Chronic pain is a prevalent global public health issue affecting more than one in five (19.6%) people worldwide. Emerging evidence indicates that patients are receiving mismanagement, insufficient management, and inequitable management of chronic pain, both in low- to middle-income and high-income countries. Evidence suggests that there is insufficient knowledge and skill about chronic pain of many contemporary health professionals.
1. Introduction
Spa therapy is a collection of treatments that may assist with the management of chronic pain (I. Johnson, 2019). Chronic pain is a multidimensional/biopsychosocial experience that involves excitement, thoughts, biological structures, and context. Numerous evidence bases indicate that there is no class of medications that sufficiently treat chronic pain. Evidence base demonstrates various therapies that attempt to harness the psychobiological nature of chronic pain and encompass physical, psychological, social, herbal, surgical, and technological approaches. Complementary and alternative therapies as well as holistic approaches have been highlighted to address the psychobiological experience of chronic pain. However, spa treatment, a modality routinely used for the management of chronic pain, remains understudied. A holistic treatment option featuring a medley of therapy types, climate, lifestyle, and setting, spa treatment has been argued to provide a treatment package that associates positively with the well-being of individuals (Windham Karlson, 2011). Understanding the effects and mechanisms underlying spa treatment would potentially provide a new treatment option for the management of chronic pain. Therefore, the aim of this project is to assess the effects of spa treatment as compared to control conditions as well as the underlying psychobiological treatments of pain on patients experiencing chronic pain in a pilot trial.
2. Understanding Chronic Pain
Chronic pain is a condition which affects diverse populations comprising children to adults. Chronic pain has been reported to impair the mood, quality of life, and interpersonal relationships of patients. Acute pain ensues from noxious stimuli, injury, tissue damage, or as a host response to inflammation or infection that heals within days or weeks. Chronic pain persists beyond usual recovery time (>3 months) which otherwise may harm tissues, dysregulates the healing process, and fails to serve its protective function. Chronic pain can occur following noxious stimulation, nociceptive injuries, somatic pain, nerve damage, or may be due to noxious conditions with unknown peripheral causes such as fibromyalgia. Chronic pain devoid of any peripheral source is termed as idiopathic (I. Johnson, 2019).
Different types of chronic pain including acute pain with musculoskeletal injuries, migraines, diabetic neuropathy, post-herpetic neuralgia, neuromas, phantom pain, complex regional pain syndrome, cancer, after surgery, etc. are prevalent. New mechanisms underlying neuropathic pain have been suggested including sensitization and amplification of the pain signal via peripheral and central nociceptive pathways. Long-term changes involving neuroplasticity may occur in the peripheral and central nervous system following intrusions from infectious agents, toxic by-products, or inflammation after noxious stimulation, surgery, or ischemia. These neuropathic conditions or chronic pain states maintain some of the signatures of acute pain but cannot be treated with traditional analgesics (Tajerian and David Clark, 2017). Chronic pain primarily manifests in individuals as headaches, tic bouts, sleep disorders, premenstrual syndrome, back pain, and osteoarthritis and leads them to seek analgesics for long-term pain management.
Current treatment approaches for chronic pain focus mainly on analgesics with rapid-onset effects. However, the gold standard drugs for treating chronic pain, i.e., opioids, exhibit varying degrees of side effects including dependence, tolerance, addiction, and various central nervous system-related syndromes following repeated chronic use. Prevention of chronic pain using analgesics has failed in most experimental animal models and failed to be translated to chronic pain patients. Therefore, the management of chronic pain states and neuropathic conditions using alternative therapies lacking the side effects associated with traditional analgesics is needed.
2.1. Causes and Types
Chronic pain refers to pain that persists beyond the usual recovery period or occurs along with a chronic health condition. It frequently overlaps with health conditions, like arthritis, migraine, fibromyalgia, and irritable bowel syndrome. Chronic pain may be classified according to the type of injury or condition that is taking place. Such categorization is crucial to better manage chronic pain (Kataria et al., 2024). Four different categories of chronic pain comprise nociceptive pain, neuropathic pain, primary and secondary chronic pain, and central pain syndrome (CPS). Nociceptive pain is a severe form of pain caused due to injury to tissue or body parts. A sprained ankle, broken bone, and post-operative pain, etc., are examples of nociceptive pain. Unlike nociceptive pain, neuropathic pain is an unusual pain that occurs due to bizarre nervous system damage or injury. Multiple sclerosis, shingles, carpal tunnel syndrome, and fibromyalgia, etc., are examples of neuropathic pain. Pain that occurs for more than 6 months after the death of a loved one is an example of primary chronic pain. Pain disorders such as chronic fatigue syndrome (CFS), and tension-type headaches are also included in this category of pain. Contrary to primary chronic pain, secondary chronic pain is due to some other health disorder. Migraine headache (due to stress), infertility due to endometriosis, and low back pain due to some paralysis diseases are examples of secondary chronic pain. Chronic pain of central origin is the last category of chronic pain. In this type, however, injury or damage to the nervous system is the primary cause. Central pain syndrome (CPS) after post-stroke or multiple sclerosis injury of brain characterize this condition (Scheidegger et al., 2023).
