Therapeutic Benefit of Balneotherapy and Hydrotherapy in the Management of Fibromyalgia Syndrome

A Qualitative Systematic Review and Meta-analysis of Randomized Controlled Trials

Johannes Naumann; Catharina Sadaghiani


Arthritis Res Ther. 2014;16(R141) 

In This Article

Abstract and Introduction


Introduction: In the present systematic review and meta-analysis, we assessed the effectiveness of different forms of balneotherapy (BT) and hydrotherapy (HT) in the management of fibromyalgia syndrome (FMS).

Methods: A systematic literature search was conducted through April 2013 (Medline via Pubmed, Cochrane Central Register of Controlled Trials, EMBASE, and CAMBASE). Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated using a random-effects model.

Results: Meta-analysis showed moderate-to-strong evidence for a small reduction in pain (SMD −0.42; 95% CI [−0.61, −0.24]; P < 0.00001; I2 = 0%) with regard to HT (8 studies, 462 participants; 3 low-risk studies, 223 participants), and moderate-to-strong evidence for a small improvement in health-related quality of life (HRQOL; 7 studies, 398 participants; 3 low-risk studies, 223 participants) at the end of treatment (SMD −0.40; 95% CI [−0.62, −0.18]; P = 0.0004; I2 = 15%). No effect was seen at the end of treatment for depressive symptoms and tender point count (TPC).

BT in mineral/thermal water (5 studies, 177 participants; 3 high-risk and 2 unclear risk studies) showed moderate evidence for a medium-to-large size reduction in pain and TPC at the end of treatment: SMD −0.84; 95% CI [−1.36, −0.31]; P = 0.002; I2 = 63% and SMD −0.83; 95% CI [−1.42, −0.24]; P = 0.006; I2 = 71%. After sensitivity analysis, and excluding one study, the effect size for pain decreased: SMD −0.58; 95% CI [−0.91, −0.26], P = 0.0004; I2 = 0. Moderate evidence is given for a medium improvement of HRQOL (SMD −0.78; 95% CI [−1.13, −0.43]; P < 0.0001; I2 = 0%). A significant effect on depressive symptoms was not found. The improvements for pain could be maintained at follow-up with smaller effects.

Conclusions: High-quality studies with larger sample sizes are needed to confirm the therapeutic benefit of BT and HT, with focus on long-term results and maintenance of the beneficial effects.


Fibromyalgia syndrome (FMS) is a debilitating condition of almost unknown etiology and pathogenesis that is characterized by widespread musculoskeletal pain and tenderness, as well as secondary symptoms like fatigue, depression, irritable bowel syndrome and sleep disturbances. A standard therapy regimen is lacking and the condition causes high direct and indirect costs (for example, health care use, sick leave).[1] In a survey of the German population using the modified American College of Rheumatology (ACR) 2010 preliminary diagnostic criteria for FMS,[2] the overall prevalence of FMS was found to be 2.1% to 2.4% in women and 1.8% in men; however, the difference was not statistically significant.[3] Adequate treatment recommendations are therefore needed both in the interests of the welfare of the patient and for economic reasons. Current evidence-based guidelines are built on the fact that there is no single ideal treatment for FMS. Patient-tailored approaches are emphasized recommending non-pharmacological and pharmacological interventions according to individual symptoms (for example, pain, sleep problems, fatigue, and depression). Especially, self-management strategies (for example, exercise, psychological techniques) involving active patient participation should be an integral component of the therapeutic plan.[4]

In this context, balneotherapy (BT) and hydrotherapy (HT) offer interesting treatment alternatives and are commonly used additional interventions in the management of FMS, despite ongoing debate about their effícacy. Prior research (an Internet survey of 2,596 people with FMS) found that around 26% of individuals suffering from FMS use pool therapy and 74% heat modalities (warm water, hot packs). The interventions perceived to be most effective (effectiveness rating ≥6.0) on a scale of 0 to 10, with 10 being most effective, were rest, (6.3 ± 2.5) (mean ± SD), heat modalities (6.3 ± 2.3), pain medication (6.3 ± 2.4), sleep medication (6.5 ± 2.7) and pool therapy (6.0 ± 3.0).[5]

However, the mechanisms by which immersion in mineral or thermal water or application of mud alleviates the symptoms of FMS are almost unknown. Pain, the key symptom of FMS, may be relieved by the hydrostatic pressure and the effects of temperature on the nerve endings, as well as by muscle relaxation.[6] Furthermore, it has been shown that thermal mud baths increase plasma levels of beta-endorphin, thus explaining their analgesic and antispastic effect, which is particularly important in patients with FMS.[7] The beneficial effects of water treatments are probably the result of a combination of specific (for example, buoyancy, aquatic resistance, heat) and unspecific effects (for example, change of environment, spa-scenery).

However, the definitions BT, HT and spa therapy are frequently confused and the terms tend to be used interchangeably.[8] In contrast to HT, which generally employs normal tap water, BT uses thermal mineral water from natural springs, but also natural gases (CO2, iodine, sulfur, radon, et cetera), peloids (mud) and other edaphic remedies (for example, hay) for medical treatment. BT is usually practiced in spas with their special therapeutic atmosphere as part of a complex therapy program, which is why the term is often used synonymously for spa therapy. Thalassotherapy is a special form of BT or spa treatment that uses seawater and the seaside climate. New definitions, such as health resort medicine, rather than BT and spa therapy, have not reached general acceptance.[9]

Prior systematic reviews and meta-analyses covering BT (spa therapy) and HT in FMS have respectively covered the literature up to May 2011,[6] and December 2008.[10] The systematic review by Terhorst et al. (2011)[11] on complementary and alternative medicine analyzed, among others, 11 studies on BT up to December 2010. The network meta-analysis by Nüesch et al. (2013),[12] which investigated pharmacological and non-pharmacological interventions (land- and water-based aerobic exercise, multicomponent treatment (MCT), BT and cognitive behavioral therapy (CBT)), covered the literature up to 2011. In summary, these reviews found some evidence of beneficial effects arising from BT and HT, however, due to methodological flaws, their efficacy remains unclear.

Despite these limitations, German and Israeli guidelines recommend temporary use of BT and HT (grade B/C).[13,14] Furthermore, BT and HT are often part of MCT (at least one exercise and one psychological component) but they are not analyzed separately. In several evidenced-based guidelines and reviews, MCT and aerobic exercises (land-based or water-based) are strongly recommended.[12–15] The aim of the present review is to offer an update of the literature on BT and HT in FMS, with special focus on separate analyses of the different treatment modalities.