title: A pilot study to evaluate the effects of floatation spa treatment on patients with osteoarthritis. Sulphur bath and mud pack treatment for rheumatoid arthritis at the Dead Sea area. Dead Sea bath salts for the treatment of rheumatoid arthritis. Immediate and delayed effects of treatment at the Dead Sea in patients with psoriatic arthritis The role of trace elements in psoriatic patients undergoing balneotherapy with Dead Sea bath salt. Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial. Spa therapy for gonarthrosis: a prospective study Kangal hot spring with fish and psoriasis treatment. Balneotherapy for fibromyalgia at the Dead Sea The Change of Well-Being Associated with Spa Therapy The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. The Effect of Balneotherapy at the Dead Sea on the Quality of Life of Patients with Fibromyalgia Syndrome Long-term efficacy of radon spa therapy in rheumatoid arthritis--a randomized, sham-controlled study and follow-up. A randomized and controlled trial of hydrotherapy in rheumatoid arthritis. Effect of Sulfur Baths on Antioxidative Defense Systems, Peroxide Concentrations and Lipid Levels in Patients with Degenerative Osteoarthritis 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. [No difference in effectiveness measured between treatment in a thermal bath and in an exercise bath in patients with rheumatoid arthritis]. Quantitative Synthesis in Systematic Reviews The therapeutic effects of Cserkeszölö thermal water in osteoarthritis of the knee: a double blind, controlled, follow-up study Balneotherapy at the Dead Sea area for knee osteoarthritis. [Dead Sea bath salts for osteoarthritis of the knee]. Effect on osteoarthritis of spa therapy at Bourbonne-les-Bains. Balneotherapy for rheumatoid arthritis at the Dead Sea. Home exercises are as effective as outpatient hydrotherapy for osteoarthritis of the hip. The effectiveness of modified ingram therapy compared with severity of psoriasis. Balneophototherapy of psoriasis: highly concentrated salt water versus tap water--a randomized, one-blind, right/left comparative study. Balneotherapy at the Dead Sea area for patients with psoriatic arthritis and concomitant fibromyalgia. Double-Blind Trial on the Effectiveness of the Puspokladany Thermal Water on Arthrosis of the Knee-Joints
abstract: OBJECTIVE To conduct a preliminary investigation of the effects on floatation spa therapy on quality of life in patients with osteoarthritis to see if controlled trials are warranted . DESIGN Uncontrolled clinical trial . SETTING Private floatation spa therapy centre . PATIENTS Fourteen patients with chronic osteoarthritis of the weight-bearing joints , of whom four dropped out . INTERVENTION Six weekly sessions of floatation spa therapy . OUTCOME MEASURES SF36 , AIMS 2 and MYMOP quality -of-life question naires . MAIN RESULTS All patients improved . Differences between baseline and discharge scores showed statistically significant improvement for MYMOP , but not AIMS 2 or SF-36 . CONCLUSIONS Controlled trials of floatation spa therapy for patients with osteoarthritis are warranted Forty patients with classical or definite rheumatoid arthritis in a stage of active disease were treated for two weeks at a spa hotel . The patients were divided into four groups of 10 . Group I was treated with daily mud packs , group II with daily hot sulphur baths , group III with a combination of mud packs and hot sulphur baths , and group IV served as a control group . The patients were assessed by a rheumatologist who was blinded to the treatment modalities . Statistically significant improvement for a period of up to three months was observed in the three treatment groups in most of the clinical indices . Improvement in the control group was minor in comparison and not statistically significant . No significant improvement was observed in any of the laboratory variables measured . Except for three mild cases of thermal reaction there were no side effects Thirty patients with classical or definite rheumatoid arthritis were r and omly divided into two groups of fifteen patients each of similar age , sex , duration and severity of disease , and medical treatment . All patients were treated once a day with bath salts heated to 35 degrees C for twenty minutes . Group I received Dead Sea bath salts and Group II , the control group , received sodium chloride ( NaCl ) . The study was double-blind and of two weeks ' duration . All patients were evaluated by one rheumatologist both before treatment , and two weeks later at the end of the treatment period . Follow-up evaluations were made one and three months after conclusion of the treatments . The clinical parameters evaluated included duration of morning stiffness , fifteen meter walk time , h and -grip strength , activities of daily living , circumference of proximal interphalangeal joints , number of active joints , Ritchie index and the patient 's own assessment of disease activity . The laboratory parameters evaluated included erythrocyte sedimentation rate and serum levels of amyloid A , rheumatoid factor , sodium , potassium , calcium and magnesium . A statistically significant improvement ( p less than 0.01 or p less than 0.05 ) was observed in Group I only , in most of the clinical parameters assessed . Maximal therapeutic effect was obtained at the end of the treatment and lasted up to one month Abstract The purpose of this study was to evaluate the immediate and delayed effects of balneotherapy at the Dead Sea on patients with psoriatic arthritis ( PsA ) . A total of 42 patients with PsA were treated at the Dead Sea for 4 weeks . Patients were r and omly allocated into two groups : group 1 ( 23 patients ) and group 2 ( 19 patients ) . Both groups received daily exposure to sun ultraviolet rays and regular bathing at the Dead Sea . Group 1 was also treated with mud packs and sulfur baths . Patients were assessed by a dermatologist and a rheumatologist 3 days before arrival , at the end of treatment , and at weeks 8 , 16 , and 28 from the