Scand J Rheumatol 2006;35:283–289 283

The effect of balneotherapy on patients with ankylosing spondylitis

L Altan, Ü Bingöl, M Aslan, M Yurtkuran

Uludağ University Medical Faculty, Atatürk Rehabilitation Centre, Rheumatic Disease and Hydrotherapy Section, Bursa, Turkey

Objective: To compare the effect of balneotherapy on physical activity and quality of life as well as the symptoms
of pain and stiffness with exercise alone in ankylosing spondylitis (AS) patients.
Methods: A total of 60 patients who had a diagnosis of AS according to the modified New York criteria were
included in the study. The patients were randomly assigned to two groups. In Group I (n530) the patients
received balneotherapy in a therapeutic pool for 30 min once a day for 3 weeks. All patients received instructions
on the exercise programme, which they were requested to repeat once a day for 30 min during the study. The
patients in this group continued the same exercise programme after the end of the balneotherapy protocol to
Scand J Rheumatol Downloaded from informahealthcare.com by Michigan University on 10/16/14

complete a course of 6 months. In Group II the patients were given the same exercise protocol but did not receive
balneotherapy. Patients were evaluated before the start of the study and at 3 weeks and 24 weeks. Evaluation
parameters were daily and night pain, morning stiffness, the patient’s global evaluation and the physician’s
global evaluation (according to a scoring system of 1 to 5), the Bath Ankylosing Spondilitis Disease Activity
Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Dougados Functional Index (DFI),
tragus–wall distance, chest expansion, modified Shober test (MST), fingertip–fibula head distance, and
Nottingham Health Profile (NHP).
Results: Evaluations were completed in 54 patients in the two groups. Comparison of the groups showed
significantly superior results for Group I for parameters of BASDAI, NHP total, pain, physical activity,
tiredness and sleep score, patient’s global evaluation and the physician’s global evaluation at 3 weeks, but only
For personal use only.

for the parameters of patient’s global evaluation and MST at 24 weeks.

Conclusion: Balneotherapy has a supplementary effect on improvement in disease activity and functional
parameters in AS patients immediately after the treatment period. However, in the light of our medium-term
evaluation results, we suggest that further research is needed to assess the role of balneotherapy applied for
longer durations in AS patients.

Ankylosing spondylitis (AS) is a chronic inflamma-
tory disease that predominantly affects the spine and
may cause serious functional impairment (1). The
purpose of the therapy is to reduce pain and morning
stiffness, to prevent deformity and to maintain
correct posture, physical condition and psychosocial
health. The progressive nature of the disease is a
negative factor in AS management and no treatment
modality – other than anti-tumour necrosis factor
(anti-TNF) treatment – that can reverse the under-
lying continuing inflammation has yet been defined.
Physiotherapy and exercise are among the most
popular adjuncts to pharmacotherapy but the num-
ber of controlled studies is too low to delineate a
definitive role for such supplementary agents (2).
Lale Altan, Atatürk Rehabilitasyon Merkezi, Kükürtlü cad.
No: 98, 16080 Çekirge, Bursa, Turkey.
E-mail: lalealtan@uludag.edu.tr
Received 2 May 2005
Accepted 23 October 2005
Spa therapy is a traditional treatment that has
been used in musculoskeletal disease since ancient
times (3). Spa therapy is currently usually combined
with active exercise, massage and mud packs. There
are only a few randomized controlled trials investi-
gating the role of spa therapy in rheumatic diseases
despite its long history and wide popularity (4).
Balneotherapy has been shown to be effective for
rheumatoid arthritis (RA) (5), osteoarthritis (OA)
(6), fibromyalgia syndrome (FMS) (7) and low back
pain (8), while Verhagen et al (9) have pointed out
several methodological mistakes in all studies asses-
sing the role of balneotherapy in RA and OA and
concluded that it is difficult to verify its true efficiency.
These authors also reported that life quality para-
meters had been used in only two of the above-
mentioned group of studies. Although positive results
for balneotherapy in AS have been reported in a
number of studies (10–12), it was emphasized in a
recent review that the value of different spa results and
specific therapeutic components must be taken into
account in studies in the future (13).

