Spa therapy (balneotherapy) for rehabilitation of survivors of COVID-19 with persistent symptoms

Authors: Kardeş S (1)
(1) Department of Medical Ecology and Hydroclimatology, İstanbul Medical Faculty, İstanbul University
Source: Med Hypotheses . 2021 Jan;146:110472
DOI: 10.1016/j.mehy.2020.110472 Publication date: 2021 Jan E-Publication date: Dec. 23, 2020 Availability: full text Copyright: © 2020 Elsevier Ltd. All rights reserved.
Language: English Countries: Not specified Location: Not specified Correspondence address:


Article content

Dear Editor,

Introduction for the hypothesis

The knowledge on persistent symptoms and rehabilitation needs of COVID-19 survivors began to emerge [1][2][3]. The most common persisted symptom was fatigue (53%–64%), followed by dyspnea (42%–50%) [1][2][3]. The other symptoms were (but not limited to) psychological distress, joint pain, chest pain, cough, sleep disorders, and functional disability [1][2][3]. Also, patients reported a decreased quality of life [1][2][3].

Spa therapy may include balneotherapy (immersion in thermal-mineral water), peloid therapy, aquatic exercises, physical therapy modalities, and exercise according to spas’ ability to deliver these treatments [4]. Recent reviews showed spa therapy/balneotherapy being beneficial in improving fatigue, joint pain, functional disability, psychological distress, sleep disorders, and quality of life in other diseases with these symptoms [5][6][7].

The recommendations of a recent article by Gasparyan et al. addressing the structuring and discussing the hypothesis [8] were followed in this hypothesis.

Formulate hypothesis

The proposed hypothesis is that spa therapy can be used in postacute rehabilitation for survivors of COVID-19 with persistent symptoms.

How to test the hypothesis

This hypothesis, which was based on an extrapolation of beneficial effects of spa/ sanatorium therapy seen in other diseases with similar symptoms [5][6][7], needs to be tested, because the pathophysiological mechanisms of these symptoms and experiences/perceptions of patients with different diseases may not be the same. The randomized controlled trials comparing spa therapy with usual care in survivors of COVID-19 with persistent symptoms are needed to test this hypothesis.


Spa therapy is in general deemed safe. In 2 studies with a large sample size, no serious adverse events associated with spa therapy were observed [9][10]. Regarding the mild to moderate severity of adverse events, an increase in pain, fatigue, hypertension, and upper respiratory tract infections were observed in some patients [9][10]. However, characteristics of spa therapy interventions (i.e. duration, temperature, etc.) should be individualized based on the clinical status of survivors of COVID-19, and the safety of spa therapy in these patients needs to be investigated.

There are some important clinical implications. First, survivors of COVID-19 may benefit from spa therapy. Furthermore, spas may increase the number of places delivering rehabilitation to survivors of COVID-19. Therefore, the workload on hospital rehabilitation units, which are currently overburdened by acute rehabilitation of COVID-19, would be lessened. Lastly, considering its inexpensive nature, integrating spa therapy into the rehabilitation programs may decrease the economic burden of COVID-19 on health systems, particularly for some European countries, Turkey, Israel and Japan where spa therapy/balneotherapy is widely available and preferred by patients.



Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


The author thanks Armen Yuri Gasparyan (Teaching Trust of the University of Birmingham, UK) for his help in conceiving the hypothesis.

Conflict of Interest

The author has no conflict of interest in this hypothesis.


1. Carfì A., Bernabei R., Landi F. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603. [PMC free article] [PubMed[Google Scholar]
2. Halpin S.J., McIvor C., Whyatt G., Adams A., Harvey O., McLean L. Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation. J Med Virol. 2020 doi: 10.1002/jmv.26368. [PubMed] [CrossRef[Google Scholar]
3. Garrigues E., Janvier P., Kherabi Y., Le Bot A., Hamon A., Gouze H. Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19. J Infect. 2020 doi: 10.1016/j.jinf.2020.08.029. [PMC free article] [PubMed] [CrossRef[Google Scholar]
4. Kardeş S., Karagülle M., Geçmen İ., Adıgüzel T., Yücesoy H., Karagülle M.Z. Outpatient balneological treatment of osteoarthritis in older persons: a retrospective study. Z Gerontol Geriat. 2019;52(2):164–171. [PubMed[Google Scholar]
5. Kamioka H., Nobuoka S., Iiyama J. Overview of systematic reviews with meta-analysis based on randomized controlled trials of balneotherapy and spa therapy from 2000 to 2019. Int J Gen Med. 2020;13:429–442. [PMC free article] [PubMed[Google Scholar]
6. Stier-Jarmer M., Kus S., Frisch D., Sabariego C., Schuh A. Health resort medicine in non-musculoskeletal disorders: is there evidence of its effectiveness? Int J Biometeorol. 2015;59(10):1523–1544. [PubMed[Google Scholar]
7. Khaltaev N., Solimene U., Vitale F., Zanasi A. Balneotherapy and hydrotherapy in chronic respiratory disease. J Thorac Dis. 2020;12(8):4459–4468. [PMC free article] [PubMed[Google Scholar]
8. Gasparyan A.Y., Ayvazyan L., Mukanova U., Yessirkepov M., Kitas G.D. Scientific hypotheses: writing, promoting, and predicting implications. J Korean Med Sci. 2019;34(45) [PMC free article] [PubMed[Google Scholar]
9. Forestier R., Desfour H., Tessier J.M., Francon A., Foote A.M., Genty C. Spa therapy in the treatment of knee osteoarthritis: a large randomised multicentre trial. Ann Rheum Dis. 2010;69(4):660–665. [PMC free article] [PubMed[Google Scholar]
10. Rat A.C., Loeuille D., Vallata A., Bernard L., Spitz E., Desvignes A. Spa therapy with physical rehabilitation is an alternative to usual spa therapy protocol in symptomatic knee osteoarthritis. Sci Rep. 2020;10(1):11004. [PMC free article] [PubMed[Google Scholar]
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