start of treatment . The clinical indices assessed were morning stiffness , right and left h and grip , number of tender joints , number of swollen joints , Schober test , distance from finger to floor when bending forward , patient 's self- assessment of disease severity , inflammatory neck and back pain and psoriasis area and severity index ( PASI ) score . Comparison between groups disclosed a similar statistically significant improvement for variables such as PASI , morning stiffness , patient self- assessment , right and left grip , Schober test and distance from finger to floor when bending forward . For variables such as tender and swollen joints , and inflammatory neck and back pain , improvement over time was statistically significant in group 1 . Addition of mud packs and sulfur baths to sun ultraviolet exposure and Dead Sea baths seems to prolong beneficial effects and improves inflammatory back pain BACKGROUND A beneficial effect was observed in patients with psoriasis vulgaris following balneotherapy with Dead Sea bath salt . OBJECTIVES To evaluate the possible role of trace elements in the effectiveness of balneotherapy . METHODS Serum levels of 11 trace elements were analyzed in 23 patients with psoriasis vulgaris who participated in a double-blind controlled study of balneotherapy with either Dead Sea bath salt ( 12 patients ) or common salt ( 11 patients ) . Thirteen healthy volunteers served as controls . RESULTS The mean pre-treatment serum levels of boron , cadmium , lithium and rubidium were significantly lower in patients compared to controls , whereas the mean pre-treatment serum level of manganese was significantly higher in patients compared to controls . Balneotherapy with Dead Sea bath salt result ed in a significant decrease ( P = 0.0051 ) in the mean serum level of manganese from 0.10 + /- 0.05 mol/L to 0.05 + /- 0.02 mumol/L. The mean reduction in the serum level of manganese differed significantly ( P = 0.002 ) between responders ( % Psoriasis Area and Severity Index score reduction > or = 25 ) and non-responders ( % PASI score reduction < 25 ) . Following balneotherapy with Dead Sea bath salt the mean serum level of lithium  decreased in responders by 0.01 + /- 0.02 mumol/L , whereas its level in non-responders increased by 0.03 + /- 0.03 mumol/L. ( P = 0.015 ) . CONCLUSIONS Manganese and lithium may play a role in the effectiveness of balneotherapy with Dead Sea bath salt for psoriasis OBJECTIVE To determine the efficacy of combined spa-exercise therapy in addition to st and ard treatment with drugs and weekly group physical therapy in patients with ankylosing spondylitis ( AS ) . METHODS A total of 120 Dutch out patients with AS were r and omly allocated into 3 groups of 40 patients each . Group 1 ( mean age 48 + /- 10 years ; male : female ratio 25:15 ) was treated in a spa resort in Bad Hofgastein , Austria ; group 2 ( mean age 49 + /- 9 years ; male : female ratio 28:12 ) in a spa resort in Arcen , The Netherl and s. The control group ( mean age 48 + /- 10 years ; male : female ratio 34:6 ) stayed at home and continued their usual drug treatment and weekly group physical therapy during the intervention weeks . St and ardized spa-exercise therapy of 3 weeks duration consisted of group physical exercises , walking , correction therapy ( lying supine on a bed ) , hydrotherapy , sports , and visits to either the Gasteiner Heilstollen ( Austria ) or sauna ( Netherl and s ) . After spa-exercise therapy all patients followed weekly group physical therapy for another 37 weeks . Primary outcomes were functional ability , patient 's global well-being , pain , and duration of morning stiffness , aggregated in a pooled index of change ( PIC ) . RESULTS Analysis of variance showed a statistically significant time-effect ( P < 0.001 ) and time-by-treatment interaction ( P = 0.004 ) , indicating that the 3 groups differed over time with respect to the course of the PIC . Four weeks after start of spa-exercise therapy , the mean difference in PIC between group 1 and controls was 0.49 ( 95 % confidence interval [ CI ] 0.16 - 0.82 , P = 0.004 ) and between group 2 and controls was 0.46 ( 95 % CI 0.15 - 0.78 , P = 0.005 ) . At 16 weeks , the difference between group 1 and controls was 0.63 ( 95 % CI 0.23 - 1.02 , P = 0.002 ) and between group 2 and controls was 0.34 ( 95 % CI--0.05 - 0.73 ; P = 0.086 ) . At 28 and 40 weeks , more improvement was found for group 1 compared with controls ( P = 0.012 and P = 0.062 , respectively ) but not for group 2 compared with controls . CONCLUSION In patients with AS , a 3-week course of combined spa-exercise therapy , in addition to drug treatment and weekly group physical therapy alone , provides beneficial effects . These beneficial effects may last for at least 40 weeks The objective of this study was to evaluate the effect of spa therapy on clinical parameters of patients with gonarthrosis . Patients with gonarthrosis ( n=33 ) underwent a 2-week spa therapy using three treatment regimes and a 20-week follow-up as follows : group I ( n=11 ) had mineral water baths and hot native mineral mud packs , group II ( n=12 ) had mineral water baths and rinsed mineral-free mud packs and group III ( n=10 ) had tap water baths and mineral-free mud packs . The patients and the assessing rheumatologist were blinded to the difference in the treatment protocol s. A significant improvement in the index of severity of the knee ( ISK ) , as well as night pain scores , was achieved in group I. Improvement in physical findings and a reduction in pain ratings on a visual analogue scale ( VAS ) did not reach statistical significance . Analgesic consumption was significantly decreased in both groups I and III for up to 12 weeks . Global improvement assessed by patients and physician was observed in all three groups up to 16 weeks but persisted to the end of the follow-up period in group I only . Patients with gonarthrosis seemed to benefit from spa therapy under all three regimes . However , for two parameters ( night pain and ISK ) the combination of mineral water baths and mud packs ( group I ) appeared to be superior The effect of " Kangal Hot Spring with Fish " in the treatment of psoriasis is investigated . The study was carried out on 87 patients with psoriasis vulgaris and the patients were evaluated by a dermatologist for 21 days . The evaluation of the disease was performed using PASI ( Psoriasis Area and Severity Index ) scores . Recurrences were investigated in the patient population , who had been previously treated in the same hot spring . The first examination scores were significantly higher than the scores of the 3 , 6 , 9 , 12 , 15 and 21 days after treatment ( p < 0.01 ) . Longer remission periods , when compared to the topical corticosteroid treatment , expressed by the 35 patients previously treated in hot spring ( p < 0.01 ) . Spa therapy under observation of a dermatologist may be effective and useful for psoriasis vulgaris patients Abstract . The aim of this study was to evaluate the effectiveness of balneotherapy on patients with fibromyalgia ( FM ) at the Dead Sea . Forty-eight patients with FM were r and omly assigned to a treatment group receiving sulfur baths and a control group .  All participants stayed for 10 days at a Dead Sea spa .  Physical functioning , FM-related symptoms , and tenderness measurements ( point count and dolorimetry ) were assessed at four time points : prior to arrival at the Dead Sea , after 10 days of treatment , and 1 and 3 months after leaving the spa . Physical functioning and tenderness moderately improved in both groups . With the exception of tenderness threshold , the improvement was especially notable in the treatment group and it persisted even after 3 months . Relief in the severity of FM-related symptoms ( pain , fatigue , stiffness , and anxiety ) and reduced frequency of symptoms ( headache , sleep problems , and subjective joint swelling ) were reported in both groups but lasted longer in the treatment group . In conclusion , treatment of FM at the Dead Sea is effective and safe and may become an additional therapeutic modality in FM . Future studies should address the outcome and possible mechanisms of this treatment in FM patients Objective : The present exploratory study sought to examine the changes of well-being associated with 3 weeks of resort based spa therapy . This is a traditional form of health enhancement incorporating balneotherapy , physical therapies , and health education in an inpatient setting . Patients and Method : Subjects were spa patients ( n = 153 , mean age 58 years ) with chronic pain and other age related complaints of moderately higher than normal prevalence . The well-being variables were vegetative complaints , pain , fatigue , positive and negative mood , and health satisfaction assessed at the beginning and end of spa treatment as well as 5 weeks and 12 months thereafter . Results : Well-being improved significantly in all variables during spa therapy , the improvement continuing with a slight deterioration at 5 weeks after the stay . After 12 months , vegetative complaints and fatigue had again reached pre-spa levels , whereas pain , positive and negative mood as well as health satisfaction remained improved . Both patients with high and low levels of pain increase their well-being , although pain patients showed greater improvements in some of the measures . Subjects not responding to spa therapy were older and showed less health satisfaction . Conclusions : The results suggest that spa therapy may be a powerful tool in enhancing well-being in progressed middle aged adults with common health impairments Most systematic review s rely substantially on the assessment of the method ological quality of the individual trials . The aim of this study was to obtain consensus among experts about a set of generic core items for quality assessment of r and omized clinical trials ( RCTs ) . The invited participants were experts in the field of quality assessment of RCTs . The initial item pool contained all items from existing criteria lists . Subsequently , we reduced the number of items by using the Delphi consensus technique . Each Delphi round comprised a question naire , an analysis , and a feedback report . The feedback report included staff team decisions made on the basis of the analysis and their justification . A total of 33 international experts agreed to participate , of whom 21 completed all question naires . The initial item pool of 206 items was reduced to 9 items in three Delphi rounds . The final criteria list ( the Delphi list ) was satisfactory to all participants . It is a starting point on the way to a minimum reference st and ard for RCTs on many different research topics . This list is not intended to replace , but rather to be used alongside , existing criteria lists Abstract : Fibromyalgia ( FS ) is an idiopathic chronic pain syndrome defined by widespread non-articular musculoskeletal pain and generalised tender points . As there is no effective treatment , patients with this condition have impaired quality of life ( QoL ) . The aim of this study was to assess the possible effect of balneotherapy at the Dead Sea area on the QoL of patients with FS . Forty-eight subjects participated in the study ; half of them received balneotherapy , and half did not . Their QoL ( using SF-36 ) , psychological well-being and FS-related symptoms were assessed prior to arrival at the spa hotel in the Dead Sea area , at the end of the 10-day stay , and 1 and 3 months later . A significant improvement was reported on most subscales of the SF-36 and on most symptoms . The improvement in physical aspects of QoL lasted usually 3 months , but on psychological measures the improvement was shorter . Subjects in the balneotherapy group reported higher and longer-lasting improvement than subjects in the control group . In conclusion , staying at the Dead Sea spa , in addition to balneotherapy , can transiently improve the QoL of patients with FS . Other studies with longer follow-up are needed to support our