Hypothalamic-pituitary-adrenal axis dysregulation in healthy subjects undergoing mud-bath applications

Balneotherapy and cortisol levels: an updated systematic review and meta-analysis

The main objective of this review is to examine the impact of balneotherapy on serum and salivary cortisol concentrations. A systematic search was conducted in PubMed, Scopus, Web of Science, PEDro, and Google Scholar. The databases were screened from inception up until April 2024. After screening the scientific literature, 845 articles were retrieved and 17 studies, involving a total of 765 participants, were eventually included in the review. Among them, four were randomized controlled trials, five were non-randomized studies, and eight were pre-post studies with no control group. The evidence gathered in this review indicates a significant short-term reduction in cortisol levels in healthy individuals undergoing balneotherapy, particularly those experiencing high levels of stress. Conversely, in patients with rheumatic conditions (especially if elderly), increases in cortisol levels induced by balneotherapy can act as beneficial hormetic stress, reducing inflammatory mediators and improving pain and functional quality of life. The meta-analysis shows an overall trend of reduction in stress hormone levels, more pronounced in the intervention group undergoing mud-balneotherapy compared to the control group, a finding that, however, does not reach statistical significance (g=-0.11 [95% CI: -0.30; 0.08]; p > 0.05). Current scientific evidence demonstrates that balneotherapy has a positive impact on the regulation of cortisol levels. The regulation of the hypothalamic-pituitary-adrenal axis and the beneficial effects observed on health parameters and quality of life allow mud-balneotherapy to be classified as eustressful stimuli useful in preventing stress-related pathologies in healthy individuals and in alleviating symptoms in patients with chronic conditions. Future research on the topic is advised.

Effect of hydrotherapy, balneotherapy, and spa therapy on blood pressure: a mini-review

Hypertension (high blood pressure) is one of the most common health conditions. When your blood pressure is high for a long term, it can cause health problems, such as heart disease. In addition to the main methods of treatment, there are various methods of adjuvant therapy, one of the most common of which is hydrotherapy. In this review study, we examined the effects of hydrotherapy, balneotherapy, and spa therapy on blood pressure. We searched the PubMed/MEDLINE, Web of Science, Scopus, and Science Direct databases until April 2022 using related keywords. In summary, the current study shows that different hydrotherapy methods may improve blood pressure. Hydrotherapy as one of the adjunctive therapy methods can be effective in lowering blood pressure. Blood circulation is smoothed by the warmth of the water. This improvement may be achieved by regulating heart rate, releasing hormones that control blood pressure, or regulating the activity of baroreceptors or chemoreceptors. In addition to using medications, hypertension patients also use non-pharmacological approaches in their care, including hydrotherapy, balneotherapy, and warm water foot soaks performed at home. Although several lines of evidence show the potential effects of hydrotherapy, balneotherapy, and spa therapy on blood pressure, many clinical trials are needed.

Balneotherapy for osteoarthritis: a systematic review

This systematic review is aimed to evaluate the effects of balneotherapy with thermal mineral water for managing the symptoms and signs of osteoarthritis located at any anatomical site. The systematic review was conducted according to the PRISMA Statement. The following databases were consulted: PubMed, Scopus, Web of Science, Cochrane Library, DOAJ and PEDro. We included clinical trials evaluating the effects of balneotherapy as a treatment for patients with osteoarthritis, published in English and Italian language, led on human subjects. The protocol was registered in PROSPERO. Overall, 17 studies have been included in the review. All of these studies were performed on adults or elderly patients suffering from osteoarthritis localized to knees, hips, hands or lumbar spine. The treatment assessed was always the balneotherapy with thermal mineral water. The outcomes evaluated were pain, palpation/pressure sensibility, articular tenderness, functional ability, quality of life, mobility, deambulation, ability to climb stairs, medical objective and patients' subjective evaluation, superoxide dismutase enzyme activity, serum levels of interleukin-2 receptors. The results of all the included studies agree and demonstrated an improvement of all the symptoms and signs investigated. In particular, pain and quality of life were the main symptoms evaluated and both improved after the treatment with thermal water in all the studies included in the review. These effects can be attributed to physical and chemical-physical properties of thermal mineral water used. However, the quality of many studies resulted not so high due and, consequently, it is necessary to perform new clinical trial in this field using more correct methods for conducting the study and for processing statistical data.

