Combining balneotherapy and health promotion to promote active and healthy ageing: the Balaruc-MACVIA-LR® approach

Balneotherapy for chronic venous insufficiency

BACKGROUND

Chronic venous insufficiency (CVI) is a progressive and common disease that affects the superficial and deep venous systems of the lower limbs. CVI is characterised by valvular incompetence, reflux, venous obstruction or a combination of these symptoms, with consequent distal venous hypertension. Clinical manifestations of CVI include oedema, pain, skin changes, ulcerations and dilated skin veins in the lower limbs. It places a large financial burden on health systems. There is a wide variety of treatment options for CVI, ranging from surgery and medication to compression and physiotherapy. Balneotherapy (treatments involving water) may be a relatively cheap and efficient way to deliver physiotherapy to people with CVI. This is an update of a review first published in 2019.

OBJECTIVES

To assess the effectiveness and safety of balneotherapy for the treatment of people with chronic venous insufficiency.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 June 2022.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials comparing balneotherapy to no treatment or other types of treatment for CVI. We also included studies that used a combination of treatments.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. disease severity, 2. health-related quality of life (HRQoL) and 3.

ADVERSE EFFECTS

Our secondary outcomes were 1. pain, 2. oedema, 3. leg ulcer incidence and 4. skin pigmentation changes. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included nine randomised controlled trials involving 1126 participants with CVI. Seven studies evaluated balneotherapy versus no treatment, one study evaluated balneotherapy versus a phlebotonic drug (melilotus officinalis), and one study evaluated balneotherapy versus dryland exercises. We downgraded our certainty in the evidence due to a lack of blinding of participants and investigators, participant-reported outcomes and imprecision. Balneotherapy versus no treatment Balneotherapy compared to no treatment probably results in slightly improved disease severity signs and symptoms scores as assessed by the Venous Clinical Severity Score (VCSS; mean difference (MD) -1.75, 95% confidence interval (CI) -3.02 to -0.49; 3 studies, 671 participants; moderate-certainty evidence). Balneotherapy compared to no treatment may improve HRQoL as assessed by the Chronic Venous Insufficiency Quality of Life Questionnaire 2 (CIVIQ2) at three months, but we are very uncertain about the results (MD -10.46, 95% CI -19.21 to -1.71; 2 studies, 153 participants; very low-certainty evidence). The intervention may improve HRQoL at 12 months (MD -4.48, 95% CI -8.61 to -0.36; 2 studies, 417 participants; low-certainty evidence). It is unclear if the intervention has an effect at six months (MD -2.99, 95% CI -6.53 to 0.56; 2 studies, 436 participants; low-certainty evidence) or nine months (MD -6.40, 95% CI -13.84 to 1.04; 1 study, 59 participants; very low-certainty evidence). Balneotherapy compared with no treatment may have little or no effect on the occurrence of adverse effects. The main adverse effects were thromboembolic events (odds radio (OR) 0.35, 95% CI 0.09 to 1.42; 3 studies, 584 participants; low-certainty evidence), erysipelas (OR 2.58, 95% CI 0.65 to 10.22; 2 studies, 519 participants; low-certainty evidence) and palpitations (OR 0.33, 95% CI 0.01 to 8.52; 1 study, 59 participants; low-certainty evidence). No studies reported any serious adverse effects. Balneotherapy compared with no treatment may improve pain scores slightly at three months (MD -1.12, 95% CI -1.35 to -0.88; 2 studies, 354 participants; low-certainty evidence); and six months (MD -1.02, 95% CI -1.25 to -0.78; 2 studies, 352 participants; low-certainty evidence). Balneotherapy compared with no treatment may have little or no effect on oedema (measured by leg circumference) at 24 days to three months, but we are very uncertain about the results (standardised mean difference (SMD) 0.32 cm, 95% CI -0.70 to 1.34; 3 studies, 369 participants; very low-certainty evidence). Balneotherapy compared with no treatment may have little or no effect on the incidence of leg ulcers at 12 months, but we are very uncertain about the results (OR 1.06, 95% CI 0.27 to 4.14; 2 studies, 449 participants; very low-certainty evidence). Balneotherapy compared with no treatment may slightly reduce skin pigmentation changes as measured by the pigmentation index at 12 months (MD -3.60, 95% CI -5.95 to -1.25; 1 study, 59 participants; low-certainty evidence). Balneotherapy versus melilotus officinalis For the comparison balneotherapy versus a phlebotonic drug (melilotus officinalis), there was little or no difference in pain symptoms (OR 0.29, 95% CI 0.03 to 2.87; 1 study, 35 participants; very low-certainty evidence) or oedema (OR 0.21, 95% CI 0.02 to 2.27; 1 study, 35 participants; very low-certainty evidence), but we are very uncertain about the results. The study reported no other outcomes of interest. Balneotherapy versus dryland exercise For the comparison balneotherapy versus dryland exercise, evidence from one study showed that balneotherapy may improve HRQoL as assessed by the Varicose Vein Symptom Questionnaire (VVSymQ), but we are very uncertain about the results (MD -3.00, 95% CI -3.80 to -2.20; 34 participants, very low-certainty evidence). Balneotherapy compared with dryland exercises may reduce oedema (leg volume) after five sessions of treatment (right leg: MD -840.70, 95% CI -1053.26 to -628.14; left leg: MD -767.50, 95% CI -910.07 to -624.93; 1 study, 34 participants, low-certainty evidence). The study reported no other outcomes of interest.

