The purpose of this study was to examine how constitutions, blood profiles, knee and back pain, and the psychological state of middle-aged and elderly women were influenced by comprehensive health education that consisted of instructions in appropriate ways of bathing in hot springs and education on lifestyle and exercise.
Of the middle-aged and elderly female residents in village A in Nagano prefecture, 266 underwent health check-ups in August and September 2002. Fifty-six of these women voluntarily participated in this study, and were divided into an intervention and a control group randomly. Finally, the intervention group and control groups consisted of 22 and 26 subjects, respectively, who were considered suitable for study purposes.
The intervention group received comprehensive health education once a week for 3 months (total 11 times) between the latter part of September and the middle of December. For the comprehensive health education, subjects participated in hot spa bathing in a salt spring for 20 minutes in all (two 10-minute periods), and lifestyle education and exercise, including stretching, walking, light sports, dietary instruction, etc., during 60-minute sessions. After the series of comprehensive health education was completed, the following improvements were noted in the intervention group. As to blood profiles, the plasma level of uric acid significantly decreased from 4.4±1.1mg/dl to 4.1±1.1mg/dl (p<0.05) and the arterioloscerotic index decreased from 2.85±0.90 to 2.68±0.83 (p=0.07). The intensity of lumbago expressed on a visual analogue scale significantly decreased from 23.5±28.4% to 14.2±21.5% (p<0.01). The intensity of psychological tension decreased from 45.3±6.3 points to 43.2±6.0 points (p=0.06). The mean number of comprehensive health education sessions attended was 9.9±1.4 (range 7 to 11). The number of improvements implemented with regard to a healthy lifestyle significantly increased (p<0.05). Behavior of the subjects in the intervention group appeared to have changed towards a desirable lifestyle.
The results of this study show that even intermittent and brief health education combining “hot spa bathing and lifestyle education and exercise” is effective to maintain and improve health of middle-aged and elderly women.

Balneotherapy includes several modalities of treatments and wellness programs, such as physiological and pharmacological effects of hot spring bathing and aqua-exercise, relaxing and biorhythm adjusting effects of staying in the urban climates and educational instruction for healthier life style. We examined health promoting effects of the comprehensive balneotherapy as a whole by the randomized controlled study. 89 women, who had no medical care, and were aged 40-65 years (mean +/- SD age: 59.0 +/- 8.0 years), volunteered for this investigation. Subjects were assigned at random to three groups; group 1 was the control group without any intervention; group 2 with exercise for 60min and educational guidance; group 3 with exercise for 30min and balneotherapy including aquaexercise for 30min and bathing in hot spring for 30min in addition to educational guidance. Each group followed the prescribed program twice a week for 3 months. There was no significant difference in age, body mass index (BMI), blood pressure, heart rate, %FAT, diet/exercise custom and psychological conditions among the three groups. Before and after the program, the physiological, biochemical and psychological measurements were performed: body weight, blood pressure, heart rate, physical strength using ergometer, serum lipids, liver function and questionnaires with profile of mood state (POMS) and self relating depression scale (SDS). After excluding 4 subjects who were dropped out because of their convenience, the results were compared. In group 2 (N=28) and 3 (N=28), body weight, BMI, blood pressure and heart rate were significantly decreased and their physical strength and psychological condition were improved significantly (p<0.05). Furthermore only in group 3, serum total cholesterol, atherogenic index and triglyceride were significantly decreased (p<0.05). The difference between these two groups was not due to changing of their diet and estimated energy consumption by daily activities during 3 months. These data suggest the efficacy of balneotherapy with hot spring bathing and aqua-exercise for health promotion.

The purpose of this study was to review several kinds of checklists and statements of studies in human subjects, and to examine reporting methods in order to improve the quality of studies concerning hot springs.
For randomized controlled trials (RCTs), “the CONSORT Statement” (Moher et al. JAMA 2001) consisting of 22 terms is the most well known checklist. In addition, different versions and new checklists have been developed depending upon the content of the studies (such as intervention methods) or field of the studies. There is also “the QUOROM Statement” (Moher et al. Lancet 1999) for a systematic review (SR) of RCTs, “the TREND Statement” (Jarlais et al. Am J Public Health 2004) for nonrandomized controlled trials, “the STROBE Statement” (Elm et al. Ann Inter Med 2007) for observational studies, and “the MOOSE Checklist” (Stroup et al. JAMA 2000) as a SR of observational studies. With regard to studies on hot springs, however, terms in the checklists and the statements described above are insufficient or inappropriate because of difficulties in performing such studies in a blinded manner, and the diversity of intervention methods, such as the quellen charakter.
Improvement of the quality of reports is important for validation of evidence. In order to improve the quality of assessments and reports of studies on hot springs, it may be necessary to develop a unique checklist based on the above-described statements and checklists.

