Spa therapy and peripheral serotonin and dopamine function: a systematic review

Spa therapy consists of multiple techniques based on the healing effects of water, including hydrotherapy, balneotherapy, and mud therapy, often combined with therapeutic exercises, massage, or physical therapy. Balneotherapy is a clinically effective complementary approach in the treatment of low-grade inflammation- and stress-related pathologies, especially rheumatic conditions due to its anti-inflammatory properties. The main objective of this investigation was to conduct a systematic review analyzing the available evidence on the effect of spa therapy on serotonin and dopamine function. The databases PubMed, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) were used from June to July 2023. Exclusion criteria were (1) articles not written in English, (2) full text not available, (3) article not related to the objective of the review. JADAD scale was used for methodological quality evaluation. Four studies were included in the systematic review. Two studies were related to serotonin in healthy individuals, one to serotonin in fibromyalgia, and one to dopamine in healthy individuals. One of the studies evaluated hydrotherapy, another one balneotherapy and mud-bath therapy, and the other two assessed balneotherapy interventions. Studies were very heterogeneous, and their methodological quality was low, making it difficult to draw clear conclusions regarding the effect of spa therapy on peripheral serotonin and dopamine function. The findings of this review highlight the lack of studies evaluating these neurotransmitters and hormones in the context of spa therapy. Further research is needed to evaluate the potential effects of these therapies on serotonin or dopamine function.

Circulating serotonin and dopamine concentrations in osteoarthritis patients: a pilot study on the effect of pelotherapy

Balneotherapy has demonstrated clinical efficacy in the management of pathologies involving low-grade inflammation and stress. In rheumatic conditions such as osteoarthritis (OA), this therapy presents anti-inflammatory properties and potential to improve psychological well-being. Although the neurohormones serotonin and dopamine are known to be involved in these processes, surprisingly they have not been studied in this context. The objective was to evaluate the effect of a cycle of balneotherapy with peloids (pelotherapy) on circulating serotonin and dopamine concentrations in a group of aged individuals with OA, after comparing their basal state to that of an age-matched control group. In our pilot study, a pelotherapy program (10 days) was carried out in a group of 16 elderly patients with OA, evaluating its effects on circulating serotonin and dopamine concentrations (measured by ELISA). Individuals with OA showed higher levels of serotonin and lower dopamine levels, in line with the inflammatory roles of these mediators. After pelotherapy, serotonin concentrations significantly decreased, potentially contributing to the previously reported anti-inflammatory effects of balneotherapy.

Psychosomatic states and their correlation with letting-go: two newly evaluated core factors for investigating the therapeutic effect of spa treatment

Spa therapy (aka crenobalneotherapy) has been the object of criticism due to insufficient evidence of its effectiveness. While further effectiveness studies are needed, others are also required to better evaluate the curative factors involved during spa therapy that may contribute to the effectiveness. The current study used specific scales to investigate two possible curative factors: the psychosomatic state and the letting-go of patients with mental disorders after 3 weeks of spa therapy. The Saujon Psychosomatic Questionnaire (SPQ) and the Quantified Assessment of Fluidity of Consciousness Questionnaire (QACF) evaluate psychosomatic state and letting-go, respectively. The Hospital Anxiety and Depression Scale (HAD) and the Insomnia Severity Index (ISI) evaluate depression and anxiety symptoms and insomnia symptoms, respectively. Sixty-five subjects (57 women (87.69%); 8 men), with a mean age of 56.9 (± 9.7) years, were included. SPQ and QAFC scores improved significantly before and after the 3 weeks of spa therapy. Improvement in HAD and ISI scores was significantly correlated with SPQ and QACF scores. These preliminary results suggest that the induced psychosomatic state and the letting-go induced by spa treatment with bubbling baths, jet showers, pool bathing and massage could help patients to become more available and more able to change their psychophysiological state.

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.

Exploring the potential role of health resort medicine in the management of breast cancer-related lymphedema: a viable alternative for innovative rehabilitation opportunities?

Lymphedema is a chronic and progressive disorder of the lymphatic system that impairs the return of lymphatic fluid. Breast cancer treatment can cause breast cancer-related lymphedema (BCRL), with axillary lymph node dissection and regional lymph node radiation being established risk factors. BCRL can cause severe morbidity, disability, and reduced quality of life. Early detection and treatment are essential to prevent the disease from progressing and causing complications. According to the International Society of Lymphology, complex decongestive therapy (CDT) is the most effective conservative treatment for lymphedema. Aquatic exercise is a safe and effective form of therapeutic CDT exercise that can improve joint range of motion, reduce pain, and positively impact limb volume. Additionally, health resort medicine and thermal mineral-rich waters may provide synergistic benefits for therapeutic exercise programs. Therefore, we believe that consideration should be given to whether the spa setting could represent a viable alternative for the rehabilitation of BCRL patients.

Cross-cultural adaptation of the spa therapy checklist (SPAC) in Greek

The importance of spa therapy is growing worldwide, with care practitioners paying more attention to how this intervention can alleviate various health issues. Multiple studies have been performed and reported on the efficiency of balneotherapy, creating a need to understand the quality of the information in the existing studies and how they can inform practitioners in promoting evidence-based practice. The SPAC assessment tool describes and assesses the quality of reports of interventional trials in balneotherapy. The present study had two goals. The first goal was the translation and cross-cultural adaptation of the SPAC assessment tool in Greek language following an internationally accepted methodology. The second goal was to assess the reliability of the tool employing test-retest and interrater reliability studies in a sample of 15 relative RCT papers and to assess the criterion validity of the Greek version by comparing its results with the original English version when assessing the same 15 papers. The results revealed that the SPAC checklist was translated and adapted in Greek without difficulties between the translators. Reliability of the SPAC was found excellent in both test-retest (ICC = .98) and interrater (ICC = .95) indexes. The criterion validity assessment for Greek version of SPAC checklist was also almost perfect (ICC = .98). In the present study, the Greek version of the SPAC checklist was found to be a comprehensible, reliable, and valid tool to assess the quality of interventional trial reports on the efficacy of spa therapy for cure and health enhancement.