AUTHORS' CONCLUSIONS

For the comparison balneotherapy versus no treatment, we identified moderate-certainty evidence that the intervention improves disease severity signs and symptoms scores slightly, low-certainty evidence that it improves pain and skin pigmentation changes, and very low-certainty evidence that it improves HRQoL. Balneotherapy compared with no treatment made little or no difference to adverse effects, oedema or incidence of leg ulcers. Evidence comparing balneotherapy with other interventions was very limited. To ensure adequate comparison between trials, future trials should standardise measurements of outcomes (e.g. disease severity signs and symptoms score, HRQoL, pain and oedema) and follow-up time points.

Comparison of outpatient and inpatient spa therapy in knee osteoarthritis

Osteoarthritis (OA) is a common condition that impacts many people worldwide and involves weight-bearing joints, resulting in chronic pain. In this study, we aimed to compare the effectiveness of inpatient and outpatient physical therapy modalities and spa combination treatments on pain and functional status in patients with knee osteoarthritis. Seventy-four patients diagnosed with primary knee osteoarthritis were included in this study. The patients were randomized into two groups, inpatient (n = 37) and outpatient (n = 37) physical therapy. All patients received a physical therapy program (superficial heater + deep heater + transcutaneous electrical nerve stimulation) for 2 weeks and spa therapy. All cases were evaluated clinically, laboratory, and radiographically. In order to evaluate pain and functional status, the Visual Analogue Scale (VAS), Western Ontario and McMaster Universities osteoarthritis index (WOMAC), and Timed Up and Go (TUG) test were used before and after treatment. There was no significant difference between the two groups in the TUG test and WOMAC scores (p > 0.05). However, a significant difference was found in VAS scores in favor of the outpatient group (p < 0.05). As a result, although there was a significant improvement in pain scores in the outpatient group, multicenter studies with larger patient groups may provide more evidence.

Balneotherapy with a psychoeducation program for the promotion of a balanced care in family caregivers of older adults

This study aimed to analyze the efficacy of an intervention program for informal caregivers of elderly dependent that combined balneotherapy with group psychoeducation (BT-PE) based on the balanced care model. The BT-PE intervention (N = 124) was compared with a comparison group only exposed to balneotherapy (BT) (N = 76). The two modalities included both primary and secondary informal caregivers. A three-way mixed ANOVA was conducted to determine the effects of two between-subjects´ factors (intervention group and caregiver type) and one within-subjects´ factor (time) on burden, depression, anxiety, maladjustment and care satisfaction. Results showed less burden and more care satisfaction in both primary and secondary caregivers participating in the BT-PE program after the interventions. Primary caregivers also showed lower levels of maladjustment in the experimental group at post-intervention. Although depressive symptoms and anxiety decreased significantly in both intervention groups, BT-PE did not show lower scores compared with the application of sole BT. The relevance of caregivers´ psychoeducation on the balanced care model and its combination with balneotherapy is highlighted.

Self-reported fatigue: A significant risk factor for falling in older women and men

OBJECTIVE

To determine whether fatigue may be a risk factor for falling in older men and women, independent of other components of the frailty phenotype, fear of falling, and physical performance.

DESIGN

Among 986 women and 485 men visiting a health resort (mean age 72.3 and 72.7, respectively), subjects with at least one fall in the previous year were compared with non-fallers using a multivariate logistic regression analysis. Age, fatigue and fear of falling over the previous month were assessed by visual analogue scale (VAS), and the past 7 days of activity were assessed using the International Physical Activity Questionnaire. The following parameters were also assessed: weight loss in the past year, maximum grip strength measured with a hand dynamometer, time to perform the 5-chair stand and the up and go tests, time to walk 4 m, time held on one leg, feet together, as well as in the semi-tandem and tandem positions.

