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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

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The therapeutic effect of balneotherapy: evaluation of the evidence from randomised controlled trials

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Review published: .

CRD summary

This review assessed the clinical benefits of thermal springs for people with rheumatological and other musculoskeletal conditions and concluded that there may be benefits, but firm conclusions could not be drawn as the research was not sufficiently strong. The analysis undertaken was limited and several relevant Russian studies were not included. Given the information presented, the authors' conclusions seem reasonable.

Authors' objectives

To review the evidence for the clinical effects of balneotherapy.

Searching

PubMed, Scopus and The Cochrane Library were searched from 1950 to 2006 for articles written in English, German, Italian or French. Search terms were reported. Reference lists from relevant articles were screened for additional articles.

Study selection

Randomised controlled trials (RCTs) that compared balneotherapy (including thalassotherapy) to other therapeutic modalities were eligible for inclusion provided the water temperature used was at least 34°C and the treatment was more frequent than once weekly. Exclusion criteria were: hydrotherapy patients with two or more concurrent diagnoses; patients with rheumatic, cardiovascular, gynaecological, allergic or gastrointestinal diseases; a dropout rate of more than 15% in one am; more than one month between delivery of the intervention and comparator; technical errors in treatment allocation; and multi-country studies with fewer than 50 participants per site.

Most of the included studies were of patients with rheumatological and other musculoskeletal diseases (osteoarthritis, fibromyalgia, ankylosing spondylitis, rheumatoid arthritis and chronic low back pain). Patients in other studies had psoriasis or Parkinson's Disease. In most of the studies balneotherapy was received at least five times per week. Duration of treatment ranged from two to four weeks. In some studies treatment was given in conjunction with spa treatments such as exercise or massage. There was variability between studies in the comparator used (placebo control that used tap water with the same physical characteristics as mineral water; no treatment; narrow band ultraviolet B; home exercise; short-wave diathermy). Most studies were from Israel, Turkey, Hungary and France; there were single studies from Italy, UK, Germany and Austria/Netherlands. A wide range of generic and disease-specific outcome measures were used to assess pain, function and quality of life.

Two reviewers independently assessed studies for inclusion.

Assessment of study quality

Two reviewers independently assessed quality using the Oxford Quality Scale for randomisation, blinding and information on withdrawals and the Oxford Pain Validity Scale for blinding, number of participants, outcomes, internal sensitivity and data analysis. The maximum score for the Oxford Quality Scale was 5 and more than 2 was defined as good quality. The maximum score on the Oxford Pain Validity Scale was 16.

Data extraction

It appeared that a summary of the results of each study was extracted by two reviewers and disagreements were resolved between all authors.

Methods of synthesis

A narrative synthesis was undertaken of the studies of rheumatological and other musculoskeletal diseases only. Studies were grouped by outcome and supported by tables that provided a summary of statistically significant results (including p values) for individual studies. Only outcomes assessed in five or more RCTs were included in the synthesis. Findings from higher quality studies were discussed separately.

Results of the review

Twenty-nine RCTs (including one cross-over trial) were included and 25 (n=1,720, range 23 to 224) of these were included in the synthesis. All except two of the included studies scored 3 or more on the Oxford Quality Scale (most scored 3). Oxford Pain Validity Scale scores ranged from 7 to 15. Length of follow-up ranged from two weeks to one year.

Pain: There was a statistically significant improvement in pain in 17 of the 25 trials in the balneotherapy group compared to control. There was no statistically significant difference between groups in eight trials.

Morning stiffness: There was a statistically significant improvement in the balneotherapy group compared to control in morning stiffness for one study. There was no statistically significant difference in the other seven studies that assessed this outcome.

Number of tender points and Fibromyalgia Impact Questionnaire: There was a statistically significant improvement with balneotherapy compared to control in three of the five studies that assessed these outcomes.

Analgesic consumption: There was a statistically significant improvement with balneotherapy compared to control in two of the five studies.

Quality of life: There was a statistically significant improvement with balneotherapy compared to control in all four studies.

Authors' conclusions

Balneotherapy may be associated with improvement in several rheumatological diseases, but existing research was not sufficiently strong to draw firm conclusions.

CRD commentary

The review had clearly stated inclusion criteria. A number of relevant sources were searched for studies. Unpublished studies were not sought specifically and relevant studies may have been missed. Twelve Russian-language studies were excluded and this may have altered the findings of the review. Study quality was assessed and considered in the synthesis. Appropriate methods were used to reduce error and bias in the review processes. The narrative synthesis undertaken had limitations as it relied on counting the number of studies with a statistically significant benefit; the size of any benefit derived was unclear.

The authors' conclusions are appropriately cautious and seem reasonable given the information presented. There was a possibility that the inclusion of all relevant studies may have altered the conclusions.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that randomised controlled trials were required to assess the effectiveness of balneotherapy, especially for dermatological, cardiovascular, respiratory, gastrointestinal, allergic and gynaecological diseases.

Funding

The authors stated that there was no funding.

Bibliographic details

Falagas ME, Zarkadoulia E, Rafailidis PI. The therapeutic effect of balneotherapy: evaluation of the evidence from randomised controlled trials. International Journal of Clinical Practice 2009; 63(7): 1068-1084. [PubMed: 19570124]

Indexing Status

Subject indexing assigned by NLM

MeSH

Balneology; Chronic Disease /therapy; Humans; Randomized Controlled Trials as Topic; Rheumatic Diseases /therapy; Treatment Outcome

AccessionNumber

12009107824

Database entry date

27/10/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

Copyright © 2014 University of York.
Bookshelf ID: NBK76749

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