SCIENTIFIC SESSIONS
National Academy of MedicineOpening session 
Wednesday June 23 

Lectures
French medicine academy involvement in spa therapy and mineral watersPatrice Queneau [France] Member of the French national Academy of medicine
To day, all medical actions (diagnostic, therapeutic) and procedures must be validated.The means of the assessment have to be accurate to the investigated topic.Spa therapy, as the other treatments, has to demonstrate the evidence of its benefits (medical service) as a non pharmacological and multifactorial treatment. Double blinded is often very difficult (but blind of the investigator is usually possible +++)My communication will be include three parts : 
1 - A general review of main results in international scientific literature (Pub med, 3 last years) indicates 77 publications : 46 of them have an impact factor ≥ 1 (1 to 2 : 27 // 2 to 3 : 8 // 3 to 4 : 4 // 4 to 6 : 5 // > 6 : 2). We shall give an overview of these results, with the very precious contribution of Pr. Christian Roques and Xavier de Boissezon [C Roques, X de Boissezon, P Queneau : Communication at the French National Academy of Medicine, May 26, 2009]. 
2 - A review of the best indications of Spa therapy in rheumatology, with clinical guidelines on French High Authority for health and European League Against Rheumatism (EULAR) and 19 randomized clinical trials (RCT), suggested by the excellent study of Alain Françon and Romain Forestier [Communication at the French National Academy of Medicine, June 23, 2009].Spa therapy is indicated in rheumatology. Indeed, spa therapy is recommended in France by the HAS for the chronic low back pain with a rank “B” and stabilized rheumatoid arthritis with a rank “C”. For ankylosing spondylitis spa therapy is classified by the EULAR in the treatments of physiotherapy, the latter obtaining a force “A” of recommendation. In fibromyalgia the EULAR recommends the balneology with hot water, component important of the spa therapy, with a force “B”, this starting from 5 RCT of which 3 were carried out of thermal spring.RCT Nineteen RCT including a statistical comparison of the between group evolution were identified. The results of 16 of them indicate a persistent improvement of at least 12 weeks of the pain, analgesics and non-steroidal anti-inflammatory drugs consumption, function and/or quality of life in the following indications : chronic low back pain, knee osteoarthritis, hand osteoarthritis, fibromyalgia, ankylosing spondylitis and rheumatoid arthritis (PR). Conclusion Spa therapy or its component of balneology with hot water appears to us indicated in chronic low back pain, stabilized arthritis rheumatoid, ankylosing spondylitis and fibromyalgia. RCT’ results published in knee and hand osteoarthritis could encourage to propose spa therapy for these two other indications.
3 - Recommendations of the French National Academy of Medicine for the therapeutic assessment of mineral waters given in French spa resorts [Patrice Queneau, Bernard Graber-Duvernay, Claude Boudène].The French National Academy of Medicine imposes these recommendations before giving its acceptation in spa therapy in 3 situations : • a new water, • a new technic, • a new indication.The acceptation of the French National Academy of Medicine imposes the prealble of at least one study in theses conditions : - Prospective study, - Minimum personnel depending on the methodology used and the results expected (regarding a well defined affection), - Very accurate criteria for inclusion and non- inclusion, - Instead of without the knowledge of the patient (almost totally impossible), without the knowledge of the investigator and of the people responsible for collecting the answers, - Criteria to judge most often “composites” to associate the essential symptoms of the disease (the “true life” of the patients) evaluated by :• validated symptoms scales (pain, rhinorrhea, infected surface of the skin...), and/or specific dosages (cholesterol, etc…), • validated scales or functional indexes,• medicine consumption and other treatments,• quality of life of the patients,• global opinion of the patients. - Written consent by the patients to take part in the study  - As for clinical testing of medicines :  • agreement by a CCPP (Consultative committee for the protection of persons) or by an Ethics committee,• participation of a clinical research assistant (ARC), independent from the spa,• counsel an academic for the elaboration and the realisation of the protocol,• valorisation/validation of the study with a scientifical publication in a reading committee magazine.

Teaching Medical Balneology in EuropePedro Cantista [Portugal] Universidade do Porto – Instituto de Ciências Biomédicas Abel SalazarProfessor Auxiliar Convidado de Hidrologia Médical
Medical Balneology has a strong tradition in many of the European countries. In a recent survey conducted by Bender and Cantista (2007) we concluded that Medical Hydrology (or Balneology) is officially recognized in 68 % of the countries. Medical spa units using thermal water for therapeutic purposes exist in 76 % and a reimbursement of costs by health insurances is possible in 72 % of the countries. In 19 % of the countries Balneology is a medical speciality, in 44 % is considered a medical “competence” and in 56 % it is included in another medical specialities (e.g. PRM, Rheumatology, Dermatology). In 56 % of the countries Balneology is part of the undergraduate medical education and post-graduate courses exist in the same rate.Research units exist in 48 % of the consulted countries. All in all, it can be seen that Balneology / Medical Hydrology is still widely used in Europe and is part of the medical system, both at medical specialities and health insurance systems levels. However this is mainly true for the traditional thermal countries such as Hungary, Italy, Germany, Portugal, Spain, Turkey, Austria, France or Romania. In the Anglo-Saxon and in the Scandinavian countries this is not the case. Our opinion is that in a global overview this survey reveals a very positive attitude towards Balneology / Medical Hydrology.Thus we do think that a teaching program of Medical Balneology is justified.We present our own experience at Porto University, showing the contents and the methodology of our program as an example for what could be a European model of Balneology Education.

Medical hydrology teaching adapted to European higher education areaMaraver F, Morer C [Spain]Chair of Medical Hydrology – School of Medicine, UCM, Madrid
The main aspects of the European Higher Education Area, its structure and the European Credit Transfer System are shown, as well as the last guidelines of the Spanish Ministry of Education about these matters.In the so many times cited “Bologna Declaration” [1] were consolidated the bases for the construction of the European university formation system, called Superior Education European Space (SEES), the structure of the SEES, that must be substantially introduced in 2011, is based on the following aspects :1. Qualifications easily understandable and comparable,2. ECTS credits,3. Two cycles system,4. Diploma’s supplement,5. Students, teachers and researchers mobility,6. European cooperation to reach good quality levels.
The consideration of the teaching will be done by the European Credits Transfer System (ECTS). In Spain the ECTS credit was defined as the measure unit of the academic earnings, that represent the time expended by the student in obtaining the objectives of the syllabus [2-3].Until now, in our university circle the credits were only referred to the teaching time with the presence of the student (theoretical class, practical class, seminar, tutorship, etc.) so one credit to be equivalent to 10 hours.In the ECTS system the time that the student spent in his formation was valuated, also in the presence time as in the non-presence work, (presentation preparations, internet research, study, etc). One ECTS credit being equal to 25-30 hours of student work.
The new study plans - Medical HydrologyIn our University, Complutense of Madrid, exist regulated specific education in Medical Hydrology, since the creation of the Chair in 1912 [4].In connection with the European Convergence Plan the effort of adaptation has been superlative. We remark concisely the change in the different studies :• Medical Degree [5]Subject : Medical Hydrology and Climatology from 4.5 credit (45 hours) to 3 ECTS (75h).• Alimentary Science and Technology Degree.Subject : Drink Mineral Medicine Waters from 6 c (60h) to 3 ECTS (75h)• Physiotherapy DegreeSubject : Balneotherapy and Thalassoclimatotherapy from 4.5 c (45h) to 3 ECTS (75h)• Occupational Therapy DegreeSubject : Thermal resort and Occupational Therapy from 4.5 c (45h) to 3 ECTS (75h)• Nutrition DegreeSubject : Bottled Water from 4.5 c (45h) to 3 ECTS (75h)• DoctorateMedical Hydrology from 32 C (320 h) to 6 ECTS (150 h)• Medical Hydrology Speciality [6]From 2 years in the Professional School to 4 years, two of them main line with another specialities as Family Medicine and two specifics in the Professional School and Accredited Teaching Units.Key words : European higher education area, medical hydrology teaching
Bibliography1. The European Higher Education Area. Joint Declaration of the European Ministers of Education. Bologna 19th June 1999. [cited 2010 Feb 15]. Available from : http://www.crue.org/decbolognaingles.htm.2. Real Decreto 1125/2003 de 5 de septiembre, que establece el Sistema Europeo de Créditos y de Calificaciones en las Titulaciones Universitarias Oficiales y con validez en todo el territorio nacional3. Real Decreto 1393/2007, de 29 de octubre, por el que se establece la ordenación de las enseñas universitarias oficiales4. Maraver F, Aguilera L, Corvillo I, Morer C, Armijo F. L’enseignement de l’hydrologie dans l’Université Complutense de Madrid. Press Therm Climat 2007;144:167-176.5. Nogales A. La enseña de la medicina adaptada al espacio europeo de ensña superior. An R Acad Med 2007; CXXIV(1):23-42.6. Maraver F, lvarez A, Gómez F, Romero M, Meijide R, Armijo F. Propuesta de programa de la especialidad de Hidrologia. An Hidrol Med 2010 (in press).

Spa therapy : drug and / or physical agent ?Have we to consider the mineral properties in the therapeutic effecsChristophe Gutenbrunner [Germany]Department for rehabilitation medicineInstitute for balneology and medical climatology, Hannover

Investigation in spa therapy Medicine : from evidence to cooperationRoques-Latrille  CF [France]Association française pour la recherche thermale
The last five years about 90 relevant scientific papers concerning creno-balneotherapy (i.e. medical balneology or spa therapy medicine) can be found using Pub med database, 69 of them published with an impact factor.We will analyse the papers published since the last Congress of ISMH in Porto (2008). As the previous papers, the new one emphasize the actions of thermo-mineral products (waters, muds, gases, steams) on the biological systems of the body : pain control, immune system, anti-oxidative system, cytokinic actions. Drinking mineral water can act on glucidic, lipidic and mineral metabolisms but also anti-osidative system. Dermo-cosmetological mineral products showed to be a relevant therapeutic issue. The medical benefit of thermal treatment was observed for patients with rheumatic conditions, psoriasis, venous insufficiency, chronic peripheric arterial disease, ENT conditions, gynaecological disorder, obesity and metabolic syndrome, .... But many of these papers suffer methodological flaws. Nevertheless the evidence for osteo-arthritis, chronic low back pain, inflammatory rheumatic conditions, fibromyalgia is consistant with the recommendations, made by scientific societies and / or health national authorities, of thermal balneology for such patients. By the fact, clinical investigation in thermal medicine has to cope with methodological, financial, patients recruitment difficulties. An international cooperation is needed to reach significant statistical power due to an accurate enrolment in the studies. We have to think the ways of such a cooperation


Catholic Institute of Paris 
Thursday June 24
New trends session IRoom Actes8.30 am – 10 am