RESULTS

A feeling of fatigue (VAS score ≥ 5/10 in women or ≥4/10 in men), a fear of falling (VAS score ≥ 4/10 in women or ≥2 in men), and poor balance (time held in semi-tandem position < 10 s in women and time held on one leg < 6.5 s in men) were the 3 independent parameters distinguishing fallers from non-fallers.

CONCLUSION

The present study suggests the interest of adding a VAS score of fatigue to that of fear of falling and balance measurements for screening men and women aged 65 or older who are at risk of falls.

Analysis of the health profiles and prevalence of falls for patients over 65 years of age in a thermal environment

BACKGROUND

A falls prevention programme has been initiated in balneotherapy at Balaruc-les-Bains.

AIMS

To determine the health profiles of subjects who are at risk of falls, over 65 years of age and attending balneotherapy.

METHODS

Questionnaires were used to evaluate people on their fear of falling. Fatigue was assessed by visual analog scale as well as by functional status over the past 12 months. EQ-5D-3L, the IPAQ questionnaire and Fried's frailty scale were all used. Patients' functional capabilities were tested using the Unipedal stance test, the TUG test, the SPPB, the Tandem walking test and the isometric manual grip strength test.

RESULTS

Out of the 1471 patients (72.45 years ± 5.10), the women (67%) were tested. In the last 12 months, 485 of these 1471 patients fell (33%) and 37% of them suffered a severe injury. 45-50% of these subjects are now in good health. Women had a significantly higher impaired perception of their health than men (0.02 < p < 0.0001). According to Fried's criteria, 10.2% of the population is considered frail, with a significantly greater number of women (p < 0.0001). Static equilibrium was subnormal (less than 12 s during the TUG). The number of steps in tandem position discriminates individuals and gender as does the speed of moving from A to B and muscular strength.

CONCLUSIONS

More than one-third of the subjects (more women than men) aged 65 or older visiting the Balaruc-les-Bains health resort are pre-frail or frail. They all have a recent history of falls, suffer from impaired muscle strength, and have balance and gait disorders.

Balneotherapy for musculoskeletal pain: does the mineral content matter?

Musculoskeletal pain is a health challenge with various treatment strategies. The study has been accomplished with the aim to reveal the effect of mineral water with different mineral content on musculoskeletal pain and related symptoms experienced. A randomized controlled single-blinded parallel-group study has been performed (145 participants with pain; 5 groups). The duration of treatment was 2 weeks, whereas follow-up has taken 3 months. Change in pain after a single procedure and the pain parameters with related symptoms during the study period have been measured. The effect size using Cohen's d has been estimated. Small effect (0.2-0.4) on pain has been distinguished after each mineral water procedure. Tap water procedures have been effective in 60% of cases. Twenty grams per liter water baths have had a small effect on pain intensity and tender points, body flexibility, and spinal mobility, and a medium one on sleep quality, and reduced CRP. Forty grams per liter water has had a small effect on pain intensity, frequency, and spinal mobility, and a medium one on flexibility, fatigue, and sleep quality, and reduced ESR. Sixty grams per liter water has had a small effect on pain parameters and fatigue, and a medium one on flexibility and sleep quality, and reduced ESR. The effect lasting up to 2 months has been identified mostly in the 60 g/L group. Tap water has had a short time effect on pain intensity and tender points. There have not been any changes of sufficient significance identified in the control group and any differences between mineral water groups. Sufficient difference between mineral and tap water groups has been determined in pain intensity, spinal mobility, and sleep quality, whereas in the case of the control group, significant difference in pain intensity and frequency, flexibility, and spinal mobility has been identified. The consumption of pain medication has significantly decreased in all mineral water groups. The total mineral content of the water has no significant influence on the reduction of musculoskeletal pain. Mineral water baths have small effect on pain and medium effect on other musculoskeletal disease-related symptoms and pain medication consumption lasting up to 3 months; it is more beneficial than tap water or no treatment for the improvement of symptoms associated with musculoskeletal diseases. Even single balneotherapy procedure results in small pain reduction.

