“Do we need a New Holistic Approach to Health Resort Medicine, Balneology, Medical Hydrology and Climatology?”

What is the problem?

 

Health Resort Medicine, Balneology, Medical Hydrology and Climatology are not fully recognised as an independent medical specialty at a global international level. Thus it is not represented in the European Union of Medical Specialists (UEMS). However, within the Section for Physical and Rehabilitation Medicine a task force on Balneology has been established. The foundation of a subsection has been refused recently by the executive committee of the UEMS. On the other hand in many European and non-European countries independent specialties (e.g. Turkey, Spain, and Italy) or competencies (e.g. Germany, Austria, Serbia, Czech Republic, Hungary, Portugal, and France) exist. In some European countries Balneology is included in the specialty of Physical and Rehabilitation Medicine (e.g. Poland, Slovakia, and Romania). Other countries do not know any similar medical specialization or qualification (e.g. UK, The Netherlands, Sweden, and Denmark). On the other hand Health Resort Medicine, Balneology, Medical Hydrology and Climatology are relevant parts of the health systems in many countries within and outside Europe (Germany, Austria, Poland, Hungary, France, Japan, and others), and health insurances refund health resort treatments at least partly. Additionally it has to be mentioned that a lot of scientific work on physiological mechanisms and clinical outcomes have been published within the last decades, and especially the number of randomised prospective controlled studies is growing recently. Nowadays even some systematic reviews and metananlyses are available, most of them on the effects on osteoarthritis. The conclusions are mostly in favour of spa treatments; however, due to the large variety of interventions the results mostly are still inconclusive. The same applies to studies on cost-effectiveness.      

 

In this situation it has to be reflected what arguments are used against the recognition of Health Resort Medicine, Balneology, Medical Hydrology and Climatology as independent medical specialty or – at least – as sub-specialty or competence. As mostly in such discussion there are external arguments and implicit barriers contributing to such a situation. External arguments are

• A lack of scientific evidence. This argument is widely used and Health Resort Medicine, Balneology, Medical Hydrology and Climatology are widely clamed to be paramedical. As there is a clear definition on the methods used in the field, the mechanisms involved, and growing evidence on the outcomes (at least in some conditions) the argument of lack of evidence occurs to be is not very strong and especially not stronger as for other well recognised medical interventions (e.g. Physiotherapy, Occupational Therapy, some methods of Psychotherapy).
• The fact that Balneotherapy and Climatotherapy are not used in all countries. As Balneotherapy and Climatotherapy are dependent on specific geological, geographic and meteorological preconditions regional aspects are of major influence on the use of such treatment. Taking this into account this argument seems to be justified. However, other factors have effect on the use of mineral waters and climatic factors for therapy, such as regional traditions, and national health systems, especially the refunding by health insurances. Especially the latter may be changed in future and is in some respect related to the first argument described above. If the proposal of a definition as proposed below will be accepted internationally the practice of Health Resort Medicine and Balneology will be more independent from regional factors as the use of natural resources as mineral waters and peloids outside health resorts, the use of plain water (Hydrotherapy) and the use of the contextual factors of a health resort (even without Balneotherapy). Additionally the planning and prescription of health resort interventions may be part of specialists in Health Resort Medicine.
• The fact that Health Resort Medicine, Balneology, Medical Hydrology and Climatology only focus on single methods and do not have a comprehensive concept. It is true that the treatment methods are leading for the (traditional) definition of the professional practice. On the other hand, similar to Physical and Rehabilitation Medicine, Health Resort Medicine, Balneology, Medical Hydrology and Climatology have a functional definition of treatment goals (improvement of functioning in terms of ICF, esp. improve regulatory capacities of the autonomous nervous system, use of plasticity in many organ systems) and – as Health Resort Medicine – include many other treatments (see below). A special characteristic – may be the most innovative one – is the systematic use of environmental factors for health promotion, prevention, therapy and rehabilitation. Lastly, specific diagnostic tools as functional tests and assessment as well as prognostification should be further developed by specialist organisations.

