spa therapy for chronic low back pain and lumber osteoarthritis in turkey

Spa Therapy for Chronic Low Back Spa Therapy for Chronic Low Back PainPain and Lumber Osteoarthritis in and Lumber Osteoarthritis in

TurkeyTurkey

Prof. Dr. M. Zeki KaragülleProf. Dr. M. Zeki Karagülle

Spa TherapySpa Therapy

SpaSpa

““SSpagere” pagere” ;; Latin word Latin word “to “to scatter, scatter, sprinkle, moistensprinkle, moisten””

““EEspa” spa” ; ; Walloon wordWalloon word meaning fountainmeaning fountain ““SSpapa”” ;; Belgian townBelgian town near Liege near Liege,,

where where a curative, thermal spring was a curative, thermal spring was discovered discovered in in 14th century14th century

Place with thermal bathsPlace with thermal baths; “; “Health resortHealth resort” ” ““SSalus alus PPerer AAquamquam”;”; HealthHealth t throughhrough w waterater

Spa TherapySpa Therapy ““Bathing in thermal water for Bathing in thermal water for

therapeutictherapeutic purposes has several purposes has several descriptions (fordescriptions (for example, taking theexample, taking the waters, balneotherapy, spa therapy, waters, balneotherapy, spa therapy, hydrotherapy), which willhydrotherapy), which will all be used all be used throughout this paper, and are more throughout this paper, and are more or less interchangeable.or less interchangeable.””

A brief history of spa therapy: A van Tubergen, S van der Linden, Ann Rheum Dis 2002;61:273–275


Has frequently been used Has frequently been used interchangeably with interchangeably with balneotherapy and hydrotherapy balneotherapy and hydrotherapy by patients and health care by patients and health care workers alike.workers alike.


We profoundly disagree with the authors, We profoundly disagree with the authors, that "taking the water, balneotherapy, that "taking the water, balneotherapy, spa therapy, hydrotherapy are more or spa therapy, hydrotherapy are more or less interchangeable". We are certain less interchangeable". We are certain that they are not.that they are not.

MATTERS ARISING: A brief history of spa therapy MATTERS ARISING: A brief history of spa therapy

T Bender, P V Balint and G P Balint T Bender, P V Balint and G P Balint

Ann Rheum DisAnn Rheum Dis 2002;61:949-950 2002;61:949-950


““Bathing in thermal water for therapeutic Bathing in thermal water for therapeutic purposes has several descriptions (e.g. purposes has several descriptions (e.g. taking the waters, balneotherapy, spa taking the waters, balneotherapy, spa therapy), which are more or less therapy), which are more or less interchangeable. interchangeable. Spa and exercise treatment in ankylosingSpa and exercise treatment in ankylosing spondylitis: fact or fancy? spondylitis: fact or fancy? Best Practice & Research Clinical Best Practice & Research Clinical Rheumatology, 2002; 16: 653-666 Rheumatology, 2002; 16: 653-666 A.van Tubergen and A. HiddingA.van Tubergen and A. Hidding


““Nowadays, spa therapy comprises a wide Nowadays, spa therapy comprises a wide range of strategies among which are range of strategies among which are balneotherapy (bathing in mineral water), balneotherapy (bathing in mineral water), hydrotherapy (immersion of the entire hydrotherapy (immersion of the entire body or parts of the body in thermal body or parts of the body in thermal water), massages, physical exercises, mud water), massages, physical exercises, mud applications and relaxation”applications and relaxation”Spa and exercise treatment in ankylosingSpa and exercise treatment in ankylosing spondylitis: fact or spondylitis: fact or fancy? fancy? Best Practice & Research Clinical Rheumatology, 2002; 16: 653-666 Best Practice & Research Clinical Rheumatology, 2002; 16: 653-666 A.van Tubergen and A. HiddingA.van Tubergen and A. Hidding

Hydrotherapy, balneotherapy, and spa treatment in pain management

Tamás Bender, Zeki Karagülle, Géza P. Bálint, Christoph Gutenbrunner, Péter V. Bálint and Shaul Sukenik Original Article

