Balneotherapy for osteoarthritis

Arianne P Verhagen; Sita MA Bierma‐Zeinstra; Maarten Boers; Jefferson Rosa Cardoso; Johan Lambeck; Rob de Bie; Henrica CW de Vet

doi:10.1002/14651858.CD006864

Balneoterapia para la osteoartritis

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Referencias

References to studies included in this review

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estudios a la espera de valoración
otras referencias

Allard P, Deligne J, van Bockstael V, Duquesnoy B. Is spa therapy cost‐effective in rheumatoid disorders?. Revue du Rhumatisme [Engl. Ed] 1998;65(3):173‐80.

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References to studies excluded from this review

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estudios incluidos
estudios a la espera de valoración
otras referencias

Baldwin J. Pool therapy compared with individual home exercise therapy for juvenile rheumatoid arthritic patients. Physiotherapy 1972;58:230‐1.

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van Tubbergen A, Landewé R, van der Heijde D, Hidding A, Wolter N, Asscher M, Falkenbach A, Genth E, Goei Thé H, van der Linden S. Combined spa‐exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial. Arthritis Care and Research 2001;45:430‐8.

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Özcelik S, Polat HH, Akyol M, Yalcin AN, Özcelik D, Marufinah M. Kangal hot spring with fish and psoriasis treatment. The Journal of Dermatology 2000;27:386‐90.

References to studies awaiting assessment

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estudios excluidos
otras referencias

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Kabanov SE. [Effectiveness of the treatment of dystrophic (non‐infective) polyarthritis in Sochi‐Matseta spa with special reference to remote results.] (Russian). Voprosy revmatizma 1965;5:52‐8.

Lazowski Z, Gutowska‐Grzegorczyk G, Romicka A, Marchwicki I. [Tentative assessment of rehabilitation with particular consideration of the effects of balneotherapy on the course of rheumatoid arthritis in children.] (Polish). Reumatologia 1966;4:321‐9.

Litvinenko AG, Perminov IA, Poluden' EP, Oprenko BI, Pavlova ES. [Evaluation of efficacy of balneotherapy methods in patients with rheumatoid polyarthritis.] (Russian). Vrachebnoe delo 1977;5:101‐4.

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Susta A, Pavelka K, Bremova A, Salavcova V, Svandova H, Richter M. [Controlled clinical trial with Benetazone (Spofa) during spa treatment.] (Czech). Fysiatrický a reumatologický vestník 1975;53:3‐11.

Taletene IP, Gaigalene BA. [Effect of combined chrisanol and balneological treatment on the clinical indicators and permeability of the synovian membrane in patients with rheumatoid arthritis.] (Russian). Voprosy kurortologii, fizioterapii, i lechebnoi fizicheskoi kultury 1984;2:28‐31.

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Additional references

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estudios excluidos
estudios a la espera de valoración

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Characteristics of studies

Characteristics of included studies [ordered by study ID]

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estudios excluidos

Allard 1998

Methods	RCT.
Participants	Northern France Spa. Rheumatic disease. 4% patients with RA, N=148
Interventions	I: Spa therapy, n=74 C: No treatment, n=74 Also non‐randomised Spa therapy group (n=72).
Outcomes	Medication Costs
Notes	14 drop‐out in I, 6 in C. Study designed to evaluate costs. Overall quality score: 1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Green 1993

Methods	RCT. Blinded outcome assessment.
Participants	St James Hospital, Leeds, UK, radiographic hip OA, N=63
Interventions	I: Deep pool baths twice weekly + home exercises twice daily, n=24. 25% male, mean age 65.7 yr. C: Home exercises twice daily, n=23. 26% male, mean age 68 yr. Treatment for 6 weeks. Follow‐up at 9, 12 and 18 weeks.
Outcomes	Pain: VAS Function Range of Motion Muscle strength
Notes	16 drop‐outs. Overall quality score: 3
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Kovács 2002

