Disease is defined as a mental, physical and social state that deviates from the norm, that should be accessible to treatment. As such, symptoms should be eliminated, ailments eased, functional disorders corrected or their progression prevented and emotional states improved . With many complex and chronic disease patterns, where the „restitutio ad integrum“ (curation) does not present a realistic therapeutic goal, therapeutic efforts focus on the minimization of the consequences of health impairment. This is in accordance with the WHO-Concept of the ICIDH ( International Classification of Impairments, Disabilities and Handicaps ) . This procedure is basically result oriented and includes aspects of secondary and tertiary prevention. Complex multidimensional ( „holistic“ ) therapeutic systems are characteristic. With regard to the treatment and care of chronic diseases, the therapy in a spa environment has had an important significance for a long period of time. With the specific measures of the spa setting and the integration of holistic therapeutic concepts, residual functions can be stimulated, increased or compensatory functions developed and enhanced. Integral components of the spa therapy, in addition to organ related and general somatic aspects, also include psychological and mental effects. Thus, the personal management of handicaps caused by diseases as well as the psychological coping of chronic diseases are central goals. The specific context of the spa environment seems to be particularly well suited for this holistic goal.
The goal of this study was to examine the „holistic approach“ of Kneippism with its classical therapy concepts [ 23-25} in regard to its clinical effectiveness with adequate indications. Hydrotherapy as well as kinesiotherapy and massage therapy are in the foreround of this analysis.
In the last few years the appraisal of the „quality of life“ has increasingly gained importance as an assessment criterion ( formerly designated as „soft“ data ) of medical interventions [1,4,26]. The patient's subjective appraisal of the effectiveness of a medical treatment is considered as well as the objective appraisal which is independent of the patient ( formerly called „hard“ data ). This seems to be important in the face of limited financial resources of the patient and, in many cases, with partial self financing of the medial costs. The patient takes responsibility, in conjunction with the treating physician, for the decision as to which therapy is best suited for him. The appraisal of subjective parameters such as pain, vegetative dysfunction and general emotional states, as seen in this study, provide a crucial contextual construct in the evaluation of quality of life [27,28].
The appropriate measuring instruments were developed, improved and validated starting from the Anglo-American area and within the last five years also in Germany [20,29]. At the time of the conception and start of this study important evaluation methods ( now widespread )were not available. In particular, a series of measuring instruments that are necessary for an effective analysis of health - cost efficiency had not, until recently, been strictly validated in the German version [18,20,31]. Nevertheless, the criteria chosen in the research at hand may contribute to the formulation of conclusions about the patient-oriented effectiveness of the Kneipp Kur.
The abatement and the elimination of pain, and the enhancement of quality of life are the essence of all therapeutic interventions. These therapeutic goals are also shared by the Kneipp Kur[3,24,32,33,]. In this study, for this patient population, scores for pain and emotional state showed improvement between the beginning and end of the Kur, and between beginning and after-release from the Kur; patient and physician appraisal ( IRES-Questionnaires according to Gerdes).
A further important aspect intended by Kneippism is the reduction of medication use [7,12). The consumption of pharmaceuticals was reduced, with many of the patients in this study, after completion of the Kur. The acute medication use could be reduced more often than the long term medication use. This effect was still present after 12 months in the post release observation period.In one of the few controlled studies concerning this topic, Nguyen et al.  could show a similar effect in a three week therapy in a spa environment, with regard to consumption of analgesics, pain and parameters of quality of life.
Hildebrand  in 1986, pointed out that the out-patient continuation of the effective methods of a Kur seem to be problematic. A transfer of the patient into systems that provide continued care ( out-patient physiotherapy, special post-care groups, sport groups, advanced out-patient physiotherapy and further therapies ) seem to be promising according to Donat . This is, however, difficult to put into reality under the current conditions of the compulsory health insurance and statutory pension program.
In this study, the type of post-care provided was not systematically examined. The analysis of the data showed, however, that even 12 months after completion of the Kur, a positive effect was still seen with regard to pain, quality of life and use of medication.
The goal of intervention studies in medicine is, in a classical sense, the analysis of the etiological (causal ) relationship of an effect with a therapeutic intervention. Randomization is probably the most efficient method to achieve comparability between the groups to be studied. A double-blind approach is always necessary if the study aims for an exact quantification of the specific effect, ( synonym: placebo-controlled study - classical examples are the pharmacological question methods ). The practical realization often causes considerable problems even though the methodological conditions are clear and straight forward , and the questions are simple. Nearly every original medical publication is proof of this. In the field of research in spa settings additional problems aggravate this situation. As a general rule, the medical question is complex, for example; chronic diseases, multi-morbidity, poly-symptomatic regulatory disorders, etc. In general, the treatments are applied serially and an individual modification / adaption of the program is part of the therapeutic rational. „The therapy“ usually consists of a bundel of treatments.
Almost all physical therapies are, by there nature, open and recognizable ie. ( can not be hidden from the patient ). In addition, the personal component / interaction of the therapist or physician (empathy) similarly presents an absolutely undesired „unspecific“ affecting factor, as the primary unspecific milieu of the spa environment. These unspecific, indeterministic factors of every therapeutic over-all effect, form the pro-therapeutic periphery, the so called „aura curae“, that can decide between success and failure ( happiness and sadness ) of the therapy's effect. Furthermore, considering the premiss that the Kur, for the most part, takes its substance from the long term induced effects, it is not surprising that, with regard to the described complexity, there is less concrete knowledge  than in medical fields where comparably simple cause-effect relationships are documented. It should be pointed out that, even here less is clear than commonly assumed: even such a simple question as the causal relationship between cooking salt and high blood pressure has not been definitively cleared . An examination of the therapeutic and rehabilitative effects of the Kur intervention is, if answered positively, to be completed by the analysis of the efficiency of the Kneipp Kur. Just as important would be the proof that, thru the spa environmental constellation ( „milieu“ )  compared with out-patient treatment at home, a considerable benefit is attained. At this point in time, only a few controlled randomised studies, in which a direct comparison between spa-environmental vs. out-patient therapies was examined [12,15,37], have concentrated on this question . Since randomised controlled studies, in the classical sense, are not feasible, Resch  showed study design alternatives that seem to be appropriate for the analysis of causal coherence of intervention and effectiveness of complex therapies.
In the future, appropriate scientific instruments should be transferred into the praxis of Kur clinics and used in an efficient manner in order to provide a means by which scientific research can be conducted to examine the reproducibility of results. This goal would help in eliminating existing research deficits in regard to showing the effectiveness and efficiency of the Kur treatment method.