Rheumatology InternationalClinical and Experimental Investigations

© Springer-Verlag 2004

10.1007/s00296-004-0487-4

Hydrotherapy, balneotherapy, and spa treatment in pain

management Confusion persists regarding Confusion persists regarding

hydrotherapy and balneotherapy. The hydrotherapy and balneotherapy. The former employs simply water, while the former employs simply water, while the latter uses natural thermal mineral latter uses natural thermal mineral water. Spa therapy employs a number of water. Spa therapy employs a number of different treatment modalities, including different treatment modalities, including hydrotherapy and balneotherapy, and hydrotherapy and balneotherapy, and creates a special therapeutic creates a special therapeutic atmosphere of its own through the atmosphere of its own through the change in environment and lifestyle.change in environment and lifestyle.

BalneotherapyBalneotherapy

““balneum”balneum”

Latin word for Latin word for bathbath

““terapium”terapium”

Latin word for Latin word for treatmenttreatment


The terminology “spa therapy” The terminology “spa therapy” should be reserved for balneotherapy should be reserved for balneotherapy that is that is mostly mostly combined with combined with massage, massage, exercise, physical exercise, physical therapytherapy or rehabilitation. or rehabilitation.

BalneotherapyBalneotherapy

““The therapeutic use of mineral The therapeutic use of mineral and thermal waters, usually and thermal waters, usually through water immersion of part through water immersion of part or all of the body, but also or all of the body, but also through drinking certain amount through drinking certain amount of water and inhaling the of water and inhaling the vaporized or dispersed water’’vaporized or dispersed water’’

Hydrotherapy?Hydrotherapy?

Hydrotherapy at the spas is usually Hydrotherapy at the spas is usually administered in the form of administered in the form of underwater massage, Scottish underwater massage, Scottish douche, showers and hydrodouche, showers and hydro--kinesitherapy (aquatic exercise in kinesitherapy (aquatic exercise in tap water) in the pool.tap water) in the pool.

Alternative approaches to Alternative approaches to LBP LBP [Erlich[Erlich GE GE 2003]2003]

Chiropractic “adjustment”Chiropractic “adjustment” Osteopathic manipulationOsteopathic manipulation YogaYoga AcupunctureAcupuncture HerbalsHerbals Spa therapySpa therapy and other terms of moist heat and other terms of moist heat

and physical therapyand physical therapy

Spa therapy for LPBSpa therapy for LPB

Spa Spa therapeutic methods (baths, therapeutic methods (baths, mud applications, exercises, mud applications, exercises, massagesmassages and and water therapies)water therapies) are are given according to established given according to established empiric practice and on the empiric practice and on the assumption that they benefit assumption that they benefit patients patients with LBP with LBP

Mud applications Mud applications Carbon dioxide baths Carbon dioxide baths Classic massage Classic massage Exercise therapy Exercise therapy Spinal traction Spinal traction

The Clinical Journal of Pain, Vol. 18, No. 5, 2002

Hydrotherapy (used in combination Hydrotherapy (used in combination withwith massages, exercisemassages, exercise therapy, therapy, and spinaland spinal traction)traction)

Electrotherapy (short-waveElectrotherapy (short-wave diathermy, inferentialdiathermy, inferential therapy therapy ultrasound)ultrasound) The Clinical Journal of Pain, Vol. 18, No. 5, 2002

Spa Therapy modalities in Spa Therapy modalities in Central EuropeCentral Europe

BalneotherapyBalneotherapy ClimatotherapyClimatotherapy Mud therapyMud therapy Exercise therapy Exercise therapy HydrotherapyHydrotherapy Massage therapyMassage therapy ElectrotherapyElectrotherapy

Use Use of Spa Therapy To Improve the Quality of Spa Therapy To Improve the Quality of Life of Chronic Low Back Pain Patientsof Life of Chronic Low Back Pain Patients

Constant, F; Guillemin, F; Collin, JFConstant, F; Guillemin, F; Collin, JF;; Boulangé, M Boulangé, M Med Care. 1998 Sep;36(9):1309-14.Med Care. 1998 Sep;36(9):1309-14.