 

Implicit barriers are 

• The lack of international accepted terms in the field. In international scientific literature the use of terms in the field is very inconsistent. This results from the fact that English became the dominant scientific language whereas Balneology has mainly be developed in Roman (France, Italy, Spain, Portugal), German (Germany, Austria, Switzerland, South Tyrolia) speaking and eastern European (Poland, Czech Republic, Romania, Russia and others) countries. Only two examples can be given here: the term “hydrotherapy” in the UK is used mainly to describe under water (pool) exercise and other method of external use of plain water are not used. On contrary, in Germany the external use of water (e.g. water jets) according to Kneipp aiming at thermal stimulation is called “hydrotherapy”, and pool exercise is seen as part of physiotherapy. The term “balneotherapy” in Germany is used for the use of natural mineral waters for bathing drinking and inhalation whereas in France and other Latin speaking countries this term is used for bathing outside medical concepts only, and the equivalent scientific term to “balneotherapy” is “crenotherapy”. This causes a significant barrier on research and especially limits the performance of meta-analyses. It gives a relevant barrier too to the recognition and development of the field. Therefore an international consensus process aiming at an internationally recognised terminology should be completed as soon as possible. Such a project should allow the translation into different languages (recognising the cultural differences in the use of terms).  
• The restriction of the activities to practice in specific settings only. The traditional definition of Balneology claims that it only covers the use of natural remedies at the place of origin. Such a definition excludes the use of these factors therapy outside health resorts and limits the medical specialty to given settings (see above). Additionally it has to be stated that there is no scientific proof that Balneotherapy is only affective within the setting of a health resort, on contrary for some methods the efficacy has been proven outside health resorts already (e.g. mineral water drinking for renal stone metaphylaxis, CO₂-bathing for the improvement of skin microcirculation and improvement of pO₂). The restriction to regional settings may support the development of health resorts but hinders the international recognition of the medical specialty. However, if the specialty is described by the competence to use all factors of a health resort in all possible settings and will include the management of patients with need of Health Resort Medicine, Balneotherapy and Climatotherapy the international recognition could be reached much more easily as the definition is much more universal (and additionally is in accordance with scientific criteria).
• The trend to use Balneotherapy mainly for wellness concepts. In many countries there is increasing advertisement to use interventions of Balneotherapy for wellness concepts. Most of these concepts lack of systematic medical approach and simply aim at short-term well-being (and of course economic profit). Even if there are attempts to focus wellness methods on health-promoting an prevention programs (so-called medical wellness) the promotion of wellness programs in health resorts in the public view draws the attention away from the medical use of treatments and sets health resorts on an equal level with other services providing wellness programs (e.g. hotels, health clubs, spas, and others). Even this is a political argument it should be reflected carefully. 

 

Especially the implicit barriers should be subject to intense discussions among scientists and specialists within the field and systematic problem-solving processes should be induced by scientific organisations and professional bodies. 

 

Approach and concept

 

This blog aims to discuss possible options to tackle the problem of implicit barriers by making a proposal for a structure and description of the medical field and to give some commonly acceptable descriptions of the contents and terminology. However, the descriptions have to be further discussed and a systematic international consensus process is still needed. It already has been started within the framework of the International Society for Medical Hydrology (ISMH) but not yet finalised. Regarding terminology it is of importance to find a possibility to translate words used in national languages into internationally accepted scientific terms (dictionary) may be based on recently published glossaries.   

 

It aims at 

• a description for the medical field of Health Resort Medicine, Balneology, Medical Hydrology and Climatology that is more independent from the local or national conditions and 
• short descriptions of terms within the field that could be used as a basis for an international consensus and a “dictionary” to translate these terms in different languages.    

 

Of course, this blog can not replace a systematic international consensus process on terms, descriptions and definitions. As well it does not claim to be comprehensive or complete, especially with respect to terms and methods used in specific languages or regions. Additions, comments and discussion are very welcome.  

 

Description of the medical field

 

The medical field of Health Resort Medicine can be described by a general definition that includes core elements, modalities (methods) and agents (substances, factors).

