International Journal of Biometeorology

, Volume 60, Issue 11, pp 1675–1680 | Cite as

Effects of sulfur bath on hip osteoarthritis: a randomized, controlled, single-blind, follow-up trial: a pilot study

  • Csaba Kovács
  • Ágnes Bozsik
  • Mariann Pecze
  • Ildikó Borbély
  • Andrea Fogarasi
  • Lajos Kovács
  • Ildikó Katalin Tefner
  • Tamás Bender
Original Paper


The effects of balneotherapy were evaluated in patients with osteoarthritis of the hip. This randomized, controlled, investigator-blinded study enrolled outpatients with hip osteoarthritis according to ACR criteria. In addition to home exercise therapy, one patient group received balneotherapy for 3 weeks on 15 occasions. The mineral water used in this study is one of the mineral waters with the highest sulfide ion content (13.2 mg/L) in Hungary. The control group received exercise therapy alone. The WOMAC Likert 3.1 index and the EQ-5D quality of life self-administered questionnaire were completed three times during the study: prior to first treatment, at the end of the 3-week treatment course, and 12 weeks later. The main endpoint was achievement of Minimal Clinically Important Improvement (MCII) at 12 weeks, defined as ≥7.9 points in a normalized WOMAC function score. The intention to treat analysis included 20 controls and 21 balneotherapy patients. At 12 weeks, 17 (81 %) balneotherapy group patients had Minimal Clinically Important Improvement and 6 (30 %) of controls (p = 0.001). Comparing the results of the two groups at the end of treatment, there was a significant difference in the WOMAC stiffness score only, whereas after 12 weeks, the WOMAC pain, stiffness, function, and total scores also showed a significant difference in favor of the balneotherapy group. The difference between the two groups was significant after 12 weeks in point of EQVAS score, too. The results of our study suggest that the combination of balneotherapy and exercise therapy achieves more sustained improvement of joint function and decreases in pain than exercise therapy alone.


Mineral Water Exercise Therapy WOMAC Pain Sulfur Water WOMAC Index 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We would like to thank Ms. Katalin Hodosi (Department of Internal Medicine, Medical Center, University of Debrecen, Hungary) for the statistical analysis and Ms. Melinda Venczel and Mrs. Andrea Csirmaz (Musculoskeletal Rehabilitation Center, Mezőkövesd, Hungary) for their physiotherapy work.

Compliance with ethical standard

Before starting treatment, participants read the patient information sheet and signed the consent form. The study was approved by the Regional Research Ethics Committee (approval number: 1046-294/2013).

Conflict of interest

The authors declare that they have no competing interests.