# 2006 Taylor & Francis on license from Scandinavian Rheumatology Research Foundation
DOI: 10.1080/03009740500428806 www.scandjrheumatol.dk
 284 L Altan et al

The purpose of this study was to compare the Table 1. The mineral content of the therapeutic pool.
effect of balneotherapy on physical activity and
quality of life as well as the symptoms of pain and mg/L mval/L
stiffness with exercise alone in the short and medium Anions
term. HCO322 528.87 0.67
Cl2 12.27 0.35
F2 5.46 0.29
Materials and methods SO422 277.0 5.77
Total 823.6 13.08
A total of 60 patients who had a diagnosis of AS Cations
according to the modified New York criteria, who Ca2+ 91.98 4.59
were observed to have a moderate degree of pain Mg2+ 7.41 0.61
[between 4 to 7 according to the visual analogue scale Na+ 222.5 9.68
(VAS)], stiffness, and a score of 2 or higher K+ 23.0 0.59
(according to the 1–5 score) for patient’s global Li2+ 0.68 0.10
evaluation, and were willing to participate in the Total 823.6 13.08
exercise programme were included in the study while
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they were under the regular follow-up protocol in our of the patients were performed before the start of the
rheumatology clinic at the spa centre of the study and at 3 weeks and 24 weeks by a physician
university. None of the patients had any systemic who was blinded to the patients.
problems contraindicating hydrotherapy or exercis-
ing. The patients who had active peripheral arthritis,
secondary FMS, total spinal ankylosis, an erythro- Evaluation parameters
cyte sedimentation rate (ESR)w50 mm/h, or
Pain. Daytime and nocturnal pain was measured
C-reactive protein (CRP) more than 10 times the
with a VAS.
normal value, and who were previously given
balneotherapy within 1 year were also excluded. All
For personal use only.

Morning stiffness. The existence and duration of the

the patients were informed about the purpose and
nature of the study and informed consent was
obtained. Data on age, sex, disease duration,
previous medication and human leucocyte antigen
(HLA) B27 positivity were recorded for each patient.
The patients were allowed to continue their previous
medication, but they were requested not to use
supplementary drugs or change the usual dosages
throughout the study period of 24 weeks.
The patients were randomly assigned to two
groups using a random numbers table. In Group I
(n530) the patients received balneotherapy on an
outpatient basis early in the morning in a therapeutic
pool containing spa water at 39 ˚C for 30 min once a
day for 3 weeks. The composition of the spa water is
shown in Table 1. The patients rested in bed for 2 h
following balneotherapy and then left the hospital to
come back the day after. All patients were given
instructions on the exercise programme that they
were requested to repeat once a day for 30 min
during the study. The home exercise programme
comprised respiration–postural exercises and dorsal/
lumbar extension exercises. The patients in this group
continued the same exercise programme after the end
of the balneotherapy protocol to complete a course
of 6 months.
In Group II the patients were given the same
exercise protocol but did not receive balneotherapy.
Patients’ compliance with the exercise programme
was monitored by phone calls once every month and
control examination at the third month. Evaluations
stiffness were assessed according to a four-point
scale: 05no stiffness, 15less than 15 min, 25between
15 and 30 min, and 35more than 30 min.
Patient’s global evaluation and the physician’s global
evaluation. Global evaluation of disease activity
separately by the physician and the patient used a
scoring system from 1 to 5 where: 15no activity,
25mild activity, 35moderate activity, 45severe
activity, and 55very severe activity. This scoring
system rather than the VAS scoring system was
chosen for global evaluation as the patients were not
classified as responders and nonresponders according
to the assessments in ankylosing spondylitis (ASAS)
criteria, depending on our observation that most of
the studies in the literature on the role of exercise and
balneotherapy in AS have not used the latter criteria.
Disease activity. Evaluation was performed using the
Bath Ankylosing Spondilitis Disease Activity Index
(BASDAI), for which the adaptation to the native
language of the patients has been shown to be valid
and reliable (14). The BASDAI is a self-administered
questionnaire with six specific questions regarding
disease activity in AS. Five important symptoms are
reflected: fatigue, pain, peripheral joint swelling/pain,
localized tenderness, and quantitative and qualitative
morning stiffness. A horizontal nongraded VAS
(0–10) was used. Five scales were marked from
‘none’ to ‘very severe’, while the scale for quantity of
morning stiffness was graded every 15 min between