• The field can be defined as medicine originated and derived in health resorts (or Health Resort Medicine). The term medicine includes diagnostic and treatments and can be used for health promotion, prevention, therapy, and rehabilitation.
• Core elements are 
  • the use of (natural) mineral waters, gases and peloids (Balneotherapy or Crenotherapy)
  • the use of plain water (tap water)(Hydrotherapy) 
  • the use of climatic factors (Climatotherapy)
  • the use of other therapies in health resorts, e.g. physical modalities (physical therapy, Physiotherapy), diet (nutrition therapy), exercise, massage therapy, psychotherapy, health education, complementary and alternative therapies, and others 
  • the use of environmental factors (as can be classified by the International Classification of Functioning, Disability and Health
• Modalities such as bathing, drinking (hydropinia), inhalation and others
• Agents, e.g. mineral waters, plain water, gases, peloids (fango) and others. This level includes therapeutical factors as exercise, thermotherapy, massage, galvanisation and others, too. 

 

Such a definition of the medical field is – compared to the classical approach (see below) – much more comprehensive and more appropriate to be used as a basis for an international use. Compared to the classical approach there are many advantages, namely 

• the definition is more open for the use of all factors of a health resort including treatments complementary to balneotherapy and environmental factors according to the ICF-model (holistic approach)
• the definition is open for the use of similar and/or identical substances outside health resorts (e.g. artificial CO₂ baths and injections in hospitals, mineral water drinking at home to substitute minerals or prevent renal stone formation, mud packages for use in medical practice) 
• it is focussing on general skills and aptitudes of a specialist of the field (including advise to patients when and how to use Health Resort Medicine, Balneotherapy and Climatotherapy) 
• it is nearer to the definitions of other specialties (as it includes diagnostic skills an a variety of treatments)
• it enables research on comprehensive concepts as well as on modalities and agents (incl. meta-analyses)
• it focuses on an international terminology

 

However, some limitations have to be mentioned too:

• the definition is open methods in other settings, e.g. outside traditional health resorts 
• it has some overlap with other specialties (namely Physical and Rehabilitation Medicine)
• it is somewhat different from some well-established national descriptions of the specialty or competence

 

On contrary, the traditional approach defines the medical field as the use of the regional remedies at the place of its origin that has to be a health resort (that is described elsewhere). In terms of the figure 1 this approach goes from right to left and includes the elements outside the use of mineral waters, gases and peloids (Balneology) or climatic factors (Climatotherapy) only in a secondary way. Advantages of this approach are 

• a clear definition of used substances
• supporting health resorts as exclusive places for the use of these substances
• the accordance of the use of the terminology in many countries

 

Main disadvantages and limitations are  

• the restriction to local application of therapeutic remedies (not holistic)
• the above described barriers to an international recognition
• focussing on specific properties (setting barriers on generalizing research and meta-analyses)
• and a dominance of national terms 

 

Additionally the problem of the definition of the remedies, that – in most countries – is not medically but chemically driven, is much more decisive in the classical approach.

 

Summarizing and condensing the given arguments the holistic approach describing Health Resort Medicine has to be given priority over the classical approach defining the specialty from the locally restricted use regional natural remedies.

 

Medicine in health resorts

 

Health resort therapy includes all medical activities in health resorts based on scientific evidence aiming at health promotion, prevention, therapy and rehabilitation. Core elements of the health resort therapy interventions in health resorts are balneotherapy, hydrotherapy, and climatotherapy. Other interventions frequently used are massage, exercise, sauna, Turkish bath, other physical therapies e.g. kinesiotherapy, thermotherapy, electrotherapy, occupational therapy, medication (pharmacotherapy), psychotherapy, nutrition (diet), health education and cognitive behavioural therapies, relaxation therapies, complementary therapies (e.g. integrative medicine). Additionally a health promoting environment, recreational activities, cultural and social activities as well as sports are part of health resort medicine. 

 

The arrangement of comprehensive treatment programs and the prescription of the treatments have to be done by a specialist in health resort medicine (see below) according to the medical diagnosis and functional need of the patient.

