About the Research Databases

The Wellness Evidence team of doctor consultants selected four of the most respected evidence-based medicine databases that are also particularly useful for wellness-focused research: Natural Standard, The Cochrane Library, PubMed and the TRIP Database.

Please read “Important Things to Know,” including info on each database.

We’ve made researching a particular therapy simple by pre-searching the evidence at each database. (See evidence below.) However, please note that evidence-based medicine relies on a research hierarchy, because not all evidence is created equalLearn more about how the medical experts classify this research.

We’d like to hear from you. If there is a Wellness Evidence discipline you would like to see on these pages, please email us.

Natural Standard

An international research collaboration that systematically reviews (and limits its focus to) scientific evidence on complementary and alternative medicine (CAM). Founded in 2000, Natural Standard assigns a grade to each CAM therapy, reflecting the level of available scientific data for or against the use of each therapy for a specific medical condition.

Natural Standard is subscription-based, and each of the database’s monographs aggregates data from other resources like AMED, CANCERLIT, CINAHL, CISCOM, the Cochrane Library, EMBASE, HerbMed, International Pharmaceutical Abstracts, Medline and NAPRALERT – and 20 additional journals. Data analysis is performed by healthcare professionals conducting clinical work and/or research at academic centers, using standardized instruments pertaining to each monograph section


Water has been used medicinally for thousands of years, with traditions rooted in ancient China, Japan, India, Rome, Greece, the Americas, and the Middle East. There are references to the therapeutic use of mineral water in the Old Testament. During the Middle Ages, bathing fell out of favor due to health concerns, but by the 17th century, “taking the waters” at hot springs and spas became popular across Europe (and later in the United States).

Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. These approaches have been used for the relief of various diseases and injuries, or for general well being. There are other therapies that may include the use of water as a part of a technique, but are not included in this review, such as colonic irrigation/enemas, nasal irrigation, physical therapy in pools, steam inhalation/humidifiers, drinking of mineral water/”enriched” water, coffee infusions, aquatic yoga, aquatic massage (including Watsu®), or aromatherapy/baths with added essential oils.

Modern hydrotherapy originated in 19th century Europe with the development of spas for “water cure” ailments, ranging from anxiety to pneumonia to back pain. Father Sebastian Kneipp, a 19th century Bavarian monk, spurred a movement to recognize the benefits of hydrotherapy. His methods were later adopted by Benedict Lust who immigrated to the United States from Germany in 1896, and founded an American school of naturopathic medicine. Lust claimed to have cured himself of tuberculosis with Kneipp’s methods, and hydrotherapy was included as a component of naturopathic medicine. In modern times, a wide variety of water-related therapies are used, some of which are described below.

Sitz bath: A Sitz bath is administered in a tub that allows the hips to be immersed in water. Sitz baths have been used in the management of back pain, sore muscles/muscle spasm, body aches, sprains, hemorrhoids, pruritis (itching), inflammation, rashes, anxiety, for wound care/hygiene, and to promote relaxation. For various ailments, different temperatures may be used, and minerals or medications may be added to the water.

Arm bath: For a cold arm bath, the arm is placed in a basin of cold water with the water level reaching just above the elbow. A rising temperature arm bath uses the same principle as a rising temperature footbath.

Foot bath: Cold foot baths involve placing the feet in a bath filled calf-deep with cold water. “Walking in water” involves stepping on a non-slip mat placed under water. For warm/rising temperature foot baths, the feet are immersed in water at body temperature. Hot water is gradually added until the temperature reaches approximately 103-104 degrees Fahrenheit. Therapy may last for 10-15 minutes. Caution is warranted not to cause burns.

Rising temperature hip bath: These baths are administered in tubs initially filled with shallow tepid water. Hot water is gradually added until levels reach the navel. A common temperature is 103-104 degrees Fahrenheit. The bather may then be wrapped in warm dressings.

Cold rubbings: This technique may use linens or towels soaked in cold water then wrung out and vigorously rubbed on the upper and lower trunk or the entire body.

Douches: “Douches” may be carried out with a watering can or hose. Treatments can be applied to any area of the body, with the intention to relieve tension or pain, or to affect blood flow.

Steam bath/sauna: Heat may be used to cause sweating, and these techniques are variably included in the definition of hydrotherapy. People should not spend more than 15-20 minutes in a steam bath or sauna, and individuals with medical conditions such as heart or lung disease should avoid prolonged heat exposure (as directed by a qualified healthcare provider).

Wraps: Hot or cold wet wraps may be used around various parts of the body. This technique is sometimes used with the intention to reduce fever or foster relaxation. Hot fomentation involves the application of warm liquid or moist heat with towels to the surface of the body.