Efficacy of hydrotherapy, spa therapy, and balneotherapy on sleep quality: a systematic review

The purpose of this article was to review and assess the results obtained from human studies on the effects of hydrotherapy, balneotherapy, and spa therapy on sleep disorders. In this study, databases such as Pubmed, Embase, Web of Science, Google Scholar, Cochrane, Scopus, and sciences direct database were searched from the beginning to September 2022. All human studies that examined the effect of hydrotherapy, balneotherapy, and spa therapy on sleep disorders were published in the form of a full article in English. In the end, only 18 of the 189 articles met the criteria for analysis. Most studies have shown that balneotherapy, spa therapy, and hydrotherapy may by affecting some hormones such as histamine, serotonin, sympathetic nerves, and regulating body temperature led to increased quality and quantity of sleep. Also, the results obtained from Downs and Black show that 3 studies were rated as very good, 7 studies as good, 7 studies as fair, and 1 study as weak. The results of studies also showed that hydrotherapy leads to an improvement in the PSQI score index. Nevertheless, more clinical trials are needed to determine the mechanism of action of hydrotherapy on sleep disorders.

Sleep and spa therapies: What is the role of balneotherapy associated with exercise? A systematic review

Balneotherapy and exercise are potential factors influencing sleep through several physiological pathways and relaxing effects. This review aims to assess whether balneotherapy can improve sleep quality in concomitance or not with exercise. The research was conducted on Medline, Scopus, PubMed, Web of Science, and Cochrane Library databases. The current review followed PRISMA reporting guidelines and involves twenty-one articles grouped into four sections based on the characteristics of the balneotherapy protocol: 1.a Balneotherapy–thermal water immersion alone (five studies); 1.b Balneotherapy–thermal water immersion with other spa treatments (six studies); 2.a Balneotherapy and physical exercise–balneotherapy and out-of-the-pool physical exercise (eight studies); 2.b Balneotherapy and physical exercise–balneotherapy and in-pool physical exercise (three studies). Apart from healthy or sub-healthy subjects, patients recruited in the studies were affected by fibromyalgia, ankylosing spondylitis, osteoarthritis, musculoskeletal pain, subacute supraspinatus tendinopathy, and mental disorders. Duration, number of sessions, and study protocols are very different from each other. Only one study objectively evaluated sleep, whereas the others used subjective sleep assessment methods. Eight studies considered sleep as a primary outcome and ten as secondary. Sixteen out of twenty-one studies described improvements in self-perceived sleep quality. Thus, balneotherapy associated with other spa treatments and physical exercise seems to be effective in improving self-perceived sleep quality. However, the miscellany of treatments makes it difficult to discern the isolated effects of balneotherapy and physical exercise. Future studies should consider using an objective sleep assessment method and describing the pathways and physiological mechanisms that could provoke sleep changes during balneotherapy treatments.

The Role of Thermal Water in Chronic Skin Diseases Management: A Review of the Literature

The benefits of thermal water in different diseases have been known since ancient times. Over the past decades, a re-assessment of the use of mineral water for the treatment of several pathologic conditions has taken place around the world. Today, water therapy is being practiced in many countries that have a variety of mineral springs considerably different in their hydrogeologic origin, temperature, and chemical composition. Thermal water and balneotherapy offer several advantages: this approach needs no chemicals or potentially harmful drugs; there are almost no side effects during and after treatment, and there is a low risk to the patient’s general health and well-being. However, it is difficult to evaluate the efficacy of this therapeutic approach in clinical practice due to the complexity of molecular mechanisms underlying its efficacy. Here we review the current knowledge of the chemical, immunological, and microbiological basis for therapeutic effects of thermal water with a specific focus on chronic inflammatory skin diseases. We also describe recent evidence of the major dermatologic diseases that are frequently treated by balneotherapy with a remarkable rate of success. Moreover, we discuss the potential role of balneotherapy either alone or as a complement to conventional medical treatments.

Comparison of Therapeutic Efficacy of Spa Mud and Bath Applications in the Treatment of Experimentally Induced Psoriasis and Eczema in Rats

Psoriasis and eczema are most common diseses of human and seen some animals. In this research project, a total of 49 Albino rats, 25 of which were psoriasis and 24 of eczema, were used. The back of all the animals were shaved 3 cm x 2 cm in size, and were deepilated using a 50% barium sulfate solution and deepillation tape. Then, 5% imiquimod was applied to the area for 5-6 days in the rats in psoriasis group, whereas 2%, 4-dinitrochlorobenzene was performed 2 times per day for one week in eczema group animals along with 150 μg of mite extract (Dermatophagoides farinae). After diseases formation in both groups, animals were divided into control and study groups, and then treatment period was started. In the rats with psoriasis and eczema, clinical, hematological, blood biochemical and histopathological findings were determined. In the light of the data obtained; it was concluded that a 21-day spa treatment in rats with psoriasis and eczema was very successful and could be considered as an option in the treatment of these diseases or it would increase the success of the treatment when combinated with classical medical treatments.

