International Journal of Biometeorology

, Volume 61, Issue 4, pp 719–728 | Cite as

Balneological outpatient treatment for patients with knee osteoarthritis; an effective non-drug therapy option in daily routine?

  • Kağan ÖzkukEmail author
  • Hatice Gürdal
  • Mine Karagülle
  • Yasemin Barut
  • Rıza Eröksüz
  • Müfit Zeki Karagülle
Original Paper


This study aims to compare the effects of balneological treatments applied at consecutive and intermittent sessions without interfering with their daily routine in patients with knee osteoarthritis. This is a randomized, controlled, single-blind clinical trial. Fifty patients diagnosed with knee osteoarthritis were included. The patients were divided into two groups. All patients were given a total of ten sessions of balneological treatment consisting of hydrotherapy and mud pack therapy. Group 1 received consecutive treatment for 2 weeks, while group 2 received intermittent treatment for 5 weeks. Local peloid packs at 45 °C were applied for 20 min, after a tap water (38 °C) bath. Evaluations were conducted before, after treatment, and at 12th week of post-treatment by Pain (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Short Form-36 (SF-36). Both balneological treatment regimens of knee osteoarthritis had statistically significant clinical effects as well as effects on the quality of life. Patients’ well-being continued at 3 months, except for joint stiffness (WOMAC), role-emotional (SF-36), and vitality (SF-36) in group 1 and for mental health (SF-36) in both groups. Both patient groups had improved compared to baseline. However, at 3 months after the treatment, the well-being of group 2 was unable to be maintained in terms of role-physical (SF-36) parameter, while the well-being of group 1 was unable to be maintained in terms of pain, WOMAC (pain, physical functions, total), and SF-36 (physical functioning, role-physical, pain, role-emotional, and mental health) variables, compared to data obtained immediately after treatment. Our study suggests that traditional and intermittent balneological therapies have similar efficacy in patients with knee osteoarthritis.


Knee osteoarthritis Peloidotherapy Balneotherapy Spa treatment Intermittent 





American College of Rheumatology


Visual analog scale


Western Ontario and McMaster Universities Osteoarthritis Index


Short Form-36

Group 1

Consecutive treatment group

Group 2

İntermittent treatment group


Evaluations were made before treatment


Evaluations were made after treatment


Evaluations were made at 12th Week of post-treatment


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.


This study was not funded.

Human and animal right and informed consent

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (2991/10.12.2009) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent was obtained from all individual participants included in the study.


