Effect of a 12-day balneotherapy programme on pain, mood, sleep, and depression in healthy elderly people.
Keywords
Article abstract
BACKGROUND:
The main purpose of this study is to analyze the effect of a 12-day balneotherapy programme on pain, mood state, sleep, and depression in older adults.
METHODS:
In this study, 52 elderly adults from different areas of Spain participated in a social hydrotherapy programme created by the government's Institute for Elderly and Social Services, known as IMSERSO; participants included 23 men (age, 69.74 ± 5.19 years) and 29 women (age, 70.31 ± 6.76 years). Pain was analyzed using the visual analogue scale. Mood was assessed using the Profile of Mood Status. Sleep was assessed using the Oviedo Sleep Questionnaire. Depression was assessed using the Geriatric Depression Scale. The balneotherapy programme was undertaken at Balneario San Andrés (Jaén, Spain). The water at Balneario San Andrés, according to the Handbook of Spanish Mineral Water, is a hypothermic (≥20°C) hard water of medium mineralization, with bicarbonate, sulfate, sodium, and magnesium as the dominant ions.
RESULTS:
Balneotherapy produced significant improvements (P < 0.05) for all variables (pain, mood state, sleep, and depression) in the total sample. A differential effect was found between the sexes regarding pain improvement, with men, but not women, having significantly improvement (P < 0.01) after treatment. With regard to improving mood, sex differences were also shown, with women, but not men, significantly improved (P < 0.05) in both depression and fatigue.
CONCLUSIONS:
In conclusion, a 12-day balneotherapy programme has a positive effect on pain, mood, sleep quality, and depression in healthy older people.
Article content
Introduction
Balneotherapy, also known as spa bathing, spa therapy, or thermal therapy, has been defined recently as the use of natural mineral waters, natural peloids and mud, and natural sources of different gases (CO2, H2S, and Rn) for medical purposes such as prevention, treatment, and rehabilitation.[1] It is an ancient, traditional method of treatment used in Europe and other parts of the world.[2] It involves the immersion of the subject in mineral baths or pools, and it has been shown to have beneficial properties, with no risk or side-effects, in different pain-causing disorders, particularly in rheumatologic and musculoskeletal disorders, such as fibromyalgia, rheumatoid arthritis, and osteoarthritis, as well as in patients with low back pain.[3-5] Balneotherapy has also been employed in the treatment of dermatological conditions with high rates of response,[6] chronic obstructive pulmonary diseases,[7] and peripheral vascular disease.[8] Furthermore, in subjects with so-called lifestyle-related diseases, such as hypertension, hyperlipidaemia, diabetes mellitus, obesity, and smoking, in which the vascular endothelial function is impaired, thermal therapy seems to be promising.[9]
In recent decades, an increasing number of controlled trials have demonstrated the efficacy of balneotherapy programmes (BP) in treating certain diseases, and the efficacy of these programmes has been confirmed by recent reviews.[10-12] Previous studies have concluded that this could result from the warmth and buoyancy of water blocking nociception by acting on thermal receptors and mechanoreceptors, thus influencing segmental spinal mechanisms.[13, 14] In addition, warm water may enhance blood flow, which is thought to help in dissipating algogenic chemicals, and facilitate muscle relaxation. The hydrostatic effect may relieve pain by reducing peripheral oedema and by dampening sympathetic nervous-system activity.[15, 16]
Given this information, many studies in recent years have focused on the effects of BP at the physical level.[10, 11] However, little information is available on the effect of this therapy on psychosocial variables or subjective feelings such as well-being and pain relief,[17-19] mood,[20] level of depression, or quality of sleep in a healthy elderly population.[21] Furthermore, many studies have concluded that more randomized, controlled studies are needed to obtain stronger evidence. The main purpose of this study is therefore to analyze the effect of a 12-day BP on pain, mood state, sleep, and depression in healthy older adults (≥65 years) benefiting from the Institute for Elderly and Social Services' (Instituto de Mayores y Servicios Sociales (IMSERSO), Spain) social hydrotherapy programme.
