Purpose The biologic mechanisms by which balneotherapy (BT) alleviates symptoms of different diseases are still poorly understood. Recently, preclinical models and clinical trials have been developed to study the effects of BT on the immune system. This review summarizes the currently available evidence regarding the effects of spa therapy on the immune response, to confirm the role of BT in the enhancement of immune system and open interesting research fields. Methods PubMed and Google Scholar were searched from 1997 up to June 2020, with search criteria including terms related to BT and immune system. We selected only in vitro research, randomized controlled trials (RCTs) or clinical trials. Results In vitro studies on human and animal samples have demonstrated that thermal waters exert anti-inflammatory and immunomodulatory effects. In particular, H2S donors seem to counteract the inflammatory processes in psoriatic lesions, arthritic fibroblast-like synoviocytes and chondrocytes, and regulate important factors implicated in osteoarthritis pathogenesis and progression. RCTs and clinical trials revealed, after BT, a reduction in circulating levels of pro-inflammatory molecules, such as TNF-α, IL-1β, and C-reactive protein, and an increase in anti-inflammatory molecules such as the IGF-1 growth factor especially in musculoskeletal diseases. Conclusion Further preclinical studies and RCTs could help to exploit BT in real life for preventive and therapeutic treatments.

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Background: Balance and mobility impairments are frequent in people with multiple sclerosis, partly due to cerebellar dysfunctions. Task-oriented behavioural approaches were previously shown to promote physical function. The possibility exists that cerebellar transcranial direct current stimulation (ctDCS) applied during training, known to increase the excitability of the brain, can boost rehabilitation effects through modulation of cerebellum-brain inhibition. Objective: To test the efficacy of cerebellar ctDCS stimulation combined with motor training on mobility and balance in people with multiple sclerosis. Methods: 16 subjects were randomly assigned to receive real- or sham-ctDCS and task-oriented training daily over two weeks in a double-blind, randomised clinical pilot trial. Functional mobility, balance, walking performance and quality of life were tested before and after treatment and at two-week follow-up. Effects of cerebellar stimulation on psychological and executive functions were also recorded. Results: Walking performance, balance and quality of life improved for both groups at post-treatment assessment which was maintained at 2-weeks follow up. A two-way ANOVA revealed a significant time effect for balance and walking performance. A significant interaction effect of time–treatment (F = 3.12, df = 2,26; p = 0.03) was found for motor aspects of quality of life assessment in patients who received real-ctDCS. Conclusions: Task-oriented training improves balance and mobility in people with multiple sclerosis, but ctDCS does not boost motor training effects.

To review the evidence regarding the clinical effect of spa therapy for rheumatic diseases, with particular attention given to association protocols between balneotherapy and rehabilitation interventions, and to support the literature research and studies’ selection with lexical analysis. Methods: A lexical analysis was performed considering a list of words representing diseases and outcome measures linked to the theme studied in our review. Then, two independent researchers conducted a literature search on PubMed using the string employed for lexical analysis, including Randomized Controlled Trials regarding spa therapy’s clinical effects on patients affected by rheumatic diseases published in the last 30 years. After the exclusion of works that did not meet the eligibility criteria, 14 studies were included in the final scoping review. Results: Spa therapy has shown a favourable effect on pain, function and quality of life in patients with Osteoarthritis, Fibromyalgia and Rheumatoid Arthritis. Different treatment modalities and types of water have demonstrated beneficial long-term clinical improvement. Furthermore, the association between thermal therapy and rehabilitation treatments has shown better clinical outcomes, probably due to the synergistic effect between the peculiar properties of the thermal waters and the therapeutic exercise program, if conducted in the same context. Conclusions: The combination of balneotherapy and rehabilitative interventions seems to be effective in ameliorating several outcomes in patients with rheumatic diseases. However, due to the wide variety of methodologies and interventions employed, these findings need to be further investigated. The lexical analysis should represent an auxiliary support for an extensive evaluation of scientific literature.

Clinical trials have demonstrated traditional spa therapy effects in musculoskeletal disorders (MSDs). This is the first observational study in Italy aimed at evaluating in real-life the short-time effects of spa rehabilitation on pain, mood and quality of life (QoL) among degenerative or post-surgery MSDs patients. Through the involvement of six Italian spa facilities, 160 patients were enrolled; data from 123 patients were finally analysed. Seventy-nine patients (64.3%) accessed the spa for degenerative MSDs, while 44 (35.8%) had a post-surgical condition. All the patients included in the study underwent 12 sessions of water-based exercise (joint exercises, muscle strengthening, gait training, proprioceptive and balance techniques) conducted in thermal or in warm water pools, six sessions per week, for a period of 2 weeks from March 2019 up to October 2019. A group of 45 patients (36.6%) also received traditional thermal therapies, including 12 mud therapy sessions and 12 thermal baths, six times each week, for 2 weeks. Evaluation before and after the treatment included the Numerical Rating Scale (NRS), the Short Form Health Survey (SF-12) and the EuroQol-5D (EQ-5D). The analysis of the scores reported in the questionnaires after the treatment showed a significant improvement in all the scores evaluated. Comparison between patients that performed water-based exercise protocols alone (group A) and patients that in addition to water exercise performed traditional thermal interventions (group B) showed no statistically significant differences in NRSp, NRSa, NRSm, SF-12 PCS, SF-12 MCS and EQ-5D variations; only NRSa value reduction was lower in group B. Sulphate water was found to be associated with a lower reduction of all the scores considered, when compared to the other water types. Patients with degenerative or post-surgery MSDs showed favourable effects on pain, mood and QoL after water exercise training alone or in combination with traditional thermal therapy. Our research provides the first proof that spa rehabilitation can be in real-life conditions an appropriate alternative strategy for post-orthopaedic surgical outcomes recovery. In the future, these results will need to be further investigated.