Review

Evaluation of the Role of Balneotherapy in Rehabilitation Medicine

Shuji Matsumoto

Department of Rehabilitation and Physical Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan

Balneotherapy is a treatment with healing waters, which includes bathing and physiotherapy in thermal
water, therapeutic drinks, medical massage, and water jet massage. It is based on the buoyancy, physi-
cal properties, temperature, and chemical effects of mineral water. Throughout European and Japanese
medical institutions, balneology and hot spring therapy is very much a part of routine medical treat-
ment. The mechanism of balneotherapy is not yet completely understood. Balneotherapeutic procedures
are mainly performed for the prevention, treatment, and rehabilitation of musculoskeletal diseases, but
they have also proven useful for various other indications such as for the treatment or rehabilitation of
dermatological diseases, immuno-inflammatory diseases, chronic pain syndromes, chronic cardiac dis-
eases, and metabolic syndromes or neurological diseases as well as in the rehabilitation of patients with
psychiatric conditions. Balneotherapy works well in the case of muscle tension, as it is relieving and re-
laxing, and it may be associated with improvement of various diseases. However, further investigations
are necessary to determine the effectiveness, safety, standard procedures, and potential side effects of
balneotherapy. (J Nippon Med Sch 2018; 85: 196 203)

Key words: balneotherapy, rehabilitation, chronic pain, cardiac diseases, metabolic syndrome

Introduction mal mineral water baths) is combined mostly with mud

Balneotherapy is defined as the therapeutic use of bath- thermal therapy. Furthermore, drinking cures, inhala-
ing agents such as mineral and thermal waters, muds, tions, and other balneotherapeutic interventions are be-
1,2
and gases . For thousands of years, humans have been ing combined for treating diverse conditions in different
seeking solace in the waters of a hot bath. The new de- countries1. However, the most effective complex balneo-
velopments and events in balneotherapy may be summa- therapeutic treatments for certain diseases remain to be
rized as follows. tested.
1. Balneotherapy has gone global from Japan to Asia 3. Beyond the treatment of rheumatic diseases, the use
and to all over the world. In recent years, interest in of balneotherapy for dermatologic and other indications
medical balneology and hydro-climatology has increased is being investigated6. Balneotherapy and spa therapy are
worldwide. There is now a growing number of published being increasingly considered in evidence-based treat-
articles on balneotherapy, originating from various coun- ment guidelines for rheumatic diseases, including os-
3,4
tries and centers in different locations . Japan is the teoarthritis, fibromyalgia, ankylosing spondylitis, early
country of the “onsen” (hot spring) and “ryokan” arthritis, rheumatoid arthritis, and lower back pain7.
(Japanese-style hotel), i.e., the kingdom of balneotherapy. Among other indications for balneotherapy, dermatologi-
North American, Russian, Indian, and Chinese balneo- cal diseases are first. The studies aiming to investigate
therapy organizations are up and coming. the therapeutic effects of balneotherapeutic treatments on
2. Balneotherapy protocols have become complex, as cardiovascular, metabolic, neurological, psychiatric, and
certain conditions require the most effective combinations respiratory conditions have been published recently.
4,5
of therapy . In many countries, complex balneotherapeu- 4. The preventive effects of balneotherapeutic treat-
tic interventions are being used. Depending on local ments are being studied, as this therapy is an old remedy
natural remedies, the experience of balneotherapy (ther- for contemporary health risks8. Research interest in the

Correspondence to Shuji Matsumoto, MD, PhD, Department of Rehabilitation and Physical Medicine, Graduate School of Medi-
cine, Nippon Medical School, 1 1 5 Sendagi, Bunkyo-ku, Tokyo 113 8603, Japan
E-mail: [email protected]
Journal Website (http://www2.nms.ac.jp/jnms/)