Sustained improvements in EQ-5D utility scores and self-rated health status in patients with ankylosing spondylitis after spa treatment including low-dose radon - an analysis of prospective radon indication registry data

Background

Patients with ankylosing spondylitis (AS) have significantly lower quality of life (QoL) than the general population. Holistic interventions addressing QoL comprise spa- or balneotherapy including radon. These interventions have shown to be beneficial in reducing pain and improving QoL in AS-patients. We explored the association of spa-therapy including low-dose radon with QoL in AS-patients over an extended time period.

Methods

Registry data collected for the “Radon indication registry” in the Austrian Gastein valley comprising data on QoL (EuroQol EQ-5D) directly before the treatment (baseline), directly(t1), 3 (t2); 6(t3) and 9(t4) months after the treatment, age, sex and body mass index (BMI) were analysed. Linear regression models explored the association of measurement time with 1) EQ-5D-5L utilities and 2) EuroQol visual analogue scale (VAS) score. Alterations of 0.05 (utilities) and 5.00 (VAS) were considered clinically relevant.

Results

Two-hundred-ninety-one AS-patients were included in the analyses. Forty-four percent (n = 128) were women, the mean age was 52 (SD 10) and the average BMI was 26 (SD 4). Utilities (t1: 0.09 [0.07;0.11]; t2: 0.08 [0.06; 0.10]; t3: 0.06 [0.05;0.09]; t4: 0.04 [0.02;0.06]) and VAS (t1: 11.68 [9.38; 13.97]; t2: 12.20 [9.78; 14.61]; t3: 9.70 [7.24; 12.17]; t4: 6.11 [3.57; 8.65]) were significantly higher at all timepoints compared to baseline. Improvements were clinically relevant at all timepoints in case of the VAS and until 6 months after treatment for the utilities.

Conclusion

AS-patients who received spa therapy including radon show significantly and clinically relevant improvements in Qol until 6–9 months after treatment.

Publication activity in water treatments: Web of Science-based bibliometric analysis of the last two decades

We evaluated the quantity and quality of scientific publications linked with water treatments using the Web of Science (WoS) database. The WoS was searching by using the following terms "hydrotherapy," "balneotherapy," "spa therapy," "spa treatment," "creno-balneotherapy," "water treatments," and "aqua therapy," on February 10th, 2022. The recorded data were the total number of articles, year of articles, country of articles, journal, document type, index data, and citation data. Also, the studies performed with natural source mineral water were marked to make a further subgroup analysis through quality and quantity. We obtained 816 articles; 667 (81.74%) were original research articles, and 149 (18.26%) were review articles. A statistically significant and increasing trend was shown in the publication about water treatments (p < 0.01). About three-quarters of the trials were sourced from high-income countries. Italy (n = 98; 12.01%); Turkey (n = 75; 9.19%); Australia (n = 65; 7.97%); Brazil (n = 46; 5.64%); and France (n = 38; 4.66%) were the most productive countries. Calculating the number of articles per million population, Hungary (3.38), Australia (2.53), and Italy (1.64) ranked in the top three. According to 100 billion dollars GDP, the top three countries were Brazil (24.41), Hungary (21.15), and Turkey (10.41). In the average citation calculation, the Netherlands (60.84), Israel (29.86), and Australia (29.06) were in the top three. The International Journal of Biometeorology was the leading journal for publication trials about water treatments. In the subgroup analysis, we found the total number of studies performed with natural source mineral water and non-specified source water trials as 430 and 386, respectively. We also presented that the natural source and non-specified water trials had a statistically significant and increasing trend between 2000 and 2021 (p < 0.01 and p < 0.01, respectively). The trials performed with natural source water mainly were sourced from Italy (n = 79; 18.37%), Turkey (n = 61; 14.19%), France (n = 38; 8.84%), Poland (n = 30; 6.98%), and Hungary (n = 29; 6.74%), the trials performed with non-specified water were sourced from Australia (n = 61; 15.80%), Brazil (n = 46; 11.92%), USA (n = 27; 6.99%), Italy (n = 19; 4.92%), and England (n = 18; 4.66%). The top journal of the natural source water trials was the International Journal of Biometeorology (n = 65; 15.12%), and for the non-specified water trials, it was the International Journal of Sports Physiology (n = 12; 3.11%).Our study presented an increasing trend in trial publications regarding water treatments between 2000 and 2021. Most of the trials were from high and upper-middle-income countries. We suggest that by demonstrating global productivity worldwide, our results can create more scientific attention on this topic and may promote the quantity and quality of the trials.

YouTube as a source of information for water treatments

The purpose of the study was to investigate the quality and reliability of YouTube videos as a source of information in water treatments. We searched videos on YouTube ( www.youtube.com ) using the following keywords: "health resort medicine," "spa treatment," "spa therapy," "hydrotherapy," "thermal medicine," "balneology," and "balneotherapy" on June 17th, 2021. The global quality scale (GQS) was used to evaluate the quality of the videos. The assessment of reliability was evaluated using the modified DISCERN tool. Some other video parameters and sources of the videos were also recorded. One hundred twenty-one (121) videos were analyzed. The most common video source was advertisement (46.3%). GQS and modified DISCERN median scores were generally low. They were superior for "hydrotherapy" and "balneotherapy" and were also higher in videos uploaded by health-related persons or organizations (physicians, health-related professionals, and health-related websites). A statistically significant positive correlation was found between investigated parameters (like view ratio, number of likes, video power index, video length) and GQS. Only video length was correlated with modified DISCERN for investigated parameters. The median video power index scores were statistically higher for "spa therapy" and "spa treatment." The YouTube content linked with water treatments has poor quality and reliability most of time. The hydrotherapy and balneotherapy keywords have the best quality and reliability.We think that designers of water treatment videos should involve health professionals more often so that the content of their video will better explain the details of medical conditions or interventions.The scientific experts should ensure a consensus in terminology to straighten the awareness of water treatments for patients and physicians.