www.scandjrheumatol.dk
 Balneotherapy in AS
0 and 2 h. The mean of the questions about morning
stiffness was calculated before calculating the total
BASDAI score of 1–10 by averaging the five figures.
Functional capacity. The Bath Ankylosing Spondy-
litis Functional Index (BASFI) and the Dougados
Functional Index (DFI), which were both adapted to
the native language, were used for evaluation (15).
BASFI is a self-administered questionnaire with
10 questions on daily activities. A horizontal
nongraded VAS (0–10) from ‘easy’ and ‘impossible’
was used. The mean of the scales gave a total BASFI
score (0–10). The DFI is a 20-item questionnaire used
to obtain information on difficulties in performing
daily activities. Scores of 0 (no difficulty), 1
(performing with difficulty) and 2 (no performance)
Scand J Rheumatol Downloaded from informahealthcare.com by Michigan University on 10/16/14
were given and DFI scores ranging from 0 to 40 were
obtained for each patient.
Spinal mobility. Spinal mobility of each patient was
measured using occiput–wall distance, chest
expansion, modified Shober test and fingertip–
fibula head distance.
Life quality score. The Nottingham Health Profile
(NHP) was used; the patients were asked to give ‘yes’
For personal use only.
or ‘no’ answers to the items in the questionnaire.
Eight questions for pain (NHP-Pain) and physical
activity (NHP-Physical activity), five for sleep (NHP-
Sleep), three for tiredness (NHP-Tiredness), five for
social isolation (NHP-Social isolation), and nine for
emotional reaction (NHP emotional reaction) were
asked. The ‘weighted score’ of the related question
was given for each ‘yes’ answer, and 0 for each ‘no’
score. The overall score was calculated separately for
each parameter and then the NHP total score was
obtained from the sum of the scores of these six
parameters (16).
Statistical analysis
All statistical calculations were performed under the
supervision of the staff biostatistician using the SPSS
10.0 program. Posttreatment changes occurring in
each group were compared with pretreatment values
using the Wilcoxon test. Comparison of the results
between the two groups was performed using the
Mann–Whitney U-test after calculating the percen-
tage changes for measured values and the difference
scores for overall score values.
Results
Two patients in Group I had to leave the study for
domestic reasons, and four patients in Group II
abandoned the study because they could not comply
with the exercise programme, all before the end of the
285
first 3-week period, and evaluations were completed
in 54 patients in two groups.
Pretreatment data showed no significant difference
between the two groups for any parameters except
for morning stiffness.
In Group I all parameters except for the NHP-
Social isolation score showed significant improve-
ment at 3 weeks but the improvement in the
parameters NHP-Social isolation score and chin–
manibrium distance were not found to be significant
at 24 weeks compared to pretreatment (Table 2).
In Group II significant improvement was obtained
for all parameters except for NHP-Tiredness score,
NHP-Sleep score, NHP-Social isolation score, occi-
put–wall distance and chin–manibrium distance at
3 weeks and all parameters but the patient’s global
evaluation at 24 weeks compared to pretreatment
values (Table 3).
Comparison of the groups showed significantly
superior results for Group I for parameters of
BASDAI, NHP-Total score, NHP-Pain score,
NHP-Physical activity score, NHP-Tiredness
score, NHP-Sleep score, and the physician’s and
patient’s global evaluation at 3 weeks, but only for
the parameters of patient’s global evaluation and
the modified Shober test at 24 weeks (Table 4). No
side-effects of either treatment protocol were
recorded.
Discussion
Significant improvement was obtained for all para-
meters in our study except for the NHP-Social
isolation score immediately after treatment in the
patients who received balneotherapy. Improvement
was sustained for all parameters except for the NHP-
Sleep score and chin–manibrium distance at 24 weeks
in this group.
The role of balneotherapy in AS treatment has
been investigated in several studies. Tishler et al (10)
reported improvement that lasted for 3 months
in morning stiffness, finger-to-floor distance, and
overall well being of the patient and also recorded
a lowered requirement for nonsteroidal anti-
inflammatory drugs (NSAIDs) at the end of a
2-week spa therapy in 14 AS patients in a noncon-
trolled open study. In another study Hashkes (11)
investigated the effect of climatic therapy in Tiberias
hot spring on 53 AS patients using an individualized
programme of hydrotherapy, massage and occupa-
tional therapy and obtained improvement in 60% of
the patients at the end of 1 month; however, the long-
term results were not reported. Van Tubergen et al
(12) also reported in a randomized controlled study
significant improvement lasting for 40 weeks in 120
AS patients who received a combination of spa and
exercise treatment for 3 weeks.
www.scandjrheumatol.dk
 286 L Altan et al

Table 2. Statistical comparison of clinical evaluation parameters before and after treatment in Group I.