 

Diagnostic tools included in health resort medicine too, such as evaluation of the pathology, functional assessments, psychosocial assessments, prediction parameters and others.    

 

Other (equivalent) terms of health resort medicine are Thermal Therapy, Kurorttherapie, Spa therapy, Crénotherapy, Traitements thermals, Thermalism, and other terms. 

 

At least for some indications studies showed that health resort medicine is effective. Most of them dealing with disorders of the locomotor system, however, there is evidence of beneficial effects in cardiovascular disorders, skin disease, ear, nose and throat as well as lung disease, metabolic syndromes, gastrointestinal conditions and psychosomatic disorders.  

 

A uniform and internationally used name of the medical field dealing with Health Resort Medicine, Balneotherapy, Hydrotherapy, and Climatotherapy does not exist. Two approaches are used:

• using the interventions as the basis for the umbrella term (“Balneology and Medical Climatology” or “Medical Balneology and Climatology” (Central and Eastern European Countries), “Medical Hydrology and Climatology” (UK), “Medical Hydrology” (Spain, France, Portugal, Italy), “Hydroclimatology” (Turkey), “Balneology” (USA, East Asia)
• using the setting of health resorts as basis for umbrella term, resulting in “Health resort medicine” or “Kurortmedizin”

These names should be used as equivalent according to national regulations.

 

Health strategies and purposes of treatment 

 

The treatments in health resorts can be applied to different groups of persons, e.g. healthy subjects, persons with non-specific disorders and patients with defined health conditions. Main goals of these interventions are:   

• Health promotion related to health resort medicine aims at an improvement of general health, well being and regulatory capacity as well as reduction and/or elimination of risk factors
• Prevention related to health resort medicine aims at the risk reduction for specific health conditions, e.g. cardiovascular diseases, metabolic diseases and others. 
  • Primary prevention aim at reduction of incidence of symptomatic disease including measures like change of behaviour (e.g. improvement of physical activity), reduction of nutritional risk factors and improvement of regulatory capacity of various body functions (e.g. circulatory functions, muscle functions, metabolic functions).
  • Secondary prevention aims at early diagnosis and early treatment of diseases 
  • Tertiary prevention aims at preventing the relapse of disease, improve functioning, reducing complication and educate to live with the damage
• Treatment aims at the elimination or reduction of symptoms of a disease (e.g. pain reduction, increase of range of motion, blood pressure reduction, improvement of lung function an many others). The specific action of treatments in health resort medicine cannot be describe here (see textbooks of balneology, climatology and health resort medicine)
• Rehabilitation aims at the improvement of functioning according to the WHO definition and the improvement of health related quality of life. This includes enabling strategies for people with disabilities and chronic disabling conditions as well as compensatory strategies and the adaptation of the environment to special needs of these persons. Improvements of quality of and participation life have been shown in recent studies.  

 

Health resort medicine contributes to all mentioned health strategies. 

 

Use of mineral waters, gases, peloids

 

The medical application of natural mineral waters, gases and peloids (e.g. Fango), being effective for the prevention or treatment of diseases and the improvement of functioning (rehabilitation) is one of the core elements of medicine in health resorts. Methods of application (modalities) are bathing (head out water immersion, bathing of body parts), drinking, inhalation, irrigations, packs (local application of peloids), dry peloid therapy (e.g. with sand), gas bathes, local application of gases, and others. The effects of the use of natural mineral waters, gases and peloids are based on both chemical and physical properties of the agents.  

 

The use of natural mineral waters, gases and peloids in many countries is called Balneotherapy. Other (equivalent) terms are Thermotherapy, Cura balnearia, and other terms

 

Substances

 

The following substances are used in health resorts: 

• Medical mineral waters require minimum concentrations of ions and/or gases for the evocation of relevant chemical effects. The thresholds of effective concentration should be defined on scientific evidence, taking into account the specific methodology of application, e.g. bathing, drinking, inhalation and others. These waters are described in many other documents. The composition and threshold values may vary from country to country or health resort to health resort. Temperature is an important factor for therapy. Waters can be described as hypothermal (< 35°C), isothermal (35-36°C) and hyperthermal (>36°C). 
• Medical peloids require a high specific heat and heat keeping, which are related to the composition of the peloid and the viscosity during application. Examples are peat, fango (volcanic origin), mud (from ground of the sea, lakes or rivers), clay, and others
• Natural gases used for therapy are CO₂, H₂S and radon.