Italian and Japanese public attention toward balneotherapy in the COVID-19 era

Italian and Japanese public widely use balneotherapy. The population interest in balneotherapy in coronavirus disease-2019 (COVID-19) era should be investigated. Therefore, we aimed to exploit Google Trends analysis, as a measure of peoples' interest in balneotherapy, in two countries, Italy and Japan. In this infodemiology study, Google Trends was queried for the lay terms widely used by the Italian population to refer to the balneotherapy setting (terme + termale) and by the Japanese to refer to the bathing place and balneotherapy facilities ( + スパ). The internet searches in 2020 were compared to overlapping time spans in 2016-2019 and were correlated with new confirmed cases/deaths. This study demonstrated that from February 23 to June 20, 2020, and from October 4 to December 26, 2020, the internet searches of the Italian words corresponding to balneotherapy were statistically significantly decreased; however, the internet searches were not significantly different in June 21 to October 3, 2020, compared to overlapping time spans in 2016-2019 in Italy. The study also showed that from March 15 to September 5, 2020, and from November 29 to December 26, 2020, the internet searches of the Japanese words corresponding to balneotherapy were statistically significantly decreased; however, the internet searches were significantly increased in September 13 to November 7, 2020, and were not significantly different in November 8 to 28, 2020, compared to overlapping time spans in 2016-2019 in Japan. There were significant negative correlations between the relative search volume and number of new cases (rho=-0.634; p<0.001)/deaths (rho=-0.856; p<0.001) in Italy and the number of new deaths (rho=-0.348; p=0.012) in Japan. Population interest in balneotherapy has changed in the COVID-19 era both in Italy and Japan. During the early stage of pandemic (March to June), the interest was lower. After this early stage, the interest showed a recovery in both countries. In Italy, the population interest reached to its prior levels in late June through early October, with a peak in August. In Japan, the recovery exceeded the prior 4-year levels in mid-September through early November. Then, both countries demonstrated a decline in interest: began in early October in Italy and late November in Japan. This information would allow us to understand/address the population response in the pandemic in respect of the balneotherapy and would guide the preparedness of healthcare providers and planners both in this pandemic and future similar situations.

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.

The efficacy of balneotherapy, mud therapy and spa therapy in patients with osteoarthritis: an overview of reviews

Osteoarthritis is a degenerative disease considered a leading cause of functional disability. Its treatment is based on a combination of pharmacological and non-pharmacological interventions, but the role of these latter is still debated. This overview of systematic reviews aimed at evaluating the short-term efficacy of different thermal modalities in patients with osteoarthritis. We searched PubMed, Scopus, CINHAL, Web of Science, ProQuest and the Cochrane Database of Systematic Reviews from inception until October 2020, with no language restrictions. We selected the following outcomes a priori: pain, stiffness and quality of life. Seventeen systematic reviews containing 27 unique relevant studies were included. The quality of the reviews ranged from low to critically low. Substantial variations in terms of interventions studied, comparison groups, population, outcomes and follow-up between the included SRs were found. From a re-analysis of primary data, emerged that balneotherapy was effective in reducing pain and improving stiffness and quality of life, mud therapy significantly reduced pain and stiffness, and spa therapy showed pain relief. However, the evidence supporting the efficacy of different thermal modalities could be seriously flawed due to methodological quality and sample size, to the presence of important treatment variations, and to the high level of heterogeneity and the absence of a double-blind design. There is some encouraging evidence that deserves clinicians' consideration, suggesting that thermal modalities are effective on a short-term basis for treating patients with AO.

Public interest in spa therapy during the COVID-19 pandemic: analysis of Google Trends data among Turkey

In Turkey, spas are widely used and preferred by patients who are seeking relief from their disability and pain. The spa therapy program is partly reimbursed by the national health insurance system. The objective of the present study was to leverage Google Trends to elucidate the public interest in spas in Turkey during the COVID-19 pandemic. Google Trends was queried to analyze search trends within Turkey for the Turkish term representing a spa (i.e., kaplıca) from January 01, 2016, to September 30, 2020. The relative search volume of "kaplıca" was statistically significantly decreased in the March 15-May 30, 2020 (- 73.04%; p < 0.001); May 31-July 25, 2020 (- 41.38%; p < 0.001); and July 26-September 19, 2020 (- 29.98%; p < 0.001) periods compared to similar periods of preceding 4 years (2016-2019). After June 1, 2020, the relative search volume was shown to have a moderate recovery, without reaching the level of 2016-2019. Public interest in spas showed an initial sharp decline between mid-March and May, with a moderate increase during the June-August period. This finding might be indicative of public preference in undertaking spa therapy during the COVID-19 period. In Turkey, spas might be used to increase places providing rehabilitation for both non-COVID-19 patients and survivors of COVID-19 with long-term symptoms during the pandemic.

From in vitro research to real life studies: an extensive narrative review of the effects of balneotherapy on human immune response

Purpose

The biologic mechanisms by which balneotherapy (BT) alleviates symptoms of different diseases are still poorly understood. Recently, preclinical models and clinical trials have been developed to study the effects of BT on the immune system. This review summarizes the currently available evidence regarding the effects of spa therapy on the immune response, to confirm the role of BT in the enhancement of immune system and open interesting research fields.

Methods

PubMed and Google Scholar were searched from 1997 up to June 2020, with search criteria including terms related to BT and immune system. We selected only in vitro research, randomized controlled trials (RCTs) or clinical trials.

Results

In vitro studies on human and animal samples have demonstrated that thermal waters exert anti-inflammatory and immunomodulatory effects. In particular, H₂S donors seem to counteract the inflammatory processes in psoriatic lesions, arthritic fibroblast-like synoviocytes and chondrocytes, and regulate important factors implicated in osteoarthritis pathogenesis and progression. RCTs and clinical trials revealed, after BT, a reduction in circulating levels of pro-inflammatory molecules, such as TNF-α, IL-1β, and C-reactive protein, and an increase in anti-inflammatory molecules such as the IGF-1 growth factor especially in musculoskeletal diseases.

Conclusion

Further preclinical studies and RCTs could help to exploit BT in real life for preventive and therapeutic treatments.

Usual care including home exercise with versus without spa therapy for chronic low back pain: protocol for the LOMBATHERM' study, a multicentric randomised controlled trial

BACKGROUND

Low back pain is highly prevalent and a major source of disability worldwide. Spa therapy is frequently used to treat low back pain, but the associated level of evidence for efficacy is insufficient. To fill this knowledge gap, this protocol proposes an appropriately powered, prospective, evaluator-blinded, multi-centre, two-parallel-arm, randomised (1:1), controlled trial that will compare spa therapy in addition to usual care including home exercise (UCHE) versus UCHE alone for the treatment of chronic low back pain.

