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Results of the complex treatment of lower back pain in spa hotels

István Fluck M.D.
Danubius Hotels Nyrt
2012

Hot water has been used in Europe for the treatment of locomotor diseases, particularly for the treatment of lower back pain, for hundreds of years.

The application of a range of natural therapies (medicinal baths, hydrotherapy, mud treatments, electrotherapy, medicinal gymnastics and massage) which have been carried out and then measured based on their effect on a patient’s condition have been analysed in only a few publications.

In a publication issued in 1999 we managed to justify by statistical data the effectiveness of complex spa treatment stays in spa hotels for patients suffering from osteoarthritis of the hip joint. (14) In this study we did not only intend to justify the effectiveness of natural therapies but also the fact that if properly applied their effect may, in the majority of cases, be equal to any medicine/drug based therapy – which has experienced a notable increase in recent decades.  

In countries of Anglo-Saxon medical orientation, with the exception of the medical gymnastics (physiotherapy), the effectiveness of natural healing factors is debunked by many. Any achieved results have been justified as psychological effects of a placebo type.

With our analyses/examinations our intention was to prove that, in line with the domestic and Eastern-European medical approach, that a complex range of treatments applying an entire arsenal of natural healing factors is much more effective than monotherapy. 

Owing to the restricted acceptability of the principle of monotherapy there are no medicinal resorts or medicinal establishments in Hungary where all diseases or complaints would be treated exclusively by applying a single – as effective as it may be - local medicinal factor. As opposed to principally the tradition and practise in some Mediterranean countries we do not run medicinal establishments solely for one type of treatment such as mud or only thermal water. 
  
Based on positive results experienced by prescribing a complex range of treatments on patients suffering from osteoarthritis of the hip joint in spa hotels (14) we have complemented our studies with the analysis of the medicinal effects that can be achieved as a result of complex treatment of lower back pain, one of the most general musculoskeletal complaints.
Several publications address the issue of lower back pain, (lumbago, low back pain etc.)  (21, 22) dealing with certain effective treatments (22, 23) and/or the therapeutic procedures connected to medication.

In the course of these studies we analysed the results achieved through a complex 2-3 week treatment of patients with acute lower back pain.

The examinations took place in the spa departments of DHSR Margitsziget and Grand Hotel Margitsziget as well as DHSR Hélia, DHSR Hévíz and DHSR Sárvár.

We carried out the analysis of data from a total of 105 patients/spa guests. They received all the treatments made necessary owing to their complaint and condition (balneotherapy, hydrotherapy, electrotherapy, medicinal gymnastics, medicinal massage etc.) It is to be noted that all of the spa hotels providing the spa treatment had/have qualified medicinal water acknowledged by the state and these waters were used in the bath treatments.

The analysis involved only patients who received spa treatments for the first time in Hungary.
Those who had spine surgery (laminectomy and flavotomy, fixation etc.) suffered from other diseases restricting locomotion (osteoarthritis of the knee, osteoarthritis of the hip joint, Bechterew etc.), had operations related to the before mentioned (hip-knee joint prosthesis etc.) or were restricted in their mobility due to their cardiac condition were excluded from the analysis.       

When compiling the evaluation sheets we took into consideration, based on previous experience (14), the documentation proposal made by Csermely for the qualification of medicinal waters. (20)

The evaluation sheets were filled out and the necessary examinations were carried out in Budapest by doctors of the spa hotels while in Hévíz and Sárvár – under medical supervision – by physiotherapists.

The sheets were recorded on the first day during the medical examination (in Budapest) or following that (in Hévíz and Sárvár).

The examination compared the condition of the patients before and after the treatment. The second examination took place following the final medical examination or directly afterwards. The sheets were filled out by the same person in all cases.

The statistical processing of the data sheets were carried out based on a contract concluded by Danubius Hotels Zrt. with the Foundation for Information Society (INFOTA). The processing involved several verbal and written consultations. Based on the medical professional comments INFOTA prepared five versions of the statistical summary. We based our studies predominantly on the fourth version that altered very little from the last version.