 

Of course, these substances can be used outside health resorts as well (e.g. mineral water drinking, CO₂-baths, mud packs, and others.

 

For all these remedies physiological studies are available showing some relevant effects in healthy subjects and patients. The investigated substances mainly were mud, CO₂, H₂S, brine, hydrogen carbonate, and sulfate. For some of them controlled trials showed relevant effects in specific health conditions.

 

Modalities

Mineral waters, gases and peloids can be used in different ways, e.g. internal end external application. The most important modalities of use are: 

• Bathing. Bathing is the therapy by immersion of the body (head-out water immersion) or of body parts into water, peloid or gas. Bathing has chemical and physical effects on the body. They cause local effects on the skin, adsorption of ingredients and/or elution of skin substances as well as subsequent reaction in the neuro-immuno-endocine-system.
• Drinking (Hydropenia). Drinking (cure) is the treatment method using the ingestion of waters (mainly medical mineral waters) aiming at modifications of gastro-intestinal, metabolic, renal and urodynamic functions. Substitution and supplementation of minerals is part of drinking mineral waters too.
• Inhalation. Inhalation is the application of aerosols via the respiratory tract. For this purpose medical mineral waters and some natural gases (mainly Radon) are used. Inhalations have beneficial effects on the mucosa of the respiratory tract and may improve respiratory functions. Some substances will be absorbed after inhalation and may induce systemic effects. 

 

Other modalities not regularly used in all countries and all health resorts are mucosal irrigations with mineral waters (lavage), tampon with peloids, injections (e.g. CO₂-gas), showers and water jets, Jacuzzi, facial and body masks with peloids, and others. This list can be continued due to other specific methods and new developments in the field.

Scientific studies of the efficacy of the application of these modalities do not make sense isolating them from the effects of the medium used. These studies are summarized already (see above). However the physiologic effects are well known and have to be taken into account prescribing these modalities. 

Use of plain water

The use of plain water (tap water) for therapy is called Hydrotherapy. It includes the external application of water for medical purposes and uses the physical properties of water, being temperature, hydrostatic pressure, hydrodynamics, buoyancy, viscosity, and electric conductivity. Methods of application and modalities in hydrotherapy are bathing (head out water immersion, bathing of body parts), showers, water jets, compresses, body wraps under-water-exercise, hydro-electrical baths, and others.

 

Another (equivalent term for hydrotherapy is aquatic therapy. 

 

For under-water exercise recently some studies have been published showing god effects in osteoarthritis, rheumatoid arthritis, and fibromyalgia. The use of water in order to apply cold stimuli has been studied very intensively in 50ies and 60ties of the last century. Here again physiologic reaction are studied well, however, a few studies show long-term adaptation to serial applications with good effects on autonomous dysregulation and well being. Water exercise is used in cardiac rehabilitation programs too. 

 

Use of climatic factors

The use of climatic factors for therapy is called Climatotherapy. It includes the planned medical application of climatic factors, being effective for the prevention or treatment of diseases and the improvement of functioning (rehabilitation). Climatotherapy is performed in specific climates, e.g. high altitude climate, sea cost climate and includes the change of climatic environment. Climatic factors with relevance for therapy are radiation (ultra violet, light, infrared), thermal stimuli (temperature, wind, humidity and others) and air composition (pO₂, therapeutic aerosols, absence of pollution and allergens, and others). Psychological reactions from the experience of landscapes may be a factor too. Methods of exposure and modalities in climatotherapy are open air resting with exposure of the whole body or body parts to climatic factors [e.g. cold and radiation (heliotherapy)], walking in conjunction with exposure to climatic factors (so-called Terrainkur), Speleotherpy (therapy in caves), and others  

 

Other (equivalent) terms for Climatotherapy are Klimakur, and other terms. The term of Biotropy is not included into this paper because the paper is restricted to therapeutic interventions, however in some countries specialists of balneology and medical climatology deal with this. 