Methods	RCT. Blinded patients and outcome assessment.
Participants	Cserkeszölö health resort, Hungary. Clinically and radiologically established OA of the knee, N=70.
Interventions	I: Daily bathing in thermal water for 30 minutes for 15 days, n=31. C: Daily bathing in tap water (placebo) for 30 min for 15 days, n=27.
Outcomes	Pain: VAS, 4‐point Likert Range of motion: goniometer Function: stair climbing, 4‐point Likert Perceived recovery
Notes	12 drop‐outs. Only pre‐post analysis Overall quality score: 4
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Nguyen 1997

Methods	RCT. Observer was clearly aware of treatment allocation.
Participants	France. Patients with knee, hip or lumbar spine OA, N=233
Interventions	I: Spa treatment for 21 days, n=91. 22% male, mean age 64 yr, mean DOC 11 yr. C: No treatment, routine maintained, n=97. 16% male, mean age 63, mean DOC 12 yr. Follow‐up at 24 wks.
Outcomes	Pain: VAS Function: WDI, AIMS Mobility Medication
Notes	45 drop‐outs directly after randomisation, 4 extra drop‐outs after 24 weeks. Overall quality score: 4
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Sukenik 1999

Methods	RCT. Blinded outcome assessment.
Participants	Outpatient clinic Soroca MC, Israel. Moderate or severe radiographic knee OA, N=40
Interventions	I1: Sulphur baths, n=10. 20% male, mean age 63.2 yr, mean DOC 11.6 yr. I2: Dead Sea Baths, n=10. 10% male, mean age 65.4 yr, mean DOC 9.2 yr. I3: I1 + I2. n=10. 0% male, mean age 57.6 yr. mean DOC 9.3 yr. C: No treatment, n=10. 11% male, mean age 65,9 yr, mean DOC 8.4 yr. All treatments 20 min twice daily for 2 wks.
Outcomes	Pain: patient assessment of severity. Function: Lequesne Index Range of motion
Notes	3 drop‐outs in I3, 1 in C. Only pre‐post analysis. Overall quality score: 4
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Tishler 2004

Methods	RCT.
Participants	Israel. Patients with knee OA, N=72
Interventions	I: Mineral baths once weekly for 6 weeks, n=48. 21% male, mean age 65.2 yr, mean DOC 8.6 yr. C: No treatment, n=24. 21% male, mean age 63.1 yr, mean DOC 7.5 yr. Follow‐up at 10 weeks.
Outcomes	Pain (VAS), WOMAC, analgesic intake.
Notes	4 dropouts in I. Pre‐post analysis.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Wigler 1995

Methods	RCT. Blinded patients and outcome assessment.
Participants	Tiberias spa hotel, Israel. Moderate or severe radiographic knee OA. N=33
Interventions	I: Mineral baths daily + mud packs on alternate days for 20 min, n=11. 9% male, mean age 66 yr, mean DOC 8 yr. C1: Mineral baths daily + rinsed mud packs on alternate days, n=10. 10% male, mean age 63 yr, mean DOC 10 yr. C2: tap water baths daily + rinsed mud packs on alternate days for 20 min, n=12. 16% male, mean age 65 yr, mean DOC 7 yr. Treatment period of 2 weeks; Follow‐up: 20 weeks
Outcomes	Pain: VAS Function: ISK
Notes	2 drop‐outs. Overall quality score: 6
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

OA = osteoarthritis, DOC = duration of complaints; VAS = visual analogue scale; WDI = Waddel Disability Index
HAQ = Health Assessment Questionnaire; ISK = index of severity knee osteoarthrosis; WOMAC = West Ontario and McMaster Universities OA Index

Characteristics of excluded studies [ordered by study ID]