findings OBJECTIVE To quantify the efficacy of a series of baths containing natural radon and carbon dioxide ( 1.3 kBq/l , 1.6 g carbon dioxide/l on average ) versus artificial carbon dioxide baths alone in patients with rheumatoid arthritis . SUBJECTS Sixty patients participating in an in-patient rehabilitation programme including a series of 15 baths were r and omly assigned to two groups . DESIGN Pain intensity ( 100 mm visual analogue scale ) and functional restrictions [ Keitel functional test , Arthritis Impact Measurement Scales ( AIMS question naire ) ] were measured at baseline , after completion of treatment and 3 and 6 months thereafter . To investigate whether the overall value of the outcomes was the same in both groups , the overall mean was analysed by Student 's t-test for independent sample s. RESULTS The two groups showed a similar baseline situation . After completion of treatment , relevant clinical improvements were observed in both groups , with no notable group differences . However , the follow-up revealed sustained effects in the radon arm , and a return to baseline levels in the sham arm . After 6 months , marked between-group differences were found for both end-points ( pain intensity : -16.9 % , 95 % confidence interval -27.6 to -6.2 % ; AIMS score : 0.57 , 95 % confidence interval 0.16 to 0.98 ) . The between-group differences were statistically significant for both overall means ( pain intensity , P : = 0.04 ; AIMS , P : = 0.01 ) . CONCLUSION Marked short-term improvements in both groups at the end of treatment may have masked potential specific therapeutic effects of radon baths . However , after 6 months of follow-up the effects were lasting only in patients of the radon arm . This suggests that this component of the rehabilitative intervention can induce beneficial long-term effects OBJECTIVE The aim of this study was to evaluate the therapeutic effects of hydrotherapy which combines elements of warm water immersion and exercise . It was predicted that hydrotherapy would result in a greater therapeutic benefit than either of these components separately . METHODS One hundred thirty-nine patients with chronic rheumatoid arthritis were r and omly assigned to hydrotherapy , seated immersion , l and exercise , or progressive relaxation . Patients attended 30-minute sessions twice weekly for 4 weeks . Physical and psychological measures were completed before and after intervention , and at a 3-month followup . RESULTS All patients improved physically and emotionally , as assessed by the Arthritis Impact Measurement Scales 2 question naire . Belief that pain was controlled by chance happenings decreased , signifying improvement . In addition , hydrotherapy patients showed significantly greater improvement in joint tenderness and in knee range of movement ( women only ) . At followup , hydrotherapy patients maintained the improvement in emotional and psychological state . CONCLUSIONS Although all patients experienced some benefit , hydrotherapy produced the greatest improvements . This study , therefore , provides some justification for the continued use of hydrotherapy Background : Due to possible antiinflammatory effects , sulfur baths are widely used for the treatment of rheumatic diseases . Previously it was demonstrated that drinking cures with sulfur can improve the antioxidative defense system and lower the peroxide levels of patients with chronic degenerative osteoarthritis . Objective : This study therefore sought to investigate the effect of 3-week therapy with sulfur baths on antioxidative defense systems , peroxide concentrations , and lipid levels in patients with degenerative osteoarthritis . Patients and Methods : After r and omization one group of patients ( n = 19 ) received sulfur baths during their stay at a health resort ( sulfur group ) , whereas the other age-matched patient group served as controls ( n = 19 , control group ) , only receiving spa therapy .  Total cholesterol levels , HDL , LDL , triglycerides and the antioxidative status , glutathione peroxidase , and superoxide dismutase ( SOD ) activities , and peroxide concentration , as an oxidative stress parameter , were evaluated at the begin and end of therapy . Results : A 17.2 % decline in peroxide concentrations ( p = 0.10 , n.s . ) and significant lower SOD activities ( p < 0.001 ) were detected in the sulfur group at the end of the therapy . Until the end of therapy total cholesterol levels changed differentially ( p = 0.007 ) in the sulfur group ( from 229.11 ± 34.47 mg/dl to 217.46 ± 40.45 mg/dl ) and in the control group ( from 197.63 ± 34.66 mg/dl to 207.95 ± 33.02 mg/dl ) . A similar significant group difference was found for LDL ( p = 0.017 ) , with a 5.9 % reduction in the sulfur group and a 6.1 % increase in the control group . Triglyceride concentrations were nonsignificantly reduced in both groups after 3 weeks at the health resort ( sulfur group 11.2 % , control group 20.2 % ) . HDL values only minimally changed in both groups . Conclusions : The results presented here suggest that a sulfur bath therapy could cause a reduction in oxidative stress , alterations of SOD activities , and a tendency towards improvement of lipid levels Spa therapy is frequently used in daily rheumatological practice , but its benefit remains to be evaluated . A prospect i ve r and omized controlled study was conducted in 1993 in patients with osteoarthritis of the hip , knee or lumbar spine . Treatment was either  spa therapy at Vichy ( France ) of 3 weeks duration ( spa group ) or usual therapy ( control group ) . Assessment criteria were pain ( visual analogue scale ) , functional impairment ( Lequesne 's index for hip or knee disease , Main and Waddell 's for lumbar spinal diseases ) , quality of life index [ revised Arthritis Impact Measurement Scale ( AIMS 2 ) ] , and  analgesic and /or non-steroidal anti-inflammatory drug ( NSAID ) consumption .  