Sulfurous-arsenical-ferruginous balneotherapy for osteoarthritis of the hand: results from a retrospective observational study

Balneotherapy (BT) is a complementary therapy widely used in several rheumatic conditions, however, the evidence in hand osteoarthritis (HOA) is still scarce. The aim of this preliminary study is to retrospectively evaluate the symptomatic effects of a cycle of mud-bath therapy in HOA patients. Two hundred twelve outpatients with primary bilateral HOA treated with 12 daily local mud packs and generalized thermal baths with a sulfurous-arsenical-ferruginous mineral water added to usual treatment were included in the study. Each patient was examined at baseline and at the end of thermal therapy (2 weeks). Primary outcome measures were global spontaneous hand pain on a Visual Analogue Scale (VAS) and the Functional Index for Hand Osteoarthritis (FIHOA) score; secondary outcomes were handgrip strength, duration of morning stiffness, Health Assessment Questionnaire (HAQ), Short Form Health Survey (SF-12), tolerability and patients' and physicians' global impression of treatment efficacy and tolerability. Our results demonstrated that the efficacy of mud-bath therapy was significant in all the assessed parameters at the end of therapy, except for the physical component score of SF-12. The thermal treatment was well tolerated. The patient's and the physician's global assessments showed a high level of satisfaction in terms of efficacy and safety. In conclusion, our results may suggest a short-term effectiveness of mud-bath therapy in controlling pain and improving functionality in HOA patients, supporting the role of this treatment as a complementary strategy in the management of HOA; however, further randomized controlled trials with a long-term follow-up are needed.

Mud-bath treatment of seronegative spondyloarthritis: experience at the Euganean Thermal Area

Mud-bath therapy (MBT) has been used as a treatment for rheumatic diseases and musculoskeletal complaints in the Euganean Thermal Area (near Padova, Italy) since ancient time. There is no consensus about the use of MBT in patients with inflammatory rheumatic diseases, although experimental studies have suggested a beneficial effect of MBT on chronic articular inflammation. To evaluate the effects of MBT in patients affected by seronegative spondyloarthritis, very common chronic inflammatory rheumatic diseases, randomized controlled trials (RCT) performed in the Euganean Thermal Area have been reviewed. A significant improvement of spondylitis parameters was observed in enteropathic spondylitis, without bowel symptom exacerbation. A long-term amelioration of clinical evaluation indices was found in ankylosing spondylitis. A significant improvement of cutaneous lesions, arthritis activity, and patient's functional ability was observed in psoriatic arthritis. MBT was usually well tolerated and adverse side effects were rarely reported. The review of the RCT suggests that MBT may exert additional beneficial effects in patients with seronegative spondyloarthritis treated with pharmacological therapy.

Ameliorative potential of black sand therapy on carpal tunnel syndrome during pregnancy: A case report

Hot sand baths are used for the treatment musculoskeletal diseases. The aim of this study was to assess beneficial effect of black sand bathing in the treatment of antenatal carpal tunnel syndrome (CTS). Study was conducted in single case with CTS of the right dominant hand. The treatment time was 20 min/day, 5 days/week for 2 weeks. CTS were evaluated using a visual analogue scale (VAS), pinch gauge dynamometer and Boston Carpal Tunnel Questionnaire (BCTQ) with electrophysiological studies at baseline and at week 2. Pain intensity (VAS) was decreased (34.2%), Tip, Key and Tripod pinch strengths were increased (14.29%), (19.23%) and (21.74%) respectively. Mean scores on the BCTQ-SSS and BCTSQ-FSS were decreased (23.69%) and (20.7%) respectively. Electrophysiological studies revealed that decreased mMDL (11.47%), increased mSNCV (9.23%) at the end of treatment. The black sand bathing is supported as a complementary therapy in antenatal CTS.

Hot sand baths (psammotherapy): A systematic review

INTRODUCTION

Psammotherapy is a traditional practice in which hot sand baths are employed for therapeutic purposes. This systematic review aims to investigate the potential efficacy of psammotherapy in the treatment of any disease.

METHODS

Medline via PubMed, Embase, Web of Science, Cochrane Library, and Google Scholar were searched for articles describing studies on the efficacy of psammotherapy in patients with different health conditions. Articles were screened by the two author independently and, in case of disagreements, items were discussed until consensus was reached. All relevant clinical outcomes (symptom and pain relief, modifications in any functional and laboratory parameter, changes in drug consumption, variations of quality of life) were extracted from included studies.

RESULTS

After article screening and selection, three studies were included in the review. One study involved patients with chronic obstructive pulmonary disease, while in the other two studies patients with rheumatoid arthritis were recruited. Included trials indicate that psammotherapy might be useful for the management of studied diseases.

DISCUSSION

Based on available data, no conclusions can be driven on the clinical efficacy of psammotherapy. However, very limited evidence suggests that hot sand baths might be useful in improving symptoms and functionality of patients with some rheumatic and respiratory chronic illnesses. Further studies are encouraged to better assess the clinical efficacy of hot sand baths.