196 J Nippon Med Sch 2018; 85 (4)

 Balneotherapy and Rehabilitation

beneficial and health effects of balneotherapeutic applica- Bender et al.3 concluded that the studied thermal mineral
tions is growing as a need for measures to modify the waters significantly reduced pain in degenerative joint
major health risks of our time. Recently published scien- and spinal disease, and osteoarthritis of the hand and
tific balneotherapeutic trials reported scientific evidence knee, and they alleviated chronic lower back pain. How-
on the preventive effects of balneotherapy and spa ther- ever, better quality randomized controlled trials (well de-
apy on metabolic syndrome and obesity as well as cogni- signed, conducted, and reported) are needed to evaluate
tive function and physiological status9. the short-term and long-term effects of balneotherapy for
5. More insights into the effects of local natural spa relieving chronic back pain and providing broader bene-
waters and the specific chemical components of balneo- ficial effects1.
therapeutic waters have been provided. Authors from Subsequently, Kamioka et al. proposed the spa therapy
various disciplines have published studies evaluating the checklist (SPAC) that could assess the quality of studies
specific effects of local natural spa water and mud used reported on spa therapy, based on randomized controlled
in balneological treatments and the effects of the specific trials12,13. Assessing the quality of studies is particularly
chemical components of balneotherapeutic waters10. Be- important for researchers’ and clinicians’ critical ap-
sides the clinical trials with measurements of biological praisal of health care literature and for systematic re-
markers, some other publications have reported results views14. Recently, a checklist to assess the quality of re-
obtained from cell cultures and experimental animal ports on SPAC was developed using the Delphi consen-
model studies, and they shed more light on the specific sus method13. This checklist is simple and quick to com-
biological effects of a given balneotherapeutic remedy plete, and it should help clinicians and researchers criti-
and specific elements of the mineral water, particularly cally appraise medical and health care literature, review-
sulfur and carbon dioxide11. ers assess the quality of reports included in systematic
reviews, and researchers plan interventional trials of spa
Evidence-Based Medicine on Balneotherapy therapy. To assess the quality of studies on spa therapy
Japan has many thermal and mineral springs and a his- based on randomized controlled trials by SPAC and to
tory of the tradition of spa therapy and balneotherapy, determine the relationship between the SPAC score and
which was used for the treatment of various diseases. characteristics of publications, Kamioka et al.12,13 searched
The main aims of balneotherapy in the medical context the following databases: MEDLINE via PubMed, CI-
are to relieve pain and increase muscular power and NAHL, Web of Science, Ichushi Web, Global Health Li-
range of joint movement. Balneotherapy has been a brary, the Western Pacific Region Index Medicus, Psyc
mainstay of treatment for many years in the management INFO, and the Cochrane Database of Systematic Reviews
of numerous medical conditions including arthritic and for articles from 1990 to September 30, 2013. They con-
neurological conditions, and in rehabilitation following cluded that to prevent a flawed description SPAC could
sporting injuries. provide indispensable information for researchers who
Bender et al.3 reported a systematic review and meta- are going to design a research protocol according to each
analysis of clinical trials conducted with thermal mineral disease15.
waters, and the findings of which have been published in
English by authors worldwide. The 122 studies identified Immuno-Inflammatory Regulation Effects
from different databases include 18 clinical trials. Five of of Hot Spring Water
these trials evaluated the effect of hydrotherapy and bal- Balneotherapy and spa therapy have long been used as
neotherapy on chronic lower back pain7, four on osteoar- safe, effective, and long-term alternative therapies for
thritis of the knee, two on osteoarthritis of the hand, and various dermatologic diseases in Japan. Among them are
one on osteoarthritis of the shoulder. All reviewed trials pruritic, xerotic, immuno-inflammatory, infectious, and
reported that balneotherapy was superior in the long- ulcerative skin diseases. There are about 3,450 spas in Ja-
term to tap water therapy in relieving pain and improv- pan, and many of them are recognized as having specific
ing function, and spa therapy combining balneotherapy therapeutic effects. However, the beneficial clinical effects
with mud pack therapy and/or exercise therapy, physio- of spa therapy and their underlying mechanisms are still
therapy, and/or education was effective in the manage- poorly defined and understood. In Japan, the areas of
ment of lower back pain and superior or equally effective distribution of hot springs coincide with the areas of
to the control treatments in the short- and long-term. granite distribution, and they are far from the geothermal

