International Journal of Biometeorology

, Volume 61, Issue 1, pp 169–180 | Cite as

Effect of spa therapy with saline balneotherapy on oxidant/antioxidant status in patients with rheumatoid arthritis: a single-blind randomized controlled trial

  • Mine KaragülleEmail author
  • Sinan Kardeş
  • Oğuz Karagülle
  • Rian Dişçi
  • Aslıhan Avcı
  • İlker Durak
  • Müfit Zeki Karagülle
Original Paper


Oxidative stress has been shown to play a contributory role in the pathogenesis of rheumatoid arthritis (RA). Recent studies have provided evidence for antioxidant properties of spa therapy. The purpose of this study is to investigate whether spa therapy with saline balneotherapy has any influence on the oxidant/antioxidant status in patients with RA and to assess clinical effects of spa therapy. In this investigator-blind randomized controlled trial, we randomly assigned 50 patients in a 1:1 ratio to spa therapy plus standard drug treatment (spa group) or standard drug treatment alone (control group). Spa group followed a 2-week course of spa therapy regimen consisting of a total of 12 balneotherapy sessions in a thermal mineral water pool at 36–37 °C for 20 min every day except Sunday. All clinical and biochemical parameters were assessed at baseline and after spa therapy (2 weeks). The clinical parameters were pain intensity, patient global assessment, physician global assessment, Health Assessment Questionnaire disability index (HAQ-DI), Disease Activity Score for 28-joints based on erythrocyte sedimentation rate (DAS28–4[ESR]). Oxidative status parameters were malondialdehyde (MDA), nonenzymatic superoxide radical scavenger activity (NSSA), antioxidant potential (AOP), and superoxide dismutase (SOD). The NSSA levels were increased significantly in the spa group (p = 0.003) but not in the control group (p = 0.509); and there was a trend in favor of spa therapy for improvements in NSSA levels compared to control (p = 0.091). Significant clinical improvement was found in the spa group compared to the control in terms of patient global assessment (p = 0.011), physician global assessment (p = 0.043), function (HAQ-DI) (p = 0.037), disease activity (DAS28–4[ESR]) (0.044) and swollen joint count (0.009), and a trend toward improvement in pain scores (0.057). Spa therapy with saline balneotherapy exerts antioxidant effect in patients with RA as reflected by the increase in NSSA levels after spa therapy; whether this antioxidant effect contributes to the clinical improvements observed remains to be verified.


Spa therapy Balneotherapy Rheumatoid arthritis Salt water Oxidative stress Antioxidant effect 



Antioxidant potential


Carbon dioxide


C-reactive protein


Disease Activity Score for 28-joints of 4 variables


Disease-modifying antirheumatic drug


Erythrocyte sedimentation rate


Hydrogen sulfide


Health Assessment Questionnaire Disability Index




Sodium chloride


Nitroblue tetrazolium


Nonenzymatic superoxide radical scavenger activity


Rheumatoid arthritis


Reactive nitrogen species


Reactive oxygen species


Standard deviation


Superoxide dismutase


Trichloroacetic acid


Tumor necrosis factor


Visual analog scale


Compliance with ethical standards



Conflict of interest

The authors declare that they have no conflict of interest.


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Authors and Affiliations

  1. 1.Department of Medical Ecology and Hydroclimatology, İstanbul Faculty of Medicineİstanbul UniversityİstanbulTurkey
  2. 2.Fachklinik Am HasenbachClaustinal-ZellerfedGermany
  3. 3.Department of Biostatistics, İstanbul Faculty of Medicineİstanbul UniversityİstanbulTurkey
  4. 4.Department of BiochemistryAnkara University Faculty of MedicineAnkaraTurkey

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