Ir a:

estudios incluidos

Study	Reason for exclusion
Baldwin 1972	No RCT
Buskila 2001	No OA
Danneskiold 1987	No RCT
Ekmekcioglu 2002	Outcome inappropriate
Elkayam 2000	No OA
Estefan 1999	Letter to the editor
Forestier 1970	No RCT
Franke 2000	No OA
Gambichler 2001	No OA
Guillemin 2001	No RCT
Halevy 2001	No OA
Hall 1996	No OA
Hill 1999	No RCT
Klemm 1971	Outcome inappropriate
Landewe 1992	No RCT
Neumann 2001	No OA
Nicholls 1990	No balneotherapy
Rijswijk 1992	No RCT
Steiner 1979	No RCT
Strauss‐Blasche 2000	No RCT
Sukenik 1990a	No OA
Sukenik 1990b	No OA
Sukenik 1994b	No RCT, no OA
Sukenik 1995	No OA
Sukenik 2001	No RCT, No OA
Svarcova 1990	No RCT
Sylvester 1989	No balneotherapy
Szucz 1989	No RCT
van Tubbergen 2001	No OA
Youn 1998	No RCT, no OA
Özcelik 2000	No RCT, no OA

Data and analyses

Open in table viewer

Comparison 2. Sulphur baths versus Dead Sea baths

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.1 Comparison 2 Sulphur baths versus Dead Sea baths, Outcome 1 Function.
1.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Pain (10 cm VAS) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.2 Comparison 2 Sulphur baths versus Dead Sea baths, Outcome 2 Pain (10 cm VAS).
2.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Open in table viewer

Comparison 3. Tapwater baths additional on exercises

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Stiffness Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.1 Comparison 3 Tapwater baths additional on exercises, Outcome 1 Stiffness.

Open in table viewer

Comparison 5. Sulphur baths versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain (10 cm VAS) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 5.1 Comparison 5 Sulphur baths versus no treatment, Outcome 1 Pain (10 cm VAS).
1.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 5.2 Comparison 5 Sulphur baths versus no treatment, Outcome 2 Function.
2.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Open in table viewer

Comparison 6. Dead Sea baths versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain (10 cm VAS) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 6.1 Comparison 6 Dead Sea baths versus no treatment, Outcome 1 Pain (10 cm VAS).
1.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 6.2 Comparison 6 Dead Sea baths versus no treatment, Outcome 2 Function.
2.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Open in table viewer

Comparison 7. Sulphur + Dead Sea baths versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain (10 cm VAS) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 7.1 Comparison 7 Sulphur + Dead Sea baths versus no treatment, Outcome 1 Pain (10 cm VAS).
1.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 7.2 Comparison 7 Sulphur + Dead Sea baths versus no treatment, Outcome 2 Function.
2.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Open in table viewer

Comparison 8. Mineral baths versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain (100 mm VAS) Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 8.1 Comparison 8 Mineral baths versus no treatment, Outcome 1 Pain (100 mm VAS).
1.1 End of treatment	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 1 month follow‐up	2		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 6 month follow‐up	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Quality of life Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 8.2 Comparison 8 Mineral baths versus no treatment, Outcome 2 Quality of life.
2.1 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 6 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Analgesic intake Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 8.3 Comparison 8 Mineral baths versus no treatment, Outcome 3 Analgesic intake.
3.1 End of treatment	0		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.3 6 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Analgesic intake Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 8.4 Comparison 8 Mineral baths versus no treatment, Outcome 4 Analgesic intake.

Analysis 2.1

Comparison 2 Sulphur baths versus Dead Sea baths, Outcome 1 Function.

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Analysis 2.2

Comparison 2 Sulphur baths versus Dead Sea baths, Outcome 2 Pain (10 cm VAS).

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Analysis 3.1

Comparison 3 Tapwater baths additional on exercises, Outcome 1 Stiffness.

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Analysis 5.1

Comparison 5 Sulphur baths versus no treatment, Outcome 1 Pain (10 cm VAS).

