Outpatient balneological treatment of osteoarthritis in older persons

A retrospective study
  • Sinan Kardeş
  • Mine Karagülle
  • İlker Geçmen
  • Tuba Adıgüzel
  • Hidayet Yücesoy
  • Müfit Zeki Karagülle
Original Article



To evaluate the effectiveness and safety of outpatient balneological treatment consisting of hydrotherapy and peloid therapy in elderly patients with osteoarthritis.


In this retrospective observational study all patients aged ≥65 years with any type of osteoarthritis who received balneological treatment (hydrotherapy and peloid therapy) at our clinic between 2007 and 2016 were included. Hydrotherapy was applied as head-out immersion in a tap water pool at 36–38 °C for 20 min and then peloid therapy was applied as a local peloid pack on the painful region or joint at 42–43 °C for 20 min, on each weekday for 2 weeks. Patients were evaluated before and after the treatment and outcome measurements were pain, patient’s global assessment, physician’s global assessment, Western Ontario and McMaster Universities index, Lequesne hip index, Waddell index, neck pain and disability scale, and health assessment questionnaire.


In total, 235 osteoarthritis patients comprising 61 generalized, 91 knee, 6 hip; 32 lumbar, 12 cervical, 1 foot and 32 hand osteoarthritis, were included in the analysis. We found significant improvements in pain and function scores in generalized, knee, lumbar, cervical and hand osteoarthritis. Patient’s global assessment was also improved in all subtypes except hip (p = 1.000) and hand (p = 0.132) osteoarthritis subtypes. The majority of patients (59.1%) fulfilled the outcome measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria. The treatment demonstrated a good safety profile.


Study results provide initial evidence for the potential beneficial effects and safety of outpatient balneological treatment (hydrotherapy and peloid therapy) in the management of older patients with osteoarthritis. Future randomized controlled studies are needed to confirm these results.


Hydrotherapy Peloid therapy Retrospective study Pain management Older adults 

Ambulante balneologische Behandlung der Arthrose bei älteren Patienten

Eine retrospektive Studie



Die Wirksamkeit und Sicherheit einer ambulanten balneologischen Behandlung in Form von Hydro- und Peloidtherapie bei älteren Patienten mit Arthrose sollte untersucht werden.


In diese retrospektive Beobachtungsstudie wurden alle Patienten ≥65 Jahre eingeschlossen, die einen beliebigen Arthrosetyp aufwiesen und in unserer Klinik zwischen 2007 und 2016 eine balneologische Behandlung (Hydro- und Peloidtherapie) erhielten. Die Hydrotherapie bestand im Eintauchen bis zum Kopf in ein Becken mit Leitungswasser bei 36–38 °C für 20 min, dann erfolgte die Peloidtherapie mit einer lokalen Peloidpackung auf den schmerzhaften Bereich oder das entsprechende Gelenk bei 42–43 °C für 20 min. Die Behandlung erfolgte für 2 Wochen an jedem Werktag. Die Patienten wurden vor und nach der Behandlung untersucht. Bestimmt wurden der Schmerz, das Patient Global Assessment, das Physician Global Assessment, der Western Ontario and McMaster Universities Index, der Lequesne Hip Index, der Waddell Index, die Neck Pain and Disability Scale und der Health Assessment Questionnaire.


Insgesamt 235 Patienten mit Arthrose wurden in die Analyse eingeschlossen. In 61 Fällen bestand eine generalisierte Arthrose, in 91 war das Kniegelenk, in 6 das Hüftgelenk, in 32 die Lendenwirbelsäule, in 12 die Halswirbelsäule, in einem der Fuß und in 32 die Hand betroffen. Es zeigten sich signifikante Verbesserungen bezüglich des Schmerzes und der Funktionsscores bei generalisierter Arthrose sowie bei Arthrose des Kniegelenks, der Lendenwirbelsäule, der Halswirbelsäule und der Hand. Das Patient Global Assessment war ebenfalls verbessert – bei allen Arthrosesubtypen außer an Hüfte (p = 1,000) und Hand (p = 0,132). Die Mehrzahl der Patienten (59,1 %) erfüllte die Responder-Kriterien der Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI). Die Behandlung hatte ein gutes Sicherheitsprofil.