Lectures
New Trends in Balneology Medical Hydrology and Climatology
M Zeki Karagülle [Turkey]Department of Medical Ecology and Hydro-climatology Istanbul Medical Faculty, Istanbul University, Istanbul
Medical Balneology, Hydrology and Climatology, is not a well known and recognised as an independent medical field at an international level [1,2]. Furthermore a uniform and internationally accepted term of the medical field of Balneology or Hydrology and Climatotherapy does not exist. One approach is to use the interventions as the basis for the umbrella term like “Medical Hydrology and Climatology” (Roman countries, UK), (“Balneology and Medical Climatology” or “Medical Balneology and Climatology” (Central and Eastern European Countries), “Medical Hydrology” (Spain), “Hydroclimatology” (Turkey), “Balneology” (USA, East Asia). The other is using the setting of health resort or spa resort as the basis for an umbrella term, resulting in “Health Resort Medicine” or “Spa Medicine” [3-5]. These terms should be used as equivalent, but I would refer the both terms and I will attempt to describe the new developments in our common field briefly.Increasing scientific evidenceIt is noteworthy to mention that a lot of scientific studies 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 [6,7]. Furthermore the number of published systematic reviews and meta-analyses are increasing ; most of them are focusing on the efficacy on rheumatic diseases [8-11]. The evidence occurs to be very promising and in some cases as stronger as for other well recognised medical interventions. The same applies to studies on cost-effectiveness [12-14]. Even tough the conclusions are mostly in favour of hydrological or balneological treatments ; due to the large variety of interventions and some methodological drawbacks the results mostly are still inconclusive [15-17]. Recognition of Medical Hydrology and Climatology as a comprehensive concept  It is true that the balneological, hydrological, climatological treatment methods are leading for the (traditional) definition of the field. On the other hand, 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) [18] and – as Health Resort Medicine – may include many other treatments both from mainstream and complementary medicine [19,20]. A special characteristic of health resort therapy is the systematic use of environmental factors for health promotion, prevention, therapy and rehabilitation [21,22]. The expansion of the balneo-hydrological methods beyond the specific settings 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 practice to given settings. The restriction to regional settings has supported the development of health resorts and rural spa towns. The practice of Spa Medicine and Balneology is going to be more independent from local healing factors and the natural resources, mineral waters and peloids are being packed  and being increasingly introduced for usage outside health resorts. There is no convincing evidence that balneotherapy is only effective within the setting of a health resort, on the contrary for some methods the efficacy has been proven outside health resorts already. Just giving some examples mineral water drinking for renal stone metaphylaxis [23], CO2-bathing for the improvement of skin microcirculation and improvement of pO2 [24], mud compresses or mud gels for treating knee osteoarthritis [25,26] and mud compresses therapy for the hands of patients with rheumatoid arthritis [27]. Health Resort Medicine is being re-introduced in non-user countriesVirtually all the natural resources and types of mineral waters can be found in any country in the world, but regional aspects and regional traditions are of major influence on the use of these factors in medicine. Furthermore national health systems, especially the refunding by health insurances, have also considerable effects in the use of mineral waters and climatic factors for therapy. Yet despites natural resources, America, Canada and UK never really developed their spas to the same sophisticated level as the European spas [28,29]. And health resort medicine does not exist as a part of mainstream medicine in those, unlike in European countries. But the traditional health resort interventions are now being included among the natural treatment methods or introduced into so called integrative medicine practices in those countries [30]. The revival of spa medicine in those countries and elsewhere is being occurred at an opportune time when patients are seeking for alternative methods of healing and health besides drug therapy [31].  Increasing demand for international accepted terms Medical Hydrology / Climatology is not a well known and recognised as an independent medical specialty at an international level [1,2,30]. In international scientific literature the use of terms in the field is very inconsistent. Here only two examples can be given : 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 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) [32].  The trend of Spa and Wellness Wellness is an artificially created term and is supposed to create harmony in (mental, physical, spiritual or biological) health in general [33]. There are attempts to focus wellness methods on health-promoting or prevention programs (so-called medical wellness) and the promotion of wellness programs in traditional health resorts and spas is being increasingly considered as an option [34]. While the fast growing appearance of wellness services in health resorts can be considered as a positive trend, here there is a challenge drawing the attention away from the traditional spas and sets them on an equal level with other new “spas” originated from United States of America providing wellness programs [32,35]. In the traditional approach, a traditional spa or health resort means a place or establishment where the traditional therapeutic usage of thermal and mineral waters and medicinal muds with documented therapeutic effects is prevailing. In contrast, the meaning of the term ‘spa’ in the United States of America covers an establishment engaged in offering services designed to create the physical, spiritual and mental well-being of guests (e.g. hotels, health clubs spas and others) [36].
References 1. Cantor D. The contradictions of specialization : rheumatism and the decline of the spa in inter-war Britain. Med Hist Suppl 1990;(10):127-44.  2. Bender T, Karagülle Z, Bálint GP, Gutenbrunner C, Bálint PV, Sukenik S. Hydrotherapy, balneotherapy, and spa treatment in pain management. Rheumatol Int 2005 Apr;25(3):220-4. 3. Gordon EE. On the resurrection of "spa" medicine. Arch Phys Med Rehabil 1988 Apr;69(4):239. 4. Routh HB, Bhowmik KR, Parish LC, Witkowski JA. Balneology, mineral water, and spas in historical perspective. Clin Dermatol 1996 Nov-Dec;14(6):551-4.  5. Frosch WA. "Taking the waters"-springs, wells, and spas. FASEB J 2007 Jul;21(9):1948-50.  6. Karagülle M, Karagülle MZ, Karagülle O, Dönmez A, Turan M. 10-day course of SPA therapy is benificial for people with severe knee osteoarthritis, A 24 week randomised, controlled pilot study”. Clin Rheumatol 2007;26,2063-71  7. Forestier R, Desfour H, Tessier JM, Françon A, Foote AM, Genty C, Rolland C, Roques CF, Bosson JL. Spa therapy in the treatment of knee osteoarthritis : a large randomised multicentre trial. Ann Rheum Dis 2010 Apr;69(4):660-5.  8. Karagülle MZ, Karagülle M. Balneotherapy and spa therapy of rheumatic diseases in Turkey : a systematic review]. Forsch Komplementarmed Klass Naturheilkd 2004 Feb;11(1):33-41. German.  9. Pittler MH, Karagülle MZ, Karagülle M, Ernst E. Spa therapy and balneothrepy for treating low back pain : meta-analysis of randomized trials. Rheumatology 2006;45, 880-884.  10. Forestier R, Françon A. Crenobalneotherapy for limb osteoarthritis : systematic literature review and methodological analysis. Joint Bone Spine 2008 Mar;75(2):138-48. 11. Langhorst J, Musial F, Klose P, Häuser W. Efficacy of hydrotherapy in fibromyalgia syndrome - a meta-analysis of randomized controlled clinical trials. Rheumatology (Oxford) 2009 Sep;48(9):1155-9.  12. Van Tubergen A, Boonen A, Landewé R, Rutten-Van Mölken M, Van Der Heijde D, Hidding A, Van Der Linden S.  Cost effectiveness of combined spa-exercise therapy in ankylosing spondylitis : a randomized controlled trial. Arthritis Rheum 2002 Oct 15;47(5):459-67. 13. Fioravanti A, Valenti M, Altobelli E, Di Orio F, Nappi G, Crisanti A, Cantarini L, Marcolongo R. Clinical efficacy and cost-effectiveness evidence of spa therapy in osteoarthritis. The results of "Naiade" Italian Project. Panminerva Med 2003 Sep;45(3):211-7. 14. Coccheri S, Gasbarrini G, Valenti M, Nappi G, Di Orio F. Has time come for a re-assessment of spa therapy ? The NAIADE survey in Italy. Int J Biometeorol 2008 Jan;52(3):231-7. 15. Verhagen A, Bierma-Zeinstra S, Lambeck J, Cardoso JR, de Bie R, Boers M, de Vet HC. Balneotherapy for osteoarthritis. A Cochrane review. J Rheumatol 2008 Jun;35(6):1118-23.  16. Verhagen AP, Bierma-Zeinstra SM, Boers M, Cardoso JR, Lambeck J, de Bie RA, de Vet HC. Balneotherapy for osteoarthritis. Cochrane Database Syst Rev 2007 Oct 17;(4):CD006864.  17. Roques CF, de Boissezon X, Queneau P. [Crenobalneotherapy : a medical and scientific update] Bull Acad Natl Med 2009 May;193(5):1165-80. French.  18. Morita E, Weigl M, Schuh A, Stucki G. Identification of relevant ICF categories for indication, intervention planning and evaluation of health resort programs : a Delphi exercise. Int J Biometeorol 2006 Jan;50(3):183-91.  19. Frost GJ. The spa as a model of an optimal healing environment. J Altern Complement Med 2004;10 Suppl 1:S85-92.  20. Halevy S, Sukenik S. Different modalities of spa therapy for skin diseases at the Dead Sea area. Arch Dermatol 1998 Nov;134(11):1416-20.  21. Masiero S. Thermal rehabilitation and osteoarticular diseases of the elderly. Aging Clin Exp Res 2008 Jun;20(3):189-94.  22. Kamioka H, Nakamura Y, Okada S, Kitayuguchi J, Kamada M, Honda T, Matsui Y, Mutoh Y. Effectiveness of comprehensive health education combining lifestyle education and hot spa bathing for male white-collar employees : a randomized controlled trial with 1-year follow-up. J Epidemiol 2009;19(5):219-30.  23. Karagülle O, Smorag U, Candir F, Gundermann G, Jonas U, Becker AJ, Gehrke A, Gutenbrunner C. Clinical study on the effect of mineral waters containing bicarbonate on the risk of urinary stone formation in patients with multiple episodes of CaOx-urolithiasis. World J Urol 2007 Jun;25(3):315-23.  24. Karagülle O, Candır F, Kalinin J, Gehrke A, Karagülle MZ, Gutenbrunner Chr. The effects of cold CO2-containing forearm bath on skin blood flow and pain thresholds. Phys. Med. Rehab. Kuror. 2002,12:221.  25. Flusser D, Abu-Shakra M, Friger M, Codish S, Sukenik S. Therapy with mud compresses for knee osteoarthritis : comparison of natural mud preparations with mineral-depleted mud. J Clin Rheumatol 2002 Aug;8(4):197-203. 26. Mahboob N, Sousan K, Shirzad A, Amir G, Mohammad V, Reza M, Mansour VA, Hadi V. The efficacy of a topical gel prepared using Lake Urmia mud in patients with knee osteoarthritis. J Altern Complement Med 2009 Nov;15(11):1239-42. 27. Codish S, Abu-Shakra M, Flusser D, Friger M, Sukenik S. Mud compress therapy for the hands of patients with rheumatoid arthritis. Rheumatol Int 2005 Jan;25(1):49-54.  28. Benedetto AV, Millikan LE. Mineral water and spas in the United States. Clin Dermatol 1996 Nov-Dec;14(6):583-600.  29. Francis I. Spa therapy-a lost art. Physiotherapy Theory and Practice 1986;2,4:171-3. 30. Frost GJ. The spa as a model of an optimal healing environment. J Altern Complement Med 2004;10 Suppl 1:S85-92.  31. Vaccarezza M, Vitale M. Crenotherapy : a neglected resource for human health now re-emerging on sound scientific concepts. Int J Biometeorol 2010,Mar 29. [Epub ahead of print] 32. Gutenbrunner Chr, Bender T, Cantista P, Karagülle MZ. A Proposal for a Worldwide Definition of Health Resort Medicine, Balneology, Medical Hydrology and Climatology. International Journal of Biometeorology 2010 (In press) 33. Smith M and Kelly C. Wellness Tourism. Tourism Recreation Research 2006; 31(1):1-4. 34. Smith M and Pucsko L. Health and Wellness Tourism. 2008. Oxford. Elsevier 35. ITER project. http://www.iter-cadses.it/en/main1.htm   accessed 12.05.2010 36. ISPA (International Spa Association) www.experienceispa.com/ISPA/ accessed 12.05.2010