Week 0 Week 3 Week 24

Daily pain (0–10) 3.46¡2.11 1.96¡1.37*** 1.92¡1.32**
Night pain (0–10) 5.0¡1.9 3.26¡1.67*** 2.84¡1.84***
Morning stiffness (0–3) 1.57¡0.74 1.03¡0.51*** 1.12¡0.33**
Patient’s global evaluation (1–5) 2.89¡0.87 1.92¡0.85*** 2.12¡0.72***
Physician’s global evaluation (1–5) 2.43¡0.57 1.64¡0.56*** 1.76¡0.83**
BASDAI (0–10) 3.42¡1.57 1.11¡0.77*** 1.49¡1.37***
BASFI (0–10) 1.28¡1.15 0.50¡0.73*** 0.38¡0.57***
DFI (0–40) 11.14¡9.46 6.39¡7.47*** 6.16¡5.80**
NHP-Total (0–600) 134.5¡78.83 55.74¡52.93*** 70.49¡82.74**
NHP-Pain (0–100) 43.30¡17.83 16.96¡14.91*** 18.0¡20.75***
NHP-Physical activity (0–100) 21.87¡15.45 10.27¡11.81** 11.06¡13.84**
NHP-Tiredness (0–100) 38.07¡38.16 13.08¡24.55** 13.32¡30.42*
NHP-Sleep (0–100) 18.30¡28.26 12.14¡23.94* 18.60¡29.98
NHP-Social isolation (0–100) 4.02¡9.63 2.86¡7.13 2.40¡6.63
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NHP-Emotional reaction (0–100) 8.91¡12.62 3.12¡8.07* 3.0¡9.04**

Occiput–wall distance (cm) 3.28¡5.74 2.30¡4.32* 1.76¡3.95*
Chin–manibrium distance (cm) 2.35¡3.12 1.75¡2.57** 1.48¡2.23
Chest expansion (cm) 4.11¡1.55 4.94¡1.62*** 4.97¡1.88**
Modified Shober test (cm) 3.19¡1.52 3.65¡1.46*** 4.12¡1.46***
Fingertip–fibula head distance (cm) 5.03¡5.82 3.76¡4.04*** 2.82¡3.09**

BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; BASFI, Bath Ankylosing Spondylitis Functional Index; DFI, Dougados Functional
Index; NHP, Nottingham Health Profile. *pv0.05; **pv0.01; ***pv0.001.

Several mechanisms have been suggested for the following the decrease in muscle tone. According to
For personal use only.

analgesic effect of balneotherapy. The vasodilatory
effect of heat removes the alogenic substances from
the affected region and also causes muscle relaxation
by reduction of muscular gamma-efferent activity by
stimulation of the type Ib fibres and golgi tendon
organ reflex. An indirect analgesic effect occurs
the gate-control mechanism suggested by Melzac and
Wall (17), thermal stimulus contributes to blocking
of pain perception at the dorsal horn level, thus
providing a general sedation effect. While it was
suggested that balneotherapy might stimulate secre-
tion of opioids (18), we failed to show any increase in

Table 3. Statistical comparison of clinical evaluation parameters before and after treatment in Group II.

Week 0 Week 3 Week 24

Daily pain (0–10) 3.53¡1.55 2.0¡1.44*** 2.11¡1.58***
Night pain (0–10) 4.77¡1.17 3.23¡1.53*** 3.0¡1.83***
Morning stiffness (0–3) 2.04¡0.66 1.31¡0.47*** 1.27¡0.45***
Patient’s global evaluation (1–5) 2.61¡0.75 2.19¡0.57* 2.23¡0.86
Physician’s global evaluation (1–5) 2.19¡0.40 1.73¡0.67** 1.61¡0.64**
BASDAI (0–10) 3.05¡1.58 1.78¡0.98*** 1.62¡1.40***
BASFI (0–10) 0.91¡0.75 0.61¡0.6.0** 0.54¡0.71**
DFI (0–40) 8.27¡5.79 6.11¡4.95** 5.42¡4.75**
NHP-Total (0–600) 136.46¡112.78 108.76¡114.49*** 80.63¡100.14***
NHP-Pain (0–100) 32.69¡19.06 24.04¡19.34** 19.71¡23.23**
NHP-Physical activity (0–100) 20.19¡12.28 16.34¡15.31** 12.50¡13.69**
NHP-Tiredness (0–100) 28.18¡36.12 24.34¡35.96 14.08¡26.93**
NHP-Sleep (0–100) 32.31¡35.81 28.46¡34.95 19.23¡32.23**
NHP-Social isolation (0–100) 7.69¡20.45 6.92¡20.35 4.61¡19.84*
NHP-Emotional reaction (0–100) 14.90¡25.25 8.65¡22.84* 8.17¡22.34*
Occiput–wall distance (cm) 2.92¡5.18 2.67¡4.85 2.48¡4.54*
Chin–manibrium distance (cm) 1.41¡1.97 1.21¡1.90 1.12¡1.77*
Chest expansion (cm) 4.57¡1.64 5.02¡1.62** 4.94¡1.90*
Modified Shober test (cm) 3.41¡1.41 3.61¡1.46* 3.91¡1.73***
Fingertip–fibula head distance (cm) 3.94¡4.14 2.73¡3.23** 2.63¡3.30**

BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; BASFI, Bath Ankylosing Spondylitis Functional Index; DFI, Dougados Functional
Index; NHP, Nottingham Health Profile. *pv0.05; **pv0.01; ***pv0.001.

www.scandjrheumatol.dk
 Balneotherapy in AS 287

Table 4. Comparison of the two groups on the basis of the posttreatment (both 3 and 24 weeks) percentage changes and difference scores
relative to pretreatment values.

0–3 weeks 0–24 weeks

Group I Group II Group I Group II

Daily pain (0–10) 21.50¡1.69 21.54¡1.27 21.68¡2.05 21.42¡1.42
Night pain (0–10) 21.92¡1.79 21.54¡1.47 22.44¡1.61 21.77¡1.82
Morning stiffness(0–3) 20.53¡0.51 20.73¡0.66 20.48¡0.71 20.76¡0.65
Patient’s global evaluation (1–5) 20.96¡0.88* 20.42¡0.85 20.84¡0.74* 20.38¡0.98
Physician’s global evaluation (1–5) 20.78¡0.57* 20.46¡0.51 20.60¡0.64 20.57¡0.70
BASDAI (0–10) 22.31¡1.30** 21.26¡1.36 21.77¡1.70 21.43¡1.50
BASFI (0–10) 20.78¡0.89 20.29¡0.45 20.73¡0.88 20.36¡0.64
DFI (0–40) 24.75¡6.16 22.15¡2.65 23.60¡5.80 22.84¡4.20
NHP-Total (0–600) 278.76¡66.94** 227.69¡45.67 258.92¡72.11 255.82¡68.71
NHP-Pain (0–100) 226.34¡22.13** 28.65¡11.60 223.0¡22.44 212.98¡18.86
NHP-Physical activity (0–100) 211.61¡13.58* 23.84¡9.85 29.61¡14.71 27.69¡11.76
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NHP-Tiredness (0–100) 224.99¡32.22** 23.84¡14.36 223.98¡37.90 214.11¡23.40

NHP-Sleep (0–100) 26.16¡12.01* 23.84¡9.83 21.10¡25.92 213.07¡20.35
NHP-Social isolation (0–100) 21.16¡4.38 20.77¡3.92 20.50¡2.50 23.07¡7.36
NHP-Emotional reaction (0–100) 25.78¡11.53 26.25¡11.32 25.98¡10.22 26.73¡13.79
Occiput–wall distance (cm) 20.09¡0.22** 20.04¡0.20 20.08¡0.22 20.06¡0.21
Chin–manibrium distance (cm) 20.16¡0.29 20.10¡0.28 20.16¡0.38 20.17¡0.33
Chest expansion (cm) 0.26¡0.26 0.13¡0.17 0.16¡0.21 0.08¡0.15
Modified Shober test (cm) 0.23¡0.30 0.07¡0.13 0.34¡0.37* 0.14¡0.16
Fingertip–fibula head distance (cm) 20.10¡0.47 20.26¡0.37 20.17¡0.47 20.28¡0.39

BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; BASFI, Bath Ankylosing Spondylitis Functional Index; DFI, Dougados Functional
Index; NHP, Nottingham Health Profile. *pv0.05; **pv0.01.
For personal use only.

