118 papers have been published in english speaking journals with impact factor these last twenty years: 90 randomized Controlled Trials (RCT) and 28 reviews and/or meta-analysis (RMA).   Rheumatolgy is the first topic: 63 RCT, 22 RMA. Knee osteoarthritis is the most investigated condition : 18 RCT, 5 RMA ; chronic inflammatory diseases 12 RCT, 1 RMA; Fibromyalgia 10 RCT, 2 RM ; Chronic low back pain: 11 RCT, 1 RMA. The patients with musculo-skeletal conditions have a significant actual clinical benefit on pain, function and quality of life.   Spa therapy is beneficial for patients with psoriasis (9 RCT) and atopic dermatitis (1 RCT).   Overweight or obese patients treated in spa resorts have a significant weight reduction according (3 RCT).   SPA therapy is also beneficial for patients with chronic venous insufficiency (2 RCT) or chronic occlusive peripheric arterial disease (4 RCT and 2 RMA).   Gynaecology (2 RCT) and psycho-somatic conditions (1 RCT) are more poorly investigated.   The lack of investigation about respiratory lower tract or Ear-Nose-Throat conditions is a questionnable issue.   Despite a significant number of trials, the level of evidence is impaired by many methodological flaws.   The actual medico-economic benefit assessment is based on more limited data of evidence.

  Overweight, obesity and the metabolic syndrome are usual conditions treated in french balneotherapy care facilities. 42,507 patients were treated last year in France for metabolic conditions, most of them benefiting a social security reimbursed treatment. The therapeutic intervention core is made of hydro-thermal cares: drinking mineral water (alkaline sodium bicarbonated water), individual mineral water bathing, showers, massages under mineral water, mineral water pool collective exercise; education on nutritional concepts, adapted physical activity are also essential informations delivered in group or customized sessions. AFRETH promoted two clinical studies investigating the topic.   The randomised controlled trial Maathermes (1) assessed the benefit of the intervention on 257 overweight or obese patients randomized between balneotherapy (delivered in Brides, Capvern, Vals, Vichy, Vittel) and a control group (usual care and booklet on nutrition from the french health autorithy). At month 14th, the patients treated in the balneotherapy group showed a significant weight reduction (5.17 kg vs .54 kg ; p<.001) and they had more perspective to reach a stable weight loss of 5% (57.1% vs 18.6 % ; p<.001).   Prisme (2), a feasability cohort study, investigated the results of the intervention in 93 patients with a metabolic syndrome treated in Eugenie les Bains. At month 12th, 67 patients could be assessed. Metabolic syndrome had disappeared in 76% of the patients (glycemia normalised in 15%, waist circumference returned to acceptable in 15%, lipidic disorders disappeared in 33% ; blood pressure had acceptable values, without increased drug intake, in 67%.). 75 % of the patients were continuing the adapted physical activity, 65 % had a correct lipid intake.   Balneotherapy is useful for patients with overweight or obesity. Education during the stay is helpful for the weight and metabolic syndrome control. The medico-economic benefit of such an intervention remains to be established on scientific basis.

  A limited number of randomised clinical trials investigated drinking mineral waters benefit.   Alcaline sodium bicarbonated waters demonstrated their ability to enhance gastric motility and emptying (Bertoni, 2002; Wakisaka, 2012); vesicular emptying (Toxqui, 2012). But it also acts on lipid metabolism (Schoppen, 2005; Toxqui, 2012; Perez granados, 2010), insulin sensitivity (Schoppen, 2007), oxalo-calcic and uratic compounds urinary excretion (Karagülle, 2007).   Calcic carbonated waters act mainly on the calcium homeostatsis; they can reduce bone modeling with a significant decrease of PTH and bone modeling markers levels (Guillemand, 2002; Roux, 2004; Meunier, 2005; Wynn, 2009).   Magnesium and/or calcium rich waters can offer a profitable income of such minerals (Aptel, 1999; Galan, 2002; Sabatier, 2011).   Sulfide waters can be damageable for erythrocyte through their deleterious action on enzymatic pathways (GAPDH, G6PDH) and methemoglobin (Albertini, 2008).   Epidemiologic studies emphasized the ability of some tap waters to facilitate some disorders, mainly acid waters and type I diabetes (Skenes, 2002), poorly silicated waters and Alzheimer’s disease (Gillette Guyonnet, 2005).   If the studies demonstrated actual pharmacological effects of mineral waters, the clinical relevance of these properties as the medical benefit in real life conditions have still to be established.