Patients were included by r and omization into one of the two arms ( spa or control ) and assessment criteria were collected before spa therapy or the control period , and 3 and 24 weeks thereafter . A total of 188 patients ( lumbar spine 95 , knee 64 , hip 29 ) were included in the study ( spa group 91 , control group 97 ) . Changes in the assessment criteria after a 6 month follow-up period showed improvement in terms of pain , functional impairment and quality of life , with a reduced intake of symptomatic drugs ( NSAID and analgesic drugs ) in the spa group . This study suggests that spa therapy of 3 weeks duration has a prolonged , beneficial , symptomatic effect in osteoarthritis OBJECTIVE To determine whether hydrotherapy in a thermomineral institution is superior to the same hydrotherapy in an ordinary hospital exercise-bath . DESIGN Controlled therapeutic trial . SETTING The thermomineral institution at Arcen and the exercise bath at the Maasl and Hospital in Sittard , the Netherl and s. PATIENTS AND METHODS 46 patients with rheumatoid arthritis were treated in a by a skilled physiotherapist , according to a st and ardized exercise-scheme : 27 were treated in the thermomineral institution  and 19 ( control-group ) in the hospital exercise-bath .  Each patient received 12 treatments in 12 weeks . ENDPOINTS PARAMETERS : Morning stiffness , erythrocyte sedimentation rate , Ritchie index , amount of pain , answers to 11 questions concerning the activities of daily life , and psychosocial aspects of the disease . The various subjective and objective parameters were scored by the same physician . RESULTS Statistically significant improvement was observed in both groups concerning morning stiffness . Other subjective parameters improved , but did not reach significance . Objective parameters did not change significantly . Between-group differences were not found . CONCLUSION Hydrotherapy has a positive effect on some subjective but not on objective parameters in patients with rheumatoid arthritis , whether it is applied in a thermomineral institution or an ordinary hospital exercise bath A quantitative systematic review , or meta- analysis , uses statistical methods to combine the results of multiple studies . Meta-analyses have been done for systematic review s of therapeutic trials , diagnostic test evaluations , and epidemiologic studies . Although the statistical methods involved may at first appear to be mathematically complex , their purpose is simple : They are trying to answer four basic questions . Are the results of the different studies similar ? To the extent that they are similar , what is the best overall estimate ? How precise and robust is this estimate ? Finally , can dissimilarities be explained ? This article provides some guidance in underst and ing the key technical aspects of the quantitative approach to these questions . We have avoided using equations and statistical notations ; interested readers will find implementations of the described methods in the listed references . We focus here on the quantitative synthesis of reports of r and omized , controlled , therapeutic trials because far more meta-analyses on therapeutic studies than on other types of studies have been published . For practical reasons , we present a stepwise description of the tasks that are performed when statistical methods are used to combine data . These tasks are 1 ) deciding whether to combine data and defining what to combine , 2 ) evaluating the statistical heterogeneity of the data , 3 ) estimating a common effect , 4 ) exploring and explaining heterogeneity , 5 ) assessing the potential for bias , and 6 ) presenting the results . Deciding Whether To Combine Data and Defining What To Combine By the time one performs a quantitative synthesis , certain decisions should already have been made about the formulation of the question and the selection of included studies . These topics were discussed in two previous articles in this series [ 1 , 2 ] . Statistical tests can not compensate for lack of common sense , clinical acumen , and biological plausibility in the design of the protocol of a meta- analysis . Thus , a reader of a systematic review should always address these issues before evaluating the statistical methods that have been used and the results that have been generated . Combining poor- quality data , overly biased data , or data that do not make sense can easily produce unreliable results . The data to be combined in a meta- analysis are usually either binary or continuous . Binary data involve a yes/no categorization ( for example , death or survival ) . Continuous data take a range of values ( for example , change in diastolic blood pressure after antihypertensive treatment , measured in mm Hg ) . When one is comparing groups of patients , binary data can be summarized by using several measures of treatment effect that were discussed earlier in this series [ 3 ] . These measures include the risk ratio ; the odds ratio ; the risk difference ; and , when study duration is important , the incidence rate . Another useful clinical measure , the number needed to treat ( NNT ) , is derived from the inverse of the risk difference [ 3 ] . Treatment effect measures , such as the risk ratio and the odds ratio , provide an estimate of the relative efficacy of an intervention , whereas the risk difference describes the intervention 's absolute benefit . The various measures of treatment effect offer complementary information , and all should be examined [ 4 ] . Continuous data can be summarized by the raw mean difference between the treatment and control groups when the treatment effect is measured on the same scale ( for example , diastolic blood pressure in mm Hg ) , by the st and ardized mean difference when different scales are used to measure the same treatment effect ( for example , different pain scales being combined ) , or by the correlation coefficients between two continuous variables [ 5 ] . The st and ardized mean difference , also called the effect size , is obtained by dividing the difference between the mean in the treatment group and the mean in the control group