Spa/hot tub/whirlpool/motion-based hydrotherapy: These therapies are sometimes used in people with wounds, chronic musculoskeletal pain, or inflammation. People should be aware of the risk of introducing infections into wounds, and the importance of keeping wounds clean.

Purifying/mineral bath: Prior to immersion, solutes or other components may be added to water, such as sea salt, lemon juice, turmeric, Epsom salts, baking soda, chlorine bleach, or essential oils.

Dead Sea balneotherapy: There are numerous published articles regarding the use of therapeutic uses of water immersion in the Dead Sea (and other salt water bodies), particularly for chronic skin conditions. Because this therapy also involves prolonged exposure to sunlight, it is not clear to what extent possible benefits are due to the water, to minerals/high salt content in the water, to sun exposure, or to a combination of factors

Water birth: Potential benefits of giving birth in water have been explored. Research is not definitive in this area.

Aquatic physical therapy/Watsu®: Physical therapy in pools is a well-established technique that takes advantage of buoyancy and resistance to movement in water. Watsu® is a form of bodywork conducted in pools.

Evidence Table
The grades A-F ascribed to the specific health conditions below have a very specific meaning. i.e., a “C” can still mean evidence of benefit from a small randomized trial, etc. Read about what each grade actually means. Grade
Low back pain
Several small controlled trials report that regular use of hot whirlpool baths with massaging jets improves the duration and severity of back pain when added to standard therapy, compared to standard therapy alone (Constant, 1995; Constant, 1998; Guillemin, 1994; McIlveen, 1998). It is not clear if there is a reduced need for pain control drugs, or if benefits are long-standing. Because these studies are small with flaws in design and reporting, better quality research is necessary before a strong conclusion can be drawn.
Anorectal lesions (hemorrhoids, anal fissures)
There is preliminary evidence supporting the use of sitz baths people with anorectal conditions, particularly for symptom relief. Sitz baths are offered to patients in many hospitals. However, controlled studies are needed to determine the effectiveness and optimal use of sitz baths.
Skin bacteria
There is preliminary evidence that some hydrotherapy techniques may reduce bacteria on the surface of the skin. It is not known if there are benefits (or potentially harmful effects) of reducing skin bacteria. There may be benefits in people with skin wounds or ulcers who are at risk of infection. There is no evidence that infection of the skin itself (cellulitis) is improved.
Hydrotherapy has been used historically for the treatment of symptoms related to rheumatoid arthritis and osteoarthritis. Multiple studies have been published, largely based on therapy given at Dead Sea spa sites in Israel. Although most studies report benefits in pain, range of motion, or muscle strength, due to design flaws, there is not enough reliable evidence upon which to base recommendations.
Atopic dermatitis
There is preliminary evidence that hydrotherapy in an acidic hot spring bath may reduce the severity of symptoms in atopic dermatitis. Evidence from controlled trials is necessary before a clear conclusion can be drawn.
Hydrotherapy is widely used in hospitals and rehabilitation centers in the management of burns. Various techniques are used, with variations in methods, lengths of time, frequency, and training levels of personnel administering treatments. There is limited research at this time, and no clear conclusions can be drawn.
Chronic obstructive pulmonary disease (COPD)
There is preliminary evidence that daily breathing exercises in a warm pool may improve lung function measurements in patients with COPD. It is not clear if this technique is superior to breathing exercises alone. Evidence from controlled trials is necessary before a clear conclusion can be drawn.
Chronic venous insufficiency (CVI)
Hydrotherapy is used in Europe for chronic venous insufficiency (CVI), a syndrome that may include leg swelling, varicose veins, leg pain, itching, and skin ulcers. A small number of trials have applied cold water stimulation alone or in combination with warm water, and reported improvements in cramps and itching when compared to no therapy. Better quality research is needed before a clear conclusion can be drawn.
Common cold
There is preliminary evidence that daily showers with warm water followed by cold water, or cold water alone, may reduce the duration and frequency of common cold symptoms. Additional research is needed in this area before a clear conclusion can be drawn.
Diabetes mellitus
There is insufficient research in this area to make a recommendation.
Claudication (painful legs from clogged arteries)
Studies report that hydrotherapy may improve blood flow to the legs, and increase the pain-free walking distance of people with claudication due to peripheral vascular disease. Additional research is needed in this area before a clear conclusion can be drawn.
There is preliminary research of the effects of giving birth in water on labor pain, duration of labor, perineal damage to the mother, and birth complications. Further studies of effectiveness and safety are necessary before a conclusion can be drawn.
Pelvic inflammatory disease (PID)
There is insufficient research in this area to make a recommendation. PID is a potentially serious medical condition that should be evaluated by a qualified, licensed healthcare provider.
Pressure ulcers/wound care
Hydrotherapy has been used in patients with pressure ulcers, and preliminary research suggests that daily whirlpool baths may reduce the time for wound healing. Better research is necessary in this area before a firm conclusion can be drawn. There is a risk of infection from contaminated water if sanitary conditions are not maintained.
There is insufficient research in this area to make a recommendation.
Spinal muscular atrophy
There is insufficient research in this area to make a recommendation.
Varicose veins
Preliminary research reports improved symptoms and blood flow in patients with varicose veins undergoing hydrotherapy with intermittent cold and hot water hydrotherapy. Additional research is needed in this area before a clear conclusion can be drawn.