From the 105 treated persons 36 were men and 69 women. This figure is based on the characteristic guest composition of spa hotels, as women tend to care more for their health than men.

Unfortunately INFOTA did not examine data broken down to genders, ages or hotels, so we can only report about consolidated age distribution.

The eldest person was 88 the youngest 40 while the average age was 68,8.


50 patients had a two week treatment while 55 patients had a complex three week cure.
Against expectations we did not find any significant discrepancy between the therapeutic outcome of the two- and three week treatments so the evaluation combined the two groups.
The results achieved in each spa hotel did not deviate from each other considerably since the treatments were carried out considering the same professional principles, practically under similar circumstances. We had patients from 12 different countries.


Distribution by hotels and genders

It is apparent from the above that the majority of spa guests namely Germans (61 pax) prefer the country spa hotels, 50 of them chose to undergo treatments in Hévíz and Sárvár.   

The majority of the patients had been suffering from lower back pain for years, however, five of the persons taking part in the study came to us with a back pain that only started a couple of weeks earlier.

The five varieties of the sensation of pain (morning pain before getting up; pain felt  in a sedentary  position, pain felt during motion, pain caused by coughing-sneezing and pain radiating into the lower limbs) have been recorded based on the subjective opinion of the patients. Improvement was significant in all cases, however, indicating major differences: pain caused by motion was moderated in 83% of cases while pain as a result of coughing and sneezing only in 32%.
Pain radiating into the lower limbs did not improve in 70% of all cases, it got stronger in 1% and completely disappeared in 29% of all cases.  
This means that we registered significant improvement following the treatments in all pain groups examined (that is: p=0,05).
The outcome of the analysis of the visual analogue scale (VAS) was also positive. The figure deteriorated in one case, however, patients signalled an improvement on the 100 mm scale to be 32,9 mm in average (100 represents extremely strong pain while 0 means no pain at all). 
There were 17 registered persons among whom the pain disappeared following the treatment in case of women from an average of 51,4 to zero and in case of men from an average of 38,8 to zero.
Data of one person involved in the examination – a 58 year old woman – were not taken into consideration showing 100 at the first examination and 0,1 at the control test, as this 100% pain decrease can not be regarded a realistic figure. (She is assumed to have provided an unrealistic high figure at the first examination.)    
The walking time measured per seconds on flat ground remained unchanged in 39 cases after the treatment while it decreased in 62 cases and deteriorated for 4 persons. The average improvement was 2 seconds with the most striking case being 10 seconds. 


The walking time measured down and up the stairs (20 stairs) remained unchanged following the treatment in about half of the cases. It worsened in 9 cases stairs upwards and in 7 cases stairs downward. The changes – that are significant despite the above – are shown on the diagram below based on figures measured walking upstairs.

The examination of walking ability involved looking at the necessity of the use of medical aid (stick, crutch). Practically we did not observe any changes in those cases where patients needed the use of a medical aid either on the street or in their homes. Consequently the complex treatment did not result in substantive improvement.

Before and after the treatment we tested the paravertebral muscle spasm, pressure sensitivity, forced position, tension symptoms e.g. Laségue symptom), Schober symptoms, lateral flexion, rotational movements of the spine, floor-finger distance as well as Achilles and patella reflex.

Spasm of the muscles reduced significantly in the paravertebral muscles:


The outcome was similarly positive in the examination of pressure sensitivity:


We observed the forced position in 31 cases which ceased in 29 cases and worsened in 2 following the treatment. All in all this improvement is clearly significant.
 
Positive tension symptoms were found - as opposed to the expected – only in 15 cases in the course of the first examination which terminated at the end of the treatment while only 1 deteriorated. We can declare this equally a substantial improvement.

Looking at the Schober symptom although improvement was recorded in case of 52 patients the average change was only 0,2 cm. Worsening was observed in only 3 cases while the value remained practically unchanged in all the other cases. 