1. A 10-minute bath at 36°C with 1. A 10-minute bath at 36°C with underwater flow;underwater flow;

2. A local application of mud at 45°C 2. A local application of mud at 45°C for 15 minutes; for 15 minutes;

3. A 20-minute massage under flowing 3. A 20-minute massage under flowing water at 36°C.water at 36°C.

Spa Therapy modalities in Spa Therapy modalities in Southern EuropeSouthern Europe

BalneotherapyBalneotherapy Mud therapyMud therapy MMassage under flowing waterassage under flowing water (Vichy (Vichy

Shower)Shower) HydrotherapyHydrotherapy

ShowersShowers Underwater high pressure showers Underwater high pressure showers

((massages)massages)

BalneotherapyBalneotherapy Exercise therapyExercise therapy Patient education (Back school)Patient education (Back school)

Balneotherapie und Kurorttherapie Balneotherapie und Kurorttherapie rheumatischerrheumatischer

Erkrankungen in der Türkei: Ein Erkrankungen in der Türkei: Ein systhematischer Review systhematischer Review

M.Z KaragülleM.Z Karagülle. . M.Karagülle M.Karagülle Forsch Komplementärmed Klass Naturheilkd 2004;11:Forsch Komplementärmed Klass Naturheilkd 2004;11:33-4133-41

BalneotherapyBalneotherapy Mud therapyMud therapy Massage therapyMassage therapy Exercise therapyExercise therapy

Spa Therapy modalities in Spa Therapy modalities in TurkeyTurkey

Complex(ed) Spa therapyComplex(ed) Spa therapy

Electro-therapy

Others ??

Exercise Therapy

Mud therapy

Spinal Traction

Hydrotherapy

Massage therapy

Balneotherapy


In general, they In general, they consisted of a mixed consisted of a mixed bag of balneotherapeutic andbag of balneotherapeutic and//oror peloidotherapeutic, hydrpeloidotherapeutic, hydrotherapeutic otherapeutic and physiotherapeutic and physiotherapeutic interventionsinterventions

Studies; Spa therapy for LBP in Studies; Spa therapy for LBP in TurkeyTurkey

HorozHoroz,, 19971997 Spa therapy vs Spa therapy vs conventional therapyconventional therapyGrGr.1 (n 14):.1 (n 14): 3 3--wweekeek spa therapy,spa therapy, Balneotherapy;tBalneotherapy;thermal water bath at hermal water bath at 37-37-38ºC38ºC for 20 min for 20 min, total 20, total 20 baths baths ++ Patient Patient education (Back schooleducation (Back school 4 hours), at Spa 4 hours), at Spa resort, stay in the spa hotelresort, stay in the spa hotel

GrGr.2 (n 8).2 (n 8): : CConventional therapyonventional therapy + + Patient education (Back schoolPatient education (Back school 4 hours)4 hours) at home townat home town


HorozHoroz,,19971997 Spa therapy vs conventional Spa therapy vs conventional therapytherapy

There were statistically significant There were statistically significant improvements in improvements in Oswestry Oswestry IIndendex at the x at the end and after 3 months of spa therapyend and after 3 months of spa therapy. . In pain score (In pain score (VASVAS)) after after 33 months and months and inin Beck Depres Beck Depression Scale after the spa sion Scale after the spa therapytherapy. .

In the control group the only observed In the control group the only observed improvement was in lumber ROM.improvement was in lumber ROM.