Die Studienergebnisse liefern erste Belege für die potenziell positiven Wirkungen und die Sicherheit der ambulanten balneologischen Behandlung (Hydro- und Peloidtherapie) in der Behandlung älterer Patienten mit Arthrose. Zur Bestätigung dieser Ergebnisse sind randomisierte, kontrollierte Studien erforderlich.


Hydrotherapie Peloidtherapie Retrospektive Studie Schmerzbehandlung Ältere Erwachsene 


Compliance with ethical guidelines

Conflict of interest

S. Kardeş, M. Karagülle, İ. Geçmen, T. Adıgüzel, H. Yücesoy and M.Z. Karagülle declare that they have no competing interests.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ethics Committee of the Istanbul Faculty of Medicine and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Ethics Committee of the Istanbul Faculty of Medicine waived the informed consent requirement because this was a retrospective study.

Supplementary material

391_2018_1370_MOESM1_ESM.jpg (5.9 mb)
Supplementary Figure S1. Photograph of the hydrotherapy pool at Balneological Treatment Unit, Department of Medical Ecology and Hydroclimatology, Istanbul Faculty of Medicine.
391_2018_1370_MOESM2_ESM.jpg (450 kb)
Supplementary Figure S2. Example photographs of peloid pack application at Balneological Treatment Unit, Department of Medical Ecology and Hydroclimatology, Istanbul Faculty of Medicine.