J Nippon Med Sch 2018; 85 (4) 197

 S. Matsumoto

heat energy related to volcanoes. Natural hot spring Chronic Pain Syndromes
water in Japan can be classified into four main hydro- Balneotherapy has been practiced for centuries in the
chemical groups, i.e., Ca(Na)-HCO3, Na(Ca)-HCO 3, management of chronic pain syndromes. It is based on
Na(Ca)-Cl, and acidic Ca-HCO3 types. They are mostly the indigenous natural remedies of natural spas, such as
alkaline in nature and have low levels of chemical con- thermal and mineral water and gases (carbon dioxide
stituents. Some authors have performed series of clinical and radon). The beneficial effect of balneotherapy for
and laboratory studies on several hot springs in different chronic pain syndromes is probably a result of mechani-
locations and mineral concentrations to better understand cal, thermal, and chemical effects.
their clinical effects and possible mechanisms of their Lower back pain (LBP) is the most common muscu-
beneficial effects1,4,16. These include the Haeundae (Na-Cl loskeletal complaint, and its lifetime incidence is esti-
type), Seokmo-do (Na-Cl, Ca-Cl type), Suanbo (Na-HCO3 mated at 80%. It is a main cause of loss of work and has
type), Baekam (Na-HCO3 type), and Dukku (Na-Cl type) significant effects on the economy. Most patients with
areas. Utilizing humans, mice models17, and keratinocyte acute LBP improve spontaneously within 4 weeks; how-
cell lines, we evaluated the effects of each type of hot ever, chronic LBP is extremely common and usually me-
spring water on the changes of clinical symptoms of in- chanical in nature.
duced dermatitis, skin barrier functions, skin-infiltrating Gore et al.23 demonstrated economic benefits in using
cells and related histologic findings, pro-inflammatory hydrotherapy to rehabilitate patients with LBP. Bello et
cytokine production, and helper T cell subset differentia- al.24 randomized 306 adults with chronic LBP to group
tion and proliferation. Generally, Lee et al.17 found that hydrotherapy or land-based exercises, and they showed
the studied hot spring waters had the capacity to im- statistically significant improvements in those undergo-
prove skin inflammation associated with atopic dermati- ing hydrotherapy and deterioration in those treated with
tis and a tendency to downregulate the production of standard physiotherapy, which is in accordance with
skin inflammatory cytokines and increase the Foxp3+ Treg Jókai’s results25. Additionally, Balogh et al.26 compared
cell population while decreasing the Th1, Th2, and Th17 balneotherapy with mineral water versus tap water in in-
18
populations . They concluded that spa spring water dividuals with LBP and showed some minor benefit from
treatment suppressed inflammatory cytokine production spa water therapy in the pain score, spinal movement,
+
and modulated the differentiation of CD4 T cells into and local tenderness. Sjogren et al.27 also showed im-
Th1, Th2, and Th17 cells, but not Regulatory T cells19. provement with hydrotherapy versus conventional land-
With these experimental protocols, researchers can com- based treatment in patients with chronic LBP. Further,
pare the efficacy of spa spring waters immunologically. Guillemin et al.28 compared 50 patients with chronic LBP
The effects of balneotherapy on the immune system attending a spa resort in France with 52 similar patients
have been evaluated in some studies. Ernst et al.20 pre- receiving no spa treatment. This trial was of particular
scribed a regular hydrotherapy regimen to 25 volunteers interest because the long-term effects were assessed after
over a 6-month period and compared them with another 9 months, and the authors showed continued reduction
25 volunteers who received no hydrotherapy; they found in pain, drug consumption, and spinal mobility in the
a significant reduction in the frequency of head colds in spa-treated group.
those receiving hydrotherapy. Furthermore, those subjects Two out of three adults will experience chronic neck
who contracted a cold were less severely affected, and pain during their lifetime, but balneotherapy could help.
the duration of the infection was shorter, suggesting that The most common causes of neck pain strains and
regular hydrotherapy represents an effective prophylaxis sprains heal within a few days or weeks after balneo-
against common colds. This finding was not confirmed therapy. A strain is when a muscle or tendon has been ir-
in a further study of community hydrotherapy in school- ritated by overuse or overextension. Similarly, a sprain is
21
aged children . when a ligament has been irritated by overuse or overex-
17
Chronic skin diseases such as psoriasis have been as- tension. Neck pain usually resolves within 2 3 months,
sessed but mainly in the comparison of standard tap but in some cases, it can be chronic. Forestier et al.29 com-
water with specific spa waters in Europe. Some of these pared 44 patients with chronic neck pain treated with spa
studies have shown improvement with specific spas, sug- therapy to 42 patients treated with pulsed electromag-
gesting that the minerals in the water have a direct effect netic field therapy. Significant improvement was seen in
22
on skin disease . both groups in terms of the pain score and range of

