# Short-Term Sulfurous Balneotherapy and Self-Reported Sleep Quality: An Exploratory Retrospective Real-World Pre–Post Observational Study at Terme di Saturnia (Italy)

## TL;DR

This study explores whether sulfurous balneotherapy improves self-reported sleep quality in people with sleep issues, finding some positive effects but noting limitations in proving causality.

## Contribution

The study provides real-world evidence on the potential benefits of sulfurous balneotherapy for sleep quality, despite its observational and non-controlled design.

## Key findings

- Participants with severe insomnia showed significant improvement in sleep quality after sulfurous balneotherapy.
- Sleep satisfaction scores increased significantly in the group with severe insomnia.
- Most participants without severe insomnia reported enhanced relaxation during the spa stay.

## Abstract

Background: Sleep disturbances are highly prevalent, affecting approximately 21% of the European population, with chronic insomnia disorder estimated at 6%. Non-pharmacological alternatives to pharmacotherapy are needed. Sulfurous balneotherapy represents a potential intervention, yet real-world evidence remains limited. Objective: To explore changes in self-reported sleep quality following sulfurous balneotherapy at Terme di Saturnia (Italy). Methods: Retrospective single-arm observational study of 76 participants (mean age 47.3 years, 54% female) undergoing a 7–12-day consecutive balneotherapy cycle with daily sulfurous thermal water immersion sessions (60–90 min/session). The Oviedo Sleep Questionnaire (OSQ) was administered pre- and post-treatment. Participants were stratified by baseline insomnia severity into Group A (OSQ ≥ 22, n = 47) and Group B (OSQ < 22, n = 29). The primary outcome was change in OSQ insomnia score in Group A. Statistical analysis was performed using the Wilcoxon signed-rank test. Results: In Group A, insomnia severity decreased significantly from 26.4 ± 8.3 at baseline to 20.1 ± 7.5 post-treatment (Δ = −6.3, 95% CI: −7.9 to −4.7, p < 0.001, r = 0.54). Sleep satisfaction also improved significantly from 3.2 ± 1.1 to 4.6 ± 1.2 (Δ = +1.4, 95% CI: 1.1–1.7, p < 0.001, r = 0.60). In Group B, no statistically significant changes were observed, consistent with ceiling effects. However, in an open-ended question, 72.4% (21/29; 95% CI: 54.3–85.3) of Group B participants reported enhanced relaxation during the spa stay. Due to the single-arm observational design without control groups, the observed improvements cannot be distinguished from non-specific factors, including the vacation effect, reduced work-related stress, placebo and expectancy responses, regression to the mean, or the effects of warm water immersion itself independent of sulfurous mineral content. Conclusions: This exploratory study documents pre–post improvements in self-reported sleep quality in a cohort undergoing sulfurous balneotherapy during a spa vacation. The absence of control groups and unmeasured confounders precludes causal inferences. Future randomized trials with heated non-mineral water controls are needed to isolate specific therapeutic contributions of sulfurous thermal waters.