In Japan, balneotherapy is now on fashion as one of complementary therapies. Nevertheless, in the ageing society, we are facing to needs in relation to evidence-based health care on every direction. This paper reviews current articles on the use of balneotherapy in health care.
We made a systematic review on related articles in the Medline and Cochrane Library database from 1966 to 2005 that included randomized controlled and non-randomized clinical trials using balneotherapy. We also tried to classify spas in determining the chemical composition and their health effects. Ten kinds of spas (acidic, salty, sulfur, magnesium, carbon dioxide, arsenical-ferruginose, selenium, radon, sulfate, bicarbonate) were classified, and three disorders such as skin, joint/muscleskelton and circulatory system have been mainly treated by balneothrapy. In half of articles, randomized controlled trial appeared as the comparative method.
In future, certain developed methods are requested to investigate effects of spas consisting of huge diversity of chemical content.

The studies on spa's health promotion effects on healthy or slightly unhealthy persons published in past two decades in Japan have been reviewed. Multidimensional findings from these studies have suggested that the spa resort using may have the effects of increasing and retention of skin and body temperature, improving peripheral circulation function, lowering blood pressure, improving gastrointestinal hormones secretion and increasing gastric mucosal blood flow, bettering metabolism, regulating the function of immune system, regulating the balance of autonomous nervous and internal secretion systems, relieving stress and relaxing, improving the quality of life (QOL), relieving the symptoms of those who are slightly unhealthy, promoting physical strength and fitness, promoting the well-being of the aged, reducing medical expenses of individuals or the community, keeping skin in good shape and restraining the skin's aging.
Of the 58 papers reviewed, the studies of hot spring bathing effects on increasing and retention of skin and body temperature, improving peripheral circulation function and lowering blood pressure were the most in numbers (12 papers, 20.7%), and then the studies of relieving the symptoms of those who were slightly unhealthy (10 papers, 17.2%). Case-control studies (26 papers, 44.8%) were the most used study designs, and then the clinical observation (20 papers, 34.5%). No findings from any one study reviewed in this paper showed that the spa resort using had definite evidence of health promotion effects. Probable effects were suggested from 32 studies (55.2%), but findings from the rest ones (26 papers, 44.8%) showed little evidence to support this consideration. Recently randomized controlled trials (RCT) had been used in studying the health effects of spa resort using in Japan and showed significantly better effects in the intervention group. However, the intervention methods used in the studies were comprehensive health education combing the instructions in appropriate ways of hot spring bathing and education on lifestyle and exercise. It was difficult, if not impossible, to separate the effect of hot spring bathing alone from the combination. The outcomes as effects used in the studies were blood profile, physique and other non-specific items. It may be also difficult to design and carry out a near perfect RCT study on the health promotion effects of spa resort using in field in the future. However, based on experience from past studies it is practicable and important to purse better epidemiological methods such as randomizing and crossover design. On the other side, as specific readers can be influenced marvelously by one book, the health conditions of users may be improved greatly and continuously by some spa. While evidence-based health care places emphasis on RCT, it is also extremely important to inspect the health promotion effects of spa using systematically and rapidly from the viewpoint of narrative-based health care.

  The studies on the effects of balneotherapy in combination with other therapies (kinesitherapy, bath agents, diet therapy, pharmaceutical therapy, climatotherapy and phototherapy, and multiple therapies) published in past two decades have been reviewed. The effects of the combined baleotherapies on diabetes, rheumatoid arthritis, osteoarthritis, psoriasis vulgaris, atopic dermatitis, ankylosing spondylitis, stiff neck, chronic back pain, peripheral circulatory failure, emphysema, bronchial asthma, and fibromyalgia syndrome have been suggested or evidenced. The health promotion effects of combined balneotherapies among healthy or ill-healthy persons have also been showed.

