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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Spa therapy for treating chronic low back pain

MH Pittler.

Review published: 2005.

CRD summary

This review assessed the effectiveness of spa therapy in the treatment of chronic lower back pain. The author concluded that there is limited evidence to suggest that spa therapy may be effective. Despite some concerns about the review methodology, the author's cautious conclusions would appear valid.

Authors' objectives

To evaluate the effectiveness of spa therapy for treating chronic lower back pain.


MEDLINE, EMBASE, the Cochrane CENTRAL Register and AMED were searched from inception to April 2005. The bibliographies of retrieved articles were handsearched to identify additional studies. No language restrictions were applied.

Study selection

Study designs of evaluations included in the review

Randomised controlled trials (RCTs) were eligible for inclusion.

Specific interventions included in the review

Studies of spa therapy were eligible for inclusion. The included studies used a variety of spa treatments, often carried out in combination: high-pressure water massage, warm baths with underwater flow, local mud application and high-pressure showers. Treatment periods were usually 6 days and then weekly for a further 3 weeks. All of the included studies used waiting-list controls. Two of the included studies allowed concomitant routine drug treatment; the third did not.

Participants included in the review

Studies of individuals with chronic lower back pain were eligible for inclusion. No further details were reported.

Outcomes assessed in the review

The primary review outcome was the mean change in pain, measured on a 100-mm visual analogue scale (VAS) compared with baseline. The review also assessed the Schober index and adverse events and reported the incidence of adverse events.

How were decisions on the relevance of primary studies made?

The author did not state how the papers were selected for the review, or how many reviewers performed the selection.

Assessment of study quality

Validity was assessed using the Jadad scale. The studies were awarded a quality score (maximum 5 points); the higher the score the better the quality of the study. The author did not state who performed the validity assessment.

Data extraction

The author did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

The numbers of randomised and analysed participants were recorded, along with any concomitant treatments they were using. Data were extracted on a per protocol basis. Specific details of the exact nature of the intervention and the duration of the treatment were also recorded. Weighted mean differences (WMDs) in the 100-mm pain VAS were calculated.

Methods of synthesis

How were the studies combined?

WMDs with 95% confidence intervals (CIs) were calculated for continuous outcomes using a random-effects model.

How were differences between studies investigated?

A chi-squared test for heterogeneity was performed.

Results of the review

Three RCTs (n=454) were included. The author did not report how many individuals received spa therapies and how many did not (i.e. waiting-list controls).

One study had a quality score of 3 points and the other two studies scored 2 points.

Spa therapy was associated with a statistically significant reduction in pain compared with waiting-list control groups; the WMD on the 100-mm pain VAS was -26.6 mm (95% CI: -20.4, -32.8; n=442). There was no statistically significant difference between treatments on the Schober Index (WMD 3.6 mm, 95% CI: -2.7, 9.8; n=442).

No adverse effects were reported in the included studies.

Authors' conclusions

There is some hopeful evidence to suggest that spa therapy is effective for treating chronic low back pain. However, the data were limited and further research is required.

CRD commentary

This single author review addressed a clear research question that was defined in terms of the participants, study design and intervention; inclusion criteria for the outcomes were not explicitly reported but the primary review outcome was clearly stated. Three relevant databases were searched, no real attempts were made to locate unpublished studies, and no language restrictions were applied. The methods used to select studies, assess validity and extract the data were not described, so it is not known whether any efforts were made to reduce reviewer errors and bias.

Given that this was a single-author review, it is possible that only one reviewer was involved in all stages of the review, which could introduce selection and reporting bias. There was also little attempt to locate unpublished work, which could introduce publication bias. This is a real possibility given the nature of the studies and the fact that it is likely that many studies in this area are not published in journals. However, by limiting the review to only randomised controlled studies and assessing the quality of the studies using the Jadad scale, the author has tried to limit his review to the best-quality evidence available. Validity was assessed using specified criteria but only the composite score was reported, making it difficult for the reader to judge the potential sources of bias.

No details of the participants were given, so the population results may not be generalisable. The data were pooled by meta-analysis. However, although statistical heterogeneity was assessed it was not reported, thus it was not possible to judge the appropriateness of the study pooling. Overall, the author's cautious conclusions appear valid given the limitations and the paucity of evidence available.

Implications of the review for practice and research

Practice: The author did not state any implications for practice.

Research: The author stated that there is a need for adequately powered randomised studies, with adequate concealment of treatment allocation, treatment given under similar conditions and comparable control treatments. The author also stated that there is a need to compare the effects of spa therapies administered at a spa resort with the same treatments administered in a 'non-residential setting at home'.

Bibliographic details

Pittler M H. Spa therapy for treating chronic low back pain. Focus on Alternative and Complementary Therapies 2005; 10(4): 271-274.

Indexing Status

Subject indexing assigned by CRD


Baths; Low Back Pain /therapy



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

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