Studies; Spa therapy for Studies; Spa therapy for Lumber OA in TurkeyLumber OA in Turkey

Biçki et alBiçki et al, , 20022002, Spa therapy vs Spa , Spa therapy vs Spa therapytherapy

33--wweekeek spa therapyspa therapy stay stay at a Spa at a Spa clinicclinic,,

GrGr.1 (n 15):,.1 (n 15):, balneotherapy; balneotherapy; one one bath a daybath a day,, 36-37ºC36-37ºC,, 20 min 20 min, total 20, total 20 baths baths,,

GrGr.2 (n 15).2 (n 15): : Balneotherapy,as above + Balneotherapy,as above + Exercise therapyExercise therapy

Gr. Gr. (n 15)(n 15): : Balneotherapy,as above + Balneotherapy,as above + Exercise therapy + Physical therapyExercise therapy + Physical therapy

Studies; Spa therapy for Studies; Spa therapy for Lumber OA in TurkeyLumber OA in Turkey

Biçki et alBiçki et al, , 20022002, Spa therapy vs Spa , Spa therapy vs Spa therapytherapy Statistically significant improvement in Pain (VAS) Statistically significant improvement in Pain (VAS) and Functional Index (Waddel) was observed in all 3 and Functional Index (Waddel) was observed in all 3 study groups at the end of 3-week treatment study groups at the end of 3-week treatment The improvement in Spinal Mobility was superior in The improvement in Spinal Mobility was superior in balneotherapy + exercise group and balneotherapy balneotherapy + exercise group and balneotherapy + exercise + physical therapy group compared to + exercise + physical therapy group compared to balneotherapy only group, balneotherapy only group, At 6 month significant improvement in pain (VAS) At 6 month significant improvement in pain (VAS) continued in combined group onlycontinued in combined group only


AktasAktas,,19971997, Spa therapy vs Spa therapy, Spa therapy vs Spa therapy

GrGr.1 (n 15):.1 (n 15): 10 10--day day spa therapy,spa therapy, two two baths a baths a dayday in in Thermal pool, Thermal pool, 36-37ºC36-37ºC for 20 min for 20 min, total , total 2020 baths baths ++ Exercise therapy at a Spa Hotel, Exercise therapy at a Spa Hotel, patients living near bypatients living near by

GrGr.2 (n 15).2 (n 15): 3: 3--wweekeek spa therapy,spa therapy, one one bath a bath a dayday in in Thermal pool, Thermal pool, 36-37ºC36-37ºC for 20 min for 20 min, total , total 2020 baths + Exercise therapy at a Spa Hotel, baths + Exercise therapy at a Spa Hotel, patients living near bypatients living near by


AktasAktas,,19971997, Spa therapy vs Spa therapy, Spa therapy vs Spa therapy

Significant improvement has been found Significant improvement has been found in pain (VAS) and Functional Index in pain (VAS) and Functional Index ((OswestryOswestry) in both spa therapy groups, ) in both spa therapy groups, this improvement was preserved at 1 this improvement was preserved at 1 month follow up assessment, there was month follow up assessment, there was no difference between the study no difference between the study groups. groups.

Spa therapy for low back paSpa therapy for low back paiinn -- FFrench RCT’rench RCT’ss

Authors and Authors and PublicationPublication

Guillemin et al Guillemin et al 1994 1994 (Rheumatolog(Rheumatology)y)

Constant et Constant et al 1995 al 1995

(J (J Rheumatol)Rheumatol)

Constant et Constant et al 1998 al 1998

(Med Care)(Med Care)

Spa TherapySpa Therapy 3 weeks3 weeks,, 6 days a 6 days a weekweek, total, total

18 times18 times

3 weeks3 weeks,, 6 days 6 days a weeka week, total, total

18 time18 timess

3 weeks3 weeks,, 6 days 6 days a weeka week, total, total

18 times18 times

Spa ResortSpa Resort Bains les BainsBains les Bains Saint NectarineSaint Nectarine VittelVittel

Type of Spa Type of Spa Therapy Therapy

Ambulatory, Ambulatory, patients living patients living within 30 km of within 30 km of Spa ResortSpa Resort