There are numerous proposed mechanisms of action of hydrotherapy, depending on the specific technique used. Hydrotherapy practitioners and texts propose that immersion treatments and wraps may serve to detoxify the blood.

Alternating cold with hot temperatures is suggested to alter blood circulation, enhance the immune system, and improve digestion. Applying warmth to skin surfaces does cause vasodilation (expansion of blood vessels), which brings blood to the body’s surface. Cold temperature has the contrary effect. Warmth also causes muscle relaxation. Some hydrotherapy techniques make use of these physiologic changes, although correlation to long-term health benefits is not clear.

Electrical stimulation is sometimes used, and is proposed to stimulate muscles, digestion, and circulation (although caution is warranted due to risks associated with using electricity while in water).

Physical therapy in water makes use of buoyancy (ability to float) to reduce work against gravity, as well as the resistance of motion through water.

It is difficult to design high-quality studies in this area due to the challenge of creating “placebo” hydrotherapy.


The below uses are based on tradition, scientific theories, or limited research. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider. There may be other proposed uses that are not listed below.

Acute tubular necrosis, allergies, angina pectoris, animal bites, anxiety, ascites, asthma, attention deficit hyperactivity disorder, back muscle strengthening, bacterial infections, balance disorders, blood clot prevention, blood detoxification, blood flow enhancement, body tone improvement, bowel function improvement, bronchitis, cancer, candidiasis, chronic pain, colitis, constipation, contusions, cough, Crohn’s disease, cystitis, dental surgery adjunct, depression, digestion disorders, eczema, energy level enhancement, fibromyalgia, gallbladder disorders, gastric acid reduction, fatigue, fever reduction, food poisoning, fractures, glomerulonephritis, headache, heart disease, high blood pressure, high cholesterol, hormonal disorders, Huntington’s disease, immune system stimulation, inflammation, influenza, insect bites, intestinal motility disorders, kidney infection (pyelonephritis), kidney stones, laryngitis, liver disorders, low blood pressure, lung diseases, lymphatic disorders, menstrual cramps, mucositis, mucus production enhancement, multiple sclerosis (MS), muscle atrophy, musculoskeletal injuries, neurologic disorders, otitis media (ear infection), paralysis, parasitic infections, peptic ulcer disease, peripheral edema (leg swelling from fluid accumulation), peritonitis (abdominal wall irritation), polio, pleurisy (inflammation of the pleural lining around the lung), post-operative recovery, pregnancy preparation, premenstrual syndrome (PMS), prostatitis, psychiatric disorders, rash, relaxation, sciatica, scleroderma, sepsis, sinus pain, sleep enhancement, soft tissue injuries, sore muscles, sore throat, sprains, stiff muscles, tinnitus, tired eyes, toothache, trigeminal neuralgia, tuberculosis, urinary tract infection, vaginitis, viral infections, vocal cord disorders, well-being.


Many complementary techniques are practiced by healthcare professionals with formal training, in accordance with the standards of national organizations. However, this is not universally the case, and adverse effects are possible. Due to limited research, in some cases only limited safety information is available.

The safety of various hydrotherapy techniques is not well studied.

Sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy should be avoided, particularly in patients with heart disease, lung disease, or during pregnancy. Warm temperature therapies can cause dehydration or low blood sodium levels, and adequate hydration and electrolyte intake should be maintained. Cold temperatures may worsen symptoms in patients with Raynaud’s disease, chilblains, acrocyanosis, or erythrocyanosis.

The temperature of water should always be carefully monitored, particularly when treating patients with impaired temperature sensitivity, such as neuropathy. High temperatures or hydrotherapy involving electrical currents should be avoided in patients with implanted medical devices such as pacemakers, defibrillators, or hepatic (liver) infusion pumps.