Balneotherapy in chronic inflammatory rheumatic diseases-a narrative review

Since ancient time, thermal baths and mudpacks have been used as treatments for rheumatic diseases and other musculoskeletal complaints. Despite basic researches suggest an anti-inflammatory effect of spa therapy, there is no consensus about the benefits of balneotherapy in patients with chronic inflammatory rheumatic diseases. The aim of this review is to summarize the currently available information on clinical effects of balneotherapy in these diseases. We did a literature search for articles considering the randomized controlled trials (RCTs) published until today. Although many selected studies do not have an elevated methodological quality, data from these RCTs support a beneficial effect of spa therapy. Balneotherapy highly improves the clinical course of the disease in patients with predominant axial involvement, such as with ankylosing and enteropathic spondylitis; the effects are less favorable in patients with predominant peripheral articular inflammation, such as rheumatoid arthritis. Good results have been observed in patients with psoriatic arthritis, but only few RCTs have been conducted on this disease. Spa therapy appears safe, and adverse events have been reported only in a few patients.

Effects of balneotherapy and spa therapy on levels of cortisol as a stress biomarker: a systematic review

Balneotherapy and spa therapy are well-known practices, even though limited evidence has been produced about their biological effects. This systematic review primarily aims at assessing if balneotherapy, mud/peloid therapy, and spa therapy may influence cortisol levels. Secondarily, it aims at understanding if these interventions may improve stress resilience. PubMed/Medline, Embase, and Cochrane Library were searched for relevant articles in English or Italian about studies involving healthy and sub-healthy subjects or patients with a diagnosed disease about effects of balneotherapy, mud/peloid therapy, and spa therapy on serum and salivary cortisol levels. Fifteen studies involving 684 subjects were included. Five studies investigated biological effects of balneotherapy alone. Two of them reported significant changes of cortisol levels in healthy participants. The other three studies reported no significant variations in patients with rheumatic conditions. No studies investigated biological effects of mud/peloid therapy alone. Ten studies investigated biological effects of spa therapy with or without included mud/peloid therapy, and in all but two studies, significant variations of cortisol levels were reported. Our main findings suggest that balneotherapy may have the potential to influence cortisol levels in healthy subjects, in such a way as to improve stress resilience. Spa therapy with or without included mud/peloid therapy demonstrated the same potential to influence cortisol levels also in sub-healthy subjects and in patients with a diagnosed disease. Therefore, balneotherapy and spa therapy may be considered as useful interventions for the management of stress conditions. Further investigation is needed because of limited available data.

Effect of mud compress therapy on cartilage destruction detected by CTX-II in patients with knee osteoarthritis

BACKGROUND/OBJECTIVE

The aim of this study is to investigate the effect of mud compress (MC) therapy compared to hot pack (HP) therapy on cartilage destruction and subchondral bone alterations detected by urine levels of C telopeptide fragment of collagen type-II (uCTX-II) in patients with knee osteoarthritis (OA).

METHODS

Fifty-nine patients between 49-74 years of age with bilateral knee OA divided into 2 groups. Twenty-five patients (16 females, 9 males) and 34 patients (22 females, 13 males) were given HP versus local natural organic and mineral-rich MC therapy respectively for 2 weeks as a total of 12 sessions. uCTX-II, Visual Analog Scale (VAS), 15 m walking time, Western Ontario and McMaster Universities multifunctional (WOMAC) index were measured at baseline, after-treatment and 3 months after treatment.

RESULTS

uCTX-II level did not show any difference between the two groups, however it decreased significantly in MC and HP groups 3 months after treatment (p< 0.017). WOMAC stiffness sore was significantly lower in MC group 3 months after treatment (p< 0.05). Both MC and HP therapies lowered VAS, WOMAC total and subscores significantly up to 3 months (p< 0.017).

CONCLUSIONS

HP and MC therapies for OA of knee are not superior to one another with respect to the level of uCTX-II. MC may probably decrease the ongoing cartilage destruction and related subchonral bone interactions earlier compared to HP treatment in patients with knee OA as evidenced by decreased uCTX-II levels after-treatment.

Immunomodulatory Effects of Deokgu Thermomineral Water Balneotherapy on Oxazolone-Induced Atopic Dermatitis Murine Model

BACKGROUND

Although the therapeutic mechanism of balneotherapy for atopic dermatitis has not been clarified, many atopic patients who visit thermomineral springs have shown clinical improvements.

OBJECTIVE

This study was aimed to evaluate the immunomodulatory effect of thermomineral water balneotherapy on the atopic dermatitis murine model.

METHODS

The oxazolone-induced atopic dermatitis murine model was used to evaluate the therapeutic effect of balneotherapy with Deokgu thermomineral water compared with distilled water. Histologic evaluation and confocal microscopic imaging were performed to analyze the lesional expression of cluster-of-differentiation (CD)4 and forkhead box p3 (Foxp3). Lesional mRNA expression of interleukin (IL) 33, thymic stromal lymphopoietin (TSLP), and Foxp3 was evaluated by real-time reverse transcription polymerase chain reaction.