2.2. Current Treatment Approaches
Chronic pain is an ongoing, unrelenting pain (i.e. lasting longer than three months), often without an underlying structure or biological cause. It affects roughly 20% of the population (Hylands-White et al., 2016) and is associated with poor quality of life, mental health issues, social withdrawal, and excessive healthcare costs. Chronic pain is also the ‘core symptom’ of various poorly understood diseases, such as fibromyalgia and chronic fatigue syndrome. These diseases constitute a ‘curiosity-driven’ frontier of research as they highlight gaps in the currently prevailing neuroscientific paradigms of pain. Pain is present in a significant proportion of the world’s population and imposes significant strain on currently available healthcare systems.
Treatment for chronic pain almost always includes pharmacological components. Where possible, pharmacotherapy is augmented by non-pharmacological approaches (e.g. physical therapy, acupuncture, cognitive behavioral therapy, etc.) (LaRue Anthony, 2017). Despite widespread use and many years of research, available pharmacological treatments fail to provide adequate pain relief in the majority of patients with chronic pain and may produce severe, unwanted side effects. Growing skepticism about the efficacy of pharmacological approaches to pain is increasing the interest in alternative and complementary non-pharmacological approaches. As chronic pain is as much a psychosocial problem as it is a physiological one, alternative non-pharmacological approaches that directly involve a more complex type of treatment, such as spa treatment wellness programs, are presumed to shape the experience of pain in a more fruitful manner than the biomedical paradigm. Moreover, these alternative non-pharmacological approaches carry fewer adverse side effects.
3. Spa Treatments as Alternative Therapy
Chronic pain is growing common in current society. While drugs such as analgesics and non-steroidal anti-inflammatory drugs have been widely used to treat chronic pain, they mostly target symptoms but not its origin and have some drawbacks like tolerance and side effects. Because of this, alternative therapies for chronic pain have received increased attention. Alternative therapies such as acupuncture and tai-chi can effectively manage chronic pain (Tajerian and David Clark, 2017). These alternative therapies often involve spa treatments like hot springs, herbal baths, mud baths, etc. Spa treatments are not invasive/chemical, easy, and inexpensive. Other than the cost of traveling, accommodation, and medical treatments, spa treatments often do not have costs, unlike packaged meds. Although there have been several well-designed clinical studies of spa treatments on chronic pain, there has been limited focus on the basic science aspects of spa treatments in recent years.
Which type of spa treatment is effective for which chronic pain? There are many kinds of spa treatments, but there has been limited study focusing on the efficacy of different kinds of spa treatments on chronic pain. Which component of a spa treatment is necessary for the efficacy of the therapy? A spa treatment usually consists of multiple components such as noise, light, humidity, wind velocity, temperature, and water evenness on the body (MM et al., 2019). It is extremely difficult to control each of these components because changing one component possibly changes others.
3.1. Types of Spa Treatments
Chronic pain can seriously affect someone’s life quality. People suffering from chronic pain have a constant sense of ache or sore that persists for weeks or even years and often accompanies one or more painful conditions. Given the adverse effects of long-term medications used in conventional pain management approaches, such as Non-Steroid Anti-Inflammatory Drugs (NSAIDs), a growing number of chronic pain subjects have turned to or at least considered the use of Complementary and Alternative Medicine (CAM) therapies. Spa treatments are among the most widely accepted CAM therapies targeting various chronic pain conditions (Tajerian and David Clark, 2017). A spa treatment usually involves the application of a variety of mineral and thermal waters combining altitude, climate, bath practices, eating habits, mineral water source and its bicarbonate, calcium, sodium or chloride contents to bring therapeutic benefits to the body (MM et al., 2019).
Spa treatments have been considered as alternative therapeutic methods for numerous chronic pain conditions—for example, arthritis, fibromyalgia, chronic back pain, and so on. The underlying mechanisms and mode-of-actions of common spa practices on chronic pain alleviation are not so well understood. Nevertheless, a variety of biological and physiological changes have been proposed to take place in individuals after spa experiences. These include analgesia, improvement in pain-related daily function, recovery of heart rate variability and quality of life, alteration of inflammatory cytokines and neuro-peptides levels in the plasma, or the exothermic effect of drinking spa water. To better understand chronic pain and the potential impact of spa treatments on pain relief or diminution, an in-depth exploration of diverse types of spa treatments is first presented.
3.2. Mechanisms of Action
To date, literature exists exploring the efficacy of spa treatments in alleviating symptoms of individual conditions, including musculoskeletal disorders, fibromyalgia, rheumatoid arthritis, and osteoarthritis, but a limited number aimed to investigate spa treatments for chronic pain syndromes as a whole. Additionally, knowledge concerning the possible physiological and psychological mechanisms through which the effects of spa treatments could be produced is even more limited, with a focus on psycho-physiological mechanisms given spa treatments often encompass several approaches with both psychological and physical components, including exercise, massage, and balneotherapy.