Phytothermotherapy : a possible complementary therapy for fibromyalgia patientsFioravanti A1, Bellisai B1, Capitani S2, Manica P3, Paolazzi G4, Galeazzi M1 [Italy]1 - Rheumatology Unit, Department of Clinical Medicine and Immunological Sciences, University of Siena2 - Department of Physiopathology –Experimental Medicine and Public Health, University of Siena3 - Thermal Resort of Garniga Terme, Trento4 - Rheumatology Unit, S. Chiara Hospital, Trento
Objective It is a traditional practice in the Alpine region of Trentino and Alto Adige (Italy) to use phytothermotherapeutic treatment with fermenting grass (“hay baths”) for rheumatic diseases [1]. However, despite its long history and popularity, a clinical validation of the efficacy and tolerability of the treatment has yet to be found in current literature. Fibromyalgia syndrome (FMS) is characterized by generalised musculoskeletal pain, high tender point counts, sleep disturbance, fatigue, headaches, irritable bowel syndrome, frequent psychological distress and depressed mood [2]. There is no standard therapy regime for FMS and the variety of medical treatments used have given limited benefits [1]. The aim of this study was to assess the efficacy and tolerability of a cycle of phytothermotherapy through a single-blind, controlled, randomized trial, in patients with primary FMS.Methods Fifty-six patients with primary FMS according to the ACR criteria [3] were randomly allocated to two groups : • group I (30 patients) submitted to phytothermotherapy  at the thermal resort of Garniga Terme (Trento, Italy) and • group II, which continued the pharmacological treatment alone (26 patients). Group I patients were submitted to 10 generalized daily immersions of 20 min each in warm (50-58°C) hay. The grass used was grown 1200-1500 m above sea level, on Monte Bondone (Trento, Italy). The grass is cut, gathered and transported before it dries to the spa of Garniga Terme, according to traditional methods. At the spa, a 50 cm layer of hay is placed in baths, where fermentation produces heat that reaches a temperature of approximately 60°C in the deepest layers after 1-2 days. The patients are immersed in this fermenting hay and covered with a layer 10-20 cm thick.  All patients were evaluated using the Fibromyalgia Impact Questionnaire (FIQ) [4], Tender Points Count (determined by digital pressure) [3], Health Assessment Questionnaire (HAQ) [5] and Arthritis Impact Measurement Scales (AIMS1) [6] at baseline, after 10 days, then after 12 and 24 weeks. Results Patients submitted to phytothermotherapy showed an evident improvement at the end of the cycle of the therapy and all evaluation parameters were significantly reduced in comparison to the baseline. The improvement remained significant (p < 0.001) after a follow-up period of 24 weeks. No significant changes in the evaluation parameters were observed in the control group. Regarding the tolerability, none of the patients presented side effects.The results of our study are in agreement with other trials previously performed with spa therapy and hydrokinesitherapy [7-10], but it is important to underline that a randomized trial on the effects of phytothermotherapy has never before been performed in FMS. The mechanisms of action of phytothermotherapy are not known, although it is recognised that the effects of phytothermotherapy are, in part, related to temperature. Other effects of phytothermotherapy may be due to the active ingredients contained in the fermenting grasses, which are rich in aromatic species that, aided by vasodilatation, are able to enter the organism in the form of essential oils, terpenes and other aromatic substances [11].Our results suggest that phytothermotherapy can represent a useful aid alongside the usual pharmacological and physio-kinesitherapy in FMS patients.
References1. Miori R, Contu C, Marzano A, Fedrizzi A, Bambara LM. Valutazione critica del trattamento fitotermoterapico (“bagni di fieno”) nelle artropatie degenerative. Clin Ter 1994; 144:31-42.2. Mease P. Fibromyalgia syndrome : review of clinical presentation, pathogenesis, outcome measures and treatment. J Rheumatol 2005; 32: 6-21.3. Wolfe F, Smythe H, Yunus MB et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia : report of the multicenter criteria committee. Arthritis Rheum 1990;33:160-72.4. Sarzi-Puttini P, Atzeni F, Fiorini T et al. Validation of an Italian version of the fibromyalgia impact questionnaire (FIQ-I). Clin Exp Rheumatol 2003;21:459–64. 5. Ranza R, Marchesoni A, Calori G et al. The Italian version of the functional disability index of the health assessment questionnaire. A reliable instrument for multicenter studies on rheumatoid arthritis. Clin Exp Rheumatol 1993;11:123-8. 6. Salaffi F, Ferraccioli GF, Trise Rioda W, Carotti M, Sacchini G, Cervini C. The validity and reliability of the Italian version of the arthritis impact measurement scales in patients with rheumatoid arthritis. Rec Prog Med 1992;83:7-11.7. Dönmez A, Zeki Karagülle M, Tercan N et al. SPA therapy in fibromyalgia : a randomised controlled clinic study. Rheumatol Int 2005;26:168-172.8. Zijlstra TR, van de Laar MAFJ, Bernelot Moens HJ, Taal E, Zakraoui L, Rasker JJ. Spa treatment for primary fibromyalgia syndrome : a combination of thalassotherapy, exercise and patient education improves symptoms and quality of life. Rheumatology 2005;44:539-46.9. Munguía-Izquierdo D, Legaz-Arrese A. Exercise in warm water decreases pain and improves cognitive function in middle-aged women with fibromyalgia. Clin Exp Rheumatol 2007;25:823-30.10. Fioravanti A, Perpignano G, Tirri G, et al. Effects of mud-bath treatment on fibromyalgia patients : a randomized clinical trial. Rheumatol Int 2007; 27:1157-61.11. Defrancesco F, Nicolini G, Chemini C, Girardi M. Simulator for chemical and physical study in the phyto-bathing-therapy. In Bender T, Pratzel HG (Eds) : Health Resort Medicine in 2nd Millenium, 34th World Congress of the I.S.M.H., Budapest, Héviz - Hungary 2002; 391-400.

PapersRandomized controlled trial of spa therapy versus GP usual care on the overweight managementHanh T1, Blin P 2, Meunier JP3, Fauconnier J4, Serog P1 [France] 1 - Nutrition, Paris2 - Santé Publique, Soisy-sur-Seine, 3 - Axonal, Nanterre, 4 - SIIM CHU Grenoble
Thierry Hanhhat@noos.fr
Objective  SPA therapy is one of the non-drug therapeutic strategy in the weight management of overweight and obese patients. A weight loss after a spa therapy and within the following year has been described in non-controlled studies. A methodology has been therefore proposed to achieve a controlled study to assess the benefit of crenotherapy in this indication versus other non drug strategy.Material and methods An open multicenter randomized controlled trial, using Zelen design, was proposed to compare spa therapy versus GP usual care for the management of overweight or obese patients (27 > BMI < 35 kg/m2). A 2*2 factorial design was added to compare monthly phone dietary support versus no phone dietary support and the addition value of phone dietary support after spa therapy. Three analyses are performed i) intention to treat (ITT) analysis that compares randomized patients, ii) Done analysis that compare the patient’s therapy choice whatever the randomization and iii) Per Protocol (PP) analysis that compared randomized patients for patients who have accepted the randomization. The main outcome is the BMI variation between inclusion and after 14 months follow-up. Secondary objectives studied concern the nutritional education, quality of life (SF12), dietary behaviour evolution and comorbidities.Results This clinical trial has been achieved from March 2007 to November 2009. One hundred GPs have included 282 patients, with 25 (8,3 %) who did not achieve the 14 months follow-up. Among them, 6 (2 %) have decided to stop the follow-up, withdrawing their consent, 8 (2,8 %) have had an adverse event and we lost contact with only 11 (3,9 %). 257 patients actually achieved the 14 months follow-up.The main difficulty concerns the patients’ recruitment by GPs. Another difficulty concerns the patients’ approval of the strategy proposed by the GPs (randomization) which can have an impact on the number of patients in PP analysis.Conclusion This clinical trial underlines the methodological difficulty when comparing very different therapeutic strategy in the same indication that can be randomized but not necessarily accepted by patients.

The impact of an aquatic exercise protocol on physiologic measures within an asthmatic population Becker Bruce, Hildenbrand Kassee, Fresen Timothy, Barbosa-Leiker Celestina, Nordio Sara, Miller Ashley [USA]Washington State University
Becker Bruce13125 S. Fairway Ridge Lane, 99224 Spokane, Washington (US)beckerb@wsu.edu
Purpose The first goal of this study was to develop an exercise program (frequency, intensities, durations, types of exercises and program progression) that could be used specifically for asthmatic individuals with varying fitness levels. The second goal was to examine the impact of this new aquatic exercise protocol on physiological variables in a group of asthmatics.Methods Participants were diagnosed, medically managed asthmatics in a rural community. A total of 8 males and 12 females were accepted into the study with 7 males and 9 females completing the 12-week study. Physiological measures were taken pre- and post-treatment with paired t-test used for analyses.Results Significant increases in O2max (pre-treatment M=33.431, SD=10.387 ; post-treatment M=31.244, SD=9.772 ; partial η²=.257) ; lean body muscle mass (pre-treatment M=119.606, SD=28.210 ; post-treatment M=122.012, SD=30.475 ; partial η²=.237) ; and blood glucose (pre-treatment M=83.937, SD=7.584 ; post-treatment M=89.812, SD=7.799 ; partial η²=.603) were seen from pre- to post-treatment. Power and effect sizes were calculated for future studies.Discussion The exercise protocol was successful as seen by the increase in O2max and lean body mass. The protocol was well tolerated and enjoyed by the participants suggesting it is useful in the asthmatic population.

Eficacy of halotherapy in asthma patients Chervinskaya Alina [Russia]Clinical Research Respiratory Center of Hospital 122, Institute of Professional Development of Federal Medical Biological Agency
Chervinskaya AlinaSerebristy blv 21-225, 197341 St.Petersburg (RU)+7 812 3274495 / +7 921 9346498alina.chervinskaya@gmail.com
Introduction The experts of WHO forecast the subsequent increase of allergy and asthma worldwide. Mainly it has been related to deteriorative ecologic situation. To stop this tendency aerosol methods with physical factors are preferable because of physiological action without system side effects.Dry salt inhalation therapy has a long history in Europe since 19th century. Nowadays there are a number of resorts exploiting salt caves for patients with pulmonary diseases. Halotherapy (HT) is the result of adapting natural salt aerosol from salt caves to flexible usage in other locations. Curative effect of HT is caused by an air medium saturated with dry sodium chloride aerosol (DSCA) with predominance amount of particles of 1 to 5 µm in size and of a certain density range. HT is carried out in the premises equipped with medical facilities - dry salt aerosol generators (halogenerators) and control devices. Over 15 years, numerous expert groups have worked on standardization of halochambers based on an exact understanding of conditions in salt caves. In addition to availability the ability to deliver a specified varied dose of DSCA represents a major advantage of HT over the treatment in natural salt caves. HT was sanctioned by the Ministry of Public Health in Russia and Lithuania.Material and methods The randomized placebo study lasted for 12 months. Controlled HT was evaluated in 115 patients (pts) with asthma (37 males, 78 females, mean age 41.2±2.2 years). 60 % of pts received a base medication without a full effect. DSCA with the dominating amount of 1 to 5 µm particles was produced by halogenerator ASA-01.3 (Aeromed Ltd.). Treatment was performed in a special room with salt coated walls. The pts breathed quietly while reclining in the chairs. The DSCA course comprised 15-20 daily one hour procedures.  The duration of each course and density of aerosol medium (from 1 to 5 mg/m3) depend on clinical features of asthma and functional parameters. The control matched group of 95 pts (30 males, 65 females, mean age 39.4±1.5 years) received placebo. Placebo course consisted of 15 procedures of musical psycho-suggestive program in the same room with salt coated walls but DSCA was not produced by halogenerator.Results During HT most pts showed positive dynamics of symptoms indicative of a better drain function of their airways : sputum secretion alleviated, it became less viscous and more mucousal, coughing relieved, and the auscultative picture of the lungs altered. By the end of the course of HT, the number of asthma attacks decreased significantly as compared to the initial ones (94 and 56 %, p<0.01). The number of severe asthma attacks controlled by combined medication also decreased (24 % and 3 %, p<0.01). After HT inhaled corticosteroids were discontinued in 5 % of pts. In 40 % of pts it was possible to reduce the dose. Those were the cases when inhaled corticosteroids were prescribed as anti-inflammatory agents. Dynamics of beta-agonists usage was positive as well. Reduction or cancellation in medication usage was an indicator of HT clinical benefit. None of the pts complained of bad condition during HT procedures. The pts showed significant increase of FVC, FEV1, PEF, FEF50 and decrease of Raw by the end of the treatment. HT resulted in improvement of clinical state in 85 % of mild and moderate asthma cases, 75 % of severe asthma cases. The pts were examined 6 and 12 months after the HT course. The average duration of remission was 7.6±0.9 months.The inclusion of HT into the rehabilitation course of asthma pts allowed achieving therapeutic effect in 82–95 % of cases along with the most optimal use of pharmacotherapy. It has shown that the application of the HT assured 1,5-2 times reduction of morbidity level in long term observation. The changes of the majority of the clinical and functional parameters in the control group were less statistically as compared to the HT group’s ones.Conclusion The application of HT on the background of the basic medicinal therapy in pts with asthma renders to positive influence on the clinical and lung functional parameters. The results of HT application demonstrate its efficacy.We look at positioning of dry sodium chloride aerosol with controlled HT as a component of rehabilitation programs for asthma pts.