  1. 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 15:1833–1840Google Scholar
  2. Bender T, Karagülle Z, Bálint GP, Gutenbrunner C, Bálint PV, Sukenik S (2005) Hydrotherapy, balneotherapy and spa treatment in pain management [review]. Rheumatol Int 25:220–224CrossRefGoogle Scholar
  3. Benedetti S, Canino C, Tonti G, Medda V, Calcaterra P, Nappi G, Salaffi F, Canestrari F (2010) Biomarkers of oxidation, inflammation and cartilage degradation in osteoarthritis patients undergoing sulfur-based spa therapies. Clin Biochem 43:973–978CrossRefGoogle Scholar
  4. Bennel K (2013) Physiotherapy management of hip osteoarthritis. J Physiother 59:145–57CrossRefGoogle Scholar
  5. Bennell KL, Egerton T, Martin J, Abbott JH, Metcalf B, McManus F, Sims K, Pua YH, Wrigley TV, Forbes A, Smith C, Harris A, Buchbinder R (2014) Effect of physical therapy on pain and function in patients with hip osteoarthritis: a randomized clinical trial. JAMA 311:1987–1997CrossRefGoogle Scholar
  6. Bierma-Zeinstra S, Bohnen A, Ginai A, Prins A, Verhaar J (1991) Validity of American College of Rheumatology criteria for diagnosing hip osteoarthritis in primary care research. Arthritis Rheum 34:505–514CrossRefGoogle Scholar
  7. Braga PC, Sambataro G, Dal Sasso M, Culici M, Alfieri M, Nappi G (2008) Antioxidant effect of sulphurous thermal water on human neutrophil bursts: chemiluminescence evaluation. Respiration 75:193–201CrossRefGoogle Scholar
  8. Chen CQ, Xin H, Zhu YZ (2007) Hydrogen sulfide: third gaseous transmitter, but with great pharmacological potential. Acta Pharmacol Sin 28:1709–1716CrossRefGoogle Scholar
  9. EuroQol Group (1990) EuroQol: a new facility for the measurement of health related quality of life. Health Policy 16:199–208CrossRefGoogle Scholar
  10. Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG, Doherty M, Geenen R, Hammond A, Kjeken I, Lohmander LS, Lund H, Mallen CD, Nava T, Oliver S, Pavelka K, Pitsillidou I, da Silva JA, de la Torre J, Zanoli G, Vliet Vlieland TP (2013) EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis 72:1125–1135CrossRefGoogle Scholar
  11. Fioravanti A, Cantarini L, Guidelli GM, Galeazzi M (2011) Mechanisms of action of spa therapies in rheumatic diseases: what scientific evidence is there? Rheumatol Int 31:1–8CrossRefGoogle Scholar
  12. Forestier R (2000) Magnitude and duration of the effects of two spa therapy courses on knee and hip osteoarthritis: an open prospective study in 51 consecutive patients. Joint Bone Spine 67:296–304Google Scholar
  13. Forestier R, Desfour H, Tessier JM, Françon A, Foote AM, Genty C, Rolland C, Roques CF, Bosson JL (2009) Spa therapy in the treatment of knee osteoarthritis: a large randomised multicentre trial. Ann Rheum Dis 69:660–665CrossRefGoogle Scholar
  14. Fortunati NA, Fioravanti A, Seri G, Cinelli S, Tenti S (2015) May spa therapy be a valid opportunity to treat hand osteoarthritis? A review of clinical trials and mechanisms of action. Int J Biometeorol, Epub ahead of printGoogle Scholar
  15. Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S (2014) Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev 4:CD007912Google Scholar
  16. Ghersetic I, Lotti T (1996) Immunologic aspects: immunology of mineral waters. Clin Dermatol 14:563–566CrossRefGoogle Scholar
  17. Guillemin F, Virion JM, Escudier P, De Talancé N, Weryha G (2001) Effect on osteoarthritis of spa therapy at Bourbonne-les-Bains. Joint Bone Spine 68:499–503CrossRefGoogle Scholar
  18. 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 54:495–507CrossRefGoogle Scholar
  19. Harzy T, Ghani N, Akasbi N, Bono W, Nejjari C (2009) Short- and long term therapeutic effects of thermal mineral waters in knee osteoarthritis: a systematic review of randomized controlled trials. Clin Rheumatol 28:501–507CrossRefGoogle Scholar
  20. Kovács C (2008) SPA therapy in Hungary. Press Therm Climat 145:187–190Google Scholar
  21. Kovács C, Pecze M, Tihanyi Á, Kovács L, Balogh S, Bender T (2012) The effect of sulphurous water in patients with osteoarthritis of hand. Double-blind, randomized, controlled follow-up study. Clin Rheumatol 31:1437–1442CrossRefGoogle Scholar
  22. Krauß I, Steinhilber B, Haupt G, Miller R, Martus P, Janßen P (2014) Exercise therapy in hip osteoarthritis—a randomized controlled trial. Dtsch Arztebl Int 111:592–599Google Scholar
  23. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, Kwoh K, Lohmander S, Rannou F, Roos EM, Underwood M (2014) OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage 22:363–388CrossRefGoogle Scholar
  24. 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 36:77–81CrossRefGoogle Scholar
  25. Péntek M, Genti G, Pintye A, Ratkó I (1999) A WOMAC VA3.0 index magyar verziójának vizsgálata térd- és csípőarthrosisos betegeken. Magyar Reumatológia 94-97Google Scholar
  26. Peter WF, Jansen MJ, Hurkmans EJ, Bloo H, Dekker J, Dilling RG, Hilberdink W, Kersten-Smit C, de Rooij M, Veenhof C, Vermeulen HM, de Vos RJ, Schoones JW, Vliet Vlieland TP, Guideline Steering Committee - Hip and Knee Osteoarthritis (2011) Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation. Acta Reumatol Port 36:268–281Google Scholar
  27. Tak E, Staats P, Van Hespen A, Hopman-Rock M (2005) The effects of an exercise program for older adults with osteoarthritis of the hip. J Rheumatol 32:1106–1113Google Scholar
  28. Tubach F, Ravaud P, Beaton D, Boers M, Bombardier C, Felson DT, van der Heijde D, Wells G, Dougados M (2007) Minimal clinically important improvement and patient acceptable symptom state for subjective outcome measures in rheumatic disorders. J Rheumatol 34(5):1188–93Google Scholar
  29. Vaht M, Birkenfeldt R, Ubner M (2008) An evaluation of the effect of differing lengths of spa therapy upon patients with osteoarthritis (OA). Complement Ther Clin Pract 14:60–64CrossRefGoogle Scholar
  30. Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P (2010) OARSI recommendations for the management of hip and knee osteoarthritis. Part III: changes in evidence following systematic cumulative update of research published through January 2010. Osteoarthritis Cartilage 18:476–499CrossRefGoogle Scholar

Copyright information

© ISB 2016

Authors and Affiliations

  • Csaba Kovács
    • 1
  • Ágnes Bozsik
    • 1
  • Mariann Pecze
    • 1
  • Ildikó Borbély
    • 1
  • Andrea Fogarasi
    • 1
  • Lajos Kovács
    • 1
  • Ildikó Katalin Tefner
    • 2
  • Tamás Bender
    • 3
  1. 1.Musculoskeletal Rehabilitation CenterMezőkövesdHungary
  2. 2.Józsefváros Municipal Health ServiceBudapestHungary
  3. 3.Polyclinic of Brother of St. John of God HospitalsBudapestHungary

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