A report on Health Resort Medicine offers some thought-provoking perspectives on new proposals for Spa as in Medical Spa or even Global Healthcare Corporation. This post explores some of the issues that deserve more careful consideration in the light of recent scientific studies of spa-related health practices.
As some in the spa world turn their attention towards medical credibility and application by promoting a scientific medical base for spa practices, the terminology used for these practices will need to be more clearly outlined. If the discussion process that ensues is not inclusive of all approaches to health and healing, much of the unique contribution that spa can make could be lost.
A proposal for Primary Care 2025 from Integrator Blog and the Institute of Alternative Futures suggests that 'integrative encounters address all dimensions of health by bringing the knowledge of conventional, unconventional, complementary, alternative, traditional and integrative medicine disciplines to bear across the many different cultural traditions of persons cared for.' Key phrase 'all dimensions of health'.
Recent studies of spa practices published in scientific journals highlight some important issues that remain to be addressed. Spa professionals would do well to study some of this scientific and medical interest closely and consider it from the perspective of the unique and distinct service offered by spa. The issue is not just one of expanding business opportunities.
What is health resort medicine?
An article published last year in the International Journal of Biometeorology by authors from the Department for Rehabilitation Medicine, Institute for Balneology and Medical Climatology, Hanover Medical School in Germany, proposed a systematic international discussion of descriptions in a field described as 'Health Resort Medicine' with the goal of achieving internationally accepted distinct terms.
See 'Proposal for a worldwide definition of health resort medicine, balneology, medical hydrology and climatology' Int J Biometeorol. 2010 Sep;54(5):495-507.
It was suggested in the IJB article above that: 'This task should be done via a structured consensus process and is of major importance for the publication of scientific results as well as for systematic reviews and meta-analyses.' A summary of systematic reviews based on randomized controlled trials of water immersion therapies, published in the Journal of Epidemiology in 2010, illustrates this concern about terminology.
See 'Effectiveness of aquatic exercise and balneotherapy: A summary of systematic reviews based on randomized controlled trials of water immersion therapies.'' Hiroharu Kamioka et al. J. Epidemiol. 2010, 20(1):2-12.
In the latter article, out of 111 potentially relevant studies gleaned from international database searches, the researchers found only 7 that fit their criteria - 3 on Aquatic Exercise, 5 on Balneotherapy (bathing), while 1 study included both. These few studies provided 'no clear evidence of curative effect for bathing'; while, for aquatic exercise, they showed 'small but significant effects on pain, function, quality of life and mental health'.
I wrote about this systematic review on my website for non-clinical aquatic bodyworkers to illustrate some of the problems faced in scientific research for the kind of work they do. For more detail see Is immersion in warm water beneficial? Gaining scientific validity for aquatic modalities (and no doubt other healing modalities) in spas is not likely to be easy, though this is not necessarily because these modalities have nothing to offer.
Among the Balneotherapy studies in particular, the researchers for the systematic review article found great heterogeneity, multiple and varied outcome measurements, poor methodological quality of randomized controlled trials, and poor overall quality. The authors called for better research methodology and noted the problem with terminology. After reading the article carefully, I found myself asking some fundamental and practical questions.
Given the current problems with terminology, scientific methodology and unbiased financial support, can the scientific research into spa therapies called for be done in a timely and effective way? Will the results have real practical application? Will they really tell us what we need and want to know about therapeutic modalities, some of which have been in use since ancient times? I have my doubts.
I don't think that doing scientific studies is a waste of time but I do wonder if those involved in spa understand the limitations inherent in these studies and their application. There is a lot more to health and healing than our current scientific models and methodologies are able to demonstrate. Health problems arguably have more to do with social and environmental pressures, our attitudes and ideologies, than with a specific lack of science.
In that respect the International Journal of Biomateriology is an interesting publication since it reports on studies examining the interactions between living organisms (including but not only humans) and factors of the natural and artificial atmospheric environment (climate and weather, electromagnetic radiation, and chemical and biological pollutants). It covers research and practical aspects of living conditions, agriculture, forestry, and health.