METHODS

Eligible patients (anticipated sample size of 358) will have had low back pain for more than 3 months and scores for pain greater than 40 mm on a visual analogue scale (VAS). Following initial consent for UCHE and baseline evaluations, patients are randomised (1:1) to UCHE alone, or UCHE plus spa therapy (18 days of mud packs, underwater massages, showers and water exercises under medical supervision). Patients in the latter arm will be requested to sign an additional consent form as per Zelen randomisation. Follow-up visits will occur at approximately months 1, 6 and 12 and (along with baseline assessments) will cover changes over time in VAS pain scores, the impact of lower back pain on daily life (the Rolland and Morris Disability Questionnaire (RMDQ)), inappropriate fears and beliefs about lower back pain (the fear, avoidance, belief questionnaire (FABQ)), general quality of life (the Euroqol Group 5 dimension, 5 level questionnaire (EQ-5D-5 L)), Patient Acceptable Symptom State (PASS), consumption of analgesic drugs and nonsteroidal anti-inflammatory drugs (NSAIDs), and overall state of health. Health resource use and days of sick leave (and subsequently the associated costs) will also be recorded. The primary outcome is the presence/absence of a clinically relevant change (improvement of at least 30%) in the VAS score for pain at 6 months.

DISCUSSION

Despite the fact that previous, rather dated recommendations encourage spa therapy for the treatment of low back pain, the current literary corpus is methodologically poor. This protocol has been designed to provide results spanning a thorough range of outcomes at the highest evidence level possible.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03910023. Registered on 10 April 2019.

Green exercise and mg-ca-SO4 thermal balneotherapy for the treatment of non-specific chronic low back pain: a randomized controlled clinical trial

BACKGROUND

Non-specific chronic low back pain (nscLBP) has a high socio-economic relevance due to its high incidence, prevalence and associated costs. Therefore, it is essential to evaluate effective therapeutic strategies. This study examines the effects of moderate mountain exercise and spa therapy on orthopedic and psychophysiological parameters. Based on a three-armed randomized controlled trial, guided mountain hiking tours and balneotherapy in thermal water were compared to a control group.

METHODS

Eighty patients with diagnosed nscLBP were separated into three groups: The two intervention groups GE (green exercise) and GEBT (green exercise and balneotherapy) undertook daily mountain hiking tours, whereas the GEBT group got an additional treatment with baths in Mg-Ca-SO₄ thermal water. The third group (CO) received no intervention. GE and GEBT group were treated for 6 days; all groups were followed up for 120 days.

RESULTS

Compared to GE and CO group, the GEBT treatment showed significant improvements of pain, some orthopedic parameters, health-related quality of life and mental well-being in patients with nscLBP.

CONCLUSIONS

The results of this study confirmed a benefit of mountain hiking combined with Mg-Ca-SO₄ spa therapy as a multimodal treatment of patients with nscLBP. Further studies should focus on long-term-effects of this therapeutic approach.

TRIAL REGISTRATION

ISRCTN, ISRCTN99926592 . Registered 06. July 2018 - Retrospectively registered.

Sulphate mineral waters: A medical resource in several disorders

Based on their chemical composition, salus per aquam (spa) mineral waters (or medical mineral waters) can be classified as sulphurous, sulphate, bicarbonate etc. Sulphate mineral waters where the predominant element is sulphate anion SO₄²⁻, are frequently used in clinical therapy. In this review, we describe and analyze the current scientific knowledge concerning the therapeutic effect of sulphate mineral waters in the treatment of several disorders.

Moreover, we underline how important is to integrate spa treatments with other therapeutic approaches to meet the various needs that can arise during a specific pathological state.

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Now, there is no systematic Review on Sulphate mineral waters in literature.

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The Review focuses on the importance of spa treatment as complementary therapy.

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The Review highlights the efficacy and tolerability of the spa in several disorders.

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.

Efficacy of self-management exercise program with spa therapy for behavioral management of knee osteoarthritis: research protocol for a quasi-randomized controlled trial (GEET one)

BACKGROUND

Osteoarthritis (OA) is not limited to joint pain and stiffness, which can lead to disability; it is also linked to comorbidities such as overweight, obesity and fears and beliefs related to the pathology. The knee OA population appears more affected by these risk factors and has a lower physical activity (PA) level than the general population. The key challenge for OA treatment is increasing the PA level to decrease the risk factors.

METHODS

We aim to perform a prospective, multicentric, quasi-randomized controlled trial with an alternate-month design (1-month periods). People aged 50-75 years old with symptomatic knee OA (stage I-IV Kellgren and Lawrence scale) with low and moderate PA level will be included in 3 spa therapy resorts. The experimental arm will receive 5 self-management exercise sessions (1.5 h each; education, aerobics, strength training, range of motion) + an information booklet + 18 sessions (1 h each) of spa therapy treatment (STT). The active comparator arm will receive an information booklet + 18 sessions of STT. The primary outcome will be a change at 3 months in PA level (International Physical Activity Questionnaire short form score). Secondary outcomes will be function (WOMAC) pain (numerical scale), anxiety/depression (HAD), fears and beliefs about OA (KOFBeQ) and arthritis self-efficacy (ASES). The barriers to and facilitators of regular PA practice will be assessed by using specific items specifically designed for the study because of lack of any reference scale.

DISCUSSION

The study could demonstrate the impact of a self-management exercise program associated with spa therapy in the medium term by increasing PA level in people with OA. A benefit for ameliorating fears and beliefs and anxiety/depression and improving self-efficacy will also be analysed. The findings could offer new prospects while establishing best clinical practice guidelines for this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02598804 (November 5, 2015).

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.

Salt water and skin interactions: new lines of evidence

In Health Resort Medicine, both balneotherapy and thalassotherapy, salt waters and their peloids, or mud products are mainly used to treat rheumatic and skin disorders. These therapeutic agents act jointly via numerous mechanical, thermal, and chemical mechanisms. In this review, we examine a new mechanism of action specific to saline waters. When topically administered, this water rich in sodium and chloride penetrates the skin where it is able to modify cellular osmotic pressure and stimulate nerve receptors in the skin via cell membrane ion channels known as "Piezo" proteins. We describe several models of cutaneous adsorption/desorption and penetration of dissolved ions in mineral waters through the skin (osmosis and cell volume mechanisms in keratinocytes) and examine the role of these resources in stimulating cutaneous nerve receptors. The actions of salt mineral waters are mediated by a mechanism conditioned by the concentration and quality of their salts involving cellular osmosis-mediated activation/inhibition of cell apoptotic or necrotic processes. In turn, this osmotic mechanism modulates the recently described mechanosensitive piezoelectric channels.

