A meta-analysis 1 included 5 RCTs with a total of 674 subjects. The effects of spa treatments (3 studies, 454 subjects with low back pain for at least 1 year) and balneotherapy (2 studies, 220 subjects with low back pain for 1-6 months) were assessed. Treatment periods were 3-6 times weekly for 3-4 weeks. The included spa studies used a variety of treatments, often carried out in combination: high-pressure water massage, warm baths with underwater flow, local mud application and high-pressure showers. All spa studies used waiting list controls. Two of the spa studies allowed concomitant routine drug treatment. Balneotherapy studies included baths, underwater massage, underwater traction and bath plus flexion exercises outside pool. Control groups were: NSAIDs only and flexion exercises controls. Spa therapy was associated with a statistically significant reduction in pain compared with waiting-list control groups (WMD on the 100-mm pain VAS was 26.6 mm, 95% CI 20.4 to 32.8; n=442). There was no statistically significant difference between treatments on the Schober Index assessing lumbar flexibility (WMD 3.6 mm, 95% CI -2.7 to 9.8; n=442). For balneotherapy the data, assessed on a 100 mm VAS, also suggest beneficial effects compared with control groups (WMD 18.8 mm, 95% CI 10.3 to 27.3, n=138). No adverse effects were reported in the included studies.
Comment: The quality of evidence is downgraded by heterogeneity in interventions and by indirectness (waiting list as control group).
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