• A P Verhagen, S M A Bierma-Zeinstra, J R Cardoso, R A de Bie, M Boers, and H C W de Vet.
• Department of General Practice, Erasmus MC, P.O. Box 1738, 3000 DR Rotterdam, Netherlands.
• Cochrane Db Syst Rev. 2003 Jan 1 (4): CD000518.

BackgroundBalneotherapy (spa therapy) for patients with arthritis is one of the oldest forms of therapy. One of the aims of balneotherapy is to soothe the pain, improve joint motion and as a consequence to relieve people' suffering and make them feel well.ObjectivesTo perform a systematic review on the effectiveness of balneotherapy for rheumatoid arthritis.Search StrategyUsing the Cochrane search strategy, studies were found by screening: 1) The MEDLINE CD-ROM database from 1966 to June 2002 and 2) the database from the Cochrane 'Rehabilitation and Related Therapies' Field, the Pedro database up to June 2002. Also, 3) reference checking and 4) personal communications with authors was carried out to retrieve eligible studies. Date of the most recent literature search: June, 2002Selection CriteriaStudies were eligible if they were randomised controlled trials (RCTs) comparing balneotherapy with any other intervention or with no intervention. Included participants all suffered from definite or classical rheumatoid arthritis (RA) as defined by the American Rheumatism Association Criteria (ARA) or by the criteria of Steinbrocker. At least one of the WHO/ILAR core set of endpoints for RA clinical trials had to be among the main outcome measures.Data Collection And AnalysisThe Delphi list was the criteria list used to assess the components of methodological quality. Two reviewers carried out quality assessment and data extraction of the studies. Disagreements were solved by consensus.Main ResultsSix trials, representing 355 people, were included in this review. Most trials reported positive findings (the absolute improvement in measured outcomes ranged from 0 to 44%), but were methodologically flawed to some extent. A 'quality of life' outcome was reported by two trials. None of the trials performed an intention-to-treat analysis and only two performed a comparison of effects between groups. Pooling of the data was not performed; because of heterogeneity of the studies, multiple outcome measurements, and the overall data presentation was too scarce.Reviewer's ConclusionsOne cannot ignore the positive findings reported in most trials. However the scientific evidence is insufficient because of the poor methodological quality, the absence of an adequate statistical analysis, and the absence, for the patient, of most essential outcome measures (pain, self assessed function, quality of life). Therefore, the noted "positive findings" should be viewed with caution. Because of the methodological flaws an answer about the apparent effectiveness of balneotherapy cannot be provided at this moment. A large, methodological sound trial is needed.

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