Spa therapy together with supervised self-mobilisation improves pain, function and quality of life in patients with chronic shoulder pain: a single-blind randomised controlled trial

To determine whether spa therapy has a beneficial effect on pain and disability in patients with chronic shoulder pain, this single-blind randomised controlled clinical trial included patients with chronic shoulder pain due to miscellaneous conditions attending one of four spa centres as outpatients. Patients were randomised into two groups: spa therapy (18 days of standardised treatment combining thermal therapy together with supervised mobilisation in a thermal pool) and controls (spa therapy delayed for 6 months: 'immediate versus delayed treatment' paradigm). All patients continued usual treatments during the 6-month follow-up period. The main endpoint was the mean change in the French-Quick DASH (F-QD) score at 6 months. The effect size of spa therapy was calculated, and the proportion of patients reaching minimal clinically important improvement (MCII) was compared. Secondary endpoints were the mean change in SF-36, treatment use and tolerance. One hundred eighty-six patients were included (94 patients as controls, 92 in the spa group) and analysed by intention to treat. At 6 months, the mean change in the F-QD score was statistically significantly greater among spa therapy patients than controls (- 32.6 versus - 8.15%; p < 0.001) with an effect size of 1.32 (95%CI: 0.97-1.68). A significantly greater proportion of spa therapy patients reached MCII (59.3 versus 17.9%). Spa therapy was well tolerated with a significant impact on SF-36 components but not on drug intake. Spa therapy provided a statistically significant benefit on pain, function and quality of life in patients with chronic shoulder pain after 6 months compared with usual care.

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.

How does spa treatment affect cardiovascular function and vascular endothelium in patients with generalized osteoarthritis? A pilot study through plasma asymmetric di-methyl arginine (ADMA) and L-arginine/ADMA ratio

The study aims to investigate the effect of spa treatment on vascular endothelium and clinical symptoms of generalized osteoarthritis. Forty generalized osteoarthritis (GOA) patients referred to a government spa hospital, and 40 GOA patients followed on university hospital locomotor system disease ambulatory clinics were included as study and control groups, respectively. Study group received spa treatment including thermal water baths, physical therapy modalities, and exercises. Control group was followed with home exercises for 15 days. Plasma ADMA, L-arginine, L-arginine/ADMA ratio, routine blood analyses, 6-min walking test, including fingertip O₂ saturation, systolic/diastolic blood pressure, and pulse rate, were measured at the beginning and at the end of treatment. Groups were evaluated with VAS pain, patient, and physician global assessment; HAQ; and WOMAC at the beginning, at the end, and after 1 month of treatment. In study group, L-arginine and L-arginine/ADMA ratio showed statistically significant increase after treatment. Plasma ADMA levels did not change. There is no significant difference in intergroup comparison. Study group displayed statistically significant improvements in all clinical parameters. The study showed that spa treatment does not cause any harm to the vascular endothelium through ADMA. Significant increase in plasma L-arginine and L-arginine/ADMA ratio suggests that balneotherapy may play a preventive role on cardiovascular diseases. Balneotherapy provides meaningful improvements on clinical parameters of GOA.

Spa therapy (balneotherapy) relieves mental stress, sleep disorder, and general health problems in sub-healthy people

To investigate the relieving effects of hot spring balneotherapy on mental stress, sleep disorder, general health problems, and women's health problems in sub-healthy people, we recruited 500 volunteers in sub-health in Chongqing, and 362 volunteers completed the project, including 223 in the intervention group and 139 in the control group. The intervention group underwent hot spring balneotherapy for 5 months, while the control group did not. The two groups took questionnaire investigation (general data, mental stress, emotional status, sleep quality, general health problems, as well as some women's health problems) and physical examination (height, weight, waist circumference, blood pressure, blood lipid, blood sugar) 5 months before and after the intervention, respectively. After intervention, sleep disorder (difficulty in falling asleep (P = 0.017); dreaminess, nightmare suffering, and restless sleep (P = 0.013); easy awakening (P = 0.003) and difficulty in falling into sleep again after awakening(P = 0.016); and mental stress (P = 0.031) and problems of general health (head pain (P = 0.026), joint pain(P = 0.009), leg or foot cramps (P = 0.001), blurred vision (P = 0.009)) were relieved significantly in the intervention group, as compared with the control group. While other indicators (fatigue, eye tiredness, limb numbness, constipation, skin allergy) and women's health problems (breast distending pain; dysmenorrhea, irregular menstruation) were relieved significantly in the self-comparison of the intervention group before and after intervention (P < 0.05), but showed no statistically significant difference between two groups (P > 0.05). All indications (except bad mood, low mood, and worry or irritability) in the intervention group significantly improved, with effect size from 0.096 to 1.302. Multiple logistic regression analysis showed that the frequency, length, and location of balneotherapy in the intervention group were the factors influencing emotion, sleep, and health condition (P < 0.05). Relief of insomnia, fatigue, and leg or foot cramps was greater in old-age group than in young-aged group (P < 0.05). Physical examination found that waist circumferences in women of various ages under 55 years were significantly reduced in the intervention group (P < 0.05), while that in men did not significantly change (P > 0.05). Spa therapy (balneotherapy) relieves mental stress, sleep disorder, general health, and reduces women's waist circumferences in sub-healthy people.

Spa therapy adjunct to pharmacotherapy is beneficial in rheumatoid arthritis: a crossover randomized controlled trial

This study aims to investigate whether 2-week spa therapy, as an adjunct to usual pharmacological therapy, has any beneficial effect in patients with rheumatoid arthritis (RA). In this single-blind crossover study, 50 patients were randomly assigned in a 1:1 manner to receive usual pharmacological therapy plus 2-week spa therapy or usual pharmacological therapy alone (period 1.6 months); after a 9-month washout, patients were crossed over to the opposite assignment (period 2.6 months). Spa therapy program included a daily saline balneotherapy session at 36-37 °C for 20 min except Sundays. The clinical outcomes were evaluated at baseline, after spa therapy (2 weeks) and 3 and 6 months after the spa therapy in both period and were pain (Visual Analogue Scale (VAS)), patient and physician global assessments (VAS), Health Assessment Questionnaire (HAQ), and Disease Activity Score (DAS28). Spa therapy was superior to control therapy in improving all the assessed clinical outcomes at the end of the spa therapy. This superiority persisted significantly in physician global assessment (p = 0.010) and with a trend in favor of spa group in patient global assessment (p = 0.058), function (p = 0.092), and disease activity (p = 0.098) at 3 months. Statistically significant improvements were found in spa therapy compared to control in disease activity (p = 0.006) and patient (p = 0.020) and physician global (p = 0.011) assessments, and a trend toward improvements in pain (p = 0.069) and swollen joints (p = 0.070) at 6 months. A 2-week spa therapy adjunct to usual pharmacological therapy provided beneficial clinical effects compared to usual pharmacological therapy alone, in RA patients treated with traditional disease-modifying antirheumatic drugs. These beneficial effects may last for 6 months.