Efficacy of aquatic therapy for neck pain: a systematic review

This study systematically reviews the current state of aquatic treatment of neck pain and assesses the scientific evidence of its benefits. The databases PubMed, Scopus, Web of Science and PEDro were searched for relevant reports published from January 1, 2008, to November 7, 2017, using the keywords "neck pain" in addition to "balneotherapy", "spa treatment", "spa", "thalassotherapy", "hydrotherapy", "aquatic therapy" or "aquatic". Inclusion criteria were full-text articles published in journals included in Journal Citation Reports in English and Spanish describing human studies. Case studies, letters to the editor and meeting presentations or other contributions were excluded. Of 367 articles identified, only 13 fulfilled the inclusion criteria: 5 randomized trials, 1 single blind controlled study, 2 pilot studies, 2 observational retrospective studies, 1 prospective study, 1 clinical study and 1 not specified. Participants were 658 subjects with chronic neck pain. Main symptoms and signs treated were neck pain, disability, cervical disc herniation and compromised quality of life. Evidence that aquatic treatment improves quality of life in affected individuals was good in four studies, fair in eight and weak in one. Treatment of neck pain using different waters and techniques reduced pain and disability, and improved functional capacity, quality of life, joint mobility, balance, relaxation and mood.

Balneotherapy for chronic venous insufficiency

BACKGROUND

Chronic venous insufficiency (CVI) is a progressive and common disease that affects the superficial and deep venous systems of the lower limbs. CVI is characterised by valvular incompetence, reflux, venous obstruction, or a combination of these with consequent distal venous hypertension. Clinical manifestations of CVI include oedema, pain, skin changes, ulcerations and dilated skin veins in the lower limbs. It can result in a large financial burden on health systems. There is a wide variety of treatment options or therapies for CVI, ranging from surgery and medication to compression and physiotherapy. Balneotherapy (treatments involving water) is a relatively cheap option and potentially efficient way to deliver physical therapy for people with CVI.

OBJECTIVES

To assess the efficacy and safety of balneotherapy for the treatment of people with chronic venous insufficiency (CVI).

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, the World Health Organization International Clinical Trials Registry Platform and the Clinical Trials.gov trials register to August 2018. We searched the LILACS and IBECS databases. We also checked references, searched citations and contacted study authors to identify additional studies.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials comparing balneotherapy with no treatment or other types of treatment for CVI. We also included studies that used a combination of treatments.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed studies retrieved by the search strategies. Both review authors independently assessed selected studies for complete analysis. We resolved conflicts through discussion. We attempted to contact trial authors for missing data, obtaining additional information. For binary outcomes (leg ulcer incidence and adverse events), we presented the results using odds ratio (OR) with 95% confidence intervals (CI). For continuous outcomes (disease severity, health-related quality of life (HRQoL), pain, oedema, skin pigmentation), we presented the results as a mean difference (MD) with 95% CI.

MAIN RESULTS

We included seven randomised controlled trials with 891 participants (outpatients in secondary care). We found no quasi-randomised controlled trials. Six studies (836 participants) evaluated balneotherapy versus no treatment. One study evaluated balneotherapy versus a phlebotonic drug (melilotus officinalis) (55 participants). There was a lack of blinding of participants and investigators, imprecision and inconsistency, which downgraded the certainty of the evidence.For the balneotherapy versus no treatment comparison, there probably was no improvement in favour of balneotherapy in disease severity signs and symptom score as assessed using the Venous Clinical Severity Score (VCSS) (MD -1.66, 95% CI -4.14 to 0.83; 2 studies, 484 participants; moderate-certainty evidence). Balneotherapy probably resulted in a moderate improvement in HRQoL as assessed by the Chronic Venous Insufficiency Questionnaire 2 (CVIQ2) at three months (MD -9.38, 95% CI -18.18 to -0.57; 2 studies, 149 participants; moderate-certainty evidence), nine months (MD -10.46, 95% CI -11.81 to -9.11; 1 study; 55 participants; moderate-certainty evidence), and 12 months (MD -4.99, 95% CI -9.19 to -0.78; 2 studies, 455 participants; moderate-certainty evidence). There was no clear difference in HRQoL between balneotherapy and no treatment at six months (MD -1.64, 95% CI -9.18 to 5.89; 2 studies, 445 participants; moderate-certainty evidence). Balneotherapy probably slightly improved pain compared with no treatment (MD -1.23, 95% CI -1.33 to -1.13; 1 study; 390 participants; moderate-certainty evidence). There was no clear effect related to oedema between the two groups at 24 days (MD 43.28 mL, 95% CI -102.74 to 189.30; 2 studies, 153 participants; very-low certainty evidence). There probably was no improvement in favour of balneotherapy in the incidence of leg ulcers (OR 1.69, 95% CI 0.82 to 3.48; 2 studies, 449 participants; moderate-certainty evidence). There was probably a reduction in incidence of skin pigmentation changes in favour of balneotherapy at 12 months (pigmentation index: MD -3.59, 95% CI -4.02 to -3.16; 1 study; 59 participants; low-certainty evidence). The main complications reported included erysipelas (OR 2.58, 95% CI 0.65 to 10.22; 2 studies, 519 participants; moderate-certainty evidence), thromboembolic events (OR 0.35, 95% CI 0.09 to 1.42; 3 studies, 584 participants; moderate-certainty evidence) and palpitations (OR 0.33, 95% CI 0.01 to 8.52; 1 study; 59 participants; low-certainty evidence), with no clear evidence of an increase in reported adverse effects with balneotherapy. There were no serious adverse events reported in any of the studies.For the balneotherapy versus a phlebotonic drug (melilotus officinalis) comparison, we observed no clear difference in pain symptoms (OR 0.29, 95% CI 0.03 to 2.87; 1 study; 35 participants; very low-certainty evidence) and oedema (OR 0.21, 95% CI 0.02 to 2.27; 1 study; 35 participants; very low-certainty evidence). This single study did not report on the other outcomes of interest.