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 Balneotherapy and Rehabilitation

movement, which is in accordance with Koyuncu’s re- changed the name to Waon therapy, “Wa” means sooth-
sults30. ing and “on” means warmth; hence, Waon infers sooth-
The beneficial effect of balneotherapy was also ob- ing warmth that comfortably refreshes the mind and
31
served in patients with fibromyalgia . Fibromyalgia syn- body. Waon therapy is defined as “therapy in which the
drome (FMS) is a chronic disorder characterized by wide- entire body is warmed in an evenly maintained far infra-
spread pain with localized tenderness. FMS leads to dif- red dry sauna at a temperature of 60°C for 15 minutes
fuse musculoskeletal pain with multiple tender points and then rested supine on a bed outside the sauna where
that are distributed widely and symmetrically through- the body is covered with blankets for an additional 30
out the body. FMS is extremely prevalent in the general minutes, with fluids corresponding to perspiration being
population, affecting between 3% and 5% of women and supplied at the end.” Waon therapy has several charac-
about 1% of men. It is a condition associated with wide- teristic features, that is, it is safe, nontoxic, gentle, and
spread chronic pain, fatigue, sleep disturbance, changes cost effective. This holistic medical care is globally avail-
in personality and mood, and multiple other symptoms able to patients with refractory diseases. There are vari-
than cannot be easily explained. The condition is a sig- ous clinical applications of Waon therapy, and its effects
nificant cause of disability in the community, and unfor- are often dramatic. Particularly, a drastic recovery is
tunately, no specific treatments have proven efficacy. Nu- often seen in severe CHF as well as peripheral artery dis-
merous studies have been performed in FMS to assess ease (PAD) with intractable ulcers, chronic fatigue syn-
the effects of balneotherapy. Tomas-Carus et al.32 com- drome, fibromyalgia syndrome, and salivary secretion
pared hydrotherapy with land-based exercise in 34 pa- failure caused by conditions such as Sjögren’s syndrome.
tients with FMS and showed long-term improvements in Tei et al. demonstrated that Waon therapy improved
pain, quality of life (QOL), muscle strength, and power hemodynamics, cardiac function, ventricular arrhythmias,
in those receiving hydrotherapy. Several but not all pa- vascular endothelial function, neurohumoral factors, and
tients with FMS showed prolonged benefit from water- sympathetic and para-sympathetic nervous system func-
33,34
based exercise . tion38,39. They also found that 2 4 weeks of Waon therapy
(once per day, 5 days per week) significantly improved
Cardiac Disease clinical symptoms, and decreased brain natriuretic pep-
As a cardiovascular disease syndrome, chronic heart fail- tide level and cardiac size in patients with CHF39,40. Waon
ure (CHF) continues to gain importance and is the com- therapy improved the prognosis of patients with CHF as
mon outcome of many cardiovascular diseases such as well as CHF in hamster and mouse models. The molecu-
hypertension and coronary atherosclerosis; thus, it re- lar mechanism by which Waon therapy improves vascu-
quires additional new strategies. A role for balneotherapy lar flow and the expression of endothelial nitric oxide
has been found in the treatment of chronic cardiac dis- synthase and capillary density has been demonstrated.
ease including heart failure. Hydrotherapy was thought Moreover, repeated Waon therapy is effective for patients
to be potentially dangerous for patients with long-term with severe PAD, as evidenced by a substantial decrease
heart disease; however, current studies have suggested in pain scores, increases in both the ankle-brachial pres-
that the heart can tolerate emersion in warm water, and sure index and blood flow assessed by laser Doppler per-
heart function and general well-being can improve. Cider fusion imaging, and formation of new collateral vessels
35
et al. assessed the cardio-respiratory effects of warm on angiography41. Waon therapy often heals ischemic ul-
water emersion in elderly patients with chronic heart cers markedly. Waon therapy upregulates heat shock pro-
failure and showed that hydrotherapy was well-tolerated tein 90 and leads to angiogenesis through the Akt-
and posed no danger to patients. Several reports have endothelial nitric oxide synthase pathway in mouse hin-
shown positive benefits in QOL, heart failure-related dlimb ischemia. Further, Tei et al.39 conducted a multicen-
symptoms, heart rate responses, and stress hormone lev- ter, randomized study to establish the efficacy and safety
els in patients with chronic heart failure treated with of Waon therapy. They concluded that Waon therapy
regular hydrotherapy regimens36,37. may accelerate the favorable actions of the renin-
In 1989, Tei et al. developed a form of thermal therapy angiotensin-aldosterone (RAA) system modulators in
for heart failure, and it has been approved as one of the CHF. Therefore, Waon therapy is an innovative and
advanced medical care treatments by the Japanese gov- highly promising strategy for cardiovascular diseases, es-
38,39
ernment insurance system since 2013 . In 2007, they pecially for treating refractory CHF and PAD.

