Climatotherapy in marine and dead sea environments for musculoskeletal and rheumatologic conditions: a systematic review of effectiveness and safety.

The short version

This systematic review of nine studies with 465 adults looked at climatotherapy, the therapeutic use of climate and natural settings, for musculoskeletal and rheumatologic disorders such as osteoarthritis, rheumatoid arthritis, fibromyalgia and ankylosing spondylitis. The settings were the Dead Sea (very salty water, low humidity, distinctive solar radiation and air pressure about 5% above sea level) and coastal sites using thalassotherapy, which means bathing and exercising in seawater, sometimes with marine mud, sun exposure and sea air. Because these programs vary widely, the authors wanted to gather what trials say about pain, physical function, quality of life and safety. The reviewers searched three databases through September 2025 and included eight randomized trials and one non-randomized study from 1995 to 2011, mostly in Israel. Participants were aged 18 to 65 and stayed at a spa or coast for 10 days up to 12 weeks. Comparison groups used freshwater pools, usual care, pool exercise or the same program in Norway. Pain was usually rated on a 0 to 100 visual analog scale, and quality of life was measured with questionnaires such as the SF-36. Most studies reported short-term improvements in pain, stiffness, function and quality of life, mainly within groups. Only two studies could be pooled for pain, giving an inconclusive overall result (SMD -0.47, 95% CI -5.47 to 4.53; an interval too wide to show benefit or no benefit). Split by condition, osteoarthritis showed a large effect (SMD -1.01, meaning pain fell by roughly one standard deviation more than with comparison) while fibromyalgia showed a small non-significant one (SMD -0.18, p = 0.158). In fibromyalgia, single-study estimates showed fewer tender points (SMD -0.50, p = 0.0047) and better physical quality of life (SF-36 physical score 0.36, p = 0.0391), but mood scores (p = 0.5968) and overall fibromyalgia impact (p = 0.0612) did not change significantly. No serious adverse events were reported, though only one study recorded adverse events explicitly. The evidence has important limits: trials were small and published between 1995 and 2011, participants and therapists could not be blinded, safety was inconsistently recorded, and several programs combined many components, so the effect of the climate itself is hard to separate. Only one trial analyzed all participants as randomized, and the pooled estimate rests on two studies. Certainty was judged low. The authors suggest climatotherapy may be a complementary option, particularly for osteoarthritis, and call for multicenter randomized trials with standard outcome sets and systematic safety reporting.

Key findings

• This systematic review combined nine studies (465 adults aged 18 to 65) of climatotherapy, meaning treatment through the climate, seawater and sun at the Dead Sea or the coast, for conditions such as osteoarthritis, fibromyalgia, rheumatoid arthritis and ankylosing spondylitis.
• Most studies reported short-term improvements in pain, stiffness, physical function and quality of life, but many of these improvements were seen within groups rather than compared with a control group.
• Pooling pain results from only two studies was statistically inconclusive (standardized mean difference, SMD, a size-of-effect measure: -0.47, 95% CI -5.47 to 4.53), while the condition-specific estimates showed a large pain effect in osteoarthritis (SMD -1.01) and a small non-significant effect in fibromyalgia (SMD -0.18, p = 0.158).
• No serious adverse events were reported, but only one study recorded adverse events explicitly, so safety is not firmly established.
• The authors rated the certainty of evidence as low because trials were small, mostly from 1995 to 2011, could not blind participants, and combined many treatment components.

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