1) The number of newly employed medical residents per 100,000 persons and Gini coefficients were calculated using 2005 census data and the numbers of newly employed medical residents from 2003 through 2008.2) The maximum/minimum number of medical residents per 100,000 persons decreased from 9.3 in 2003 to 3.6 to 4.7 from 2004 through 2008. Gini coefficients also decreased from 0.21 in 2003 to 0.17 to 0.19 from 2004 through 2008.3) The interprefectural inequality was large before the introduction of the new system but decreased slightly after its introduction.

  This center was established at its downtown in 2011. In order to either maintain or promote health-welfare status at the elderly life stage, the center has been providing regular physical exercise courses using hot spring water pumped up there. These activities have been performed cooperating with all 32 community general support centers covered whole the city.  Main findings and indication from our activities in these10 years were as follows:  1．Total number of attendants increased from around 60 to 90 thousands a year. About one fourth of them were the QOL (Quality of Life) tour member aged 65 years or more attending twice a week in every 3-month by the courtesy bus, and the others aged 40 years or more attended with their own ways.   The attendants aged 75 years or more has gradually increased to 70〜80% of QOL tour member. For the other member, it has been in 20〜30% these 10 years.  In addition to the physical exercise in 33〜36°C hot spring water consisted of walking, stretch & flex, aquatic exercise for joint-musculoskeletal pain and others, power-up rehabilitation, exercise for joint-musculoskeletal pain and others were performed on floor, too. The grade of these exercise consisted of 30, 40 and 50% of maximum heart rates depending on physical examination results of 5 m-walk, timed up & go test (TUG), the 30 seconds chair-stand test (CS30), hand grip, functional reach and posture forward bending, and doctors’ inspection.  2．On the follow-up of the physical examinations measured every 3-month, 5 m-walk, hand grip and CS30 were shown to be suitable items due to the availability as the routine examination. The results are substantially useful for reviewing each attendant status in longitudinal course, and indicate our treatments for them.  3．The attendants increased and distributed over the whole city in these 10 years. However, as the proportion of new ones is several percentages each year, the exchange of attendants was less than we expected. This indicates that we should have closer communication with community general support centers in order to distribute our activities to people who need health-welfare promotion, but have never been in the center. On top of that, the usage of our center should be increased for people of middle ages for ideal prevention.

  This center was established at its downtown in 2011. In order to either maintain or promote health-welfare status at the elderly life stage, the center has been providing regular physical exercise courses using hot spring water pumped up there. These activities have been performed cooperating with all 32 community general support centers covered whole the city.  Main findings and indication from our activities in these10 years were as follows:  1．Total number of attendants increased from around 60 to 90 thousands a year. About one fourth of them were the QOL (Quality of Life) tour member aged 65 years or more attending twice a week in every 3-month by the courtesy bus, and the others aged 40 years or more attended with their own ways.   The attendants aged 75 years or more has gradually increased to 70〜80% of QOL tour member. For the other member, it has been in 20〜30% these 10 years.  In addition to the physical exercise in 33〜36°C hot spring water consisted of walking, stretch & flex, aquatic exercise for joint-musculoskeletal pain and others, power-up rehabilitation, exercise for joint-musculoskeletal pain and others were performed on floor, too. The grade of these exercise consisted of 30, 40 and 50% of maximum heart rates depending on physical examination results of 5 m-walk, timed up & go test (TUG), the 30 seconds chair-stand test (CS30), hand grip, functional reach and posture forward bending, and doctors’ inspection.  2．On the follow-up of the physical examinations measured every 3-month, 5 m-walk, hand grip and CS30 were shown to be suitable items due to the availability as the routine examination. The results are substantially useful for reviewing each attendant status in longitudinal course, and indicate our treatments for them.  3．The attendants increased and distributed over the whole city in these 10 years. However, as the proportion of new ones is several percentages each year, the exchange of attendants was less than we expected. This indicates that we should have closer communication with community general support centers in order to distribute our activities to people who need health-welfare promotion, but have never been in the center. On top of that, the usage of our center should be increased for people of middle ages for ideal prevention.