The components of spa treatments are processed simultaneously within the brain, making it difficult to differentiate between mechanisms of action. Moreover, the distinction of massage from balneotherapy in spa treatments addresses mechanisms differently. Massage applications are primarily a form of touch, which has been studied in relation to the gate control model (GCM) mechanism of action (Windham Karlson, 2011) , while balneotherapy is a complex intervention that has received less attention in relation to its mechanisms of action.
4. Research Studies on Spa Treatments for Chronic Pain
Chronic pain is one of the most common complaints leading patients to seek, frequently unsuccessfully, medical help. In the age of evidence-based medicine, chronic pain treatments need to be properly investigated in long and well-designed trials and by qualified independent research centers, scoring both objective and subjective effects. To accomplish all these requirements, spa treatment can be considered a suitable model for investigation. Spa treatments include a unique set of complementary therapeutic modalities (MM et al., 2019). Spa treatment regulations may guarantee standardization. Patients unaware of the treatments are especially indicating to check subjective improvement. Patients with chronic pain treated in spa centers may represent a unique source of important epidemiological data on long-term pain effects. Spa treatment has no side effects and a low financial burden compared with medication.
Overall, the inclusion of a single spa treatment does not induce more side effects than the impurities of natural water. In addition, spa treatment does not and cannot substitute proper medical assistance in acute diseases like heart attack or cancer but may serve as an auxiliary procedure in further management. Strong evidence on side effects of medical drugs, like Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), or clearly negative long-term improvement in the quality of life (QoL) and possibility of drug abuse in chronic pain treatment clearly indicate the necessity of developing alternative, complementary and innocent therapeutic procedures (M. et al., 2021). Encouragement in spa treatment from medical and governmental sides may serve psychosocially important, non-massive and inexpensive mitigation of the current chronic pain crisis. Social importance consider attention of highly motivated patients as preselected and, therefore, less expensive. A number of research studies strongly indicating beneficial effects of spa treatment on chronic pain have been published recently.
5. Conclusion and Future Directions
The possibility of the use of complementary and alternative approaches to provide greater patient choice and acceptance of pursuing treatment for chronic pain has impacted both the health care community and health policy enterprises (J. F. Jones and O. R. Littzen, 2022). Although continued research into evidence-based approaches is warranted, this work should not eliminate the exploration of therapies and treatment regimens that may have scientific potential and relevance even if they do not meet the exacting methodologies established by the Academy of Sciences. The studies included in this special issue provide insight into theories, on a variety of levels, that might undergird the investigation of nature as therapy for pain. However, further rigorous translational research with appropriate controls is necessary to explore whether such elements can withstand scientific scrutiny as treatment regimens for chronic pain.
The 10 papers reviewed here significantly add to the scientific literature on spa treatment (addition of nature-based, more mechanism based research), open avenues for continued exploration into this area of inquiry (pending questions with practical relevance), and present compelling narratives that demonstrate the sociocultural relevance of this tradition across a variety of world locales. Consequently there may be opportunities for active collaboration between the health services and planning components of government, local health services, and interested organizations, businesses and alumni to improve this situation.
References:
I. Johnson, M. “The Landscape of Chronic Pain: Broader Perspectives.” (2019). ncbi.nlm.nih.gov
Windham Karlson, C. “Massage and the Gate Control Model.” (2011). [PDF]
Tajerian, M. and David Clark, J. “Nonpharmacological Interventions in Targeting Pain-Related Brain Plasticity.” (2017). ncbi.nlm.nih.gov
Kataria, S., Patel, U., Yabut, K., Patel, J., Patel, R., Patel, S., Hilkiah Wijaya, J., Maniyar, P., Karki, Y., P. Makrani, M., Viswanath, O., and D. Kaye, A. “Recent Advances in Management of Neuropathic, Nociceptive, and Chronic Pain: A Narrative Review with Focus on Nanomedicine, Gene Therapy, Stem Cell Therapy, and Newer Therapeutic Options.” (2024). ncbi.nlm.nih.gov
Scheidegger, A., Jäger, J., T. Blättler, L., Aybek, S., Bischoff, N., and grosse Holtforth, M. “Identification and Characterization of Pain Processing Patterns Among Patients With Chronic Primary Pain: A Replication.” (2023). ncbi.nlm.nih.gov
Hylands-White, N., Duarte, R. V., and Raphael, J. H. “An overview of treatment approaches for chronic pain management.” (2016). [PDF]
LaRue Anthony, Y. “Appraisal of Nonpharmacological Chronic Pain Management.” (2017). [PDF]
MM, A., DENOTTI, A. N. T. O. N. I. O., S, P., C, S., MONTISCI, F. A. B. R. I. Z. I. O., G, D., A, L., and A., C. “Spa therapy induces clinical improvement and protein changes in patients with chronic back pain.” (2019). [PDF]
M., A., D., D., L., V., M., V., and C., P. “Clinical efficacy of medical hydrology: an umbrella review.” (2021). [PDF]
J. F. Jones, R. and O. R. Littzen, C. “An Analysis of Theoretical Perspectives in Research on Nature-Based Interventions and Pain.” (2022). ncbi.nlm.nih.gov