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Analysis 5.2

Comparison 5 Sulphur baths versus no treatment, Outcome 2 Function.

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Analysis 6.1

Comparison 6 Dead Sea baths versus no treatment, Outcome 1 Pain (10 cm VAS).

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Analysis 6.2

Comparison 6 Dead Sea baths versus no treatment, Outcome 2 Function.

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Analysis 7.1

Comparison 7 Sulphur + Dead Sea baths versus no treatment, Outcome 1 Pain (10 cm VAS).

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Analysis 7.2

Comparison 7 Sulphur + Dead Sea baths versus no treatment, Outcome 2 Function.

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Analysis 8.1

Comparison 8 Mineral baths versus no treatment, Outcome 1 Pain (100 mm VAS).

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Analysis 8.2

Comparison 8 Mineral baths versus no treatment, Outcome 2 Quality of life.

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Analysis 8.3

Comparison 8 Mineral baths versus no treatment, Outcome 3 Analgesic intake.

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Analysis 8.4

Comparison 8 Mineral baths versus no treatment, Outcome 4 Analgesic intake.

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Table 1. Methodological quality

Study	Randomisation	Concealment	Baseline comparison	Eligibility criteria	Blinded outcome ass	Blinded careprovider	Blinded patient	Data presentation	Intention to treat
Allard '98	Yes	Unclear	Unclear	No	Unclear	No	No	No	No
Green '93	Yes	Unclear	Unclear	Yes	Yes	Unclear	Unclear	No	No
Kovács '02	Yes	Unclear	Unclear	No	Yes	Unclear	Yes	Yes	No
Nguyen '97	Yes	Unclear	Yes	Yes	No	No	No	Yes	No
Sukenik '99	Yes	Unclear	Unclear	Yes	Yes	No	No	Yes	No
Tishler '04	Yes	Unclear	Yes	Yes	Unclear	No	No	Yes	No
Wigler '95	Yes	Unclear	Yes	Yes	Yes	Unclear	Yes	No	Yes

Table 1. Methodological quality

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Table 2. Clinical relevance table: pain at follow‐up

Study	Treatment group	Outcome	N	Baseline mean	End of study mean	Abs benefit	Rel difference	Stat significance	Quality of evidence
Kovacs '02	E: Mineral baths	Pain (10 cm VAS)	31		diff: ‐0.29 (SD 1.22)	0.006 (0.0006%)		Not sign
	C: Placebo baths		27		diff: ‐0.296 (SD 0.78)
Nguyen '97	E: Mineral baths	Pain (100 mm VAS)	91	50 (SD 20)	41 (SD 28)	9 (0.09%)	18.5 %; NNT=5	Sign	Silver
	C: Usual care		97	47 (SD 22)	50 (SD 24)
Sukenik '99	E: Sulphur baths	Pain (0‐10)	10	6.1 (SD 1.6)	6.2 (SD 1.5)	0.4 (0.004%)	6.6%	Not sign
	C: Control		9	6.1 (1.5)	6.6 (SD 1.5)
Sukenik '99	E: Dead Sea baths	Pain (0‐10)	10	6.5 (SD 1.0)	6.1 (SD 1.0)	0.9 (0.009%)	14.8%	Not sign
	C: Control		9	6.1 (SD 1.5)	6.6 (SD 1.5)
Sukenik '99	E: Sulphur + Dead Sea baths	Pain (0‐10)	7	6.6 (SD 1.0)	5.7 (SD 1.7)	1.4 (0.014%)	23.0%	Not sign
	C: Control		9	6.1 (SD 1.5)	6.6 (SD 1.5)
Tishler '04	E: Mineral baths	Pain (100 mm VAS)	48	64.8 (SD 22.3)	26.3 (SD 22.3)	37.6 (0.376%)	56.6 %; NNT=2	Sign	Silver
	C: No treatment		24	68.1 (SD 23.3)	63.9 (SD 23.3)
Legend:	0‐10 scale, 0 = no pain and 10 = severe pain Sign = significant Abs = absolute Rel = relative N = # of patients NNT=number needed to treat (for an improvement of 15%)