RESULTS

Compared with the distilled water bath group, confocal microscopic evaluation of CD4 and Foxp3 merged images showed increased expression of regulatory T cells in the thermomineral balneotherapy group. The lesional mRNA level of IL-33 showed a reduced trend in the thermomineral balneotherapy group, whereas the level of mRNA of Foxp3 was increased. TSLP showed a decreased trend in both distilled water and thermomineral water bath groups. There was a trend of reduced expression in lesional IL-33 mRNA but increased cell count of CD4(+) Foxp3(+) regulatory T cells in thermomineral balneotherapy compared with distilled water bath.

CONCLUSION

Therefore, thermomineral balneotherapy can be an effective and safe adjuvant therapeutic option for atopic dermatitis.

Does addition of 'mud-pack and hot pool treatment' to patient education make a difference in fibromyalgia patients? A randomized controlled single blind study

The aim of this randomized controlled single-blind study is to explore whether addition of mud-pack and hot pool treatments to patient education make a significant difference in short and mild term outcomes of the patients with fibromyalgia. Seventy women with fibromyalgia syndrome were randomly assigned to either balneotherapy with mud-pack and hot pool treatments (35) or control (35) groups. After randomization, five patients from balneotherapy group and five patients from control group were dropped out from the study with different excuses. All patients had 6-h patient education programme about fibromyalgia syndrome and were given a home exercise programme. The patients in balneotherapy group had heated pool treatment at 38 °C for 20 min a day, and mud-pack treatment afterwards on back region at 45 °C. Balneotherapy was applied on weekdays for 2 weeks. All patients continued to take their medical treatment. An investigator who was blinded to the intervention assessed all the patients before and after the treatment, at the first and the third months of follow-up. Outcome measures were FIQ, BDI and both patient's and physician's global assessments. Balneotherapy group was significantly better than control group at after the treatment and at the end of the first month follow-up assessments in terms of patient's and physician's global assessment, total FIQ score, and pain intensity, fatigue, non-refreshed awaking, stiffness, anxiety and depression subscales of FIQ. No significant difference was found between the groups in terms of BDI scores. It is concluded that patient education combined with 2 weeks balneotherapy application has more beneficial effects in patients with fibromyalgia syndrome as compared to patient education alone.

Effects of Balneotherapy and Physical Therapy on Sleep Quality in Patients with Osteoarthritis Aged 50 to 85 Years

Objectives

This study aims to investigate the effect of balneotherapy (BT) and physical therapy (PT) on sleep quality in patients with knee osteoarthritis (OA) aged 50 to 85 years.

Patients and methods

A total of 199 patients (76 males, 123 females; mean age 67.8±7.3 years; range 50 to 85 years) suffering from knee OA (Kellgren-Lawrence grade 2-3) for more than six months were enrolled. Sleep and functional status were assessed at baseline and after 19 sessions of BT and 15 sessions of PT by using Pittsburgh Sleep Quality Index and Western Ontario and McMaster Universities Osteoarthritis Index, respectively.

Results

A high prevalence of abnormal sleep quality in patients with knee OA was observed. The most common abnormality was sleep fragmentation (71%), with an increased sleep disturbance score. Patients reported significantly improved sleep, pain, stiffness, and functional status after BT and PT.

Conclusion

Balneotherapy and PT improved self-reported sleep and functional status in patients with OA aged 50 to 85 years. We may conclude that BT and PT, which are used in the treatment of OA, not only reduce nocturnal pain, but also improve sleep quality.

One-year follow-up of mud-bath therapy in patients with bilateral knee osteoarthritis: a randomized, single-blind controlled trial

The objective of this prospective parallel randomized single-blind study was to assess that a cycle of mud-bath therapy (MBT) provides any benefits over usual treatment in patients with bilateral knee osteoarthritis (OA). Patients with symptomatic primary bilateral knee OA, according to ACR criteria, were included in the study and randomized to one of two groups: one group received a cycle of MBT at spa center of Chianciano Terme (Italy) in addition to the usual treatment, and one group continued their regular care routine alone. Clinical assessments were performed 7 days before enrollment (screening visit), at the time of enrollment (basal time), after 2 weeks, and after 3, 6, 9, and 12 months after the beginning of the study. All assessments were conducted by two researchers blinded to treatment allocation. The primary efficacy outcomes were the global pain score evaluated by Visual Analog Scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) subscore for physical function (W-TPFS). Of the 235 patients screened, 103 met the inclusion criteria: 53 patients were included in the MBT group and 50 in the control group. In the group of patients treated with MBT, we observed a statistically significant (p < 0.001) reduction of VAS and W-TPFS score at the end of the treatment; this improvement was significant (p < 0.05) also at 3 months of follow-up. The control group did not show significant differences between baseline time and all other times. The differences between one group were significant for both primary parameters already from the 15th day and persisted up to the 9th month. This beneficial effect was confirmed by the significant reduction of symptomatic drug consumption. Tolerability of MBT seemed to be good, with light and transitory side effects. Our results confirm that a cycle of MBT added to usual treatment provides a beneficial effect on the painful symptoms and functional capacities in patients with knee OA that lasts over time. Mud-bath therapy can represent a useful backup to pharmacologic treatment of knee OA or a valid alternative for patients who do not tolerate pharmacological treatments.