Methods
Participants
Fifty-two elderly adults from different areas of Spain participated in IMSERSO's social hydrotherapy programme. Participants included 23 men (age, 69.74 ± 5.19 years) and 29 women (age, 70.31 ± 6.76 years) who were randomly selected from the individuals staying at Balneario San Andrés (Jaén, Spain) during the period of study. All subjects in the study gave informed consent. Subjects were required to meet the following inclusion criteria: (i) not institutionalized; (ii) age 65 or older; and (iii) free from mental and/or intellectual disease. The study was conducted in compliance with the Declaration of Helsinki (2008), and followed the European Community for Good Clinical Practice guidelines (111/3976/88 July 1990) and the Spanish legal framework for clinical research in humans (Royal Decree 561/1993 on clinical trials). It was approved by the Bioethics Committee of the Masters of Science Research in Physical Activity and Health at the University of Jaen.
Materials and testing
Pain was analyzed with the visual analogue scale. The scale was a straight line, approximately 10 cm in length, with the labels ‘No pain’ at one end and ‘Worst pain’ at the other, and it was divided in centimetre units starting at zero (‘No pain’). Each individual indicated the degree of pain felt along the visual analogue scale by pointing to the place on the line that marked the perceived degree of pain felt.
Mood was assessed with the 29-item Profile of Mood Status,[22] adapted and validated in Spanish.[23] In this version, the dimensions constituting the test are stress, anger, vigour, fatigue, and depression. The scale score is between 0 and 4 points for each item.
Sleep was assessed with the Oviedo Sleep Questionnaire,[24] a questionnaire to help diagnose insomnia- and hypersomnia-type sleep disorders. It consists of three subscales: subjective sleep satisfaction (one item), insomnia (nine items), and hypersomnia (three items). It also contains two items that provide information about the use of sleep aids or the presence of adverse events during sleep (parasomnias, snoring). All items are answered with a Likert scale from 1 to 5, except for item 1 (1 to 7).
Procedures
Subjects were evaluated before the BP (pretest) and immediately after the BP (post-test). The questionnaires were completed individually and in the presence of researchers, who respected the confidentiality of the data while clarifying any questions that arose. The BP was conducted and performed at Balneario San Andrés with elderly beneficiaries of IMSERSO's Social Cures, a programme offered throughout Spain that aims to provide appropriate balneotherapeutic treatments to pensioners within the Social Security system to increase their quality of life and personal autonomy.
The duration of the treatment programme was 12 days, and spa sessions were conducted in two groups (morning and afternoon) during March 2014. The treatments included a hot thermal bath (36–38°C) for 15–20 min; a bubble bath (with low-pressure bubbles that were 0.4–1.2 mm in diameter) and indifferent-hot water (36–38°C) for 15–20 min; a hot tub bath with underwater hydrojets (36–38°C) for 15–20 min; a thermal jet with pressure (ranging from 0.5 atm or drooling, to 12 atm or filiform jets, with 1–3 atm being the most common) and variable temperature variables (10–42°C), both of which varied according to the area and user; and a thermal shower with varying temperatures for the upper and lower body (from indifferent-warm to cold temperature) and varying water pressure for 15–20 min. Other treatments included inhalations, including nebulized mineral water from the spa, for treatments ranging from nasal mucosa to the pulmonary alveoli; a steam room in which the steam cave spring water was 40 or 45°C for 10–20 min; and a vapourarium in which vapours were released with water without heat (at any temperature) for 15–20 min. In some cases, thermal muds (peloid sludge (mixed with hot paraffin)) was applied to different parts of the body as prescribed (shoulders, cervical-thoracic-lumbar area, knees, ankles) for 15–35 min, with an initial temperature of 40–50°C, depending on the area and tolerance of the individual. Similarly, a warm paraffin treatment was used for inflammation of the hands and pain on the osteoarticular shell of the hands. Also, daily water aerobics, physiotherapy sessions, and massage were conducted in a thermal circuit in a dynamic pool with different features such as jets, massagers, and spa beds, in 32–34°C water. With the exception of physical therapy and chiropractic, treatments were provided daily, including weekends, and were tailored to the individual based on his or her conditions.
All therapies were performed by qualified spa assistants, chiropractors, and physical therapists with medical and nursing equipment. According to the Handbook of Spanish Mineral Water, the water at Balneario San Andrés is hypothermic (≥20°C), is a hard water of medium mineralization, with bicarbonate, sulfate, sodium, and magnesium as its dominant ions. It has anti-inflammatory and anti-fungal qualities, and is indicated for problems in the lower respiratory tract and skin conditions.