Skin irritation (dermatitis) may be caused by contact with contaminants or additives in water (such as essential oils or chlorine). Skin infections may occur if water is not sanitary, particularly in patients with open wounds. There are several reported cases of dermatitis and bacterial skin infections (such as with Pseudomonas aeruginosa or Staphylococcus aureus) associated with hot tub or whirlpool use.

Vigorous use of water jets should be avoided in patients with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy.

Although water births are used popularly, safety has not been well studied. The fetal effects of prolonged labor in high or low temperature waters are not known.

Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.


This client information is based on a professional level monograph edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).


Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. Selected references are listed below.

  1. Acikel C, Ulkur E, Guler MM. Prolonged intermittent hydrotherapy and early tangential excision in the treatment of an extensive strong alkali burn. Burns 2001;27(3):293-296.
  2. Aderhold KJ, Perry L. Jet hydrotherapy for labor and postpartum pain relief. MCN Am J Matern Child Nurs 1991;16(2):97-99.
  3. Agius G, Degand F, Herisse J, et al. Suspected transmission of eczema herpeticum in a thermal bath establishment. Eur J Clin Microbiol Infect Dis 1994;13(12):1084-1086.
  4. Aird IA, Luckas MJ, Buckett WM, et al. Effects of intrapartum hydrotherapy on labour related parameters. Aust N Z J Obstet Gynaecol 1997;37(2):137-142.
  5. Ammer K, Melnizky P. [Medicinal baths for treatment of generalized fibromyalgia]. Forsch Komplementarmed 1999;6(2):80-85.
  6. Anstey KH, Roskell C. Hydrotherapy: detrimental or beneficial to the respiratory system? Physiotherapy 2000;86(1):5-13.
  7. Babina LM, Arzumanova VV, Iordanova II. [Balneotherapy of children with sequelae of brain injury]. Zh Nevrol Psikhiatr Im S S Korsakova 2001;101(4):29-31.
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  10. Benfield RD. Hydrotherapy in labor. J Nurs Scholarsh 2002;34(4):347-352.
  11. Brock FE. [Additive effects of vein-typical hydrotherapy according to Kneipp and topic treatment with arnica-containing gel in patients with chronic venous insufficiency-synergism of naturopathic therapies]. Erfahrungsheilkunde 2001;6:357-363.
  12. Buskila D, Abu-Shakra M, Neumann L, et al. Balneotherapy for fibromyalgia at the Dead Sea. Rheumatol Int 2001;20(3):105-108.
  13. Constant F, Collin JF, Guillemin F, et al. Effectiveness of spa therapy in chronic low back pain: a randomized clinical trial. J Rheumatol 1995;22(7):1315-1320.
  14. Constant F, Guillemin F, Collin JF, et al. Use of spa therapy to improve the quality of life of chronic low back pain patients. Med Care 1998;36(9):1309-1314.
  15. Danesino V. [Balneotherapy with arsenical-ferruginous water in chronic cervico- vaginitis. A case-control study]. Minerva Ginecol 2001;53(1):63-69.
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  29. Gunther V, Mur E, Kinigadner U, et al. Fibromyalgia–the effect of relaxation and hydrogalvanic bath therapy on the subjective pain experience. Clin Rheumatol 1994;13(4):573-578.
  30. Halevy S, Giryes H, Friger M, et al. Dead Sea bath salt for the treatment of psoriasis vulgaris: a double-blind controlled study. J Eur Acad Dermatol Venereol 1997;9:237-242.
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  32. Hall J, Skevington SM, Maddison PJ, et al. A randomized and controlled trial of hydrotherapy in rheumatoid arthritis. Arthritis Care Res 1996;9(3):206-215.
  33. Harari M, Shani J, Seidl V, et al. Climatotherapy of atopic dermatitis at the Dead Sea: demographic evaluation and cost-effectiveness. Int J Dermatol 2000;39(1):59-69.
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  35. Hooper PL. Hot-tub therapy for type 2 diabetes mellitus. N Engl J Med 1999;341(12):924-925.
  36. Hubert B, de Mahenge A, Grimont F, et al. An outbreak of pneumonia and meningitis caused by a previously undescribed gram-negative bacterium in a hot spring spa. Epidemiol Infect 1991;107(2):373-381.
  37. Insler MS, Gore H. Pseudomonas keratitis and folliculitis from whirlpool exposure. Am J Ophthalmol 1986;101(1):41-43.
  38. Konrad K, Tatrai T, Hunka A, et al. Controlled trial of balneotherapy in treatment of low back pain. Ann Rheum Dis 1992;51(6):820-822.
  39. Krajnc I, Siftar M, Turk Z, et al. The effect of balneotherapy on the low-back pain disease at the Moravci spa and the department of physiotherapy and rheumatology – Maribor teaching hospital. Scand J Rheumatol 1992;(suppl 94):55.