The emphasis of the article in IJB is on the medical value of 'health resort' (we could read 'spa') practices. One of the 'implicit problems' identified with the use of terms such as Balneotherapy was its adoption as part of 'wellness concepts'. Since the spa industry is currently putting great emphasis on Wellness, this 'implicit' divide between spa and clinic may continue to haunt conversations if it is not addressed forthrightly.
Some terminology for water-based health practices
Let's look at some of the terminology involved. Bathing for relaxation or pleasure, without a specific medical purpose, might well be considered healthy or healing (both derived from Old English meaning 'whole'). However, it could be argued that a bathing practice only becomes therapeutic if it involves treatment or attendance (as per the derivation from Greek) and is offered with the intent to improve a specific health condition.
Balneotherapy (from Latin: balneum, 'bath') is a term traditionally used for medical procedures involving the treatment of disease by bathing. The bathing process uses particular types of water (hot or cold) and fluids, rich in salts, minerals and other organic compounds, considered to have beneficial properties. Balneotherapy is not restricted to water, while the related therapeutic practice of Hydrotherapy involves only water.
Thalassotherapy (from Greek: thalassa, 'sea') includes bathing but is limited to elements associated with the sea, marine climate, seawater, marine mud, other sea substances. Aquatic therapy is used by physical therapists and exercise specialists to describe mobilization and movement practices involving immersion in water. Other immersion practices - aquatic bodywork, aqua-meditation, dance in water - have evolved in spas.
..........................................................................................................................................................
The website Aqua for Balance provides general information on many of the current popular uses of water in healing and therapy. Regards Balneotherapy, for example, it notes:
Balneotherapy may be recommended for wide range of illnesses, including arthritis, skin conditions and fibromyalgia. As with any medical treatment, balneotherapy should be discussed with a physician before beginning treatment, since a number of conditions, like heart disease and pregnancy, can result in a serious adverse reaction.
Scientific studies into the effectiveness of Balneotherapy tend to be neutral or positive, finding that Balneotherapy provides no effect or a placebo effect, or that there is a positive effect. However, many of these studies suffer from methodological flaws, and so may not be entirely reliable. A 2009 review of all published clinical evidence concluded that existing research is not sufficiently strong to draw firm conclusions about effectiveness of balneotherapy for any medical condition.
..........................................................................................................................................................
The article 'Proposal for a worldwide definition of health resort medicine, balneology, medical hydrology and climatology' in the International Journal of Biomateriology notes that none of the terms given in its title is recognised as an independent medical specialty at a global international level. The article also distinguishes what the authors call 'explicit' and 'implicit' problems that need to be addressed before further studies can be done.
Explicit problems:
- lack of scientific evidence
- not used in all countries
- focus only on single methods without a comprehensive concept
Implicit problems:
- lack of internationally accepted terms in the field
- restriction of being allowed to practice the activities only in specific settings
- trend in using practices (like Balneotherapy) mainly for wellness concepts
The last of these suggests that, for the medical profession, the use of Balneotherapy (and other such therapies) in spas with a non-medical focus is seen as a 'problem'. A distinction is being made here between wellness and medical therapy. Later on in the article, medical is linked with health promotion and prevention - both can be considered aspects of wellness.
Should spa therapies become medical specialties?
Perhaps the underlying issue with Wellness (as a concept) for medicine is one of lack of scientific evidence. However, this lack may have as much to do with research methodology and attitude as with any actual ineffectiveness of the health practices that are examined by scientists. The article noted that: 'Especially the implicit barriers should be subject to intense discussions among scientists and specialists.'
Those involved with spa and healing modalities not recognized by conventional medicine would do well to ensure they are included in these kinds of discussion. They should also make sure they are equipped to hold their own in the face of an historical opposition to practices not understood or acknowledged by medical science. In actual fact, many medical practices themselves lack a good evidence-base.
The continued use of these unproven medical practices may involve a mixture of 'because we've always done this' and 'because it works'. The second reason is more reasonable than the first. It is also why some so-called alternative healing practices have stood the test of time even when how they work is not understood. For me, the tipping point is one of evaluating the potential harm involved in a particular practice.