Spa therapy: can be a valid option for treating knee osteoarthritis?

Osteoarthritis (OA) continues to be one of the leading causes of 'years lived with disability' worldwide. Symptomatic knee OA is highly prevalent among people aged 50 years and over and is destined to become an ever more important healthcare problem. Current management of knee OA includes non-pharmacological and pharmacological treatments. Spa therapy is one of the most commonly used non-pharmacological approaches for OA in many European countries, as well as in Japan and Israel. Despite its long history and popularity, spa treatment is still the subject of debate and its role in modern medicine continues to be unclear. The objective of this review is to summarize the currently available information on clinical effects and mechanisms of action of spa therapy in knee OA. Various randomized controlled clinical trials (RCTs) were conducted to assess the efficacy and tolerability of balneotherapy and mud-pack therapy in patients with knee OA. Data from these clinical trials support a beneficial effect of spa therapy on pain, function and quality of life in knee OA that lasts over time, until 6-9 months after the treatment. The mechanisms by which immersion in mineral or thermal water or the application of mud alleviate suffering in OA are not fully understood. The net benefit is probably the result of a combination of factors, among which the mechanical, thermal and chemical effects are most prominent. In conclusion, spa therapy seems to have a role in the treatment of knee OA. Additional RCTs and further studies of mechanisms of action with high methodological quality are necessary to prove the effects of spa therapy.

Inhibitory effects of Taraxacum mongolicum with phreatic water on melanin synthesis

BACKGROUND

Recently, people have begun showing heightened interest in skin whitening. Melanin is an important factor that determines skin color. The purpose of this study is to investigate the inhibitory effect of Taraxacum mongolicum (TAM) with phreatic water (PW) from Dogo Hot Springs on melanin synthesis.

METHODS

We assessed the inhibitory effects of TAM on melanin synthesis in B16F10 mouse melanoma cells. The mRNA levels of tyrosinase related protein (TRP)-1, TRP-2, tyrosinase, MITF, ERK, and PKA protein were analyzed with reverse transcription polymerase chain reaction and Western blot analysis. We also assessed the inhibitory effects of TAM with PW on melanin synthesis in HRM-2 melanin-possessing hairless mice. After UVB irradiation, differences in melanin were analyzed with an image analysis software between the left dorsal skin (untreated part) and the right dorsal skin (treated part). The mRNA levels of TRP-1, TRP-2, and matrix metalloproteinase (MMP)-9 were analyzed with real-time quantitative polymerase chain reaction. The dorsal skins were analyzed with histological test by hematoxylin and eosin staining.

RESULTS

TAM inhibited the TRP-1, TRP-2, tyrosinase, MITF mRNA gene expression, and PKA protein expression on the concentration-dependent B16F10 cell. Moreover, TAM increased the ERK mRNA gene expression in the B16F10 cell. After UVB irradiation, TAM with PW increased the differences in melanin between the left dorsal skin (untreated part) and the right dorsal skin (treated part) in HRM-2 mice. TAM with PW inhibited the TRP-1, TRP-2, and MMP-9 mRNA gene expression in HRM-2 mice. TAM with PW decreased the epidermal thickness, around the cell deformation, keratinization, and infiltration in HRM-2 mice.

CONCLUSION

These results indicate that TAM with PW has the inhibitory effect of decreasing the melanin synthesis.

Immunomodulatory effects of balneotherapy with hae-un-dae thermal water on imiquimod-induced psoriasis-like murine model

Background

Balneotherapy, although not a well-established dermatological treatment, is thought to have therapeutic properties for psoriasis and is used as an alternative treatment modality throughout the world.

Objective

To evaluate the mechanism underlying the therapeutic immunologic effects of thermomineral water.

Methods

A murine model of imiquimod-induced psoriasis-like skin inflammation was used for evaluating the therapeutic effects of balneotherapy with Hae-Un-Dae hot spring mineral water. The clinical improvements were evaluated by a dermatologist. Lesional cytokines, including interleukin (IL)-17A, IL-23, and IL-22, were quantitatively measured by real-time reverse transcriptase polymerase chain reaction. Serum levels of interferon-γ, IL-4, IL-5, and IL-17A were measured by enzyme-linked immunosorbent assay. T cell proportions in the spleen were evaluated by flow cytometry, and histopathological evaluation of the skin was also performed.