by the SD in the control group . Evaluating the Statistical Heterogeneity of the Data This step is intended to answer the question , Are the results of the different studies similar ( homogeneous ) ? It is important to answer this question before combining any data . To do this , one must calculate the magnitude of the statistical diversity ( heterogeneity ) of the treatment effect that exists among the different sets of data . Statistical diversity can be thought of as attributable to one or both of two causes . First , study results can differ because of r and om sampling error . Even if the true effect is the same in each study , the results of different studies would be expected to vary r and omly around the true common fixed effect . This diversity is called the within- study variance . Second , each study may have been drawn from a different population , depending on the particular patients chosen and the interventions and conditions unique to the study . Therefore , even if each study enrolled a large patient sample , the treatment effect would be expected to differ . These differences , called r and om effects , describe the between- study variation with regard to an overall mean of the effects of all of the studies that could be undertaken . The test most commonly used to assess the statistical significance of between- study heterogeneity is based on the chi-square distribution [ 6 ] . It provides a measure of the sum of the squared differences between the results observed and the results expected in each study , under the assumption that each study estimates the same common treatment effect . A large total deviation indicates that a single common treatment effect is unlikely . Any pooled estimate calculated must account for the between- study heterogeneity . In practice , this test has low sensitivity for detecting heterogeneity , and it has been suggested that a liberal significance level , such as 0.1 , should be used [ 6 ] . Estimating a Common Effect The questions that this step tries to answers are , 1 ) To the extent that data are similar , what is their best common point estimate of a therapeutic effect , and 2 ) how precise is this estimate ? The mathematical process involved in this step generally involves combining ( pooling ) the results of different studies into an overall estimate . Compared with the results of individual studies , pooled results can increase statistical power and lead to more precise estimates of treatment effect . Each study is given a weight according to the precision of its results . The rationale is that studies with narrow CIs should be weighted more heavily than studies with greater uncertainty . The precision is generally expressed by the inverse of the variance of the estimate of each study . The variance has two components : the variance of the individual study and the variance between different studies . When the between- study variance is found to be or assumed to be zero , each study is simply weighted by the inverse of its own variance , which is a function of the study size and the number of events in the study . This approach characterizes a fixed-effects model , as exemplified by the Mantel-Haenszel method [ 7 , 8 ] or the Peto method [ 9 ] for dichotomous data . The Peto method has been particularly popular in the past . It has the advantage of simple calculation ; however , although it is appropriate in most cases , it may introduce large biases if the data are unbalanced [ 10 , 11 ] . On the other h and , r and om-effects models also add the between- study variance to the within- study variance of each individual study when the pooled mean of the r and om effects is calculated . The r and om-effects model most commonly used for dichotomous data is the DerSimonian and Laird estimate of the between- study variance [ 12 ] . Fixed- and r and om-effects models for continuous data have also been described [ 13 ] . Pooled results are generally reported as a point estimate and CI , typically a 95 % CI . Other quantitative techniques for combining data , such as the Confidence Profile Method [ 14 ] , use Bayesian methods to calculate posterior probability distributions for effects of interest . Bayesian statistics are based on the principle that each observation or set of observations should be viewed in conjunction with a prior probability describing the prior knowledge about the phenomenon of interest [ 15 ] . The new observations alter this prior probability to generate a posterior probability . Traditional meta- analysis assumes that nothing is known about the magnitude of the treatment effect before r and omized trials are performed . In Bayesian terms , the prior probability distribution is noninformative . Bayesian approaches may also allow the incorporation of indirect evidence in generating prior distributions [ 14 ] and may be particularly helpful in situations in which few data from r and omized studies exist [ 16 ] . Bayesian analyses may also be used to account for the uncertainty introduced by estimating the between- study variance in the r and om-effects model , leading to more appropriate estimates and predictions of treatment efficacy [ 17 ] . Exploring and Explaining Heterogeneity The next important issue is whether the common estimate obtained in the previous step is robust . Sensitivity analyses determine whether the common estimate is influenced by changes in the assumptions and in the protocol for combining the data . A comparison of the results of fixed- and r and om-effects models is one such sensitivity analysis [ 18 ] . Generally , the r and om-effects model produces wider CIs than does the fixed-effects model , and the level of statistical significance may therefore be different depending on the model used . The pooled point estimate per se is less likely to be affected , although exceptions are possible [ 19 ] . Other sensitivity analyses may include the examination of the residuals and the chi-square components [ 13 ] and assessment of the effect of deleting each study in turn . Statistically significant results that depend on a single study may require further exploration . Cumulative Meta- Analysis Abstract . The effects of thermal water from Cserkeszölö in Hungary were appraised in a r and omised , double blind study conducted on 58 patients with osteoarthritis of the knee .  