pretation of this pattern is that responders are more optimistic in
regard to their physical health than non-responders, and therefore
are more able to benefit from therapy. This interpretation is in ac-
cordance with other research showing that optimism is beneficial
for the recovery from illness [31].
To find out whether spa therapy is also beneficial for patients with
less pain, differences between patients with high and low levels of
pain in their response to spa therapy were studied. Results show
that although patients with high levels of pain had a poorer well-
being in all measures, a greater improvement only occurred for
general pain, negative mood, and health satisfaction. The improve-
ment of vegetative complaints, positive mood, and fatigue was in-
dependent of the level of pain. These results suggest that spa ther-
apy is also beneficial for subjects without predominant pain prob-
lems and that the beneficial effects of spa therapy may not only be
due to pain improvement. This is in accordance with findings pro-
posing that staying at resort hotels without receiving balneother-
apy also improve aspects of physical and mental health [18, 32] as
well as with other studies on spa therapy with diverse disorders
[33].
The authors are conscious of the fact that the inclusion of a control
group would have allowed a causal attribution of the observed ef-
fects to balneotherapy as well as precise estimation of the magni-
tude of spa effects, both of which cannot be derived from this lon-
gitudinal design. But the observed short- and long-term effects on
some aspects of well-being should encourage further research to
study these issues.
In conclusion, 3 weeks of spa therapy were associated with an im-
mediate increase of both physical and emotional well-being, which
declined slightly during a 5-week period back at home. One year
after spa treatment, the level of pain, negative and positive mood
as well as health satisfaction were still found to be improved. These
long-term positive change of well-being not only are the basis of a
greater quality of life [34], but might also have a positive effect on
longevity [35].
The Change of Well-Being Associated
with Spa Therapy

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