PatientsPatients Treatment 52Treatment 52

Control 50Control 50 Treatment 59Treatment 59

Control 62Control 62 Treatment 128Treatment 128

Control 116Control 116


Authors Authors and and PublicatioPublicationn

Guillemin et al Guillemin et al 1994 1994 (Rheumatology)(Rheumatology)

Constant et al Constant et al 1995 1995

(J Rheumatol)(J Rheumatol)

Constant et al Constant et al 19981998 (Med (Med Care)Care)

Control Control

TreatmentTreatment Ambulatory care,Ambulatory care, drugsdrugs

Any therapyAny therapy Drug therapyDrug therapy

Spa Spa

TreatmentsTreatments 1. 15 min under water 1. 15 min under water high-pressure shower high-pressure shower at a water temp. 36at a water temp. 36ooC C

2. 3 min shower at 2. 3 min shower at varying pressures and varying pressures and varying temperatures varying temperatures from 31from 31oo to 36 to 36ooCC

1. 10 min bath at 1. 10 min bath at 3636ooC with C with underwater flowunderwater flow

2. 20 min local mud 2. 20 min local mud application at 45application at 45ooCC

3. 2.5 min high-3. 2.5 min high-pressure shower at pressure shower at 3636ooC with a massage C with a massage device with device with regulated pulse flowregulated pulse flow

1. 10 min bath at 1. 10 min bath at 3636ooC with C with underwater flowunderwater flow

2. 15 min local mud 2. 15 min local mud application at 45application at 45ooCC

3. 20 min massage 3. 20 min massage under flowing under flowing water at 36water at 36ooC C (every other day) (every other day)



Constant et al 1995 Constant et al 1995

(J Rheumatol)(J Rheumatol) Constant et al Constant et al 1998 1998


The comparison The comparison with baseline with baseline measures measures at at 3 3 weeks and weeks and 99 months months showed a significant showed a significant improvement iimprovement inn all all clinical variables in clinical variables in the spa therapy the spa therapy group. The group. The consumption of consumption of analgesics was also analgesics was also less frequent in the less frequent in the spa group.spa group.

Post spa therapyPost spa therapy and and at 6at 6 months months statistically statistically significant significant improveimprovement in ment in patients' health patients' health status in the status in the treatment group treatment group was was found found compared with compared with the control group.the control group.

3 weeks and 3 3 weeks and 3 months considered months considered together, patients' together, patients' health status health status improved improved significantly in the significantly in the treatment group treatment group compared with the compared with the control group. control group.




(J Rheumatol)(J Rheumatol)



The change in the The change in the Waddel disability Waddel disability score did not differ score did not differ significantly significantly after 9 after 9 months months between between groups.groups.

Furthermore,Furthermore, functional disability functional disability and drug and drug consumption consumption significantly significantly decreased over time decreased over time in the spa therapy in the spa therapy group compared with group compared with the control group.the control group.

Significant Significant improvements were improvements were noted in measures noted in measures of: the physical (of: the physical (PP = = 0.011) and mental 0.011) and mental ((PP< 0.0001) < 0.0001) dimensions of QoL, dimensions of QoL, self-esteem (self-esteem (PP = = 0.033), anxiety (0.033), anxiety (PP = = 0.001), and 0.001), and depression (depression (PP < < 0.0001)0.0001)

Spa therapy for LBP Spa therapy for LBP observational studiesobservational studies

Peter et al, Peter et al, 19931993

Strauss-Blasche et al 2002,Strauss-Blasche et al 2002,

3-week spa 3-week spa therapy Lavey-therapy Lavey-les-Bains, Franceles-Bains, France

111 patients with 111 patients with CLBPCLBP

In the short term In the short term an appreciable an appreciable relief of pain relief of pain observed.observed.

3-week spa therapy at Spa Clinic in 3-week spa therapy at Spa Clinic in Bad Tatzmannsdorf, AustriaBad Tatzmannsdorf, Austria,,

153 patients with CLBP153 patients with CLBP

2 to 4 treatments daily: mud packs, 2 to 4 treatments daily: mud packs, carbon dioxide baths, massages, carbon dioxide baths, massages, exercise therapies,exercise therapies, spinal traction,spinal traction, electrotherapy.electrotherapy.