Balneotherapy was delivered as a 15-day course of 30-min daily sessions performed with thermal water ( active treatment ) or tap water of similar colour and odour ( placebo treatment ) . The musculoskeletal status of participants was evaluated at baseline , at the end of the balneotherapy course , and 3 months later . Study endpoints ( initial pain , range of motion , tenderness on palpation , stair climbing , physicians ' opinion and subjective rating by patients , and ambulation ) were assessed using visual analogue scales and symptom scores . Both groups improved ; however , the magnitude of improvement was significantly greater in patients treated with thermal water from Cserkeszölö BACKGROUND Balneotherapy at the Dead Sea area has been applied in various inflammatory rheumatic diseases such as rheumatoid arthritis and psoriatic arthritis . The efficacy of balneotherapy at the Dead Sea area for the treatment of degenerative rheumatic diseases has not yet been formally evaluated . OBJECTIVE To evaluate the efficacy of balneotherapy at the Dead Sea area in patients suffering from osteoarthritis of the knees . METHODS Forty patients were r and omly allocated into four groups of 10 patients . Group I was treated by bathing in a sulphur pool , group 2 by bathing in the Dead Sea , group 3 by a combination of sulphur pool and bathing in the Dead Sea , and group 4 served as the control group receiving no balneotherapy . The duration of balneotherapy was 2 weeks . RESULTS Significant improvement as measured by the Lequesne index of severity of osteoarthritis was observed in all three treatment groups , but not in the control group . This improvement lasted up to 3 months of follow-up in patients in all three treatment groups . CONCLUSION Balneotherapy at the Dead Sea area has a beneficial effect on patients with osteoarthritis of the knees , an effect that lastas at least 3 months 26 patients with osteoarthritis of the knees were r and omly divided into 2 groups of 13 each with patients of similar ages , sex distribution and duration and severity of disease . All were treated with daily baths at 34 - 35 degrees C for 20 min . containing Dead Sea bath salts ( Group I ) or sodium chloride ( Group II ) . The study was double-blind and of 2 weeks duration . Patients were evaluated by a rheumatologist before , at the end of treatment and 1 month later . Clinical parameters evaluated included index of severity of osteoarthritis , patient 's assessment of disease severity , range of movement of knees , soft tissue swelling , effusion and crepitus . There was significant improvement in the index of severity of osteoarthritis at the end of the treatment in both groups ( p < 0.01 ) . 1 month later , in Group I the significance of the index was still p < 0.01 , but p < 0.05 in Group II . Patient 's assessment of improvement was significant only in Group I at the end of the treatment period ( p < 0.01 ) . There was no statistical improvement in either group in the other parameters assessed OBJECTIVES Several studies suggest a beneficial overall effect of spa therapy in chronic musculoskeletal diseases . The present open controlled study investigated the effects of spa therapy at Bourbonne-Les-Bains , France , in patients with hip or knee osteoarthritis or low back pain . PATIENTS AND METHODS In 1998 , 102 men and women older than 50 years were included in the study . All had low back pain or lower limb osteoarthritis , and none had contraindications to spa therapy .  Quality of life was assessed three times at intervals of 4 weeks , twice before and once immediately after 3 weeks of spa therapy , using the Duke Health Profile ( five dimensions and five dysfunctions ) . RESULTS Mean age was 66.4 years , and 67 % of the patients were women .  Quality of life was markedly decreased as compared to the population at large ( 1996 , CFES ) . The two pretreatment evaluations produced similar quality -of-life scores .  Spa therapy was associated with significant improvements in overall quality of life ( P=0.004 ) , self-esteem ( P=0.009 ) , and pain ( P=0.01 ) . CONCLUSION These findings support those of other studies conducted in France and in other European countries . They indicate that patients report meaningful improvements in their quality of life after spa therapy Thirty-six patients with active rheumatoid arthritis were treated for 12 days at the Ein Gedi Spa . The patients were allocated r and omly to four study groups . Group 1 ( n = 9 ) was treated with daily baths in the Dead Sea , group 2 ( n = 9 ) was treated with daily sulphur baths , group 3 ( n = 10 ) was treated with a combination of daily Dead Sea bathing and sulphur baths , and group 4 ( n = 8) served as a control group . All patients were assessed by a rheumatologist who was blinded to the treatment modalities and group allocation . Clinical parameters assessed included : duration of morning stiffness , 15 m walk time , grip strength , activities of daily living , patient 's assessment of disease severity , number of active joints , and the Ritchie articular index . Statistically significant improvement lasting up to 3 months was observed only in the three treatment groups Hydrotherapy for OA of the hip has rarely been evaluated in controlled studies . Forty-seven patients with OA of the hip were followed for 18 weeks . Patients were r and omly allocated either to a regimen of home exercises or to twice weekly hydrotherapy for 6 weeks in addition to home exercises . There was an improvement seen in both subjective and objective measures in both groups with treatment . There was no significant difference between the two groups . Response to treatment appeared independent of age , sex and radiological severity . We conclude that