The lateral flexion was measured in cm on both sides of the thighs. Deterioration was observed in cases of bending both to the right and to the left in 2-2 examined patients.

The following diagram illustrates figures recorded in case of bending to the right (the lateral flexion is shown on X-axis in cm-s):



The rotation was measured in various hotels in different ways; in some places in angular degree and in others in cm-s. Despite this a definite improvement was established in all cases.

The floor-finger distance, in other words the degree of leaning forward improved by 5cm in average, with the most distinct improvement being 30 cm.  
So the results were positive here too, however, in two cases a marked deterioration was recorded, where in one case it reached 16 cm.


The Achilles and patella reflexes could be set off in the majority of the patients and practically remained unchanged following the treatments.  Improvement was experienced by 4-4- patients in both reflex tests, proving that the torpid reflexes could be well set off. 

Twenty-seven of the patients tested did not take any medication prior to the treatment. The others (78 persons) regularly took pain killers and non-steroid drugs, primarily diclofenac derivatives.
Sixteen percent of the patients who had to take drugs regularly earlier could stop, while 47% could reduce the number of drugs taken and for 37% the daily dose was not modified.
Before and after the treatment we made a comparison about how the patient felt and what was  the opinion of the doctor regardingthe patient’s condition. (104 answers were considered assessable; the outcome is illustrated on the following diagrams.)






Every patient was asked when leaving if he would consider returning to Hungary for a complex treatment  the answer to which was 100% “yes”.

SUMMARY:  

We carried out the evaluation of the effect of a complex spa treatment of 105 patients suffering from lower back pain by comparing partly subjective partly measurable parameters (walking time, floor-finger distance, Schober symptom etc.)  With the exception of the necessity of using medical aid (stick, crutch) we registered a statistically significant improvement in all recorded parameters.
Albeit we had no possibility to embark on a 3-6 months follow up or double-blind studies, it can definitely be stated that the complex spa cures providing all the necessary treatments are clearly effective and in our opinion are more efficient compared to monotherapy.

References:

Please note that points 1 – 14 refer to the original version of this article, which was cut for relevance purposes.