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 S. Matsumoto

Metabolic Syndromes lation. Although the mean right atrial pressure and pul-
Water temperature plays an important role in the meta- monary arterial pressure increased during the SB, they
bolic effects of balneotherapy. In Japan, the most out- immediately decreased after the pile of sand was re-
standing feature of balneotherapy is repeated whole- moved. All these findings indicate that the basic effects
body immersion in warm water at 39 40°C. It has been of the SB are derived from strong hydrostatic pressure of
suggested that balneotherapy is beneficial for patients the pile of heavy sand and thermal vasodilation. In-
whose platelet antioxidative defense system is damaged, creased cardiac output due to accelerated venous return
such as those with diabetes mellitus and coronary heart and reduced afterload (total peripheral resistance) will
disease. induce sufficient oxygen supply and increase discharge
The Ibusuki hot spring (“Sunamushi”) sand bath (SB) of waste matter from the peripheral tissues. These data
has traditionally been used for the relief of musculoskele- seem to be compatible with the clinical effects of the SB
tal and neurological pain for 250 years, and 260,000 peo- to relieve musculoskeletal pain and fatigue. Tanaka et
ple visit it annually. The SB involves piling heavy (40 60 al.42 concluded that the significant clinical effects were in-
kg) and hot (50°C) sand on a person’s body in the supine duced by increased cardiac output due to the increased
position; the sand is heated by the hot spring water that hydrostatic pressure of the pile of sand and thermal
42
gushes at the seashore of Ibusuki. Tanaka et al. studied vasodilation.
the cardiovascular and metabolic effects of SB from the It has been thought that balneotherapy and hydrother-
viewpoint of accelerated circulation. In this study, the apy should be avoided in patients with chronic lung dis-
general physical parameters (blood pressure, heart rate, ease; however, recent studies have shown considerable
and sublingual temperature) and plasma chemistry were benefits in these patients. Beamon et al.44 reviewed the lit-
examined in 20 healthy men (mean age 36 10 years). erature and reported an improvement in lung function in
The subjects wore a thin bathrobe, and a venous catheter patients with chronic asthma on treatment with hydro-
was placed in their forearm for blood sampling. They therapy. Moreover, Mitsunobu et al.45 assessed patients
rested in the supine position for 30 minutes and were with pulmonary emphysema over a 5-year period and
subjected to an SB for 10 minutes at the municipal SB in- showed long-term benefits from spa therapy in terms of
stitute with hot spring piping under the sand. In another lung function and oxygen capacity. Forgays46 even sug-
28 healthy subjects (mean age 44.3 2.4 years), cardiac gested that hydrotherapy can be used to assist with
outputs and plasma catecholamine and RAA activities smoking cessation. Wadell et al.47 showed an improve-
were measured. An intra-cardiac study using Swan-Ganz ment in lung function in patients with chronic obstruc-
catheterization was performed in 6 subjects. After 10 tive pulmonary disease who received high-intensity hy-
minutes of an SB, the diastolic blood pressure was sig- drotherapy. In this study, 30 patients with moderate to
nificantly decreased by 6 mmHg, and the heart rate and severe chronic obstructive pulmonary disease were ran-
sublingual temperature were significantly increased by domized to either the land-based exercise or hydrother-
+20 beats per minute and +1.1°C, respectively. The ve- apy group. Those patients receiving hydrotherapy
nous blood partial pressure of oxygen and pH levels showed improvements in QOL, activity scores, and well-
were significantly increased by 20 mm Torr and 0.03, re- being compared with those performing land-based exer-
spectively, and the partial pressure of carbon dioxide was cise and control patients who received no specific treat-
significantly reduced by 5 mm Torr. The lactate level, py- ment.
ruvate level, and lactate-to-pyruvate ratio were signifi-
cantly reduced, suggesting improved oxidative metabo- Neurological Disease
43
lism of the peripheral tissues . Plasma catecholamine and Balneotherapy has been used in the rehabilitation of pa-
plasma renin activity were elevated after the SB. All tients with numerous neurological diseases, including
these results gradually returned to the resting level 30 brain injury, multiple sclerosis, spasticity, and spinal cord
minutes later. Cardiac output measured by the dye dilu- injury with paraplegia or tetraplegia. In all studies, hy-
tion or thermo-dilution method significantly increased drotherapy has a proven role in rehabilitation, particu-
from 5.6 L/min to 10.5 L/min after 10 minutes of the SB, larly when the water temperature is between 37°C and
and it decreased to 8.1 L/min after the pile of heavy 41°C.
sand was removed. The calculated total peripheral resis- Spasticity or increased muscle tonus is a hallmark of
tance significantly decreased, suggesting thermal vasodi- upper motor neuron lesions, which is easy to identify but