for most patients , a carefully grade d and supervised regimen of home exercises is beneficial and there is little benefit in adding hydrotherapy to this regimen To treat cases of psoriasis , various modifications of the original Ingram method were tested for increased effectiveness and minimized side reactions . Our modified method consists of 0.1 - 0.5 % anthralin ointment application and selective UVB phototherapy with adjunctive warm water bath and the application of emollients . The object of this study was to evaluate the effectiveness and duration of remission in response to our modified Ingram method and compare the data with the severity of psoriasis . The clearing rate was higher and the failure rate was lower in the moderate group . The number of occasions on which therapy was used and the duration of this therapy were greater in the severe group , but there were no significant differences except for the number of occasions of therapy to the trunk . Fifty-eight percent of the moderate group did not relapse in more than one year , but 63 % of the severe group relapsed within six months . The results of this study showed that the modified Ingram regimen is an effective therapeutic modality in psoriasis , especially in the moderate group BACKGROUND / PURPOSE Apart from climatotherapy and spa therapy , combined treatment with salt water baths and artificial UV radiation ( balneophototherapy ) has been advocated for the treatment of psoriasis . As there is a lack of controlled studies on balneophototherapy ( BPT ) , we conducted a r and omized , one-blind , right/left comparison with salt water versus tap water in order to investigate the significance of the salt concentration in the efficacy of BPT . METHODS Ten psoriasis patients with chronic plaques on the elbows were included in the study . One elbow was soaked in 24 % NaCl solution and the other in tap water . Subsequently , broadb and UVB irradiation was administered . BPT was performed 4 times weekly with a total of 30 treatments . RESULTS A highly significant ( P<0.001 ) decrease of the clinical baseline score was observed after 30 treatments ; however , there was no significant ( P>0.5 ) difference in clearance of the psoriatic lesions between the sites soaked in salt water and tap water . CONCLUSION Our results suggest that any additional benefit of soaking in salt water and tap water in BPT are unlikely to be due to the salinity of the liquids BACKGROUND Balneotherapy has been successfully used to treat various rheumatic diseases , but has only recently been evaluated for the treatment of fibromyalgia . Since no effective treatment exists for this common rheumatic disease , complementary methods of treatment have been attempted . OBJECTIVES To assess the effectiveness of balneotherapy at the Dead Sea area in the treatment of patients suffering from both fibromyalgia and psoriatic arthritis . METHODS Twenty-eight patients with psoriatic arthritis and fibromyalgia were treated with various modalities of balneotherapy at the Dead Sea area . Clinical indices assessed were duration of morning stiffness , number of active joints , a point count of 18 fibrositic tender points , and determination of the threshold of tenderness in nine fibrositic and in four control points using a dolorimeter . RESULTS The number of active joints was reduced from 18.4 + /- 10.9 to 9 + /- 8.2 ( P < 0.001 ) . The number of tender points was reduced from 12.6 + /- 2 to 7.1 + /- 5 in men ( P < 0.003 ) and from 13.1 + /- 2 to 7.5 + /- 3.7 in women ( P < 0.001 ) . A significant improvement was found in dolorimetric threshold readings after the treatment period in women ( P < 0.001 ) . No correlation was observed between the reduction in the number of active joints and the reduction in the number of tender points in the same patients ( r = 0.2 ) . CONCLUSIONS Balneotherapy at the Dead Sea area appears to produce a statistically significant substantial improvement in the number of active joints and tender points in both male and female patients with fibromyalgia and psoriatic arthritis . Further research is needed to eluci date the distinction between the benefits of staying at the Dead Sea area without balneotherapy and the effects of balneotherapy in the study population THE AUTHORS examined the effectiveness of the thermal water of Puspokladany on 62 patients suffering from osteoarthritis of the knee in a double-blind , placebo controlled study . Thermal water decreased pain in movement and tenderness of the knee significantly compared to that of the control group . Bath-reaction ( increase of ESR , leukocyte number and spontaneous pain ) was observed only in the group treated with thermal water . The results indi cate , that the thermal water of Puspokladany is suitable for treating patients suffering from degenerative arthopathies . In a previous announcement , Varga and his colleagues had established that a 20-days bath treat ment in the thermal water of Puspokladany signifi cantly reduced the pain of spondylosis patients when the treatment was applied in the undiluted thermal water . Bath reaction was shown on the patients who were treated in the undiluted thermal water , which was proved by the significant increase of the leucocyte number . The present paper deals with the study and tests we conducted to establish the effect of Puspokla dany 's thermal water on patients with osteoarthritis of the knee
target: We found silver level evidence ( www.cochranemsk.org ) concerning the beneficial effects of mineral baths compared to no treatment .
  Of all other balneological treatments no clear effects were found .
background: BACKGROUND Balneotherapy ( or spa therapy , mineral baths ) for patients with arthritis is one of the oldest forms of therapy .
  One of the aims of balneotherapy is to soothe the pain and as a consequence to relieve patients ' suffering and make them feel well .
  In this up date we included one extra study .
  OBJECTIVES To assess the effectiveness of  balneotherapy  for patients with osteoarthritis ( OA ) .