Results

The mineral water balneotherapy group showed faster improvement in skin erythema and scales than the distilled water bathing group. A substantial reduction was observed in the lesional mRNA levels of IL-17A and IL-23 in the mineral water group. Serum levels of IL-4 and IL-5 were significantly decreased in the mineral water group but not in the distilled water group. Normalized T cell proportions were observed after bathing.

Conclusion

Balneotherapy showed immunomodulatory effects in a psoriasis-like murine model. Balneotherapy suppressed lesional IL-23 and IL-17A, which are important cytokines in the pathogenesis of psoriasis. These results suggest that balneotherapy can be used as an effective and safe treatment for psoriasis.

Efficacy of balneotherapy on pain, function and quality of life in patients with osteoarthritis of the knee

The aims of this study were to evaluate whether balneotherapy with mineral sulphate-bicarbonate-calcium water could determine substantial symptomatic improvement, and to detect any changes in the quality of life (QoL) of patients with symptomatic knee osteoarthritis (OA). This was a prospective randomized, single blind controlled trial. Sixty outpatients with primary bilateral knee OA, according to ACR criteria, were included in the study and randomized to one of two groups: group I (30 patients) was treated with a daily sulphate-bicarbonate-calcium mineral water bath; group II (30 patients), the control group, continued their regular outpatient care routine. At baseline, after 15 days and after 12 weeks, patients were evaluated by Visual Analogue Scale (VAS) for spontaneous pain, Lequesne and Womac Index for gonarthrosis, SF-36, Arthritis Impact Measurement Scale (AIMS) and symptomatic drugs consumption. We observed a significant improvement of all parameters at the end of the cycle of balneotherapy which persisted throughout the follow-up period, whereas in the control group no significant differences were noted. This symptomatic effect was confirmed by the significant reduction of symptomatic drugs consumption. The differences between the two groups were significant for all considered parameters already from the 15th day and persisted during follow-up. Tolerability of balneotherapy seemed to be good, with light and transitory side effects. Our results confirm that the beneficial effects of balneotherapy in patients with knee OA last over time, with positive effects on the painful symptomatology, a significant improvement on functional capacities and QoL. Balneotherapy can represent a useful backup to pharmacological treatment of knee OA or a valid alternative for patients who do not tolerate pharmacological treatments.

Fibromyalgia syndrome and spa therapy: myth or reality?

Fibromyalgia syndrome (FS) is a common musculoskeletal disorder characterized by otherwise unexplained chronic widespread pain, a lowered pain threshold, high tender point counts, sleep disturbances, fatigue, headache, irritable bowel syndrome, morning stiffness, paraesthesias in the extremities, often psychological distress and depressed mood. Consequently, FS has a negative impact on working capacity, family life, social functioning and quality of life. Because of unknown etiology and not clearly understood pathogenesis, there is no standard therapy regime for FS. A variety of medical treatments, including antidepressants, opioids, analgesic or non-steroidal anti-inflammatory drugs, sedatives, muscle relaxants and antiepileptics, have been used to treat FS. Currently, no pharmacological treatment for FS is consistently successful. According to recent guidelines, the optimal treatment of FS requires a multidisciplinary approach with a combination of non-pharmacological and pharmacological treatment modalities. Spa therapy is a popular treatment for FS in many European countries, as well as in Japan and Israel. However, despite their long history and popularity spa treatments are still the subject of debate and their role in modern medicine is still not clear. The objective of this review is to summarize the currently available information on clinical effects and mechanism of action of spa therapy in FS. We also provide some suggestions for further development in this area.

Thermal rehabilitation and osteoarticular diseases of the elderly

Elderly people with osteoarticular disease (OAD) traditionally visit spas for cycles of treatment comprising mud therapy and balneotherapy. We believe that the thermal environment is a suitable place for providing rehabilitative and preventive treatment both in association with traditional spa therapy and as the sole means of treatment. The aim of this paper is to describe the advantages and possible developments of these integrated approaches to OAD in the elderly.

Mud-bath treatment in spondylitis associated with inflammatory bowel disease – a pilot randomised clinical trial

OBJECTIVES

The objective of this study was to evaluate the effects and the tolerability of mud packs and thermal baths in a group of patients affected with this disease.

METHODS

Twenty-four patients with spondylitis and Crohn's disease or ulcerative colitis, treated with 5-ASA or sulfasalazine, were randomised and assessed by an investigator independent from the spa staff: 12 were submitted to a cycle of mud-bath treatment (12 mud packs and 12 thermal baths over a period of two weeks) and 12 were enrolled as controls. Patients were evaluated by BASDAI, BASFI, BAS-G and VAS for back pain before, at the end of a cycle of mud-bath treatment, and after 12 and 24 weeks. C reactive protein serum levels detected by high sensitivity nephelometric method and gut symptoms evaluated by CDAI or Powell-Tuck index were assessed at the same time periods.