Statistical analysis
Data from this study were analyzed with SPSS v. 19.0 for Windows (SPSS Inc, Chicago, IL, USA). The level of significance was set at P < 0.05. The data are shown in descriptive statistics: mean ± SD and percentage. A χ2 test was used to analyze the homogeneity of categorical variables according to sex. Pretest and post-test scores were compared between the sexes, and the comparison was performed using the Mann–Whitney U-test. The pretest–post-test analysis was performed using the Wilcoxon test.
Results
Table 1 shows the sociodemographic variables presented according to sex. Significant associations (P < 0.05) were found between sex and alcohol consumption and between sex and marital status.
| Men % | Women % | P-value | ||
|---|---|---|---|---|
| Physical activity | Yes | 65.2 | 77.8 | 0.324 |
| No | 34.8 | 22.2 | ||
| Tobacco consumption | Never | 27.3 | 63.0 | 0.099 |
| Occasional smoker | 18.2 | 7.4 | ||
| Non-smoker | 40.9 | 22.2 | ||
| Daily | 13.6 | 7.4 | ||
| Alcohol | Abstainer | 13.6 | 46.2 | 0.037 |
| Non-drinker | 4.5 | 0 | ||
| Moderate drinker | 81.8 | 53.8 | ||
| Studies | Uneducated | 13 | 7.7 | 0.808 |
| Primary | 26.1 | 30.8 | ||
| Secondary | 34.8 | 26.9 | ||
| University | 26.1 | 34.6 | ||
| Marital status | Married | 86.4 | 60.7 | 0.031 |
| Single | 4.5 | 3.6 | ||
| Widower | 0 | 32.1 | ||
| Separated or divorced | 9.1 | 3.6 | ||
Table 2 shows the results of the different variables analyzed in both the pretest and post-test, according to sex and the total sample. The BP caused significant improvements (P < 0.05) for all variables analyzed in the total sample.
| Men | Women | Total | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Pretest Mean ± SD | Post-test Mean ± SD | P-value | Pretest Mean ± SD | Post-test Mean ± SD | P-value | Pretest Mean ± SD | Post-test Mean ± SD | P-value | |
|
|||||||||
| VAS pain | 3.43 ± 2.71 | 2.05 ± 1.97 | 0.001 | 3.90 ± 2.61 | 2.85 ± 1.66 | 0.112 | 3.66 ± 2.64 | 2.44 ± 1.84 | 0.001 |
| Depression | 0.35 ± 0.53 | 0.27 ± 0.51 | 0.314 | 0.69 ± 0.69 | 0.43 ± 0.59 | 0.047 | 0.54 ± 0.64 | 0.36 ± 0.56 | 0.034 |
| Anxiety | 0.64 ± 0.73 | 0.21 ± 0.39 | 0.003 | 0.80 ± 0.88 | 0.46 ± 0.68 | 0.047 | 0.73 ± 0.81 | 0.35 ± 0.58 | 0.001 |
| Vigour | 2.32 ± 0.89 | 2.52 ± 0.72 | 0.224 | 2.21 ± 1.04 | 2.38 ± 0.82 | 0.153 | 2.26 ± 0.97 | 2.44 ± 0.77 | 0.049 |
| Tension | 0.88 ± 0.67 | 0.59 ± 0.47 | 0.023 | 1.21 ± 0.92 | 0.77 ± 0.72 | 0.014 | 1.06 ± 0.83 | 0.69 ± 0.62 | 0.001 |
| Fatigue | 0.88 ± 0.84 | 0.66 ± 0.69 | 0.123 | 1.15 ± 0.80 | 0.70 ± 0.62 | 0.004 | 1.03 ± 0.82 | 0.68 ± 0.65 | 0.001 |
| Satisfaction with sleep | 4.05 ± 1.52 | 4.64 ± 1.62 | 0.135 | 4.15 ± 1.04 | 4.81 ± 1.50 | 0.012 | 4.10 ± 1.28 | 4.73 ± 1.54 | 0.006 |
| Insomnia | 17.91 ± 5.38 | 14.32 ± 6.11 | 0.036 | 17.68 ± 6.16 | 14.32 ± 6.02 | 0.027 | 17.78 ± 5.78 | 14.32 ± 6.00 | 0.002 |
| Hypersomnia | 4.82 ± 2.50 | 3.41 ± 1.65 | 0.036 | 4.48 ± 1.78 | 3.62 ± 2.20 | 0.085 | 4.63 ± 2.12 | 3.53 ± 1.96 | 0.009 |
| Geriatric depression | 1.36 ± 1.50 | 1.31 ± 1.70 | 0.897 | 3.00 ± 2.40* | 1.96 ± 2.35 | 0.016 | 2.29 ± 2.20 | 1.68 ± 2.10 | 0.039 |
Figure 1 shows the mood profile of participants before and after the 12-day BP. Increased vigour and reduced tension, depression, fatigue, and anxiety were found after BP.