 

At least in some indications relevant effects of Climatotherapy have been reviewed. Moreover, randomized controlled studies on clinical effects and relevant factors are available within this area.

 

Use of other therapeutic factors

 

The use of other therapeutic factors cannot be described in detail within the framework of this paper. However they are well known and describes in the textbooks of the fields concerned. Namely these factors are physical therapies (e.g. thermotherapy, electrotherapy), physiotherapy, occupational therapy, medical training and exercise, nutritional therapy, massage therapy, psychotherapy, health education. Pharmacotherapy may be included here too. Of course this list can be extended due to special needs of the patients or specific treatment concepts (e.g. comprehensive or complementary medicine).    

 

To review scientific evidence of all these therapies would exceed this framework. Standard data bases (e.g. Medline, Cochrane Collaboration) can be used to search for scientific reports.

 

Use of (other) environmental factors

 

The environmental factors of health resorts have many specific components that contribute to the therapeutic effects. Based on the International Classification of Functioning, Disability and Health the following environmental factors are characteristic for the setting in health resorts:

• health care by specialised doctors, well educated therapists (physiotherapists, occupational therapists, sport therapists, spa therapists, massage therapists, and others), cooperating in teams (ICF-domain: e355)
• appropriate facilities for balneotherapy, hydrotherapy, climatotherapy, massage therapy, exercise therapy, other physiotherapy modalities, occupational therapy, nutritional therapy, exercise, massage therapy, health education and others (ICF-domain: e580, cf. ICF-domain: d839)
• local remedies for treatment (e.g. mineral waters, peloids, gases, climatic factors) (cf. ICF-domain: e110)
• environment supporting social contacts (family, peer groups) (cf. ICF-domain: d740, d760)
• facilities for recreation, cultural activities, leisure and sports (cf. ICF-domain: d920)
• health promoting atmosphere and environment close to nature (cf. ICF-domain: e210)
• and other factors

Within health resorts in-patient and out-patient settings are used. 

 

Other settings in which mineral waters, gases and peloids may be used are hospitals (departments for balneology and physical medicine, rehabilitation units and other wards), medical practice (specialist and general practitioners), therapist practices (after doctors´ prescription), at home (self-application by the patients or relatives). However, the influence of these factors can not be described or classified in this paper. Systematic scientific work on effects and efficacy of such factors has to be undertaken urgently.

 

Description of scientific field

 

The scientific field dealing with health resort medicine is called health resort sciences. It includes the medical sciences, psychology, social sciences, technical sciences, chemistry, physics, geography, jurisprudence and others. Other (equivalent) terms of health resort sciences are Kurortwissenschaft (Germany), Kurortologia (Russia), Medical hydrology, and others.

 

The scientific field dealing with balneotherapy is called balneology or medical hydrology. It includes physiology, medicine, chemistry, (hydro)-geology, physics, balneotechniques and others. Other (equivalent) terms for balneology are Hydrology, and others.

 

There is no separated scientific field only dealing with hydrotherapy, however the sciences dealing with hydrotherapy are include in balneology (see above) and Physical and Rehabilitation Medicine and Rehabilitation.

 

The scientific field dealing with climatotherapy and biotropy is called medical climatology. It includes physiology, medicine, meteorology, and others. Other (equivalent) terms for medical climatology are Biometeorology (Anglo-Saxon countries), Bioclimatology (Easter European Countries, German speaking countries), and others.

 

Corresponding to the scientific field of Physical and Rehabilitation Medicine science in Health Resort Medicine, Balneology and Climatology includes a wide range of research from basic science to clinical trials. Research is necessary on a scale from chemical and physical properties to the influences of Health resort Medicine on general health and the society.