RESULTS

A significant reduction of clinical evaluation indices of spondylitis was observed at the end of the cycle of mud-bath treatment. BASDAI50 improvement remained significant until the end of the follow-up (24 weeks). C reactive protein serum levels didn't show significant changes. No patient referred any gut symptom exacerbation. No significant changes in clinical evaluation indices, in IBD activity indices and in CRP serum levels were observed in the control group.

CONCLUSION

Mud-bath treatment in patients with spondylitis associated with inflammatory bowel disease is well tolerated and may improve spinal symptoms and function for several months.

Effects of mud-bath treatment on fibromyalgia patients: a randomized clinical trial

The efficacy of balneotherapy in fibromyalgia syndrome (FS) has been well demonstrated, while controlled studies using mud packs are lacking. We performed a randomized clinical trial to evaluate the effects and the tolerability of mud-bath treatment in FS patients, who are poor responders to pharmacological therapy. Eighty patients with primary FS, according to ACR criteria, were randomly allocated to two groups: 40 were submitted to a cycle of 12 mud packs and thermal baths, and 40 were considered as controls. At baseline, after thermal treatment and after 16 weeks, patients were evaluated by FIQ, tender points count, VAS for "minor" symptoms, AIMS1 and HAQ. Control patients were assessed at the same time periods. A significant improvement of all evaluation parameters after mud-bath therapy and after 16 weeks was observed. Mud packs were well tolerated and no drop-outs were recorded. Our results suggest the efficacy and the tolerability of mud-bath treatment in primary FS.

Therapeutic effect of spa therapy and short wave therapy in knee osteoarthritis: a randomized, single blind, controlled trial

Spa therapy and short wave therapy are two of the most commonly used non-pharmacological approaches for osteoarthritis. The aim of this study was to assess their efficacy in comparison to conventional therapy in patients with osteoarthritis of the knee in a single blind, randomized, controlled trial. Seventy-four outpatients were enrolled; 30 patients were treated with a combination of daily local mud packs and arsenical ferruginous mineral bath water from the thermal resort of Levico Terme (Trento, Italy) for 3 weeks; 24 patients were treated with short wave therapy for the same period and 20 patients continued regular, routine ambulatory care. Patients were assessed at baseline, upon completion of the 3-week treatment period, and 12 weeks later. Spa therapy and short wave therapy both demonstrated effective symptomatic treatment in osteoarthritis of the knee at the end of the treatment, but only the spa therapy was shown to have efficacy persistent over time. Our study demonstrated the superiority of arsenical ferruginous spa therapy compared to short wave therapy in the treatment of osteoarthritis of the knee, probably in relationship to the specific effects of the minerals in this water.

Balneotherapy in dermatology

Balneotherapy and spa therapy emerged as an important treatment modality in the 1800s, first in Europe and then in the United States. Balneotherapy involves immersion of the patient in mineral water baths or pools. Today, water therapy is being practiced in many countries. Examples of unique and special places for balneotherapy are the Dead Sea in Israel, the Kangal hot spring in Turkey, and the Blue Lagoon in Iceland. Bathing in water with a high salt concentration is safe, effective, and pleasant for healing and recovery. This approach needs no chemicals or potentially harmful drugs. There are almost no side effects during and after treatment, and there is a very low risk to the patient's general health and well-being. Mineral waters and muds are commonly used for the treatment of various dermatologic conditions. The major dermatologic diseases that are frequently treated by balneotherapy with a high rate of success are psoriasis and atopic dermatitis. The mechanisms by which broad spectrums of diseases are alleviated by spa therapy have not been fully elucidated. They probably incorporate chemical, thermal, mechanical, and immunomodulatory effects. The major importance of balneotherapy and spa therapy both individually and as complements to other therapies lies in their potential effectiveness after standard medical treatments have failed to give comfort to these patients.

Efficacy and safety of the new DMARD leflunomide: comparison to placebo and sulfasalazine in active rheumatoid arthritis

The efficacy and safety of the novel DMARD leflunomide was compared to placebo and sulfasalazine in a randomized, double-blind study. At Week 24, leflunomide significantly reduced tender and swollen joint counts and physician and patient assessment scores compared to placebo (P < 0.001). Response rates with leflunomide were significantly greater than placebo: ACR 20% (55% vs 29%, P = 0.0001). Comparable response rates were observed with sulfasalazine (ACR 20%: 56%). Leflunomide significantly improved HAQ scores compared to placebo or sulfasalazine (P < 0.009). The onset of action with leflunomide was rapid and was seen as early as Week 2. Radiographic disease progression was significantly slower with leflunomide than placebo (P < 0.01). Leflunomide was well tolerated. No long-term safety issues were reported with leflunomide in patients who opted to continue treatment for up to 2 years. Efficacy of leflunomide in the treatment of RA was maintained at 2 years.