This study attempted to clarify the effects of 3- and 6-month comprehensive health education programs based on hot spa bathing, lifestyle education and physical exercise on physique, psychological vigor, blood properties, pains in the knee and back, and mental and psychological aspects of women. We examined middle-aged and elderly women who were randomly divided into two groups and followed up until six months and one year later, respectively.
Spa programmers, an exercise instructor, and a dietician instructed subjects to one hour of life-style education and physical exercise (lecture on behavior modification, walking, rhythmic exercise, cooking practice, etc.) and one hour (including time for changing clothes and washing body) of a half bath (salt spring, temperature at 41.5) once a week. The program for the 3-month group (n=19) was repeated in the 6-month group (n=14).
The evaluation items were BMI, PWC75%HRmax (by a bicycle ergometer as aerobic capacity), blood properties (total cholesterol, HDL cholesterol, arteriolosclerotic index, uric acid, and HbAlc), profile of mood states, self-rating depression scale, subjective happiness, and pains in the knee and back.
Compared with pre-intervention data (26.3±3.6), the BMI decreased significantly (p<0.05) immediately after the intervention (25.7±3.5) and at the follow up six months later (25.7±3.3) in the group of 6-month intervention. In addition, the PWC75%HRmax, HbAlc, pains in the back, vigor, depression, and subjective happiness remained significantly improved (p<0.05), as measured at the 6-month follow-up. On the other hand, some of the items improved in the 3-month intervention group immediately after the intervention, but returned to nearly the same levels as those before intervention at the 1-year follow-up. Significant differences (p<0.05) were found in the PWC75%HRmax, HbAlc, and fatigue between the two groups, all of which were improved in the 6-month intervention group.
These results suggest that a low frequency, once-a-week intervention requires duration longer than three months to maintain the effects, and that the effects should be monitored over years for a correct assessment.

The purpose of this study was to review randomized controlled trials of the effects of treatment in spas, thereby clarifying therapeutic effects of these treatments on individual diseases, and its healthpromoting effects.
A review of the PubMed database for articles that fulfilled the following eligible criteria identified the studies that were chosen for this review. Key words were “randomized controlled trial” and “spa” or “balneotherapy”. Articles were published after 1990, and written in English. No criteria were set up concerning the number of subjects, the observation period, or the kind of disease studied. The quality of individual articles was evaluated on a 13-point modified PEDro scale that was constructed by adding three terms, representing the number of subjects, the observation period, and quellencharakter to the 10-point PEDro scale.
A total of 18 articles were chosen. Since two of them were essentially identical in content, these two articles were counted as one. As a result, a total of 17 articles were reviewed. Seven studies were conducted in France, 3 in Germany, 3 in Israel, 2 in the Netherlands, and 1 each in Italy and in Japan. Diseases studied in these articles were mostly disorders of the locomotorium, with pain as a main symptom; rheumatism in 6 articles, osteoarthritis in 4, lumbago in 3, and Parkinson's disease, varicosis, psoriasis, and health-promotion in one each. The mean score on the 13-point modified PEDro scale was 7.5 (SD, 2.3), with a minimum score of 2 points and a maximum score of 12 points.
The method of intervention in the spa varied widely from study to study. In addition to balneotherapy, exercise therapy, mud pack treatment, and douche massage were employed in numerous studies. Besides the intensity of pain and the amount of anodynes consumed by patients, emotional effects, QOL, physical working capacity, and even decreases in medical expenses were monitored as indicators for evaluation of the effect of the treatments in some studies. Improvements in the indicators were always more marked in balneotherapy intervention groups than in control groups, irrespective of the diseases studied. The improvements persisted for relatively long periods. In particular, a review of the high quality articles that reported effects of balneotherapy on patients with rheumatism, osteoarthritis, or lumbago showed that effects of intervention provided only once could be expected to persist for six months. With regard to the effect of quellencharakter on diseases, no definitive conclusion was obtained. On the basis of these results, we devised a “3-layer model of evidence to be accumulated in balneotherapy”

The purpose of this study was to clarify the relationship between frequency of bathing in a spa and at home and the characteristics of the body, blood, and lifestyle of white-collar and blue-collar male employees.
To recruit subjects, two baseline data for randomized controlled trials in two places in Shimane Prefecture and in Nagano Prefecture were used. In the two-month period between August and September 2006, 43 of 311 white-collar male employees aged between 30 and 57 years in the Unnan municipal office volunteered to participate in this study. Similarly, 44 blue-collar workers in Nagano Prefecture volunteered to be involved in this study as a result of an appeal for volunteers in local newspapers and public information journals published by large local enterprises from September through November 2006. A total of 87 men were subjects of this study. Items evaluated in this study with respect to physique included height, weight, body mass index, waist circumference, hip circumference, and percent of body fat. With respect to strength, they were grip strength, abdominal strength, back strength, and anteflexion. With respect to characteristics of the blood, they were serum glucose, hemoglobin A1c, fructosamine, lactic acid, total cholesterol, triglyceride, HDL cholesterol, LDL cholesterol, free fatty acid, GOT, GPT, γ-GTP, cholinesterase, natural killer cell activity, T cell, B cell, CD4+, CD8+, CD4/8 and uric acid. With respect to mood, Profile of Mood States was evaluated. With respect to lifestyle, the frequency of monthly bathing in a spa and at home was evaluated.
No significant correlation was revealed between frequency of monthly spa bathing and the health indices in the white and blue-collar male workers. The items that were significantly correlated (p<0.05) with frequency of monthly bathing at home were GOT (positive), CD8+ (positive), and mental stress (negative).
In this study, frequency of monthly spa bathing was found to have no significant correlation with the health indices.