blood endorphin levels following balneotherapy in a
previous study performed in our clinic (19).
Balneotherapy is also believed to have chemical
effects besides its thermal effect mentioned above.
Minerals, salts and gaseous compounds may create a
metabolic effect after they are absorbed through the
skin and carried to the relevant body parts by blood
and lymphatic vessels. Such substances may mod-
ulate skin metabolism and immunology by stimulat-
ing secretion of acetylcholine, bradykinin, histamine,
and serotonin (20). A number of clinical and
experimental studies have shown the difference
between the effects of spa and tap water (21, 22).
Approximately 20 to 40 mL/s/m2 of water, together
with a certain amount of minerals and gaseous
compounds such as H2S, CO2 and radon, is absorbed
through the skin during balneotherapy and CO2 and
sulfur are known to cause intense vasodilatation
and hyperaemia. Sukenik et al suggested the anti-
inflammatory effect of sulfur on inflammatory
diseases such as RA and psoriatic arthritis (4, 23).
However, in our therapeutic pool, the concentration
of sulfide (H2S), the sulfur form best absorbed
through the skin, is 0.36 mg/L (below the minimum
effective concentration of 1 mg/L suggested for anti-
inflammatory action) (24). Thus, we believe that
other mechanisms have played a role in the positive
results obtained in our study.
We observed significant improvement with exercise
alone for all parameters except for the NHP
subgroups of sleep, tiredness, and social isolation,
chin–manibrium distance and occiput–wall distance
at 3 weeks, and in all parameters but global
evaluation of the patients at 24 weeks.
Exercise is thought to be an essential component of
AS treatment, supported by several studies published
in recent years (1, 13). Various exercise programmes
are reported to provide relief of symptoms and
improve physical functions in these studies. However,
Dagfinrud et al (25) reported in a recent systematic
review that exercise performed by patients under
supervision was beneficial, but suggested further
research was needed to delineate the positive effects
of physiotherapy in AS management. Exercise alone
is known to have an analgesic effect (26). The
mechanisms responsible for the analgesic effect of
exercise are not clearly understood despite the results
of several studies that consistently showed an
increase in pain tolerance and threshold, and a
lowered rate for the intensity of a given pain stimulus
following exercise. While it is a widely accepted
hypothesis that activation of the endogenous opioid
system during exercise plays a key role in the
analgesic response mechanism, several researchers
have also suggested a multiple analgesic system
including nonopioid mechanisms mediated by other
substances such as growth hormone and corticotro-
phin (26, 27).
Besides this general analgesic effect, exercise may
be beneficial in AS treatment by increasing the

www.scandjrheumatol.dk
 288
mobility of spinal and peripheral joints, joint range
of motion, muscle strength and endurance, helping
in the maintenance of functional capacity at a high
level (28).
In our study comparison of the groups showed
significantly superior results for Group I for para-
meters of BASDAI, NHP-Total score, NHP-Pain
score, NHP-Physical activity score, NHP-Tiredness
score, NHP-Sleep score, and global evaluation of the
physician and patient at 3 weeks, but only for the
parameters of patient’s global evaluation and mod-
ified Shober test at 24 weeks. This may be explained
by the faster mechanism of action in balneotherapy
compared to the effect of exercise, which is evident in
the later stages, although there was almost no
difference between two groups at 24 weeks.
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Contrary to our results, Van Tubergen et al reported
beneficial effects of balneotherapy extending to 40
weeks in one of the spa groups in a study in 120 AS
patients in three treatment groups. The treatment
protocols used in that study were significantly
different from the ones used in our study. The
patients in their study stayed overnight in the spa
centre, received rehabilitation for the whole day, and
more importantly, were given radioactive radon
therapy in another centre in addition to exercise
For personal use only.
and hydrotherapy, while the patients in our study
were allowed to return to daily life immediately after
the sessions. As pointed out by van Tubergen et al,
several social and environmental factors, and radon
therapy, may have contributed significantly to the
positive results.
In conclusion, although balneotherapy improved
the disease activity and functional parameters in AS
patients over a relatively short period, its positive
effects were not found to be significantly superior to
exercise alone in the medium term. It may also be
speculated that classification of the patients as
responders and nonresponders using ASAS criteria
might have led to less significant results even in the
short term. As mentioned above, the choice of not
using ASAS criteria depended on the decision to
make our methodology comparable to the previous
studies on the role of exercise and balneotherapy in
AS, most of which did not use ASAS criteria (10, 12, 28).
However, failure to obtain such a sustained
beneficial effect with balneotherapy is not surprising,
as it is well known that even in the studies where anti-
TNF agents were used, exacerbation of the disease
has been reported following cessation of anti-TNF
treatment (29). It may be speculated from the present
data that balneotherapy undertaken even once a
week, but for much longer treatment durations, may
help to provide more enduring improvement in
disease symptoms. In the light of the results of our
study we suggest that further randomized controlled
studies using larger patient groups and longer
www.scandjrheumatol.dk
L Altan et al
treatment durations should be performed to assess
the role of balneotherapy in AS.
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