200 J Nippon Med Sch 2018; 85 (4)

 Balneotherapy and Rehabilitation

difficult to quantify and treat. Increased muscle tonus of fects, so to maintain disease stability it is necessary to
the lower limbs is a major obstacle to the rehabilitation frequently participate in water exercises.
of post-stroke patients with hemiplegia, and it can seri-
ously impair gait stability and activities of daily living. Conclusions
Spasticity in affected limbs often inhibits the efficacy of Balneotherapy has a wide role in the management of
physical therapy for the treatment of stroke or other cen- various medical conditions. Although the data in some
tral nervous disorders. Therefore, it is important to con- research studies are of limited interpretive value, there is
trol muscle tonus, especially in physiotherapy, in order to a developing body of evidence supporting the use of bal-
improve voluntary lower limb movements. neotherapy in wide-ranging conditions as varied as
Matsumoto et al. evaluated alterations in spasticity us- chronic arthritis, chronic pain syndromes, neurological
ing F-wave parameters in post-stroke patients who expe- disease, heart failure, and chronic lung conditions. As the
48,49
rienced balneotherapy . The anti-spastic effects of bal- understanding of human physiology has improved, it
neotherapeutic treatment were indicated by decreased F- can be seen that balneotherapy has diverse benefits, with
wave parameters, in parallel with decreases in the modi- particular emphasis on QOL, well-being, and physical
fied Ashworth scale score. Body temperature significantly conditioning.
increased both immediately after and 30 minutes follow-
ing balneotherapeutic treatment. These findings demon- Acknowledgements: None.
strate that the use of balneotherapy (whole-body immer-
sion at 41°C for 10 minutes and a footbath at 41°C for 15 Conflict of Interest: I declare no conflicts of interest in the
minutes) is an effective non-pharmacological anti-spastic authorship or publication of this contribution.
49,50
treatment that might facilitate stroke rehabilitation .
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48 Matsumoto S, Shimodozono M, Etoh S, Shimozono Y, (Accepted, July 6, 2018)
Tanaka N, Kawahira K: Beneficial effects of footbaths in

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