SSignificant improvements in all 4 ignificant improvements in all 4 outcome measuresoutcome measures; ; general pain, general pain, back pain, negative mood, and back pain, negative mood, and health satisfactionhealth satisfaction


Review of clinical trials on spa Review of clinical trials on spa therapy for LBP conducted in Turkey therapy for LBP conducted in Turkey and elsewhere has yielded and elsewhere has yielded remarkable short and medium term remarkable short and medium term improvements in pain, functional improvements in pain, functional status, lumber mobility and status, lumber mobility and psychological and general well-beingpsychological and general well-being


Regardless of the underlying Regardless of the underlying mechanisms, mechanisms, the breadth of the benefits the breadth of the benefits attributable to spa therapy attributable to spa therapy in the in the management of LBP management of LBP are remarkableare remarkable

Why is Why is spa spa therapy therapy effective?effective?

A combination of various factors A combination of various factors inherited in the spa therapy conceptinherited in the spa therapy concept;;

may contribute to the may contribute to the beneficial beneficial effectseffects of spa therapy of spa therapy

may be independent and important may be independent and important contributors to the overall effect of contributors to the overall effect of spa treatmentspa treatment


BalneotherapyBalneotherapy,, sspa pa wwater (ater (tthermal-hermal-mineral mineral wwater)ater),, peloidotherapy, peloidotherapy, mud mud and other and other specific spa techniques specific spa techniques

OOther ther ttreatment reatment mmodalities odalities (m(massage, exercise, traction etc.assage, exercise, traction etc.))


The temporary change of climatic The temporary change of climatic exposure and social and physical exposure and social and physical environment environment

A change in the lifestyle during the A change in the lifestyle during the stay at the spa stay at the spa resortresort


the natural history of chronic LBP the natural history of chronic LBP regression to the meanregression to the mean tthe nonspecific effects of he nonspecific effects of spa spa ttherapyherapy

(placebo effect) (placebo effect)

Effective components of Spa Effective components of Spa therapy for LPBtherapy for LPB

BalneotherapyBalneotherapy Passive immersion in thermal waterPassive immersion in thermal water Immersion in thermal water withImmersion in thermal water with

under water high-pressureunder water high-pressure shower or shower or underwater flowunderwater flow or or a stream of hot water on effected parta stream of hot water on effected part or or uunderwater traction nderwater traction

Effective components of Spa Effective components of Spa therapy for LPBtherapy for LPB

Mud application; peloidotherapyMud application; peloidotherapy Local application on low backLocal application on low back

Exercise therapyExercise therapy DryDry AquaticAquatic

Effective components of Effective components of Spa therapy for LPBSpa therapy for LPB

MassageMassage ClassicalClassical under or with waterunder or with water

HydrotherapyHydrotherapy Pressure showerPressure shower

SpinalSpinal Traction (under water) Traction (under water)

Complex(ed) Spa therapyComplex(ed) Spa therapy

Electro-therapy

Others ??

Exercise Therapy

Mud therapy

Spinal Traction

Hydrotherapy

Massage therapy

Balneotherapy


It remains impossible to identify It remains impossible to identify the most effective component of a the most effective component of a

spa therapy packagespa therapy package aand the most effective combination nd the most effective combination

of spa treatmentsof spa treatments for LPB for LPB

Spa for LPBSpa for LPB

Let us look at the results of theLet us look at the results of the efforts to examine the efforts to examine the contribution of contribution of specific specific spa spa theraptherapy y interventionsinterventions to to the overall effectiveness of spa the overall effectiveness of spa therapytherapy for chronic (low-back) painfor chronic (low-back) pain

Contribution of Individual Spa Contribution of Individual Spa Therapies in the Treatment ofTherapies in the Treatment of

Chronic PainChronic Pain On a short-term basis, mud packs and On a short-term basis, mud packs and

exercise were found to be associated exercise were found to be associated with awith a greater improvement in moodgreater improvement in mood

On a long-term basis, exercise therapy On a long-term basis, exercise therapy and spinal traction were associated and spinal traction were associated with awith a greater reduction in back paingreater reduction in back pain

Strauss-Blasche et al 2002,Strauss-Blasche et al 2002,

The best combination The best combination of Individual of Individual Spa Therapies in the Treatment ofSpa Therapies in the Treatment of

Chronic Chronic Low Back Low Back PainPain ? ?