“PACThe” : Programme of accompanying women after breast cancer treatment completion in thermal resorts : intermediate results on 122 patients at 6 months follow-up and 83 patients at 1 yearBignon YJ1, Leger-Enreille A1, Béraud JF2, Achard JL1, Bézy O1, Bridon F3, Cardinaud S1, Chapier R4, Duclos M5, Hahn T6, Kwiatkowski F1, Jouvency S1, Mouret MA1, Paul E7, Sobkowicz M1, Van Praagh I1, Vasson MP 1, Vigier M8, Travade A9 [France]1 - Centre Jean Perrin 2 - Thermauvergne3 -  IFMK Vichy 4 - Cabinet médical Châtel-Guyon 5 - Service de Médecine du sport CHU G Montpied 6 - Établissement thermal Vichy 7 - « 2P Études»8 - Cabinet médical Le Mont-Dore9 – Pôle Santé Publique Clermont-Ferrand
Bignon Yves-JeanScientific directorChief of Oncogenetics department, Centre Jean Perrin BP 392, 58 rue Montalembert, 63011 Clermont-Ferrand cedex (FR)+33 4 73 27 82 01 / +33 6 76 68 08 62Yves-jean.bignon@cjp.fr
Background Quality of life is greatly impaired in women just after the completion of the surgery-chemotherapy-radiotherapy sequences for their breast cancer. Most of the women present transient depression symptoms in the few months following their treatment although in complete remission of their cancer. Neither hospital nor home is well adapted for helping the women in this period of difficulties.Many studies demonstrate that high body mass index (BMI) at breast cancer diagnosis is linked to relapse risk and impaired survival prognosis. Moreover, adjuvant chemotherapy is significantly associated with weight gain, which is itself linked to increased mortality of breast cancer. More than one half of women showed a weight gain of 2,5 to 5 kg, when adjuvant chemotherapy regimen is applied. Each 5 kgs gain induces an increase [Nichols 2009] of 12 % of overall mortality, 13 % of breast cancer mortality and 19 % of cardio-vascular mortality. The first interventional nutrition studies were therefore undertaken to improve the prognosis of patients after chemotherapy, to avoid weight gain or with low fat diet. Long-term follow-up seem to demonstrate a positive effect on global mortality, mainly in HR-breast cancer patients [Chlebowski RT 2008, Pierce JP 2007]. Increasing physical activity seems to have even more benefits [Holmes MD 2005, Pierce JP 2007]. Nevertheless few studies are still available, and no European trials were undertaken.Hypothesis Multidisciplinary health care in spas might improve quality of life and help avoiding weight gains in women just after the completion of their breast cancer treatment (within 6-9 months).Objectives of the PACThe Long-term improvement of the quality of life of women. Secondary objectives : avoid weight gain, reduce overweight in high BMI women, increase physical activity to the international recommendations. Long-term objectives : reduce the long-term costs of breast cancer follow-up and treatments, increase disease-free survival, increase cancer-free survival.Programme Since March 2008, a randomized clinical trial was developed with 2 arms : one arm with standard recommendations and follow-up of 135 women every 6 months, one arm with an intensive course of education of protective nutritional and physical activity for two weeks in one of three spas in the region Auvergne in France (Vichy, Châtel-Guyon, Le-Mont-Dore) for 135 other women. Randomization is made before the ninth month after completion of the chemotherapy/radiotherapy/surgery sequence.During the 13-days thermal stay, a personalized programme is set up with : - medical,  nutritionist and  psycho-oncologist consultations,- nutritional education : adapted menus in complete pension at the hotel, cooking workshops, seminars,- 2 accompanied physical activities per day with a progressive increasing intensity programme according to the basal capacities of each patient,- thermal baths every day, individual relaxations,- esthetical care,- shoulder mobilisation and prevention of arm-lymphoedema.Intermediate results 193 women were included in the trial, 97 in spas, 96 at home. 122 women were followed up at 6 months (65 in spas, 57 at home), 83 at one year (43 in spas, 40 at home). 51 % are overweight or obese. There is no discordance in medical care or results between the 3 spas. At one year :• control group gained weight (non significant) and spa group lost 4 % of weight compared to control group (p<10-7), mainly in the overweight group,• physical activity level is stable in control group and significantly increased in the spa group (p=49 x 10-5) at 6 months and at one year,• quality of life increased in both group, non significantly in control group, significantly in spa group compared to the control group (p=23 x 10-5),• anxiety is only transiently improved at 6 months in spa group but not at one year. On the other hand, depression is significantly improved in the spa group (p=31 x 10-5).In conclusion, with the improvement of cancer treatments, life after initial cancer complete remission is becoming a challenge for oncologist and physicians. Accompanying women after completion of their breast cancer treatment might be recommended for their quality of life and for reducing the relapse risks. Adapted spa programmes on 2 weeks might be proposed. Preliminary results are encouraging at medical level compared to the traditional “at home follow-up”, and at least, look quite helpful at the individual level of the patients.

Balneology and cancer recoveryMoore Les [USA]Director, Integrative Medicine, Clifton Springs HospitalCo-Founder, New York Spa Promotion AllianceFellow, American Board of Naturopathic Oncology
Moore Les 2 Coulter Road, 14432 Clifton Springs, New York (US) +1 (315) 462-1350 / +1 (585) 764-4715lesmoore_nd@hotmail.com
This presentation will examine contemporary and classical uses of balneology in adjunct cancer care and cancer recovery. Recent research will be examined including the use of balneology in immune function, pain reduction, blood chemistry, fatigue, digestive dysfunction, post-surgery recovery, detoxification, depression, chemoprevention and radioprevention.

Posters session day IRoom B098.30 am – 10.30 am Safety - Products - Techniques session IRoom Actes10.30 am – 12.30 am
Lecture
Side effects of crenobalneotherapy, a narrative reviewRomain Forestier [France]Centre de recherche rhumatologique et thermal, Aix-les-Bains
IntroductionOpinions on side effects of crenobalneotherapy are in majority in favour of a well tolerated treatment. In the newspapers, most of the Journalists use to think that this is a “sweet medicine, without side effect” ; some others that “it has less side effects than drugs”. A similar opinion is expressed by the spa centre “a non aggressive treatment with no side effects”. In most of the randomized trials, trialists conclude that spa treatment has no side effects or is well tolerated but a Cochrane reviewer observed that side effects were usually not measured. Administrative French authorities were regularly questioned and consider that there is lack of scientific consensus on the effects of this therapy. French high authority for health recommends the use of spa therapy for low back pain, rheumatoid arthritis and ankylosing spondylitis.We tried to compare these statements with a review of personal data and some epidemiologic research on the subject to determine safety and potential side effect of this treatment.ResultsCommon side effectsCommon side effects are sometimes described in randomized clinical trial. It can be asthenia, headache or increasing of neck pain in a trial on chronic neck pain. In a trial on knee osteoarthritis they observed in the treatment group : painful knee episode, low back pain, increasing of chronic venous insufficiency, upper respiratory tract infections, leg erysipelas and severe asthenia but intolerance was not recorded in the control group with exercise alone. Some open observational studies were realized on greater sample size (6000 patients) but design couldn’t confirm that rare and serious side effect can be caused by a treatment in a spa centre. They confirmed that some illness often occur during a spa stay : respiratory tract infection (8 %), nervous manifestations (6 %), increasing of pain (5 %), skin diseases (2 %), falls (1 %), urinary tract infections, cellulitis (0.005 %), heart problems (0.35 %).Rare and serious side effectsNone of the randomized clinical trial was powered to detect rare and serious side effects.InfectionsThree pneumonia (no legionella) were observed in the observational study. Case and series of legionella pneumonia infections in spa centres were described in the eighties in France and since 2000 in Japan. In France, a close supervision of these infections was ordered by the health minister and the problem seems to be under control with regular disinfections of the pipe network. Pseudomona infections can be transmitted by hot water spray but it has never been described in the spa centres.A case control study found a significant over risk of infection in patients with asthma chronic bronchitis and / or respiratory insufficiency attending a spa centre for preventing crisis and infections. Relative risk of infections compared to control is over 2 (but not significant) for patients with cancer, kidney transplant, heart transplant, cortisone but not for rheumatoid arthritis, methotrexate, anti-TNF alpha (only 3 patients in this group) and chemotherapy. CancerRadon is known to cause lung cancer but no data exist in patient regularly exposed to it during repeated spa stay and no follow up seem to be organized. Radon concentrations < 200 Bq/m3 seem to be the acceptable level for health.Heart attack, sudden death.No data exist on these problems in spa studies but many works studied health problem in sauna, and Turkish bath that expose patient to heat and water.ConclusionsMinor side effects are not rare during crenobalneotherapy. Some data were collected on the risk of legionella that can be caused by the spa treatment and a rigorous disinfection of the spa installations is needed to prevent it. No data exists on potential effect of this treatment on cancer, heart attack and sudden death.Large epidemiologic studies are needed to give responses to this important subject.