  1. 1.
    Loeser RF (2010) Age-related changes in the musculoskeletal system and the development of osteoarthritis. Clin Geriatr Med 26:371–386CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Hunter DJ, Felson DT (2006) Osteoarthritis. BMJ 332:639–642CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Conaghan PG, Kloppenburg M, Schett G, Bijlsma JW, EULAR osteoarthritis ad hoc committee (2014) Osteoarthritis research priorities: a report from a EULAR ad hoc expert committee. Ann Rheum Dis 73:1442–1445CrossRefPubMedGoogle Scholar
  4. 4.
    Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells G, Tugwell P, American College of Rheumatology (2012) American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (hoboken) 64:465–474CrossRefGoogle Scholar
  5. 5.
    European League Against Rheumatism (EULAR), Fernandes L, Hagen KB, Bijlsma JW et al (2013) EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis 72:1125–1135CrossRefGoogle Scholar
  6. 6.
    Bruyère O, Cooper C, Pelletier JP et al (2014) An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin Arthritis Rheum 44:253–263CrossRefPubMedGoogle Scholar
  7. 7.
    McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM et al (2014) OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthr Cartil 22:363–388CrossRefPubMedGoogle Scholar
  8. 8.
    Espejo-Antúnez L, Cardero-Durán MA, Garrido-Ardila EM, Torres-Piles S, Caro-Puértolas B (2013) Clinical effectiveness of mud pack therapy in knee osteoarthritis. Rheumatology (Oxford) 52:659–668CrossRefGoogle Scholar
  9. 9.
    Fortunati NA, Fioravanti A, Seri G et al (2016) May spa therapy be a valid opportunity to treat hand osteoarthritis? A review of clinical trials and mechanisms of action. Int J Biometeorol 60:1–8CrossRefPubMedGoogle Scholar
  10. 10.
    Tenti S, Cheleschi S, Galeazzi M, Fioravanti A (2015) Spa therapy: can be a valid option for treating knee osteoarthritis? Int J Biometeorol 59:1133–1143CrossRefPubMedGoogle Scholar
  11. 11.
    Gutenbrunner C, Bender T, Cantista P, Karagülle Z (2010) A proposal for a worldwide definition of health resort medicine, balneology, medical hydrology and climatology. Int J Biometeorol 54:495–507CrossRefPubMedGoogle Scholar
  12. 12.
    Karagülle M, Karagülle MZ (2015) Effectiveness of balneotherapy and spa therapy for the treatment of chronic low back pain: a review on latest evidence. Clin Rheumatol 34:207–214CrossRefPubMedGoogle Scholar
  13. 13.
    Karagülle MZ, Karagülle M (2004) Balneotherapy and spa therapy of rheumatic diseases in Turkey: a systematic review. Forsch Komplementarmed Klass Naturheilkd 11:33–41PubMedGoogle Scholar
  14. 14.
    Karagülle M, Kardeş S, Karagülle MZ (2017) Real-life effectiveness of spa therapy in rheumatic and musculoskeletal diseases: a retrospective study of 819 patients. Int J Biometeorol 61:1945–1956CrossRefPubMedGoogle Scholar
  15. 15.
    Nguyen M, Revel M, Dougados M (1997) Prolonged effects of 3 week therapy in a spa resort on lumbar spine, knee and hip osteoarthritis: follow-up after 6 months. A randomized controlled trial. Br J Rheumatol 36:77–81CrossRefPubMedGoogle Scholar
  16. 16.
    Karagülle M, Karagülle MZ, Karagülle O, Dönmez A, Turan M (2007) A 10-day course of SPA therapy is beneficial for people with severe knee osteoarthritis. A 24-week randomised, controlled pilot study. Clin Rheumatol 26:2063–2071CrossRefPubMedGoogle Scholar
  17. 17.
    Forestier R, Desfour H, Tessier JM, Françon A, Foote AM, Genty C et al (2010) Spa therapy in the treatment of knee osteoarthritis: a large randomised multicentre trial. Ann Rheum Dis 69:660–665CrossRefPubMedGoogle Scholar
  18. 18.
    Fioravanti A, Iacoponi F, Bellisai B, Cantarini L, Galeazzi M (2010) Short- and long-term effects of spa therapy in knee osteoarthritis. Am J Phys Med Rehabil 89:125–132CrossRefPubMedGoogle Scholar
  19. 19.
    Horváth K, Kulisch Á, Németh A, Bender T (2012) Evaluation of the effect of balneotherapy in patients with osteoarthritis of the hands: a randomized controlled single-blind follow-up study. Clin Rehabil 26:431–441CrossRefPubMedGoogle Scholar
  20. 20.
    Peluso R, Caso F, Costa L et al (2016) Mud-bath therapy and oral glucosamine sulfate in patients with knee osteoarthritis: a randomized, controlled, crossover study. Clin Exp Rheumatol 34:618–624PubMedGoogle Scholar
  21. 21.
    Branco M, Rêgo NN, Silva PH et al (2016) Bath thermal waters in the treatment of knee osteoarthritis: a randomized controlled clinical trial. Eur J Phys Rehabil Med 52:422–430PubMedGoogle Scholar
  22. 22.
    Kovács C, Bozsik Á, Pecze M et al (2016) Effects of sulfur bath on hip osteoarthritis: a randomized, controlled, single-blind, follow-up trial: a pilot study. Int J Biometeorol 60:1675–1680CrossRefPubMedGoogle Scholar