1.    Dr I. Fluck: A hazai fürdőzés történetéből (A piece of history of domestic bathing) (Magyar Fürdőkalauz)
Publisher: Magyar Almanach. Editor: Dr Péter Soós, 1995, 6-8
2.    J. Török: A két Magyarhaza  első rangú Gyógyvizei és Fürdőintézetei (Top ranking Medicinal waters and Bath establishments of the two Hungarian homelands)
Book Press of Debrecen 1859
3.    A. Richter: A magyar gyógyvizek hatásának jellemzői az újabb biológiai kutatások alapján (The features of the effect of Hungarian medicinal waters based on new biological research)
Gyógyfürdőügy 1979, 3, 30-32
4.    G. Báthori, K. Merétey, J. Korda, Gy. Gasztonyi, F. Görgényi, U. Böhm, G. Bálint: Kettősvak vizsgálat: A kiskunhalasi termálvíz hatása RA-s betegeken (Double-blind study: The effect of the thermal water in Kiskunhalas on RA patients)
Magyar Reumatológia 1981, 22, 30-36
5.     A. Barta, T. Varjú, T. Papp, I. Berecz: Kettősvak vizsgálat a nyíregyházi termálvíz klinikai kipróbálásáról (Double-blind study on the testing of the thermal water in Nyíregyháza)
Magyar Reumatológia 1988, 29, 19-33
6.    L. Szűcs, I. Ratkó, T. Leskó, I. Szoór, Gy. Genti, G. Bálint: Double-blind trial on the effectiveness of the Püspökladány thermal water on arthrosis of the knee-joints.
J.R. Soc. Health, 1989, 109,7-9
7.    J. Bereczki, L. Görbedi, L. Kiss, B. jun. J. Jász: Az egerszalóki termálvíz gyógyhatásának vizsgálata kettősvak kísérlettel spondylosisos betegeken. (Evaluation of the therapeutic effect of the thermal water in Egerszalók with double-blind study on patients suffering from spondylosis)
Balneológia- Gyógyfürdőügy-Gyógyidegenforgalom, 1990, 1, 7-13
8.     I. Kovács, T. Bender: The therapeutic effects of Cserkeszőlő thermal water in osteoarthritis of the knee: a double-blind controlled, follow-up study
Rheumatology Int. 2002, 21,218-221.
9.    K. Konrád,T. Tátrai, A. Hunka, E. Vereckei, L. Korondi: Controlled trial of balneotherapy in treatment of chronic low back pain.
Ann. Rheum. Dis. 1992, 51, 820-822
10.    G. Bálint, T. Bender, E. Szabó: Spa treatment in arthritis
J.Rheumatol. 1993, 20, 1623-1625
11.    Á. Kulisch, T. Bender, A. Németh, L. Szekeres: Effect of thermal water and adjunctive electrotherapy on chronic low back pain: double-blind randomised follow-up study
J. Rehabil. Med. 2009,41,73-79
12.    G.B. Anderson: Epidemiological features of chronic low back pain.
Lancet, 1999, 354, 581-585.
13.    K. Horvath, Á. Kulisch, A. Németh, T. Bender: Evaluation of the effect of balneotherapy in patients with osteoarthritis of the hand: a randomised, controlled, single-blind follow up study. Clinical Rehab. 2011,26,431-441
14.    I. Fluck, J. Szakonyi, M. Mogyorósi, M. Weigl, P. Horvath: Gyógyszállói komplex fizioterápiás kúrák eredményességének vizsgálata coxarthrosisos betegeken (Evaluation of the effectiveness of complex cures with natural healing factors carried out on patients suffering from osteoarthritis of the hip joint in spa hotels)
Balneológia- Gyógyfürdőügy-Gyógyidegenforgalom, 2009,23,52-65
15.    I. Fluck: „Day-time Hospital” A new form of care for the treatment of patients with chronic locomotor diseases.
Gyógyfürdőügy 1975, 9,18-19
16.    I. Fluck, L. Fröhlich: Új betegellátási rendszer megszervezése a fővárosi gyógyfürdőkben (Organising a new patient care system in the Budapest spas)
Balneológia- Rehabilitáció- Gyógyfürdőügy, 1986,7,7-16
17.    I. Fluck: Tageskrankenhaus: eine neue Form des Behandlung von Patienten mit Erkrankungen des Bewegungsapparates. Z. Natural healing factors , 1980,41, 311-313
18.    G. Bálint, B.Szebenyi: Nonpharmalogical therapies in osteoarthritis.
Balliers Clin. Rheum. 1997,11,795-815
19.    T. Bender, P.Géher, G. Bálint: Nonpharmalogic treatment of musculeselectal disease.
Clin.J. Pain. 2001,17,278
20.    M. Csermely: Gyógyfürdők és gyógyvizek. (Medicinal baths and medicinal waters). Publisher: White Golden Book
Budapest, 2002, 15-26
21.    I.K. Tefner, A. Német. A. Lászlófi, T. Kiss, Gy. Gyetvai, T. Bender: The effect of the spa therapy in chronic low back pain: a randomised, controlled, single-blind, follow up study.
Rheumatology Int. (on line public.) 2011
(DOI 110.1007/s00296-011-2145-y)
22.    M.H. Pittler, M.Z. Karagülle, M. Ernst E. Karagülle: Spa therapy and balneotherapy for treating low back pain: metanalysis of randomised trials.
Rheumatology 2006,45,880-884
23.    M. Mogyorósi, K. Lónyai: A deréktáji fájdalom változásainak vizsgálata a XIII.B-48 OKK számú termálkút (Margitsziget (Margaret Island), Magda spring) vizével végzett kezelések során. (Study of the changes in the lower back pain as a result of treatments carried out with the thermal water of Margaret Island, Magda spring)
Balneológia-Gyógyfürdőügy-Gyógyidegenforgalom 2012,31,41-54 
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