Figure 1. Mood profile of the subjects before and after receiving balneotherapy.
Discussion
The most important finding of this study is the effectiveness of IMSERSO's BP in improving pain, mood, sleep, and depression in healthy individuals aged 65 years or older. The results obtained in this study are novel because, to date, no study has tested the effect of this type of BP on psychosocial variables in healthy older people in this age group. There have been no reports that comprehensively explain the subjective effects of balneotherapy, including relaxation, a sense of well-being, and decreased stress, which are related to changes in different hormones, such as cortisol, or endogenous opiate.[27, 28] In general, the specific literature on the subjective, psychological, and social benefits of a BP is scarce.
The data obtained in this research supports the rationale of Ablin et al.[29] While noting that the mechanisms underlying the capacity of warm water to sooth and heal remains to be completely understood, Ablin et al. found that the mass and diversity of documentation regarding these forms of therapy seem to make it self-evident that a therapeutic merit does exist. In contrast, making evidence-based recommendations remains challenging in a field with diverse treatments that lack standardization, so more research is needed.
Focusing on the effects of this 12-day BP on the variables analyzed, the results are consistent with previous studies. Tefner et al. demonstrated the effect of balneotherapy in localized pain reduction and improved quality of life related to health,[30] and Xu et al. concluded that these benefits play important roles in the improvement of mood states after treatment with balneotherapy.[20] Gonzalez et al. reported the positive effect of balneotherapy in depression and perceived health.[31] Dubois et al. found improvements in generalized anxiety after 8 weeks of BP.[32] Another study demonstrated that spa therapy during a 3-week programme can be a powerful tool to improve welfare, improve mood, and reduce pain in middle-aged adults with common health problems. Moreover, subjects were still satisfied with these health improvements 12 months after the intervention.[33] However, controversial results about the benefits of balneotherapy have also been reported. Evcik et al. found no effect on the depression of women with fibromyalgia after fewer than 15 balneotherapy sessions.[34]
Given the negative effect poor sleep quality has on mental health and its link to mortality, the improvement in the sleep quality reported after BP in this study is an important outcome.[35-37] In this study, both men and women improved with regard to insomnia, a result that confirms the findings of previous studies. van Tubergen et al. and Neumann et al. reported that spa therapy and balneotherapy may have beneficial effects on sleep and quality of life for patients with musculoskeletal and dermatological diseases.[21, 38] Xu et al. also concluded that balneotherapy with mineral water provided psychological benefits, such as improved relaxation and relief from sleep disorders and chronic pain disorders, in pilots with mood states.[20] Liao found that insomnia in the elderly is associated with changes in circadian body temperature rhythms, and in this sense, the manipulation of body temperature before sleep onset may improve sleep quality in the elderly. For example, a hot bath in the afternoon aids night-time sleep for healthy elderly subjects with insomnia.[39]
The second major finding of this study is related to a sex difference in the effect of a BP on the analyzed variables. In this study, a differential effect in improving pain was found between the sexes, with significant improvements for men (P < 0.01) after BP, but not for women. With regard to improving mood, sex differences were also found, with women reporting significantly improved (P < 0.05) in both depression and fatigue, but not men. Cimbiz et al. also reported reduced pain after spa treatments in subjects with different chronic diseases, such as fibromyalgia, osteoarthritis, or herniated disc, but found no sex differences in regard to the improvement of pain.[40]
One important limitation of this study was that there was not follow-up with participants after the 12-day BP. In conclusion, a 12-day BP has a positive effect on pain, mood, sleep quality, and depression in elderly people. Data obtained also inform about the sex influences in these improvements.