PapersAccidental death toll during bathingOhtsuka Yoshinori1, Hashimoto Yoshihiro2 [Japan]1 - Hokkaido University2 - Sapporo Fire Bureau
Ohtsuka YoshinoriN11 W7, KIta-ku, 060-0811 Sapporo (JP)yoshicat@edu.hokudai.ac.jp
Recently it has become a social problem that the accidental death during bathing is suspected to be over 13,000 cases a year in Japan and bathing related ambulance runs are estimated about 100,000 or more in the whole country. In Sapporo city, the ambulance runs for the accidents in bathrooms at home increased by 1.5 times from 2000 to 2007. However, nothing was known about the accidents related to bathing at hot spring area in Sapporo city.We analyzed and compared the trend of accidents related to bathing in Sapporo city (excluding hot spring area, mostly home bathrooms) with Jozankei hot spring area (a suburb of Sapporo city, mostly hotel public bathrooms) by looking into the annual reports of Sapporo Fire Bureau.  Number of ambulance runs according to 1) injury or illness and their severities, 2) patients’ ages, 3) cause of death etc. was investigated.Although overall bathing related ambulance runs were 0.71 % of all the called emergency cases, the accidental death accounted for 7.4 % of the total death toll and was 1.5 times the traffic death.  Eleven point seven percentages of the bathing related ambulance runs were due to the accidental death, of which 83.9 % was from the elderly aged 65 and over. The incidence of cardio-pulmonary arrest showed a lower value of 17.6 persons per 100,000 populations than that of other cities in Japan.  In the elderly, the sum of survivors from cardio-pulmonary arrest and a loss of consciousness reached by 1.7 times of accidental death. In hot spring area, compared with Sapporo city excluding hot spring area, there was lesser proportion of accidental death and serious injury. The proportion in which children and adult ages get injured by fall was higher in the hot spring area. There was negative correlation between monthly air temperature and monthly incidence number both in Sapporo city (excluding hot spring area) and Jozankei hot spring area.Although not so many accidents happened in the bathroom, death rate was high especially in the elderly. Lower rate of accidental death in hot spring area suggests that conditions in public bath such as 1) small differences in air temperature among rooms, corridors and bathrooms, 2) people around the patients might notice their malaise or sickness might be better than those at home. In order to avoid bathing related accidental death, preventive care such as health promotion is absolutely important.

Is peloidotherapy safe for the patients with chronic kidneys disease ?Surdu Olga1,2, Tuta Liliana-Ana1, Surdu T1, Nechifor Monica1, Minea Mihaela2 [Romania]1 - Ovidius University Constanta2 - Balneal and Rehabilitation Sanatorium Techirghiol
Surdu Olga 
Str. Victor Climescu nr. 34-40, 906100 Techirghiol (RO)+40 0241481714olga.surdu@yahoo.com , www.univ-ovidius.ro
Introduction A number of patients with chronic renal disease also present co-morbidities such as osteoarthritis that might have benefits from peloidotherapy. One of our previous bio-histo-metrical studies shows that peloidotherapy influences apoptosis of keratinocytes [1]. Many researchers have focused on apoptosis and found specific markers of this programmed cell death phenomenon. One of these markers, CD27 is expressed not only on lymphocytes but also on renal tubules. One study [2] has investigated CD27 expression on the renal tubular cells. Renal tubule apoptosis is induced by the CD27 ligand, Siva. So, serum level of sCD27 might be considered a marker of renal tubule apoptosis. Because the determination of serum antibody by the ELISA method showed high levels in patients with chronic renal disease, we wanted to determine the effect of peloidotherapy in this specific situation. This study was accomplished through a grant supported by the Romanian Academy [3,4].Objectives • 1. to evaluate the serum level of sCD27 in patients with chronic renal disease ;  • 2. to evaluate the serum level of sCD27 in patients with mild to moderate chronic renal disease undergoing peloidotherapy for skeletal pathology ;  • 3. to evaluate if peloidotheray is safe for patients with chronic renal disease.Materials  • 1. Sapropelic mud and mineral water from Techirghiol Lake ; • 2. Blood samples• 3. Laboratory reactives, specific dyestuffs, Abnova ELISA Human sCD27 kit.Methods of work  • 1. 20 patients who received mud-therapy (wrapping or bath), during 12 days and 20 who did not receive balneo- and/or physiotherapy ;  • 2. Including and exclusion criteria were applied upon the two batches ; • 3. In the blood samples were determined plasmatic level sCD27 before the begining of treatment, at 24 hour after first mud application and at the end of the cure. In the same time were monitored vital functions and kidney function tests.Including criteria Patients with mild (eGFR=60-90 ml/min/1,73sq m) to moderate (eGFR=30-59 ml/min/1,73sq m) chronic renal disease (CRD), having clinical and paraclinical signs of join diseases.Exclusion criteria Severe CRD and kidney failure, cancers, other organs failure.The two batches, similar statistic, included patients with the same degree of chronic renal disease. The blood samplings were taking before the treatment, 24 hours after the first mud application and at the end of the peloidotherapy. The serum level of sCD27 was determined to the patients of both groups using Abnova ELISA Human sCD27 kit.Results

SamplingsCD 27 (U/ml)Witness batchsCD 27 (U/ml)Study batchpBefore peloidotherapy380±109,54357±124,860,023124 h after first mud application385±109,65360±129,340,0246
After 10 sessions of mud application374±110,57249±70,860,0045

At the beginning of the study, the level of sCD27 was similar in both groups. After peloidotherapy, the level of sCD27 decreased in patients undergoing peloidotherapy compared to control group, the difference being statistically significant (p <0.005).Conclusion • 1. All the patients with medium chronic renal disease from both groups had high level of sCD27. • 2. After 10 days of therapy, in the study batch, the level of sCD27 decreased from 357±124,86 U/ml to 249±70,86 U/ml with p=0,0045. • 3. The most important decrease of sCD27 level was observed to patients with diabetic nephropathy and hypertension, in patients with chronic renal tubular and interstitial nephropathy and less in those with chronic glomerular pathology. • 4. The benefits of mud applications results by improving the symptoms of skeletal illness and at the same time by decreasing the renal tubular apoptosis in patients with renal chronicle disease. • 5. Peloidotherapy is a safe treatment for patients with mild to moderate chronic kidney diseases.Keywords : sCD27, peloidotherapy, chronic renal diseases
References1. Surdu Olga. Comparative histological study on skin modifications induced by mud application. PhD thesis, 2007, Ovidius University Constanta2. Nakatsuji T. High levels of serum soluble CD27 correlated with renal dysfunction. Clinical and experimental medicine   ISSN 1591-8890, 2003;2,4:192-196.3. Tuta Liliana–Ana. Research report, Roumanian Academy Grants GAR 122/2008.4. Tuta Liliana-Ana, Sburlan Alina, Tofolean Doina, Voinea F, Surdu Olga, Voineagu Lavinia. Serum sCD27 levels, a better maker of renal dysfunction than plasma creatinine levels, in early stages of tubular apoptosis. Poster presentation at The XLVIth World Congress of Nephrology, ERA-EDTA in collaboration with International Society of Nephrology, 2009, May 22-26, Milan, Italy.

Oxidative stress evaluation after mud bath Marin Viorica1, Profir Daniela1, Surdu Olga2, Demirgian Sibel1 [Romania]1 - Balneary and Rehabilitation Sanatorium of Techirghiol2 - Department of Rehabilitation, Faculty of Medicine, University “Ovidius”, Constanta
Marin VioricaStr. Duiliu Zamfirescu 47 A, 90020 Constanta (RO)+40 241/481715 / +40 744154428marin_viorica@yahoo.com
Introduction Osteoarthritis (OA) is a non-inflammatory degenerative joint disease, characterized by degeneration of articular cartilage, hypertrophy of bone at the margins and changes in the synovial membrane. It is accompanied by pain (usually before prolonged activity) and stiffness (especially after prolonged activity).The pathogenesis of OA is closely linked to the pathogenesis of cartilage degradation. The primary injury in OA is cartilage degradation. The damage of matrix collagen and proteoglycans is caused by the increased activity of chondrocyte enzymes (stromelysine, collagenase and proteoglycanase).Peroxidation of lipids, spontaneous or catalyzed by metals (iron, copper) and self-maintained by self-catalysis, generates the production of the reactive species of oxygen (ROS). The ROS are aggressive to cells and to the macromolecules of cartilage. The ROS produce negative effects inducing oxidations, damage of membranes, modification of proteins and DNA. The oxidative stress defined as the imbalance between the production and degradation of ROS is considered to play an important role in the degradation mechanism of cartilage.In Techirghiol Balneary and Rehabilitation Sanatorium we used mud from Techirghiol Lake for osteoarthritis treatment. We used the mud in different ways : bath mud and heated mud packing.Aim The aim of the present study is to evaluate the antioxidant effect of mud therapy in patients with primary osteoarthritis in order to contribute to a better understanding of the mechanism of mud treatments.Methods We performed a clinical study on 30 patients with osteoarthritis in different localization. For these patients we determined the values of glutathione-reductase (GR), total antioxidant status (TAS), superoxid dismutase (SOD) and reduced glutathione (G-SH), HCO3-, the oxygen link capacity O2CAP, the oxygen contents in hemoglobin O2CT, uric acid, pH-plasma, before and after mud applications in order to assess the oxidative stress of the body cells and relevance of value therapy with Techirghiol saprogenic mud of osteoarthritis. We took blood samples the first day before and after first mud therapy after 5 days of treatment and at the end of the cure (after 12 days). All patients have got physical therapy and exercise.Results The effects of mud bath : it seems that there is a decrease of TAS and GR and an increase of SOD, HCO3-, O2CAP, O2CT and plasma pH. These results may also suggest that mud therapy causes an extra oxidative stress. On the other hand, increase in SOD, O2CT, O2CAP level after mud therapy may be seen as an indicator of improved antioxidant potential and activity.
References1. Maddison PJ, Isenberg DA, Woo P, Blass DN. Oxford text book of Rheumatology, Ed. Oxford University Press 2nd edition, 1998.2. Curca D. Efectele benefice şi cele malefice ale speciilor de oxigen reactive şi radicalilor liberi la animale, Lucrări ştiinţifice U.Ş.A.M.V.B. Seria C, vol. XLVI-XLVII, 2003-2004.3. Ţuculescu I. Biodinamica lacului Techirghiol. Biogenezele si geneza nămolului.    Compoziţia chimica a nămolului terapeutic din lacul Techirghiol,  Ed. Academiei Romane, 1965.4. Agarbiceanu T. Studii şi cercetări de balneologie şi fizioterapie, vol. VI, Ed. Medicală Bucureşti, 1964.5.  Zira AM, Ira AM. Studii şi cercetări de balneologie şi fizioterapie, vol. VI, Ed. Medicală Bucureşti, 1964:141-145.6. Roşoiu N, Şerban M. Biochimie medicala Vol.II – Metabolism intermediar cu corelaţii clinice, Editura Muntenia, Constanţa, 2005.7. Roşoiu N, Verman GI. Biochimie clinică, Editura Muntenia, Constanţa, 2008.