The role of mineral elements and other chemical compounds used in balneology: data from double-blind randomized clinical trials

The aims of this study were to conduct a systematic literature review on balneotherapy about the specific therapeutic role of mineral elements and other chemical compounds of mineral waters and derivate peloids/muds and to discuss the study methods used to evaluate it (in musculoskeletal conditions). We searched Medline by PubMed using the following key words: "spa therapy" "balneotherapy" "mud" "peloid" "mud pack Therapy" in combination with "randomized controlled trial" "double blind trial." We also reviewed the reference list of articles retrieved by the Medline search. We selected the double-blind randomized clinical trials that assessed the effects of mineral water or mud treatments compared to tap water, attenuated peloid/mud therapy or similar treatments without the specific minerals or chemical compounds of the treatment group ("non-mineral"). We evaluated the internal validity and the quality of the statistical analysis of these trials. The final selection comprised 27 double-blind randomized clinical trials, 20 related to rheumatology. A total of 1118 patients with rheumatological and other musculoskeletal diseases were evaluated in these studies: 552 of knee osteoarthritis, 47 of hand osteoarthritis, 147 chronic low back pain, 308 of reumathoid arthritis, and 64 of osteoporosis; 293 of these participants were assigned to the experimental groups of knee osteoarthritis, 24 in hand osteoarthritis, 82 of low back pain, 152 with reumathoid arthritis, and 32 with osteoporosis. They were treated with mineral water baths and/or mud/peloid (with or without other forms of treatment, like physical therapy, exercise…). The rest were allocated to the control groups; they received mainly tap water and/or "non-mineral" mud/peloid treatments. Mineral water or mud treatments had better and longer improvements in pain, function, quality of life, clinical parameters, and others in some rheumatologic diseases (knee and hand osteoarthritis, chronic low back pain, rheumatoid arthritis, and osteoporosis) compared to baseline and non-mineral similar treatments. Internal validity and other limitations of the study's methodology impede causal relation of spa therapy on these improvements. Randomized clinical trials are very heterogeneous. Double-blind randomized clinical trials seem to be the key for studying the role of mineral elements and other chemical compounds, observing enough consistency to demonstrate better and longer improvements for mineral waters or derivate compared to tap water; but due to heterogeneity and gaps on study protocol and methodology, existing research is not sufficiently strong to draw firm conclusions. Well-designed studies in larger patients' population are needed to establish the role of minerals and other chemical compounds in spa therapy.

Real-life effectiveness of spa therapy in rheumatic and musculoskeletal diseases: a retrospective study of 819 patients

The objective of this study is to determine the use and efficacy of spa therapy in patients with a wide spectrum of rheumatic and musculoskeletal diseases under real-life clinical practice circumstances. In this retrospective observational study at the Medical Ecology and Hydroclimatology Department of Istanbul Faculty of Medicine, the records of all adult patients with rheumatic and musculoskeletal diseases who were prescribed a spa therapy in various health resorts in Turkey between 2002 and 2012 were analyzed. Patients sojourned to and stayed at a health resort and followed a usual 2-week course of spa therapy. The patients were examined within a week before and after the spa therapy at the department by the physicians and outcome measures were pain intensity (visual analog scale, VAS), patient's general evaluation (VAS), physician's general evaluation (VAS), Health Assessment Questionnaire (HAQ), Lequesne's Functional Index (LFI), Western Ontario and McMaster Universities Index (WOMAC), Waddell Index (WI), Neck Pain and Disability Scale (NPDS), Shoulder Disability Questionnaire (SDQ), Fibromyalgia Impact Questionnaire (FIQ), and Beck's Depression Inventory (BDI). In total, 819 patients were included in the analysis. The diagnoses were 536 osteoarthritis; 115 fibromyalgia; 50 lumbar disc herniation; 34 cervical disc herniation; 23 nonspecific low back pain; 22 ankylosing spondylitis; 16 rheumatoid arthritis; 9 rotator cuff tendinitis; and 14 other conditions/diseases including scoliosis, stenosing flexor tenosynovitis, congenital hip dislocation in adult, Behçet's disease, de Quervain tendinopathy, psoriatic arthritis, osteoporosis, fracture rehabilitation, and diffuse idiopathic skeletal hyperostosis. Statistically significant decrease in pain scores was found in all patients except hip osteoarthritis (p = 0.063) and rheumatoid arthritis (p = 0.134) subgroups; and statistically significant improvement in function in all patients except hip osteoarthritis (p = 0.068), rheumatoid arthritis (p = 0.111), and rotator cuff tendinitis (p = 0.078) subgroups. In daily clinical practice, spa therapy is prescribed and practiced mainly for osteoarthritis, then fibromyalgia, lumbar/cervical disc herniation, and nonspecific low back pain; and less for ankylosing spondylitis, rheumatoid arthritis, and rotator cuff tendinitis. The study results suggest that real-life spa therapy may be effective in a variety of rheumatic and musculoskeletal diseases by improving pain and function.