  1. Altman RD (2010) Early management of osteoarthritis. Am J Manag Care. 16 Suppl Management: S41–7Google Scholar
  2. Bellometti S, Cecchettin M, Galzigna L (1997) Mud-pack therapy in osteoarthrosis changes levels of chondrocytes markers. Clin Chim Acta 268:101–106CrossRefGoogle Scholar
  3. Bender T, Karagülle Z, Bálint GP, Gutenbrunner C, Bálint PV, Sukenik S (2005) Hydrotherapy, balneotherapy, and spa treatment in pain management. Rheumatol Int 25:220–224CrossRefGoogle Scholar
  4. Bender T, Bálint G, Prohászka Z et al (2014) Evidence-based hydro- and balneotherapy in Hungary—a systematic review and meta-analysis. Int J Biometeorol 58(3):311–323CrossRefGoogle Scholar
  5. Eichelsdörfer D (1990) Wirkungs mechanismen der Moor/Balneotherapie. İn: Göttlich K. Moor und Torkfunde, Stuttgart, PA: Schweizerbart science publishers pp 473Google Scholar
  6. Evcik D, Kavuncu V et al (2007) The efficacy of balneotherapy and mud-pack therapy in patients with knee osteoarthritis. Joint Bone Spine 74(1):60–65CrossRefGoogle Scholar
  7. Fioravanti A, Iacoponi F, Bellisai B et al (2010) Short- and long-term effects of spa therapy in knee osteoarthritis. Am J Phys Med Rehabil 89(2):125–132CrossRefGoogle Scholar
  8. Fioravanti A, Giannitti C, Cheleschi S, Simpatico A, Pascarelli NA, Galeazzi M (2015a) Circulating levels of adiponectin, resistin, and visfatin after mud-bath therapy in patients with bilateral knee osteoarthritis. Int J Biometeorol 59:1691–1700CrossRefGoogle Scholar
  9. Fioravanti A, Bacaro G, Giannitti C et al (2015b) One-year follow-up of mud-bath therapy in patients with bilateral knee osteoarthritis: a randomized, single-blind controlled trial. Int J Biometeorol 59(9):1333–1343CrossRefGoogle Scholar
  10. Forestier R, Desfour H, Tessier J-M et al (2010) Spa therapy in the treatment of knee osteoarthritis: a large randomized multicentre trial. Ann Rheum Dis 69(4):660–665CrossRefGoogle Scholar
  11. Gallagher EJ, Liebman M, Bijur PE (2001) Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med 38(6):633–638CrossRefGoogle Scholar
  12. Goecke C, Lüttig G (1987) Wirkungsmechanismen der Moortherapie. PA: Hippokrates VerlagGoogle Scholar
  13. Harzy T, Ghani N, Akasbi N et al (2009) Short- and long-term therapeutic effects of thermal mineral waters in knee osteoarthritis: a systematic review of randomized controlled trials. Clin Rheumatol 28(5):501–507CrossRefGoogle Scholar
  14. Hunter DJ, Lo GH (2008) The management of osteoarthritis: an overview and call to appropriate conservative treatment. Rheum Dis Clin N Am 34(3):689–712CrossRefGoogle Scholar
  15. Huskisson EC (1982) Measurement of pain. J Rheumatol 9(5):768–769Google Scholar
  16. Karagülle MZ (2002) Kaplıca tıbbı ve kaplıca tedavisi. In: Karagülle MZ ed. Balneoloji Ve Kaplıca Tıbbı. Nobel kitabevi, İstanbul. PA, pp. 15–36Google Scholar
  17. Karagülle MZ, Karagülle M (2004) Balneotherapy and spa therapy of rheumatic diseases in Turkey: a systematic review. Forsch Komplementarmed Klass Naturheilkd 11(1):33–41CrossRefGoogle Scholar
  18. Karagülle M, Karagülle MZ, Karagülle O et al (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(12):2063–2071CrossRefGoogle Scholar
  19. Katz U, Shoenfeld Y, Zakin V et al (2012) Scientific evidence of the therapeutic effects of dead sea treatments: a systematic review. Semin Arthritis Rheum 42(2):186–200CrossRefGoogle Scholar
  20. Kjellgren A, Sundequist U, Norlander T, Archer T (2001) Effects of flotation-REST on muscle tension pain. Pain Res Manag 6(4):181–189CrossRefGoogle Scholar
  21. Koçyiğit H, Aydemir Ö, Ölmez N et al (1999) Kısa fom-36 (KF-36)’nın Türkçe versiyonunun güvenilirliği ve geçerliliği. İlaç ve Tedavi Dergisi 12:102–106Google Scholar
  22. Korhanen R, Lüttig, GW (1996) Peat in Balneology and health care. In: Lappalainen E. Global peat resource, 1996; 339–345 Accession: 019685588Google Scholar
  23. Liu H, Zeng C, Gao SG et al (2013) The effect of mud therapy on pain relief in patients with knee osteoarthritis: a meta-analysis of randomized controlled trials. J Int Med Res 41(5):1418–1425CrossRefGoogle Scholar
  24. McAlindon TE, Bannuru RR, Sullivan MC et al (2014) OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthr Cartil 22(3):363–388CrossRefGoogle Scholar
  25. Million R, Hall W, Nilsen KH et al (1982) Assessment of the progress of the back-pain patient 1981 Volvo Award in Clinical Science. Spine 7(3):204–212CrossRefGoogle Scholar
  26. Odabasi E, Turan M et al (2008) Does mud pack treatment have any chemical effect? A randomized controlled clinical study. J Altern Complement Med 14(5):559–565CrossRefGoogle Scholar
  27. Pascarelli NA, Cheleschi S, Bacaro G, Guidelli GM, Galeazzi M, Fioravanti A (2016) Effect of mud-bath therapy on serum biomarkers in patients with knee osteoarthritis: results from a randomized controlled trial. Isr Med Assoc J 18(3–4):232–237Google Scholar
  28. Peat G, McCarney R, Croft P (2001) Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis 60(2):91–97CrossRefGoogle Scholar
  29. Sarsan A, Akkaya N, OzgenM YN, Atalay NS, Ardic F (2012) Comparing the efficacy of mature mud pack and hot pack treatments for knee osteoarthritis. J Back Musculoskelet Rehabil 25(3):193–199. doi: 10.3233/BMR-2012-0327 CrossRefGoogle Scholar
  30. Ware JE Jr, Sherbourne CD (1992) The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30(6):473–483CrossRefGoogle Scholar
  31. Sherman G, Zeller L, Avriel A et al (2009) Intermittent balneotherapy at the Dead Sea area for patients with knee osteoarthritis. Isr Med Assoc J 11(2):88–93Google Scholar
  32. Tenti S, Fioravanti A, Guidelli GM, Pascarelli NA, Cheleschi S (2014) New evidence on mechanisms of action of spa therapy in rheumatic diseases. TANG 4:31–38. doi: 10.5667/tang.2013.0029 Google Scholar
  33. Tenti S, Cheleschi S, Galeazzi M, Fioravanti A (2015) Spa therapy: can be a valid option for treating knee osteoarthritis? Int J Biometeorol 59(8):1133–1143CrossRefGoogle Scholar
  34. Tishler M, Rosenberg O, Levy O et al (2004) The effect of balneotherapy on osteoarthritis. Is an intermittent regimen effective? Eur J Intern Med 15(2):93–96CrossRefGoogle Scholar
  35. Tüzün EH, Eker L, Aytar A et al (2005) Acceptability, reliability, validity and responsiveness of the Turkish version of WOMAC osteoarthritis index. Osteoarthr Cartil 13(1):28–33CrossRefGoogle Scholar
  36. Yurtkuran M, Yurtkuran M, Alp A et al (2006) Balneotherapy and tap water therapy in the treatment of knee osteoarthritis. Rheumatol Int 27(1):19–27CrossRefGoogle Scholar

Copyright information

© ISB 2016

Authors and Affiliations

  • Kağan Özkuk
    • 1
    Email author
  • Hatice Gürdal
    • 2
  • Mine Karagülle
    • 2
  • Yasemin Barut
    • 3
  • Rıza Eröksüz
    • 4
  • Müfit Zeki Karagülle
    • 2
  1. 1.Department of Medical Ecology and Hydroclimatologyİzzet Baysal Physical Medicine and Rehabilitation Training and Research HospitalBoluTurkey
  2. 2.Department of Medical Ecology and Hydroclimatology, İstanbul Faculty of Medicineİstanbul UniversityİstanbulTurkey
  3. 3.Department of Medical Ecology and HydroclimatologyBüyükçekmece Public HospitalİstanbulTurkey
  4. 4.Department of Medical Ecology and HydroclimatologyYüksekİhtisas Training and Research HospitalBursaTurkey

Personalised recommendations