The Therapeutic Effect of Balneotherapy: Evaluation of the Evidence from Randomised Controlled Trials

M. E. Falagas; E. Zarkadoulia; P. I. Rafailidis


Int J Clin Pract. 2009;63(7):1068-1084. 

In This Article


A critical view of the available evidence suggests that, despite the considerable heterogeneity of patient populations included in the reviewed RCTs, there seems to be a beneficial effect of balneotherapy in the majority of them, mainly on amelioration of pain in the mentioned rheumatological diseases and chronic low back pain. The duration of the beneficial effect of balneotherapy varies and in the majority of the studies reviewed, it lasts for at least 3 months. In interpreting these data, one must take into account that periods of follow up are not identical. The scarce data from the use of balneotherapy in non-rheumatological diseases do not allow us to draw conclusions regarding its true impact in the fields of psoriasis vulgaris and Parkinson's disease.

The mechanism of action of balneotherapy is largely unknown. Various inflammatory mediators seem to be increased in patients with fibromyalgia, and balneotherapy was shown to decrease the levels of prostaglandin E2 as well as interleukin-1 and leukotriene B4.[20] An interesting finding is that balneotherapy reduces the levels of catalase, superoxide dismutase, malondialdehyde protein and glutathione peroxidase.[8] In addition, it has been postulated that some penetration of minerals in the body may confer some of the therapeutic result.[9]

In a comprehensive recent review, regarding the effect of balneotherapy in the treatment of rheumatoid arthritis, it was concluded that balneotherapy may improve symptoms of rheumatoid arthritis, but most of the randomised controlled studies performed in this field could be of higher quality.[3] Additionally, the effect of various confounders such as the environment per se and psychological factors including the avoidance of everyday stress, as is the case in spas, may influence the balneotherapy effect. In the majority of the studies reviewed herein, however, the therapeutic location was the same for the comparator groups, and this means that balneotherapy has an effect beyond the one attributed to the environment per se.

Adherence to methodological criteria[6,7,10,11,12] should be followed when conducting and reporting on an RCT. The main drawback in some of the studies reviewed is that not enough details are given regarding the blinding (i.e. unconvincingly double-blind studies or single-blinded). One should acknowledge that it is difficult to perform blinding of the intervention, i.e. whether patients receive the active treatment or not. However, blinding may be accomplished when physical characteristics of thermal water in the active treatment group of patients and water used in the control group (i.e. temperature, colour and odour) are the same. Only occasionally is information available regarding the allocation of concealment. The size of the trial groups is another limiting factor in trying to draw firm conclusions. Only four studies reported on more than 100 patients. The total number of patients reviewed herein is 1720 patients. In contrast to an excellent cohort study regarding the effects of balneotherapy, the NAIADE survey in Italy,[13,14] 23,680 patients with eight disease groups received entry and return inquiry after 1 year. Description of the interventions and reporting of the results of the herein reviewed trials was appropriate considering the complexity in evaluating the treatment of musculoskeletal diseases.[15] Information on potential adverse effects in the reviewed studies is practically absent. This is not to be ignored, as even RCTs on the management of well-known diseases do not always take into consideration this information.[16]

Not withstanding the methodological limitations,[10] one cannot ignore that there is evidence that balneotherapy improves many of the symptoms associated with rheumatic diseases. One must stress that the multitude of methods were used to assess objectively and subjectively the effect of balneotherapy on patients. More so, quality of life scores are examined, although not in all of the studies. One should acknowledge the lack of standard evaluation of evidence and the challenges arising in evaluating these therapies.[17] A limitation of our review is that a significant number of studies written in the Russian language were excluded. Also, it should be emphasised that limited data exist in the literature regarding the effect of balneotherapy in diseases other than rheumatological.

In conclusion, there is possibility that balneotherapy is associated with clinical improvement in rheumatological disease mainly such as osteoarthritis, fibromyalgia, ankylosing spondylitis, rheumatoid arthritis and in chronic low back pain. However, existing research is not sufficiently strong to draw firm conclusions. More RCTs are needed to help draw firm conclusions regarding the effectiveness of balneotherapy in various medical fields, especially on dermatological, cardiovascular, respiratory, gastrointestinal and allergic and gynaecological skin diseases.

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