A retrospective investigation of spa cure therapies effecting the biochemical  and hemogram processesEsin Ergican Kerim1, Gürdal Hatice1, Özel Sevda2, Karagülle Mine1, Dișçi Rian2, Erdoğan Nergis1, Dönmez Arif 1, Karagülle M Zeki1 [Turkey]1 - İstanbul University, İstanbul Medical Faculty, Department of Medical Ecology and Hydrocimatology 2 - İstanbul University, İstanbul  Medical Faculty, Department of Biostatistics and Medical Information
Ergican Kerim Esin ergican58@gmail.comIntroduction The effects of spa cure treatments on biochemical and hemogram processes have been observed in patients who were sent to have spa treatments, localized in different districts. Objective In this study, the short time laboratory findings of reported patients who had rheumatologic complaints and have been admitted to Istanbul Medical Faculty, Medical Ecology and Hydroclimatology Department’s Locomotor System Diseases Outpatient Clinic, were aimed to be investigated before and after 15 days of spa therapies.Methods During the last five years, 147 patients, when their recurrent spa therapy trips in different years were added, the blood analysis results obtained from the Central Laboratory of Clinical Biochemistry of a total of 246 case files, before and after spa therapies, were examined. Blood analysis results were taken into consideration retrospectively. Since some of the analysis results, mostly after spa treatments were incomplete, patient counts were lesser. For the data acquired prior and after spa, paired t test, and for the results that were not distributed normally, nonparametric Wilcoxon tests were used to solve statistically. Results and Comments Hematocrit (p=0.048) and platelet counts’ (p=0.001) difference were statistically significant contained in the hemogram values. Cholesterol (<=200 ; >=201mg/dl),  LDL-Cholesterol (<=135 ; >=136mg/dl), HDL- Cholesterol (<=40 ; >=41mg/dl), and Uric acid (<=6,5 ; >=6,51mg/dl) analysis were devided into two fractions  respectively,  and the changes were examined.The changes of albumin  (p=0,001) ; uric acid <= 6,5mg/dl (p=0,022) ; HDL-Cholesterol  <=40 mg/dl (p=0,033), HDL-Cholesterol >=41mg/dl (p=0,008) ; LDL-Cholesterol <=135mg/dl (p=0,000) LDL-Cholesterol >=136mg/dl (p=0,047) values were found statistically significant.In previous years, some of the literatures published around the world and in our country, showed similar results between former and latter values of Cholesterol in balneotherapy treaments. 

Integrated approach for thermal water resource's managementVigouroux Philippe, Gouzien Jean-Louis [France]
Vigouroux Philippe1039 rue de Pinville, 34000 Montpellier (FR)+33 467157996 / +33 642805751p.vigouroux@brgm.fr
High quality of thermal groundwater resource is the basis for thermal activities. To preserve thermal water's quality and to ensure a sustainable development for thermal activities, a comprehensive knowledge of the thermal groundwater system, which includes geological, geochemical, isotopic, hydrogeological and environmental caracterisation, is necessary.Thus, an integrated approach for thermal water resource’s management has been recently developed for numerous thermal springs exploited over more than 100 thermal areas in France.On one hand, spring thermal water’s quality depends on local water circulation conditions but also on the mineral mass exchanges during the water-rock contact. On the other hand, in order to maintain the thermal water’s quality, it is necessary to manage the exploitation resource’s conditions and the underground area’s protection. Such aspects represent the basis for the integrated approach for thermal water resource’s management that is developed by the French Geological Survey (BRGM) within the regional thermal federation of Languedoc-Roussillon (South of France).

An alternative to chlorine spin-offs for thermal pools disinfection : bromochloro-5.5-dimethyldantoin (BCDMH)Dubourg Karine, Lagiere J, Deytieux-Belleau C, Biasutti S, Cambar J [France]Institut du thermalisme
Dubourg Karine Institut du thermalisme 8 rue Sainte-Ursule, 40100 Dax (FR)+33 558561942 / +33 684483389karine.dubourg@u-bordeaux2.fr
Introduction When disinfecting thermal pools, the use of products representing an alternative to chlorine spin-offs, such as bromochloro-5.5-dimethyldantoin (BCDMH), represents a major stake to improve the health status in thermal spas.This study was at first realised with 25 litres of natural mineral water; it aims to demonstrate the efficiency of bromine. This chemical product is a true alternative to chlorine when dealing with hot thermal waters (temperature above 30°C) with a basic pH, as it gives it a specificity proper to collective treatments performed in rheumatology pools. Additional tests were realised on a 2,500-litre “experimental thermal pool” with bathers in. They made it possible to make a first approach to the efficient quantity in total brome (2 to 4 mg per L) and to identify the bacterium brought by the bathers, namely Staphylococcus aureus.Methods The tests were performed with the natural mineral water from Dax, France. This water is hyperthermal when drilled (62.5°C), with sulphate, calcareous and magnesium proprieties. E.coli, Pseudomonas aeruginosa and Enterococcus, the bacterial strains which are used for the challenge tests on 25 litres, come from the collection of the Institut du Thermalisme. As for the bacterial pollution in the “experimental thermal pool”, it was naturally introduced by the bathers themselves who brought in the nitrogenous organic pollution. Results In 25 litres, the microbiological results on Pseudomonas aeruginosa confirm this biocidal effect without considering the nitrogenous organic pollution parameter. The comparative study of the three bacteria species (E.coli, Pseudomonas aeruginosa and Enterococcus) on the bactericide power of the BCDMH proves a great sensitivity of E. coli, Pseudomonas aeruginosa and Enterococcus, in ascending order. These results are confirmed in 2500 litres, even though a longer action time for the BCDMH on Staphylococcus aureus is necessary, which obliged us to increase the concentration in total brome so as to get an optimum efficiency.Conclusions BCDMH is not an officially ratified product in France, yet it is very commonly used in some European countries. It represents an interesting alternative which reveals a comparable, not to say higher efficiency than that of chlorinated products, especially in rather high temperature and pH conditions. Keywords : disinfection, brome, hot thermal waters, pools

Heart and VesselsRoom B0110.30 am – 12.30 am
LecturesHeart conditions and medical balneology Tamás Bender [Hungary]Hospitaller Brothers of St John of God, Budapest
Balneotherapy has an outstanding role in the cadiovascular rehabilitation. Head out warm  water immersion causes a shift of blood from the extremities to the chest, with approximately 70 % of this volume in lung circulation and 30 %  in the heart. The cardiac filling volume, the stroke volume and the cardiac output increases. The peripheral resistance decreases. The central venous pressure rises, the central blood volume increases. In warm water, the heart rate generally rises as well. Immersion of the neck into warm water, strongly influences on the autonomic nervous system. The head out water immersion has beneficial effect on the ejection fraction of patients suffering from chronic heart failure. Carbonic acid water bath improves the hemorheological parameters. In case of coronary artery disease, clinical studies suggest firstly isolated immersion later the complet immersion.Warm water immersion effect beneficially on systolic and diastolic ventricular function. Balneotherapy  reduces systolic blood pressure. Iodid-bromid balneotherapy has an anti-ischemic activity in patients with coronary heart disease and the same effect has the hidrogen sulfid water. Besides the warm water immersion, the climate therapy has also benefical effect on  chronic heart diseases.The water-proof ECG system, a new Hungarian developement,  (CardioSpa project) has already been tested by healthy volunteers and now it is under investigation in heart disease. This new instrument is easy to use (built in aerial), reflecting the signs  to the computer (near to the pool and forwarding  the ECG signs immediately.
Venous conditions and crenotherapyP Carpentier [France]
PapersImmersion temperature effects upon the autonomic nervous system : age-related comparisonsBecker Bruce, Hildenbrand Kasee [USA]Washington State University
Becker Bruce13125 S. Fairway Ridge Lane, 99224 Spokane, Washington (US)beckerb@wsu.edu
Purpose Numerous studies have been conducted looking at the effects of water immersion temperatures on the cardiovascular system, but scant work has been done regarding the effects of immersion temperature on factors relating to autonomic nervous system regulation. A prior study examined autonomic nervous system effects upon thermal, circulatory and cardiac regulation in a group of college-aged subjects while immersed in cool (88°F), neutral (98°F) and warm (102°F) water for segments of 24 minutes per immersion cycle. The current study compares those results with a group of older subjects ages 42-65 using the same study protocol.Methods Two cohorts of subjects were recruited to participate in the study, a college aged group (n=16 with 8 males and 8 females) and an older aged (ages 42-65) group (n=14 with 6 males and 8 females). All subjects signed a consent form after being informed of the risks and stresses associated with the study. Each subject underwent all testing in one session. Coretemp™ capsules to measure core temperature were swallowed at the beginning of the study session. Body fat percentages were measured using BodPod™ apparatus. After subjects got acclimatized to the room and all BioPac™data gathering equipment had been set-up using a standard 3-electrode ECG placement and laser Doppler circulatory flow probe on the medial great toe, the subject sat outside the first tub for 12 minutes. Then the subject was immersed in the cool tub for 24 minutes. After getting out of the cool tub, the subject sat tub-side for 12 minutes. Subjects then got into the neutral tub and were immersed for 24 minutes. After that time had commenced, they once again sat tub-side for 12 minutes before getting in the warm tub for the last 24 minutes immersion. Once getting outside of the warm tub, the subject sat in recovery for 12 minutes. Following study completion, the data files were scrubbed of ECG artifact prior to subjecting the files to fast Fourier transformation for heart rate variability calculation.Statistical Analysis To compare the potentially unique physiological effects of water immersion on younger and older people, independent samples t-tests were chosen as an appropriate statistical method because data were derived from independent groups who experienced the same conditions at the same time points and t-tests allow for the inference of significance when sample size (and consequently statistical power) is low. Tests indicated whether there is evidence that college-age people physiologically respond to water immersion in a manner that is significantly different from people age 42 to 65. Specifically, change scores—or the amount of increase/decrease in physiological measures between a period and its preceding period—were compared. The study not only tested for age-differentiated responses to water immersion, but also responses during different conditions of water temperature. This approach required multiple tests to be performed on the dataset, increasing the likelihood of Type I errors. To combat against wrongly rejecting null hypotheses, a Bonferroni correction was employed by dividing the traditional .05 alpha level by 6—the number of change-scores examined for each of the vital and ANS measures. This lowered the cutoff point for statistical significance to .008. Although the examination of multiple outcome measures (i.e. vital and ANS measures) meant that an even stricter Bonferroni correction could have been used, the limited size of the dataset means that statistical power is already low. A stricter correction would have unduly increased the likelihood of a Type II error [Abdi, 2007].Results In both populations, immersion exerts very significant effects upon the autonomic nervous system, particularly during warm water immersion. The changes noted while quite consistent across all of the subjects tested in the study demonstrated some significant intergroup variances. Heart rate changes rose in both groups during the warm water immersion period, but not during the cool or neutral immersion period. Core temperature rose similarly in both groups but was sustained longer in the older population. Blood pressure responses were nearly identical. Sympathovagal balance rose more in the older subjects than in the younger cohort, while vagal power responses were significantly different between cohorts.Conclusions Warm water immersion produces similar HRV responses across the age spectrum including increased sympatho-vagal balance, but with some differences in magnitude of response and intersubject variation. Blood pressure and heart rate responses were very similar, as was distal superficial circulation. These changes may have health implications for warm water immersion for healthy individuals across the age span, as decreased HRV has been associated with cardiovascular risk, as well as psychological and metabolic dysfunction.