  In France, several public and or private scientific investigation bodies are involved in medical balneological scientific investigation (academic or university-linked institutes in Paris, Nancy, Bordeaux, Grenoble, Clermont-Ferrand; private structures in Paris, Aix les Bains, Saujon). However, these last 10 years, the important development in medical balneology investigation could be related to the French Association for Balneotherapy Research (AFRETH). The Afreth has been created in 2004 by the French Union of SPA Contractors, the Union of the mayors of spa resorts and the French branch of the FEMTEC. The AFRETH provides every year a budget of 1 M€ for scientific investigation in balneology. The founders’ representatives, who constitute the association’s administrative committee, take the decision of supporting financially the scientifically validated projects. The scientific validity is pronounced by the scientific committee (12 independent and acknowledged doctors and scientists) on the basis of external independent experts’ advices (methodological, clinical and biological sciences from French academic institutions).   10 calls for projects have been launched and fully implemented. They concerned mainly the actual medical benefit (cf. Table below). A global budget of 11 M€ has been engaged.   Regarding the medical benefit have been implemented and published: STOP-TAG (treatment of generalised anxiety, 237 patients); Thermarthrose (knee osteo-arthritis, 462 patients); Maathermes (obesity and overweight, 257 patients); Pacthe (treated breast cancer patients, 250 patients) Thermes & veines (chronic venous insufficiency, 425 patients). These different randomised controlled trials have demonstrated significant results in favour of balneotherapy.   Publication is in progress for Rotatherm (a RCT concerning shoulder cuff tendinitis, 186 patients).   Are in progress a RCT on COPD (BPCeaux), a RCT on subacute lumbar pain (ITILO). Pilot investigations have been implemented concerning the metabolic syndrome, Alzheimer’s disease and other ageing problems, psychotropic drugs withdrawal, therapeutic education of patients with chronic venous insufficiency.   So scientific investigation has to come with usual balneotherapy but also with the development of new trends which have to be scientifically assessed from their initiation. From our experience, we have to emphasize the difficulties related to the patients’ enrolment and the need of new methodological designs, alternative to usual RCT to investigate such a complex therapeutic intervention.

  In developped countries ageing is a major challenge. In France, the AFRETH promoted several studies investigating the role of balneotherapy on ageing.   The (Multimodal Prevention Alzheimer Trial) MAPT programme is made of nutritional education, adapted physical activity, cognitive stimulation. The programme was proposed to patients of 70 years and more attending spa resorts. 35 % estimated to be concerned, 70% accepted to be included in the programme with remarkable levels of compliance (97%) and satisfaction (90%). Every year about 50,000 persons could be involved in such a programme in the French spa resorts. It has been established that 800,000 French persons complain with the disease for a global yearly coast of € 22,000 by patient (55% family supported) ; a 4 year delay on the onset of the disease could reduce by 50% the prevalence of the disease.   In the« TCap study »we could observe that adapted physical activity education delivered in spa resorts during a spa treatment was an effective way to promote adapted physical activity in old persons.   « Prevention consultation »: the time-span of the spa treatment could be used to perform a relevant clinical investigation to detect predictive factors of frailty and propose an accurate stategy of prevention, obtain public health useful relevant data.   The« Parenthese study »designed a complex programme to prevent or treat the burn-out of Alzheimer patients’ care givers: i)The care givers could receive an intervention made of hydro-thermal cares aiming to the treatment of the burn-out and musculo-skeletal conditions associated with the emotional and physical burden of the care-giving; an educational intervention would help the care-givers to manage every day life of the patients ; ii) the patients, when accompanying the care-giver, could be attended in a geriatric day facility; iii) when the patients would be unable to stay in ordinary venues, accommodation could be organised in an adapted night facility (eventually with the care-giver).