AUTHORS' CONCLUSIONS

We identified moderate- to low-certainty evidence that suggests that balneotherapy may result in a moderate improvement in pain, quality of life and skin pigmentation changes and has no clear effect on disease severity signs and symptoms score, adverse effects, leg ulcers and oedema when compared with no treatment. For future studies, measurements of outcomes such as disease severity sign and symptom score, quality of life, pain and oedema and choice of time points during follow-up must be standardised for adequate comparison between trials.

Geothermal water for health state improvement: randomised controlled study

Abstract Introduction. Aim: to evaluate the effect of geothermal water of different mineralization on health state improvement. Material and method. A randomized controlled single blinded parallel groups interventional study was performed. 250 participants were divided into 5 groups: 3 balneotherapy (20, 40 and 60 g/l total mineralization), 1 tap water, and 1 control group. Hydrotherapy was carried out on an outpatient on everyday basis for 5 days a week over a 2-week period. The main effect on health state was measured using SHSQ-25 questionnaire after 2 weeks and each month during 3-month follow-up period. Examination by a physician and common blood and urine tests were done after the treatment period. Results and discussions. After a 2-week treatment, participants receiving all types of hydrotherapy showed a significant therapeutic response compared to the control group, especially in fatigue and mental state subcategories. The biggest total health enhancing effect after therapy was in seen in 40 g/l group, followed by 20 g/l group. The smallest effect was seen in tap water group. The most significant post-therapy effect during 3 months was given by 40 g/l procedures. Health self-rating after 2 weeks improved significantly only in geothermal water groups and lasted 2-3-month post-treatment. 2 weeks of balneotherapy had significant impact on Er, MCV, MCH, MPV, Eo, Tr, urine SG, and pH. According to the physician’s assessment, the best results after 2 weeks were in 20 g/l group, but 40 and 60 g/l water procedures gave more residual effect. Conclusions. The geothermal water of 40 g/l total mineralization has the best positive effect for health enhancement after 2 weeks and during 3-month period. 20 g/l water gives fast and short- term health effect, while 40-60 g/l water has long-lasting effect on health status. Key words: health status, balneotherapy, geothermal water, hydrotherapy,

Is the Duration of Spa Cure Treatment Important in Knee Osteoarthritis? A Randomized Controlled Study

Background: Spa therapies are applied in varying durations. Today, the duration of spa therapy may be long for people with active lives. How should we determine the duration of treatment in order to minimize therapy costs and loss of labor force? Does the duration of treatment have an impact on pain, functional status, and quality of life of patients? Objective: Our aim was to investigate the role of application time on the efficacy of spa therapy in individuals undergoing the same treatment protocol. Methods: This was a randomized, controlled, single-blind clinical trial design. Sixty individuals were divided into two groups: 3 weeks of therapy (group 1) and 2 weeks of therapy (group 2). Pretreatment, posttreatment, and 30-day posttreatment findings were recorded using a visual analog scale (VAS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Nottingham Health Profile (NHP). Results: The measurements revealed significant improvement after treatment compared to those observed prior to the treatment in both groups, except for the social isolation subgroup. When the groups were compared to each other, significant improvement was observed in pain (VAS, WOMAC, NHP) in favor of group 1 at all measurement times. Conclusion: Our results suggest that spa therapy has positive effects on pain, physical activity, and quality of life in patients, and 15 sessions of therapy had even better effects on pain. We believe that the duration of therapy should be determined considering the efficacy of the therapy on pain as well as the functional situation and quality of life of patients regarding therapy costs.