Hemodynamics changes after whole-body cryotherapy in healthy subjectsKlawe Jacek J1, Tafil-Klawe Malgorzata2, Zalewski Pawel1, Buszko Katarzyna [Poland]1 - Department of Hygiene and Epidemiology, Collegium Medicum UMK2 - Department of Physiology, Collegium Medicum UMK
Klawe Jacek J.M. Sklodowskiej-Curie 9, 85-094 Bydgoszcz (PL)+48 525853615 / +48 601629715jklawe@cm.umk.pl
Background Whole-body cryotherapy (WBC) is one of therapeutic method. Cryotherapy has been used for decades to relieve pain after many acute sport injuries. Recent researches lead to use to decrease inflammation in arthritis, fibromyalgia. It can be also used in many neurological conditions and biological renewal as well. Although cryotherapy is widely used, the physiological basis for its clinical effects remains still incompletely understood. Thermal stimulation of the body increases the activity of thermoreceptors that cause many physiological reactions, i.e. hemodynamic changes.The aim of this study was to assess the changes of a hemodynamic response to an acute whole-body cryotherapy in healthy subjects.Materials and methods Twenty-five healthy subjects (25 men) participated in this study. The average age was 31,50±5,61 yr, height 1,79±0,05 m, weight 83,70±10,10 kg, BMI 25,90± 2,82 kg/m2, BSA 2,00±0,12 m2, sBP 123,60±11,58 mm/Hg, dBP 77,80±7,30 mm/Hg. All subjects were exposed to whole-body cryotherapy (-115°C) for 3 minutes. The Task Force® Monitor was used to measure bat-to-beat hemodynamic and autonomic parameters during 5 minutes period supine rest before (01) and after (02) exposure to whole-body cryotherapy. Recording of biological signals included : RRI, HR, sBP, dBP, mBP, SV, SI, CO, CI, TPR, TPRI. During WBC, the subjects wore a bathing suit, surgical mask, cap, gloves, socks and pattens. All measurements were done according to the standardized conditions for study of autonomic nervous system.Results After whole-body cryotherapy exposure (WBC) significant effects were recorded :


mean values/SDmean values/SDParameter(01) before exposure(02) after exposureHeart rate (HR) beat/min62,79/9,7558,34/10,09R-R intervals (RRI) ms 985,04/157,041063,87/172,53Systolic blood pressure (sBP) mmHg123,69/11,5123,62/9,49Diastolic blood pressure (dBP) mmHg 77,85/7,3179,82/8,04Mean blood pressure (mBP) mmHg92,40/9,1692,21/8,47Systolic volume (SV) ml100,20/22,42106,09/21,77Systolic index (SI) ml/m249,37/11,2852,54/11,06Cardiac output (CO) l/min6,22/1,456,11/1,38Cardiac index (CI) l/min/m23,06/0,723,02/0,68Total peripheral resistance (TPR) dyn•s/cm51210,81/256,971225,31/253,50Total peripheral resistance index (TPRI) dyn•s/cm5/m22466,29/563,062481,81/549,56


Acute cold exposure decreased heart rate (HR) and increased stroke volume and stroke index (SV, SI) (p<0,05). The values of systolic (sBP), diastolic (dBP), mean (mBP) pressures remained unchanged (p>0,05), Neither significant differences in cardiac output (CO), cardiac index (CI) and total peripheral resistance (TPR) (p>0,05) were found during WBC.Conclusion The marked hemodynamic changes indicate that whole-body cryotherapy (WBC) causes an increase in cardiac preload without increase in cardiac afterload.

Circulatory responses during under water exercise to different water temperatures and the pressure-frequency-productFenzl Matthias1,2, Schnizer W 3, Knüsel O1, Hartmann B4 [Switzerland]1 - Klinik für Rheumatologie und Rehabilitation des Bewegungsapparates, Klinik Valens, 7317 Valens, Schweiz (Ärztlicher Direktor : Dr. med. O. Knüsel)2 - Medizinisches Zentrum, Swiss Olympic Medical Center Bad Ragaz, 7310 Bad Ragaz, Schweiz (Chefarzt : Dr. med. C. Schlegel)3 - Prof. Dr. med. W. Schnizer, Agnes-Bernauer-Str. 170, 80687 München4 - PD Dr. med. B. Hartmann, St. Gallerstr. 2, 79245 Merzhausen-Freiburg
Fenzl MatthiasKlinik Valens, 7317 Valens (CH)+41 798199426m.fenzl@bluewin.ch
Purpose Under water exercise as a means of training in prevention and rehabilitation gain in importance and during the performance of aqua cycling in water at different temperatures loading of the heart is open to debate. Materials and methods 8 subjects performed a sequence of exercise in water (26, 41, 53 % VO2 max) at 26, 32 and 35°C. Effects on blood pressure, heart rate and pressure frequency product (PFP) were investigated. Results Concerning systolic blood pressure, there has been approximately the same rise under the aforementioned temperature conditions. Regarding the performance at 35°C, heart rate reached the highest level compared to 26°C and 32°C (p<0.05). PFP at 35°C was also significantly different from PFP 26°C and PFP 32°C, but no difference in PFP between 26°C and 32°C was noticed. Water cycling presented no difference in systolic blood pressure (after load) with regard to water temperature. Conclusions PFP as an index of myocardiac oxygen consumption result in increasing cardiac load in water up to 33°C when compared with identical work capabilities on land. The exercise reactions indicate overexertion to heat stress. If 26°C compared to 32°C, comprising PFP assumed, physical exercise responses of the heart are not elevated.

The effect of balneotherapy on cardiovascular risk factorsFehér Judit1, Kálmánczhey Judit1, Oláh Mihály1, Nagy György2, Bender Tamás2,Koncz Ágnes 3, Oláh Csaba4 [Hungary]1 - Hungarospa Hajdúszoboszló, Hajdúszoboszló2 - Polyclinic, Hospital of the Hospitaller Brothers of St. John of God, Budapest3 - Heim Pál Paediatric Hospital, Budapest4 - Department of Neurosurgery, BAZ County Hospital, Miskolc
Judit FehérTarjan 71/G, 4032 Debrecen (HU)+36 52 789128 / +36 30 3018810drfeherj@gmail.com
Cardiovascular diseases have a pole position on the list of morbidity and mortality statistics in the majority of developed countries. The pathogenesis of these diseases are complex and strongly related to obesity, type 2 diabetes, hypertension, plasma lipid changes and other exogen (e.g.smoking) and genetic factors.Balneotherapy – which utilises the beneficial effects of mineral water – has long been a specialty of regular medicine worldwide. Altough the body of evidence substantiating the effectiveness of balneotherapy has been increasing progressively, controlled human studies exploring the potential role of balneotherapy in cardiovascular diseases are almost non-existent.In 2008 we made a study with 42 ambulatory patients – bathing in tap water or in mineral water at the same temperature and time on 15 occasions – who needed treatment for muscolo-skeletal disorders. Our results showed significant changes in the mineral water group in serum C-reactive protein (CRP) and plasma lipid levels (cholesterol, triglycerid, LDL/HDL ratio), still persisting 3 months later.In 2009 we started a new study with people having special cardiovascular risk factors. Two groups were made, in each 40 ambulatory patients. In the first group, patients with hypertension and chronic heart failure (NYHA I., II.), in the second group, overweight people (BMI > 25) with increased serum glucose level. In both groups 20 people bathed in 38°C mineral water for 30 minutes on 15 occasions, the control group had no treatment at all. Study parameters comprised CRP, plasma lipids, liver and kidney functions, total antioxidant status (TAS), vitamin E and C, serum proteins and iron, serum glucose and glycosylated hemoglobin (Hgb A1c), pro-brain natriuretic peptide (BNP) and  N-acetyl-beta glucosaminidase (NAG). Previous results showed that the balneotherapy made with mineral water from Hajdúszoboszló had more pronounced physiological effect compared to those seen in the control group treated with tap water.Our aim is to prove that balneotherapy with the termal water from Hajdúszoboszló can play an important role not only in the rehabilitation, but in the treatment of atherosclerosis and cardiovascular diseases as well.
 Effects of percutaneous natural CO2-therapy in moderate Fontaine stage II chronic arterial peripheric diseaseFabry Régine3, Monnet Pascal2, Schmidt Jeannot1, Renusson  Jean3, Carpentier Patrick-Henri4, Baguet Jean-Claude2, Dubray Claude5 [France]1 - Univiversité Clermont-Ferrand 1, Department of Therapeutic2 - Research Institute, Royat3 - Université Clermont-Ferrand 1, EA 32954 - Department of Vascular Medicine, CHU Grenoble5 - Univ Clermont 1, Department of Clinical Pharmacology, Inserm CIC-501
Fabry RégineService de thérapeutique et hydrologie-climatologie médicales63001 Clermont-Ferrand cedex 01 (FR)Regine.FABRY@u-clermont1.fr
A randomized double-blind monocentric trial involving 62 patients with intermittent claudication was conducted at the spa of Royat to quantify the clinical and microcirculatory effects of natural CO2 (active treatment) versus air (placebo).The patients were recruited on a voluntary basis and gave written consent after being informed of the experimental protocol. They were aged 45 to 75 years and for inclusion had to have had moderate stage II (walking distance : 100 – 500 meters) for more than 6 months. The claudication had to be confirmed during pre-selection test and be stable over time (no more than 20 % difference between two walking tests at no less than 15 days interval, TASC recommendations). Throughout the experimental period, patients continued to take their usual medication and made no lifestyle changes (physical activity, smoking).Patients were randomized to 18 days of CO2 (group 1) or 18 days of air (group 2). The gas was applied for 35 minutes at a constant temperature of 30°C to previously humidified skin after immersion for 10 minutes in a bath of tap water (34.5°C). The effects of the active treatment were measured by Strandness treadmill walking test (primary criteria) and by ankle systolic arterial pressure, systolic pressure of the great toe, laser Doppler flow (LDF) and trans-cutaneous oxygen partial pressure (TcPO2) (secondary criteria). Life quality scale (CLAU-S) was also used to quantify clinical assessment. These tests were performed at three different times : at the end of treatment, 3 months after and 1 year later.The Strandness test showed a significant increase in pain-free walking distance (81 meters, + 73 %, p=0.02) and total distance (131 meters, + 66 %, p=0.001) after 18 days of CO2 treatment. The beneficial effects were maintained 3 months and 1 year later. The ankle / humeral systolic pressure index (SPI) increased by 37 % (p=0.001) 1 minute after treadmill walking and mean recovery time of SPI decreased significantly by 38 % (p=0.002). Microcirculatory findings showed an increase in systolic pressure of the great toe (8.2 mm Hg, + 13 %, p < 0.0001), in baseline pO2 (9 mm Hg, + 20 %, p=0.01) and in vasomotion (1.6 strokes/minute, + 78 %, p=0.001) in the group receiving CO2 treatment. The improvement in walking performance was correlated with the increase in SPI and peripheral cutaneous oxygenation. Patients’ subjective assessments corroborated the benefits. No significant change was observed in the placebo group.

Interest of short spa CO2-therapy (9 days vs 18) in primary and secondary Raynaud’s Phenomenon. A controlled trial conducted in the spa of RoyatSchmidt Jeannot1, Monnet Pascal2, Fabry Régine1 [France]1 - University Clermont 1, Department of therapeutic 2 - Cardiovascular Research Institute, Royat
Schmidt JeannotService de Thérapeutique et Hydrologie & climatologie médicales63001 Clermont-Ferrand cedex 01 (FR)jschmidt@chu-clermontferrand.fr

A randomized double-blind monocentric trial was conducted at the spa of Royat, France, with patients with mild Raynaud’s phenomenon (one or two attacks a day during the autumn and winter months). The aim was to quantify the hemodynamic changes observed during local application of CO2 by laser Doppler flow (LDF) and computerized chronothermometric test (CT) and to compare them with the usual clinical parameters (number, duration and severity of attacks). Patients were randomized to 18 days of CO2 (group 1), which is the standard time of treatment reimbursed by the French health service, or 9 days of CO2 (group 2), a shorter period to meet a demand from patients with professional commitments.The natural carbon dioxide was applied at a constant temperature (30°C, 30 min) to previously humidified skin (tap water, 35°C, 10 min) on the forearm. Clinical assessment was made on four occasions (before, in the middle and at the end of treatment, and three months afterwards) on the basis of the number of daily attacks and the duration and severity of the attacks.LDF showed a significant increase in digital blood flow (+ 41 %) and in vasomotion (+ 42 %) during CO2 treatment but no change in placebo treatment. CT test showed a comparable response to cold in the two groups during treatment. Three months later, however, warming time was significantly decreased (by 7 min, - 25 %) and warming rate increased (+ 22.4 %) in group 1 (18 days of gas treatment). The variables measured in patients given only 9 days of natural CO2 gas treatment remained unchanged (intergroup difference p=0.02). There was no increase in the severity of the attacks in the two groups but patients in group 1 experienced attacks of shorter duration during winter with 76 % reporting an attack lasting more than 5 minutes as against 87 % in group 2.In this clinical trial, LDF evidenced positive effects of percutaneous application of natural CO2 gas on vasomotricity and vasomotion while CT test showed that patients who had received 18 days of CO2 adapted more easily to exposure to cold in the winter period, which has adverse effects on their condition. This trial shows that 9 days of CO2 treatment is greatly insufficient to improve patient status.