Effect of spa therapy with saline balneotherapy on oxidant/antioxidant status in patients with rheumatoid arthritis: a single-blind randomized controlled trial

Oxidative stress has been shown to play a contributory role in the pathogenesis of rheumatoid arthritis (RA). Recent studies have provided evidence for antioxidant properties of spa therapy. The purpose of this study is to investigate whether spa therapy with saline balneotherapy has any influence on the oxidant/antioxidant status in patients with RA and to assess clinical effects of spa therapy. In this investigator-blind randomized controlled trial, we randomly assigned 50 patients in a 1:1 ratio to spa therapy plus standard drug treatment (spa group) or standard drug treatment alone (control group). Spa group followed a 2-week course of spa therapy regimen consisting of a total of 12 balneotherapy sessions in a thermal mineral water pool at 36-37 °C for 20 min every day except Sunday. All clinical and biochemical parameters were assessed at baseline and after spa therapy (2 weeks). The clinical parameters were pain intensity, patient global assessment, physician global assessment, Health Assessment Questionnaire disability index (HAQ-DI), Disease Activity Score for 28-joints based on erythrocyte sedimentation rate (DAS28-4[ESR]). Oxidative status parameters were malondialdehyde (MDA), nonenzymatic superoxide radical scavenger activity (NSSA), antioxidant potential (AOP), and superoxide dismutase (SOD). The NSSA levels were increased significantly in the spa group (p = 0.003) but not in the control group (p = 0.509); and there was a trend in favor of spa therapy for improvements in NSSA levels compared to control (p = 0.091). Significant clinical improvement was found in the spa group compared to the control in terms of patient global assessment (p = 0.011), physician global assessment (p = 0.043), function (HAQ-DI) (p = 0.037), disease activity (DAS28-4[ESR]) (0.044) and swollen joint count (0.009), and a trend toward improvement in pain scores (0.057). Spa therapy with saline balneotherapy exerts antioxidant effect in patients with RA as reflected by the increase in NSSA levels after spa therapy; whether this antioxidant effect contributes to the clinical improvements observed remains to be verified.

Evaluation of the efficacy of a short-course, personalized self-management and intensive spa therapy intervention as active prevention of musculoskeletal disorders of the upper extremities (Muska): a research protocol for a randomized controlled trial

Background

Musculoskeletal disorders (MSDs) constitute a major occupational health problem in the working population, substantially impacting the quality of life of employees. They also cause considerable economic cost to the healthcare system, with, notably, the reimbursement of treatments and compensation for lost income. MSDs manifest as localized pain or functional difficulty in one or more anatomical areas, such as the cervical spine, shoulder, elbow, hand, and wrist. Although prevalence varies depending on the region considered and the method of assessment, a prevalence of 30% is found in different epidemiological studies. The disease needs to be prevented, not only for medical and economic reasons, but also for legal reasons, owing to the requirement of assessing occupational risks. The strategy envisaged may thus revolve around active, multimodal prevention that has employees fully involved at the heart of their care. Although physical exercise is widely recommended, few studies with a good level of evidence have enabled us to base a complete, well-constructed intervention on exercise that can be offered as secondary prevention in these disorders.

Methods

A prospective, multicenter, comparative (intervention arm vs. control arm), randomized (immediate vs. later treatment) study using Zelen’s design. This study falls under active prevention of MSDs of the upper extremities (UE-MSDs). Participants are workers aged between 18 and 65 years with latent or symptomatic MSDS, with any type of job or workstation, with or without an history of sick leave. The primary aim is to show the superiority at 3 months of a combination of spa therapy, exercise, and self-management workshops for 6 days over usual care in the management of MSDs in terms of employee functional capacity in personal and professional daily life. Secondary aims are to assess the benefit of the intervention in terms of pain, quality of life, and accumulated duration of sick leave.

Discussion

This randomized controlled trial is the first that will aim to evaluate multidisciplinary management of UE-MSDs using nonpharmacological treatment combining exercise, self-management, and spa therapy. The originality of this intervention lies, in its short, intensive format, which is compatible with remaining in work; and in its multidisciplinary approach. This trial has the potential to demonstrate, with a good level of evidence, the benefits of a short course of spa therapy combined with a personalized self-management program on the functional capacity, pain, and quality of life of employees in their daily life.

Trial registration

Clinical trial.gov NCT02702466 retrospectively registered.

Protocol: Version 4 of 9/10/2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1353-8) contains supplementary material, which is available to authorized users.

Spa therapy for elderly: a retrospective study of 239 older patients with osteoarthritis

Very few studies tested the effectiveness of spa therapy in older patients with osteoarthritis. Therefore, we aimed to evaluate the short-term effects of spa therapy in patients aged 65 years and older with generalized, knee, hip, and cervical and lumbar spine osteoarthritis. In an observational retrospective study design at the Medical Ecology and Hydroclimatology Department of Istanbul Medical Faculty, we analyzed the records of 239 patients aged over 65 years with the diagnosis of all types of osteoarthritis who were prescribed a spa therapy course in some spa resorts in Turkey between 7 March 2002 and 31 December 2012. They travelled to a spa resort where they stayed at a thermal spa hotel and followed the usual therapy packages for 2 weeks. Patients were assessed by an experienced physician within a week before the spa journey and within a week after the completion of the spa therapy. Compared with baseline in whole sample, statistically significant improvements were observed in pain (visual analog scale, VAS), patient and physician global assessments (VAS), Health Assessment Questionnaire disability index (HAQ-DI), Lequesne algofunctional index (LAFI) for knee, Western Ontario and McMaster Universities index (WOMAC), Waddell disability index (WDI), and Neck Pain and Disability Scale (NPAD). According to Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) Set of Responder Criteria, responder rate were 63.8 % (51/80) in generalized, 52 % (13/25) in knee, 50 % (2/4) in hip, 66.7 % (8/12) in lumbar, and 100 % (6/6) in cervical osteoarthritis subgroups. Spa therapy improved pain and physical functional status in older patients with osteoarthritis, especially generalized osteoarthritis and multiple joint osteoarthritis with involvement of knee. This improvement was clinically important in majority of the patients. To confirm the results of this preliminary study, there is a need of a randomized controlled clinical study comparing spa therapy with usual care in the elderly population with osteoarthritis.