[Balneotherapy and modification of risk factors in cardiovascular disease prevention programs]

Cardiovascular disease (CVD) is the leading cause of death in the Russian Federation, as in many other countries. Taking into consideration the observed increase in the spread of risk factors, modern demographic trends (an increase in the proportion of elderly people), and a high economic burden of circulatory system diseases, the search for new forms and effective strategies of prevention is becoming relevant. OBJECTIVE: To provide the data available in the scientific literature on the effectiveness of the measures to modify risk factors and lifestyle, which are implemented during balneotherapy under both resort and in non-resort conditions, and to define areas for further investigators in this field. Investigations evaluating the effectiveness of these measures were sought in the Embase, PubMed, PEDro, Web of Science, eLIBRARY databases in January 2012 to August 2018. The analysis included seven trials that showed an improvement of estimated endpoints (blood pressure, body mass index, lipid profile, physical activity, and morbidity and mortality rates). The generalization of results of the analyzed trials was limited by the high heterogeneity of their protocols and methodological quality, which does not allow for a final conclusion on the effectiveness of preventive measures implemented during balneotherapy. Future research should provide more evidence of the benefits of this approach. The analysis will be able to take into account the existing experience and to develop a strategy to enhance the effectiveness of cardiovascular disease prevention programs based on high-quality randomized clinical trials.

Health tourism: an opportunity for sustainable development

In February 2017, the "Programma Mattone Internazionale Salute" (ProMis), that is the Italian Program for Internationalization of Regional Health Systems of the Ministry of Health (MoH), presented the first version of its Position Paper on Health Tourism, which embeds a first shared approach to the recommendations expressed by the European Committee of Regions (CoR) on "Age-Friendly" tourism. The CoR stresses the importance of local and regional authorities in the coordination of multi-sectoral policies such as healthcare, social assistance, transport, urban planning and rural development in relation to the promotion of mobility, security, accessibility of services, including health care and social services. "Age-friendly" tourism is an example of an innovative tourist offer that strives to meet the health needs of the entire "traveling" population, with an integrated and cross-sector approach that involves various organizations operating in sectors such as healthcare, accessibility and transport. The aim of the workshop was to explore the interest of the stakeholders to participate in a systemic action in the field of "health" tourism, and to identify priority implementation areas that offer opportunities to take advantage of validated, innovative experiences that strengthen the accessibility to health and social services in regional, national and international contexts. This effort provides the opportunity to take advantage of aligning the European Structural and Investment Funds (ESIF) to the development of tourism, coherently with the needs and resources of local and regional health authorities.

The effects of inpatient versus outpatient spa therapy on pain, anxiety, and quality of life in elderly patients with generalized osteoarthritis: a pilot study

This study aimed to investigate the effect of inpatient vs outpatient spa therapy on pain, quality of life, and anxiety in elderly patients with generalized osteoarthritis. A total of 150 patients were randomized into three groups. Group I was given medical treatment, group II was treated as outpatients, and group III was treated as inpatient spa therapy. Assessments were made using the Pain (VAS), EQ-5D-3L Scale, and State and Trait Anxiety Inventory (STAI) at the beginning of treatment (W0), at the end of treatment (W2), and at the fourth week after treatment (W6). The comparison of outpatient spa group and etodolac treatment group showed that outpatient spa group was superior to etodolac treatment group in all evaluated parameters at W2 vs W0 and W6 vs W0. The comparison of inpatient spa group and etodolac treatment group showed that inpatient spa group was superior to etodolac treatment group in all evaluated parameters at W2 vs W0 and W6 vs W0. The comparison of inpatient spa group and outpatient spa group showed that inpatient spa group was superior to outpatient spa group in all evaluated parameters except STAI-TXII at W2 vs W0 and in all evaluated parameters W6 vs W0. Spa therapy, either as an outpatient or inpatient basis, may have a positive effect on pain, anxiety, and quality of life in geriatric patients with generalized osteoarthritis. The inpatient spa therapy may be more beneficial than outpatient spa therapy. When the side effects of drug treatments are emphasized, spa therapy may be considered as an interesting option for elderly with osteoarthritis.