Search strategy

• Hydrotherapy
• Balneotherapy
• Aquatic exercise
• Therapeutic effect
Rheumatoid Arthritis

• PubMed
• Cochrane Library online
• Google science/scholar
• Web of science


Hydrotherapy is a definition for exercise in warm water and is a popular treatment for patients with neurologic and musculoskeletal conditions. [1] The goals of this therapy are muscle relaxation, improving joint motion and reducing pain. [2] This therapy is been used for thousands of years. (Level of evidence A1)

Therapeutic Effects

1) The warmth of water blocks nociception by acting on thermal receptors and mechanoreceptors, thus influencing spinal segmental mechanisms. [1]
2) Warm water stimulates blood flow positively, which leads to muscle relaxation.[1]
3) the hydrostatic effect may relieve pain by reducing peripheral edema and by dampening the sympatic nervous system activity. [1]
4) Water exercises against resistance improves muscle strength. [3] ( Levels of evidence A1,A2)

Difference between aquatic exercise and balneotherapy

Balneotherapy is hydrotherapy but without exercise and is also called “Spa therapy”. It is frequently used in alternative medicine as a disease cure and is very popular for treatment of all types of arthritis. [1]

There are not much studies that describe the difference in therapy effects between aquatic exercise and balneotherapy without exercise. In the following review article, ‘Effectiveness of Aquatic Exercise and Balneotherapy’, results show that Aquatic exercise had a small significant effect on pain reduction, improvement of function, quality of life and mental health. Compared to balneotherapy, exercise in water is more effective for the treatment of musculoskeletal diseases than passive immersion. There are no long-term effects, so to keep the disease stable, it is necessary to frequently participate in water exercises.
It is not clear what exact the effect is of balneotherapy in musculoskeletal diseases because the studies involving this subject have poor methodological quality, which makes it difficult to determine the individual effect in this therapy. [2]

(Level of evidence A1)

Hydrotherapy in patients with rheumatoid arthritis

The study of A. Billberg confirms that temperate pool exercise has a significant effect on endurance and flexibility of the muscles, in upper and lower extremities in patients with RA. To gain this endurance and flexibility, exercises against resistance (Eccentric and concentric exercises) are necessary. Recent studies also indicate that patients with low muscle function can improve their muscle endurance with low impact exercises. The vitality of patients with Rheumatoid arthritis who participate in exercises in water is significantly improved after the hydrotherapy session. [4]

Two trials compared hydrotherapy to land-based exercise and failed to find any long
term differences in quality of life, health status, pain or functional scores. When we compare aquatic exercises to no exercise at all, there is a significant improvement in reducing pain in patients who participated in aquatic exercises.[5]

(Levels of evidence A1,A2)

Recent Related Research (from Pubmed)

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Acceptability of the aquatic environment for exercise training by people with chronic obstructive pulmonary disease with physical comorbidities: Additional results from a randomised controlled trial.


1. Hiroharu K., Kiichiro T. Effectiveness of Aquatic Exercise and Balneotherapy: A Summary of Systematic Reviews Based on Randomized Controlled Trials of Water Immersion Therapies. Journal of epidemiology 2010; Vol.20;1:2-12.
Level of evidence 1 (A1)
2. Eversden L, Maggs F, Nightingale P, Jobanputra P. A pragmatic randomized controlled trial of hydrotherapy and land exercises on overall well being and quality of life in rheumatoid arthritis. BMC Musculoskeletal Disorders 2007;Vol.8:23
Level of evidence 2 (A2)
3. Verhagen AP, de Vet HCW, de Bie RA, Kessels AGH, Boers M, Knipschild PG. Balneotherapy for rheumatoid arthritis, intervention review. The Cochrane Library 2002, Issue 3.
Level of evidence 1 (A1)
4. A. Bilberg, M. Ahlme’n and K. Mannerkorpi. Moderately intensive exercise in a temperate pool for patients with rheumatoid arthritis: a randomized controlled study. Rheumatology 2005;44:502–508.
Level of evidence 2 (A2)
5. Gordon S. Doig. Evidence-based systematic review of the effectiveness of hydrotherapy in acute and chronic medical conditions. www.EvidenceBased.net.
Level of evidence 1 (A1) 
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