Table 2. Clinical relevance table: pain at follow‐up

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Comparison 2. Sulphur baths versus Dead Sea baths

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Pain (10 cm VAS) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. Sulphur baths versus Dead Sea baths

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Comparison 3. Tapwater baths additional on exercises

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Stiffness Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 3. Tapwater baths additional on exercises

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Comparison 5. Sulphur baths versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain (10 cm VAS) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 5. Sulphur baths versus no treatment

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Comparison 6. Dead Sea baths versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain (10 cm VAS) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 6. Dead Sea baths versus no treatment

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Comparison 7. Sulphur + Dead Sea baths versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain (10 cm VAS) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 End of treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 3 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 7. Sulphur + Dead Sea baths versus no treatment

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Comparison 8. Mineral baths versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain (100 mm VAS) Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 End of treatment	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 1 month follow‐up	2		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 6 month follow‐up	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Quality of life Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 6 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Analgesic intake Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 End of treatment	0		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 1 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.3 6 month follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Analgesic intake Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 8. Mineral baths versus no treatment

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Referencias

References to studies included in this review

Allard 1998 {published data only}

Green 1993 {published data only}

Kovács 2002 {published data only}

Nguyen 1997 {published data only}

Sukenik 1999 {published data only}

Tishler 2004 {published data only}

Wigler 1995 {published data only}

References to studies excluded from this review

Baldwin 1972 {published data only}

Buskila 2001 {published data only}

Danneskiold 1987 {published data only}

Ekmekcioglu 2002 {published data only}

Elkayam 2000 {published data only}

Estefan 1999 {published data only}

Forestier 1970 {published data only}

Franke 2000 {published data only}

Gambichler 2001 {published data only}

Guillemin 2001 {published data only}

Halevy 2001 {published data only}

Hall 1996 {published data only}

Hill 1999 {published data only}

Klemm 1971 {published data only}

Landewe 1992 {published data only}

Neumann 2001 {published data only}

Nicholls 1990 {published data only}

Rijswijk 1992 {published data only}

Steiner 1979 {published data only}

Strauss‐Blasche 2000 {published data only}

Sukenik 1990a {published data only}

Sukenik 1990b {published data only}

Sukenik 1994b {published data only}

Sukenik 1995 {published data only}

Sukenik 2001 {published data only}

Svarcova 1990 {published data only}

Sylvester 1989 {published data only}

Szucz 1989 {published data only}

van Tubbergen 2001 {published data only}

Youn 1998 {published data only}

Özcelik 2000 {published data only}

References to studies awaiting assessment

Athanasiu 1972 {published data only}

Horvath 1967 {published data only}

Kabanov 1965 {published data only}

Lazowski 1966 {published data only}

Litvinenko 1977 {published data only}

Mackiewicz 1966 {published data only}

Mar'iasis 1987 {published data only}

Nobunaga 1992 {published data only}

O'Hare 1985 {published data only}

Perel'muter 1976 {published data only}

Pshetakovskii 1971 {published data only}

Rybnikov 1965 {published data only}

Sukenik 1990c {published data only}

Sukenik 1995a {published data only}

Susta 1975 {published data only}

Taletene 1984 {published data only}

Timofeev 1973 {published data only}

Veinpalu‐EIu 1979 {published data only}

Zaitseva 1979 {published data only}

Zavadiak 1976 {published data only}

Additional references

Balint 1993

Bellamy 1999

Brosseau 2002

Cosh 1982

Fam 1991

Fife 1991

Fioravanti 2003

Jackson 1990

Jagger 1984

Johnson 1990

Lau 1997

Nicholas 1994

Peyron 1993

Pham 2003

Robinson 2002