| dc.description.abstract | F E E D B A C KPoints to consider when interpreting the results and conclusions of this review, 12 April 2017SummaryWe read with great interest the Cochrane review on balneotherapy (or spa therapy) for rheumatoid arthritis by Verhagen et al. [1]. However,we would like to address the points below that should be considered when interpreting the results and conclusions of this review.1) The review authors considered the intervention of control group as a placebo in a trial included in the review, which tested mud compresstherapy for the hands of rheumatoid arthritis patients [2]. However, the intervention of control group in that study was heated attenuatedmud compress not a placebo [2]. Indeed, that study aimed to investigate whether mineral content of mud would have any additional benefitin the heated mud compress therapy. In other words, the control group received ‘heated’ attenuated mud compress; and since that therapyhad thermal eGect, categorizing that control therapy as a placebo was inappropriate. Therefore, the results and conclusions regardingthe “balneotherapy versus placebo or no treatment” should be interpreted with caution. Nevertheless, this inappropriate reporting maybe originated from lack of knowledge of basic characteristics of balneological interventions, which include balneotherapy (mineral waterimmersion), peloidotherapy/mud therapy (medical peloid or mud applications), hydropinotherapy (mineral water drinking), inhalationtherapy (mineral water inhalation) and hydrotherapy (tap water immersion and exercise), if not from lack of caution to distinguish activefrom inactive control intervention. Furthermore, the results of the review do not match those from the original study in terms of responserate (improvement). The original paper reported statistically significant diGerences (please see Table 4 in original study) [2]; however, thereview authors’ analysis revealed no significant diGerences. We believe that this discrepancy should have mentioned and explained in thereview and needs clarification.2) The review authors wrongly defined one of the investigated interventions of a study as balneotherapy. However, the tested interventionin reality was hydrotherapy since tap water was used not mineral water [3]. In fact, that study aimed to investigate whether hydrotherapyin form of aquatic exercise would result in a greater therapeutic benefit than hydrotherapy in form of seated passive immersion, landexercise or progressive relaxation [3]. Therefore, classification of that intervention as balneotherapy was ill-chosen since the waterused was not a mineral water. We think that this inaccurate classification additionally must have contributed the heterogeneity of thebalneotherapy interventions observed in the review. Thereby, the results and conclusions regarding the “balneotherapy versus other treatments” should be interpreted with caution. Nevertheless, this approach is not well-structured definition, and once again, may indicatelack of interpretation of even the basic characteristics and application modes of balneological interventions. (see above).3) The conclusions of the review authors on two radon therapy studies [4, 5] should also be read with caution: “adding radon to carbondioxide baths did not improve pain intensity at three months but may improve overall well-being and pain at six months compared withcarbon dioxide baths without radon, but this may have happened by chance.” However, they failed to explain why the results of thesetwo studies with low risk of bias might have happened by chance. The review authors should have explained the scientific rationale andevidence for attributing the diGerences to the chance. On the other hand, the radon studies by Franke and colleagues are spa therapytrials, in which both groups stayed in a spa resort and received balneotherapy (either baths with natural mineral water rich in radon andcarbondioxide or artificially produced carbondioxide baths of the same carbondioxide concentration to maintain the blinding of patientsand to investigate specific eGects of radon), diseases-specific exercises, physiotherapy, massage therapy, hydrogalvanic baths and wereoGered occupational therapy, leisure time sports and relaxation therapy [4, 5]. In other words, the groups have undertaken the samepackage of multiple interventions plus balneotherapy (radon+carbondioxide or only carbondioxide); this may explain why the expectedeGect size would be small which was correctly reported in those two studies.4) The review authors wrongly stated that information about adverse events was not reported in a radon spa therapy study [5] and abalneotherapy study [6], in plain language summary section. However, these studies have reported the adverse events. We believe thatthat information should be mentioned to provide more comprehensive information on harms of balneotherapy or spa therapy.5) Due to concerns raised above, the results and conclusions of the Cochrane review on balneotherapy (or spa therapy) for rheumatoidarthritis may mislead the readers. The Cochrane Handbook states that review teams must include expertise in the topic area being reviewed[7]; accordingly we would suggest review teams should include expertise in the balneological interventions when further reviews on thesafety and eGectiveness of any balneological intervention will be being conducted, particularly for distinguishing active from inactivecontrol intervention or hydrotherapy (tap water immersion) from balneotherapy (mineral water immersion), which were confused in thisreview. | |