Balneotherapy in rheumatoid arthritis-a systematic review

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterized by persistent inflammation of synovial joints with pain, often leading to joint destruction and disability, and despite intensive research, the cause of RA remains unknown. Balneotherapy-also called mineral baths or spa therapy-uses different types of mineral water compositions like sulphur, radon, carbon dioxin, etc. The role of balneotherapy is on debate; Sukenik wrote that the sulphur mineral water has special proprieties to rheumatologic diseases, including in the course of active inflammatory phases in RA. The aim of this review is to summarize the available evidence on the effects of balneotherapy on patients with rheumatoid arthritis. We have made a systematic search of the articles published from 1980 to 2014 on this topic in PubMed, Scopus, CRD, PEDro, Web of Science and Embase databases. We have followed the method set by the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA). These that have compared balneotherapy with other therapeutic modalities or with no intervention were considered. The inclusion criteria of these papers were randomized control trial (RCT); languages: English, French, Spanish, Italian and Portuguese; evaluation of efficacy (analysis of outcomes); use of natural mineral water baths; and participants with RA. A total of eight articles documenting RCTs were found and included for full review and critical appraisal involving a total of 496 patients. The studies selected highlighted an important improvement and statistically significant in several clinical parameters, in spite of their heterogeneity between the various studies. One study emphasized an important improvement on functional capacity up to 6 months of follow-up (FU). Some of the studies (std.) reveal an improvement on morning stiffness (5 std.), number of active joints (3 std.), Ritchie index (2 std.) and activities of daily living (2 std.) up to 3 months of FU. Three studies reveal the improvement on handgrip strength up to 1 month of FU. About pain (VAS), the three studies which evaluated this parameter were inconclusive about real significant improvement. Our tables summarize the published papers about this topic. Different authors emphasize the same problems: methodologies differing from study to study, treatment modalities, outcomes and their analysis. On the one hand, it is particularly difficult to have homogeneity on this population in all the parameters (patient's clinical heterogeneity, diverse clinical course of the disease, variety of the drugs), and on the other hand, natural mineral water composition is always unique with potential specific biological effects. This comprehensive review has revealed that there are very few published studies about the use of natural mineral water in RA. International multicentre studies, using the same methodologies, could be achieved by carrying the scientific arguments to support our clinical practice.

May spa therapy be a valid opportunity to treat hand osteoarthritis? A review of clinical trials and mechanisms of action

Osteoarthritis (OA) is the most common form of arthritis and its current treatment includes non-pharmacological and pharmacological modalities. Spa therapy represents a popular treatment for many rheumatic diseases. The aim of this review was to summarize the currently available information on clinical effects and mechanisms of action of spa therapy in OA of the hand. We conducted a search of the literature to extract articles describing randomized clinical trials (RCTs) in hand OA published in the period 1952-2015. We identified three assessable articles reporting RCTs on spa therapy in hand OA. Data from these clinical trials support a beneficial effect of spa therapy on pain, function and quality of life in hand OA. Spa therapy seems to have a role in the treatment of hand OA. However, additional RCTs are necessary to clarify the mechanisms of action and the effects of the application of thermal treatments.

Health resort medicine in non-musculoskeletal disorders: is there evidence of its effectiveness?

Health resort medicine (HRM; in German: Kurortmedizin) is a field of medicine with long-lasting tradition in several European countries. A number of systematic reviews have shown the effectiveness of HRM in musculoskeletal conditions. Reviews focusing on the effectiveness of HRM in non-musculoskeletal disorders are rare. This systematic review aims to provide an overview about all types of health resort treatments applied in non-musculoskeletal conditions, to summarize evidence for its effectiveness and to assess the quality of published studies. MEDLINE, Web of Knowledge and Embase were searched for articles published between January 2002 and December 2013. We used a broad search strategy in order to find studies investigating the effects of HRM in non-musculoskeletal disorders. Two authors independently extracted data and assessed quality using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies (EPHPP-QAT). Forty-one studies (19 of them with control group) from eight countries examining the efficacy of various forms of spa treatment for 12 disease groups were included. The studies are markedly heterogeneous regarding study design, population and treatment. HRM treatment is associated with clinical improvement in diseases of the skin, respiratory, circulatory, digestive and nervous system among others. However, small samples, the lack of control groups and an insufficient follow-up often limit the generated evidence. The scientific literature of the last decade has shown that a number of non-musculoskeletal disorders are treated with different kinds of HRM. The challenge for the future will be to carry out thoroughly designed studies in larger patient populations to corroborate the impact of HRM treatment on non-musculoskeletal disorders.

Assessing the quality of study reports on spa therapy based on randomized controlled trials by the spa therapy checklist (SPAC)

The purpose of this study was to assess the quality of study reports on spa therapy based on randomized controlled trials by the spa therapy and balneotherapy checklist (SPAC), and to show the relationship between SPAC score and the characteristics of publication. We searched the following databases from 1990 up to September 30, 2013: MEDLINE via PubMed, CINAHL, Web of Science, Ichushi Web, Global Health Library, the Western Pacific Region Index Medicus, PsycINFO, and the Cochrane Database of Systematic Reviews. We used the SPAC to assess the quality of reports on spa therapy and balneotherapy trials (SPAC) that was developed using the Delphi consensus method. Fifty-one studies met all inclusion criteria. Forty studies (78%) were about "Diseases of the musculoskeletal system and connective)". The total SPAC score (full-mark; 19 pts) was 10.8 ± 2.3 pts (mean ± SD). The items for which a description was lacking (very poor; <50%) in many studies were as follows: "locations of spa facility where the data were collected"; "pH"; "scale of bathtub"; "presence of other facility and exposure than bathing (sauna, steam bath, etc.)"; "qualification and experience of care provider"; "Instructions about daily life" and "adherence". We clarified that there was no relationship between the publish period, languages, and the impact factor (IF) for the SPAC score. In order to prevent flawed description, SPAC could provide indispensable information for researchers who are going to design a research protocol according to each disease.

Impact of sulphurous water politzer inhalation on audiometric parameters in children with otitis media with effusion

OBJECTIVES

The positive effects of spa therapy on ear, nose, and throat pathology are known but robust literature in this field, is still lacking. The aim of this study was to assess through a retrospective analysis, the effects on otitis media with effusion of Politzer endotympanic inhalation of sulphurous waters in children aged 5-9 years.

METHODS

A cohort of 95 patients was treated with Politzer insufflations of sulphurous water: 58 patients did a cycle consisting of a treatment of 12 days per year for three consecutive years; 37 patients followed the same procedure for 5 years consecutively. The control population was represented by untreated, age-matched children. A standard audiometric test was used before and after each cycle of treatment.

RESULTS

One cycle of Politzer inhalation of sulphur-rich water improved the symptoms. Three cycles definitively stabilized the improvement of hearing function.

CONCLUSION

Our results show that otitis media with effusion in children can be resolved by an appropriate non-pharmacological treatment of middle ear with sulphur-rich water.