  23. 23.
    Gyarmati N, Kulisch Á, Németh A et al (2017) Evaluation of the effect of Hévíz mud in patients with hand osteoarthritis: a randomized, controlled, single-blind follow-up study. Isr Med Assoc J 19:177–182PubMedGoogle Scholar
  24. 24.
    Özkuk K, Gürdal H, Karagülle M et al (2017) Balneological outpatient treatment for patients with knee osteoarthritis; an effective non-drug therapy option in daily routine? Int J Biometeorol 61:719–728CrossRefPubMedGoogle Scholar
  25. 25.
    Bağdatlı AO, Donmez A, Eröksüz R et al (2015) Does addition of “mud-pack and hot pool treatment” to patient education make a difference in fibromyalgia patients? A randomized controlled single blind study. Int J Biometeorol 59:1905–1911CrossRefPubMedGoogle Scholar
  26. 26.
    Liberopoulos G, Trikalinos NA, Ioannidis JP (2009) The elderly were under-represented in osteoarthritis clinical trials. J Clin Epidemiol 62:1218–1223CrossRefPubMedGoogle Scholar
  27. 27.
    Arthritis Research UK Clinical Studies Group for Osteoarthritis and Crystal Diseases, Peat G, Birrell F, Cumming J et al (2011) Under-representation of the elderly in osteoarthritis clinical trials. Rheumatology (Oxford) 50:1184–1186CrossRefGoogle Scholar
  28. 28.
    Altman R, Asch E, Bloch D et al (1986) Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and therapeutic criteria committee of the American Rheumatism Association. Arthritis Rheum 29:1039–1049CrossRefPubMedGoogle Scholar
  29. 29.
    Altman R, Alarcón G, Appelrouth D et al (1991) The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 34:505–514CrossRefPubMedGoogle Scholar
  30. 30.
    Altman R, Alarcón G, Appelrouth D et al (1990) The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hand. Arthritis Rheum 33:1601–1610CrossRefPubMedGoogle Scholar
  31. 31.
    Muraki S, Akune T, Oka H et al (2012) Incidence and risk factors for radiographic lumbar spondylosis and lower back pain in Japanese men and women: the ROAD study. Osteoarthr Cartil 20:712–718CrossRefPubMedGoogle Scholar
  32. 32.
    Lawrence JS (1969) Generalized osteoarthrosis in a population sample. Am J Epidemiol 90:381–389CrossRefPubMedGoogle Scholar
  33. 33.
    Hüsmenoğlu M (2016) Peloidotherapy and roles of the nurses. J Acad Res Nurs 2:40–43Google Scholar
  34. 34.
    Celik Karakaya M, Karakaya N, Aydin S (2017) The physical and physicochemical properties of some Turkish thermal muds and pure clay minerals and their uses in therapy. Turk J Earth Sci 26:395–409CrossRefGoogle Scholar
  35. 35.
    Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (1988) Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 15:1833–1840PubMedGoogle Scholar
  36. 36.
    Lequesne MG (1997) The algofunctional indices for hip and knee osteoarthritis. J Rheumatol 24:779–781PubMedGoogle Scholar
  37. 37.
    Waddell G, Main CJ (1984) Assessment of severity in low-back disorders. Spine (Phila Pa 1976) 9:204–208CrossRefGoogle Scholar
  38. 38.
    Wheeler AH, Goolkasian P, Baird AC, Darden BV 2nd (1999) Development of the neck pain and disability scale. Item analysis, face, and criterion-related validity. Spine (Phila Pa 1976) 24:1290–1294CrossRefGoogle Scholar
  39. 39.
    Bruce B, Fries JF (2005) The Health Assessment Questionnaire (HAQ). Clin Exp Rheumatol 23:14–S18Google Scholar
  40. 40.
    Pham T, van der Heijde D, Altman RD et al (2004) OMERACT-OARSI initiative: Osteoarthritis Research Society International set of responder criteria for osteoarthritis clinical trials revisited. Osteoarthr Cartil 12:389–399CrossRefPubMedGoogle Scholar
  41. 41.
    Benjamini Y, Hochberg Y (1995) Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc Series B Stat Methodol 57:289–300Google Scholar
  42. 42.
    Haynes W (2013) Benjamini-Hochberg method. In: Dubitzky W, Wolkenhauer O, Cho KH, Yokota H (eds) Encyclopedia of systems biology. Springer, New YorkGoogle Scholar
  43. 43.
    Erol FB, Forestier RJ, Güneri FD, Karagülle MZ, Erdoğan N (2015) Spa therapy for generalized osteoarthritis: an open, observational, preliminary study. Therapie 70:273–281CrossRefPubMedGoogle Scholar
  44. 44.
    Gaál J, Varga J, Szekanecz Z, Kurkó J, Ficzere A, Bodolay E, Bender T (2008) Balneotherapy in elderly patients: effect on pain from degenerative knee and spine conditions and on quality of life. Isr Med Assoc J 10:365–369PubMedGoogle Scholar
  45. 45.
    Karagülle M, Kardeş S, Dişçi R et al (2016) Spa therapy for elderly: a retrospective study of 239 older patients with osteoarthritis. Int J Biometeorol 60:1481–1491CrossRefPubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Medical Ecology and Hydroclimatology, Istanbul Faculty of MedicineIstanbul UniversityİstanbulTurkey

Personalised recommendations