The article on 'health resort medicine' references only three practices - Balneotherapy, Hydrotherapy (which is distinguised from Balneotherapy) and Climatotherapy. The authors stress that, at this point in time, and before this field (Health Resort Medicine) can assume the medical credibility it seeks, two main issues must be addressed: 1. a structure and description of the medical field; and 2. acceptable descriptions of content and terminology
Health resort medicine is described as (my summary):
- all medical activities originated and derived in health resorts based on scientific evidence
- core elements Balneotherapy, Hydrotherapy, and Climatotherapy
- used also for health promotion, prevention, treatment, and rehabilitation
The core elements were defined as:
- Balneotherapy using medical mineral waters, medical peloids, and natural gases (bathing, drinking, inhalation, etc.)
- Hydrotherapy using plain water (tap water)
- Climatotherapy using climatic factors
The authors call the scientific field dealing with Health Resort Medicine, health resort sciences - 'the medical sciences, psychology, social sciences, technical sciences, chemistry, physics, geography, jurisprudence, etc.' This is quite a sweeping view of 'science'. What we learn from such science will depend on attitude and practical application, and whether those who stand to profit from particular outcomes are transparent.
In addition to the factors included in Health Resort Medicine above, the article also usefully outlines some other factors based on International Classification of Functioning, Disability and Health (ICF):
- receiving health care by specialised doctors
- being well educated (ICF-domain: e355)
- having an environment supporting social contacts (family, peer groups) (cf. ICF-domains: d740, d760)
- facilities for recreation, cultural activities, leisure and sports (cf. ICF-domain: d920)
- access to a health-promoting atmosphere and an environment close to nature (cf. ICF-domain: e210)
I found it interesting to relate all this to the Ten Domains of Spa put forward about 20 years ago by a group of innovative spa professionals and later adopted by ISPA (see blue highlighted text below). Balneotherapy and Hydrotherapy, for example, relate to Spa Domain 1 (water). Of Spa Domains 2, 4, 5 and 6, 2 (nourishment) has medical components but 4, 5 and 6 (touch, integration and aesthetics) have historically been largely left out of (scientific) medical considerations.
The ICF domains covering other factors associated with health resort medicine relate closely with Spa Domains 7 to 10 (environment, social, culture, leisure). The modern spa industry has already sidelined what was once Spa Domain Number One - Water. If we are not careful we may also end up devaluing some of the subjective elements of health that the Spa Domains highlight but that are not easily assessed by conventional scientific method.
In the end perhaps all the territorial fights for healthcare provision will be seen for the distraction that they are. Perhaps what we now call spa or health resort, healthcare and hospital will all be integrated in respectful and inclusive ways. The illness/ wellness profit market will dwindle away and be replaced by a culture of sharing and caring in which all people experience truly personal and individually tailored consideration in their search for health and healing.
That is my dream, and I still believe that water provides a good means and model.
TEN DOMAINS OF SPA
1. Waters: The internal and external use of water in its many forms.
2. Nourishment: What we feed ourselves: food, herbals, supplements and medicines.
3. Movement: Vitality and energy through movement, exercise, stretching and fitness.
4. Touch: Connectivity and communication embraced through touch, massage and bodywork.
5. Integration: The personal and social relationship between mind, body, spirit and environment.
6. Aesthetics: Our concept of beauty and how botanical agents relate to the biochemical components of the body.
7. Environment: Location, placement, weather patterns, water constitution, natural agents and social responsibility.
8. Cultural Expression: The spiritual belief systems, the value of art and the scientific and political view of the time.
9. Social Contribution: Commerce, volunteer efforts, and intention as they relate to well-being.
10. Time, Space Rhythms: The perception of space and time and its relationship to natural cycles and rhythms.
Further reading for some more medical explorations of spa:
Balneology and the Spa: The Use of Water in Dermatology
Clinics in Dermatology: Volume 14, Issue 6, November-December 1996
This special issue includes articles on:
- Balneology, mineral water, and spas in historical perspective
- A glossary of concepts relating to balneology, mineral water, and the spa
- Physiologic, immunologic, dermatologic, rheumatologic aspects of mineral water
- Sexually transmitted diseases and the spa
- Mineral waters and spas in the US, Bulgaria, France, Germany, Greece, Israel, Italy, Korea, Portugal, Spain, Poland