Yet, tYet, there here is no data on the most is no data on the most effective combination of effective combination of specific specific spa spa theraptherapy y interventionsinterventions for for chronic (low-back) painchronic (low-back) pain

Let us attempt to prescribe a spa Let us attempt to prescribe a spa therapy regimen for chronic low-back therapy regimen for chronic low-back pain with a evidence based approach pain with a evidence based approach rather than empiricism and traditionrather than empiricism and tradition

A 3-week Spa therapy regimen for LBPA 3-week Spa therapy regimen for LBPAustrian-styleAustrian-style

ModalityModality TypeType DurationDuration TemTempp. .

TotalTotal

BalneotherapyBalneotherapy Bath in Bath in thermal COthermal CO22 waterwater

10-10-15min15min

32-34 32-34 ºCºC

7.17.1

Massage (dry)Massage (dry) ClassicalClassical 8.88.8

Mud therapy Mud therapy (peloidotherap(peloidotherapy)y)

Local Local applicationapplication

or mud bathor mud bath

15-20 15-20 minmin

46 46 ºCºC

42 42 ºCºC7.57.5

Jet(wet)MassagJet(wet)Massagee

with hose in with hose in tubetube

10-10-20min20min

? ? ºCºC 3.13.1

Exercise (dry) Exercise (dry) or or Hydrotherapy Hydrotherapy

on mats or in on mats or in water water

30 min30 min ? ? ºCºC 2.92.9

Traction,Traction, Underwater(5kUnderwater(5kg)g)

? ? ºCºC 2.12.1

ElectrotherapyElectrotherapy US, S-WD, etc.US, S-WD, etc. 9-15 9-15 minmin

22

Prescription a 3-week Spa therapy for Prescription a 3-week Spa therapy for LBPLBP

French-styleFrench-styleModalityModality TypeType DurationDuration Tem. Tem. TotaTota

ll

BalneotherapBalneotherapyy

Bath in thermal Bath in thermal waterwater

10-15 10-15 min.min.

36 36 ºCºC

1818

Mud packMud pack Local applicationLocal application 15-20 15-20 min.min.

45 45 ºCºC

1818

plus any belowplus any below

HydrotherapHydrotherapyy

Pressure showerPressure shower 3 min.3 min. 31-31-36 36 ºCºC

1818

HydrotherapHydrotherapyy

High Pressure High Pressure showershower

2,5 min.2,5 min. 36 36 ºCºC

1818

MassageMassage Under flowing Under flowing waterwater

20 min.20 min. 36 36 ºCºC

99

AA 3-week Spa therapy 3-week Spa therapy regimen regimen for LBPfor LBPTurkishTurkish-style-style

ModalityModality TypeType DuratioDurationn

Tem. Tem. TotaTotall

BalneotheraBalneotherapypy

Bath in Bath in thermalthermal poolpool

2020 min min 36-36-3737ºCºC

2020

Exercise dry Exercise dry Flexion-Flexion-extension extension

15-3015-30 min.min.

-- 2020

oror

Patient Patient educationeducation

Back schoolBack school -- -- 4 4 hourshours

A balneotherapy session for LBPA balneotherapy session for LBPHungarian-Turkish-styleHungarian-Turkish-style

spa therapy for chronic low back pain and lumber osteoarthritis in turkey

Documents

spa treatment

spa therapyhas

spa therapywe

physical therapy

water immersion

tap water

balneotherapy bathing

natural thermal mineral