  40. Kubota K, Machida I, Tamura K, et al. Treatment of refractory cases of atopic dermatitis with acidic hot- spring bathing. Acta Derm Venereol 1997;77(6):452-454.
  41. Kurabayashi H, Machida I, Kubota K. Improvement in ejection fraction by hydrotherapy as rehabilitation in patients with chronic pulmonary emphysema. Physiother Res Int 1998;3(4):284-291.
  42. Landewe RB, Peeters R, Verreussel RL, et al. [No difference in effectiveness measured between treatment in a thermal bath and in an exercise bath in patients with rheumatoid arthritis]. Ned Tijdschr Geneeskd 1992;136(4):173-176.
  43. Lindberg A, Rasmussen P, Steensberg J. [Pseudomonas infection associated with whirlpool bath]. Ugeskr Laeger 1992;154(49):3507-3509.
  44. Loughney E, Harrison J. Irritant contact dermatitis due to 1-bromo-3-chloro-5,5- dimethylhydantoin in a hydrotherapy pool. Risk assessments: the need for continuous evidence-based assessments. Occup Med (Lond) 1998;48(7):461-463.
  45. McIlveen B, Robertson VJ. A randomised controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain. J Manip Physiol Ther 1998;21(6):439-440.
  46. Mcllveen B, Robertson VJ. A randomised controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain. Physiotherapy 1998;84(1):17-26.
  47. Meldrum R. Survey of Staphylococcus aureus contamination in a hospital’s spa and hydrotherapy pools. Commun Dis Public Health 2001;4(3):205-208.
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  50. Nerurkar LS, West F, May M, et al. Survival of herpes simplex virus in water specimens collected from hot tubs in spa facilities and on plastic surfaces. JAMA 1983;250(22):3081-3083.
  51. Neumann L, Sukenik S, Bolotin A, et al. The effect of balneotherapy at the Dead Sea on the quality of life of patients with fibromyalgia syndrome. Clin Rheumatol 2001;20(1):15-19.
  52. Nguyen M, Revel M, Dougados M. Prolonged effects of 3 week therapy in a spa resort on lumbar spine, knee and hip osteoarthritis: follow-up after 6 months. A randomized controlled trial. Br J Rheumatol 1997;36(1):77-81.
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  56. Petrakova VS. [Possibility of using intensive peloid balneotherapy on duodenal ulcer patients]. Vopr Kurortol Fizioter Lech Fiz Kult 2001;(5):20-23.
  57. Pinton J, Friden H, Kettaneh-Wold N, et al. Clinical and biological effects of balneotherapy with selenium-rich spa water in patients with psoriasis vulgaris. Br J Dermatol 1995;133(2):344-347.
  58. Queneau P, Francon A, Graber-Duvernay B. [Methodological reflections on 20 randomized clinical hydrotherapy trials in rheumatology]. Therapie 2001;56(6):675-684.
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  71. Stanwood W, Pinzur MS. Risk of contamination of the wound in a hydrotherapeutic tank. Foot Ankle Int 1998;19(3):173-176.
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  75. Sukenik S, Baradin R, Codish S, et al. Balneotherapy at the Dead Sea area for patients with psoriatic arthritis and concomitant fibromyalgia. Isr Med Assoc J 2001;3(2):147-150.
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British epidemiologist Archie Cochrane is regarded as the originator of the Evidence-Based Medicine concept (in the 1950s). And the Cochrane Library is a collection of very high-quality medical databases, which have, at their core, the Cochrane Reviews, systematic reviews and meta-analyses which summarize and interpret the results of well-conducted, randomized controlled trials… the ‘gold standard’ in Evidence-Based Medicine.

The Cochrane Library is a subscription-based database but offers free access to abstracts.


A service of the U.S. National Library of Medicine, PubMed was released in 1996 as a free digital archive of references and abstracts on life sciences and biomedical topics. PubMed comprises 20-million-plus citations for biomedical literature from MEDLINE, life science journals and online books from around the world. Some 11.5 million articles are listed with their abstract and 3.1 million articles are available in full-text for free.


The TRIP Database, launched in 1997, is a search engine designed to allow clinicians to quickly find answers to their medical questions using the best available evidence. Trip’s founders realized medical professionals were being forced to perform time-consuming searches at multiple websites to get at the most relevant information. So, they designed TRIP as a meta-search engine, allowing users to both simultaneously search thousands of databases, medical publications and resources, as well as easily filter the results: limiting searches to the most stringent, highest-quality medical evidence or expanding them to include results like patient information, news articles, etc.