Management & resortsRoom Actes2 pm - 4 pm
LecturesSpa therapy in the national public finances in France. A macro-economic approachTabone Waïner [France]Conseil national des exploitants thermaux (Cneth), Paris 
Spa therapy in France generates activity which participates in national economy by resources as well as by expenses.The contribution of spa therapy to the national wealth may be considered as the Raw Internal Production of this activity.The intervention of social and fiscal organisations in payment of balneological treatments maybe considered as the Social and Fiscal Costs of the activity.It is possible to proceed to a macroeconomic approach of these two budget headings, even if the lack of some data leads to pragmatic evaluations.The result of this approach shows that the spa therapy almost balances with its specific contribution to the social and fiscal budgets for what national solidarity dedicates to its financing.A more exhaustive investigation would clarify this macroeconomic balance and that would be of great interest in the assessment of the global interest of French “social” spa therapy.

“Day hospital” – a tool for the promotion of balneotherapyGeher P1, Horvath R2 [Hungary]1 - Semmelweis University, Budapest, Chair of Rheumatology and Physiotherapy2 - Szechenyl Spa, Budapest Spas and Hot Springs
In the last century the “day hospital” system was developped in the Netherlands for rehabilitation of people with mental disease and also for locomotor disease. The same sytem was adopted in Hungary based on spa facilities.The most comprehensive day hospital service is operated in Budapest, in 3 different spa facilities. Nearly 1000 patients with musculoskeletal diseases are treated yearly. The duration of the treatement is three weeks. The day hospital in practice is a half-day treatment course. The treatment facilities are the following : bath, underwater massage, carbon-dioxid bath, weight bath, medical massage, mud pack, exercise, electrotherapy and medical therapy (medications, local injections). This kind of treatment is very cost-effective comparing to the in-patient treatment.The day hospital provides a means for the wider use of balneotherapy in rehabilitation.

PapersAnalysis of two emergency room databases aimed at the construction of a climatotherapy reference modelCondemi Vincenzo, Solimene Umberto, Meco Roberto [Italy]
Umberto SolimeneVia cicognara, 7, 20129 Milano (IT)umberto.solimene@unimi.it
The study of urban medical bioclimatology is of particular interest due to the by-now irreversible gradual concentration of man’s activities in densely inhabited areas. A combination of data on the slow and constant rise of the old age index and of the mean age of residents observed primarily in developed Countries highlighted the healthcare, environmental and climatotherapic management models on which focus should be made, mainly known as geriatric oriented models (medical geronto-bioclimatology). This was the baseline consideration for this paper, which considers certain climate-sensitive diseases, as such of climatotherapic interest. The starting point was a reference to the Report on the Health Status of Italy, which analyzed a variety of public health issues and provided useful guidelines, directing works towards climate and environment sensitive diseases basically referred to weak groups, and a variey of disorders affecting both the respiratory system and the cardiocirculatory and cerebrovascular system.This paper focuses on emergency morbidity, a powerful public health indicator where 13,000 ER diseases are described according to the international codes. Two Emergency Room (ER) databases were considered, built in two different environments. The first ER database was created by the San Carlo Hospital in Milan, with a potential patient base close to 400,000 units and 80,000 recorded accesses per year ; the second database was set up by four specific ER Units in the Valtellina region (Sondrio, Sondalo, Morbegno, and Chiavenna), operated by Azienda Ospedaliera della Valtellina e della Valchiavenna, with a patient base close to 200,000 units and fed by significant seasonal tourist flows (both in summer and in winter), which increased pressure on the ERs. The selected data and the relevant method satisfy the need to compare two different geographies and climates. The first ER is a significant example of an urban bioclimatic model, while the latter is a typical example of a wide Alpine valley, with a 3212 sq. km. surface in the north-western part of the Lombardy Region. The database analysis was primarily focused on two age groups considered as weak, with individuals requiring emergency services (< 14 and  > 65). All the respiratory disorders admitted to the ER were analyzed, with special focus on some that showed significant potential developments, also in perspective. The comparison and the analysis based on certain environmental profiles were possible for two polluting agents, PM10 and NO2, measured in the Verziere district for the city of Milan and in the urban areas of Sondrio and Bormio for Valtellina (ARPAL data). The average daily figure per month of PM10 points out to a 3 times greater variability in the urban environment compared to the valley and compared to the seasonal average. Similar trends are observed for NO2.It was further decided to match the measurements in Sondrio with the series collected in Bormio as a comparison within the Alpine valley. Finally the weather data collected in Milan and in Valtellina were reviewed to obtain a more comprehensive picture of the different climate conditions in Milan and of the geographic areas that refer to the ERs in Valtellina.After processing and grouping the data according to homogeneous disease classes and to a well defined time frame, the 0-15 age group turned out to be subject to different conditions that lead them to resort to hospital facilities in the two different environments. In the city hospital facility, the age groups of elderly people (>65) and youths (<15) followed the same trend in parallel, by which the demand for care is greater in winter than in spring/summer.The number of patients referring to the ER in the city shows a greater variability compared to the valley : the extent of the monthly data range is greater both for children and for the middle-age groups, except for the elderly people, who show the same value as the average. This phenomenon was observed after defining the representativeness of both population samples, performing an analysis on the seasonal access of non-resident users and defining consistency schemes comparing the composition of the age groups of both resident populations.The ER data pointed out to a significantly diversified concentration of polluting agents between the urban context and the hill-mountain context, expressed in terms of broad variability of references to the respective ERs, and stressing a different proportion of criticalities in both geographies, thus suggesting preventive, environmental and climatotherapic medicine approaches.
Health risk management and certification in French spa therapy – Gestion du risque sanitaire et certification du thermalisme françaisAinouche  R [France]Thermes de la Roche-Posay
Rachid Ainoucheainouche.rachid@neuf.fr
The management of the sanitary risk was always a concern of the French spa therapy. At first by a sanitary and bacteriological approach of the mineral water and the muds, then by an implementation of real quality systems : in 1998, a French medical centre obtained for the first time an ISO 9000 certification, for the sanitary and technical management of its mineral water and the cares. In 2004, the health reglementation asks the French medical spa centres for the implementation of a quality management system. The professionals decide then on a joint representation for the construction of a Good Thermal Practices Guide based on the HACCP method. This guide becomes the standart of a specifical certification of the French medical spa centres : the “AQUACERT” certification. This certification will have to concern the majority of the French medical spa centres before 2012.La gestion du risque sanitaire a toujours été une préoccupation des établissements thermaux français. D’abord par une approche basée sur l’hygiène des établissements et la maîtrise bactériologique des eaux thermales et des produits associés, elle s’est transformée en démarche qualité globale. C’est ainsi que dès 1998 un établissement thermal français obtenait pour la première fois une certification ISO 9000 pour l’ensemble de son activité : la maîtrise sanitaire et technique des installations et la maîtrise de la prestation de soins thermaux. Plusieurs stations ont depuis suivi ce même schéma. En 2004 s’inscrivait dans la Convention Nationale Thermale l’obligation pour les établissements thermaux de mettre en place une démarche qualité, la profession s’engage alors dans une démarche collective et élabore un Guide de Bonnes Pratiques basé sur la méthode HACCP. Ce guide s’impose aujourd’hui comme l’outil de certification spécifique des établissements thermaux : la Certification AQUACERT, amenée à s’étendre à l’ensemble des établissements français d’ici 2012. 
Medical hydrology in the United States – What’s the potential ?Ferson David, Chi Linda [USA]The University of TexasMD Anderson Cancer CentreHouston, Texas, United States
Ferson David Professor7002 Montclair Drive, 77030 Houston, Texas 77030 (US)+1 713-592-8338 / +1 713-248-8099chiferson@gmail.com
In the past ten years there has been more interest in the United States in trying to understand the effects on human health of different techniques employing water. Although, the traditional medical establishment continues to be somewhat skeptical of the effects of mineral waters on various medical conditions, new concepts have emerged in the nontraditional health industry.  Specifically, there has been a rapid renaissance of traditional balneotherapy, and its principles have been incorporated in modern spas that emphasize alternative health and fitness approaches. The day spa has literally changed the face of the health and beauty industry in the United States and has fostered a number of potentially powerful partnerships. As more and more data become available to the medical professions about spa treatments, progressive health care providers in the US are starting to offer spa treatments to their patients.  Rehabilitation centers are using methods such as Watsu (water Shiatsu), Trager massages (also known as psychological integration), and Pilates (an exercise program that emphasizes flexibility and overall strength development) to help their patients on the road to recovery.  More progressive hospitals are turning to spa treatments to ease the discomfort of patients, especially those who are terminally ill. This, however, represents only the tip of the iceberg of the true potential of spa therapy for improving the wellness of patients. Although Americans enjoy one of the most advanced medical care in the world, with many fine doctors, the most sophisticated diagnostic equipment, and the largest and most modern hospitals, the overall health of Americans is, paradoxically, declining. Degenerative diseases, heart problems, cancer, diabetes, and especially the obesity epidemic, continue to affect a large and increasing portion of the population. This, combined with serious side effects associated with the use of prescription and over-the-counter to treat those diseases, continues to consume the lives of patients and cost the health care system billions of dollars each year. As a result of their dissatisfaction with Western medicine, many Americans are spending an estimated $12 billion a year on alternative therapies such as herbal medicine, acupuncture and homeotherapy, which are usually not covered by medical insurance. Whereas the overall health of Americans has been steadily declining, many cultures and medical systems around the world enjoy the benefits of valuable spa treatments for many chronic health conditions as well as for the prevention of disease. Physicians around the world who continue to study the effectiveness of natural resources in medicine have also developed specific protocols for safe and effective treatments. The potential for incorporating spa medicine, as complimentary form of therapy, with the mainstream Western medicine in the United States is enormous but as yet completely unrealized. In America today, the word spa is used very loosely and is more likely to have recreational connotation than to refer to treatment of any particular disease entity.  One is likely to find several broad categories of spas, including day spas, amenity spas, destination or resort spas, wellness centers, and medical spas. The exposure of the medical profession in the United States to spa therapy through the medical spas provides fertile ground for revisiting the specialty of medical hydrology and for its reintroduction and integration into a modern and effective health care system.The authors of this abstract will review in detail the current spectrum of different spa categories in the United States, provide a short history of their evolution in the last 50 years, and provide a model for blueprint on how to integrate the spa medicine as a complimentary form of medical therapy in the twenty first century.

Medical treatment based on geothermal resources in Asia / Oceania : the importance of natural hot and mineral springs for balneology, medical hydrology and climatology to prevent and rehabilitate Erfurt-Cooper Patricia [Australia]James Cook University, AustraliaRitsumeikan Asia Pacific University, Japan
Patricia.Erfurt@jcu.edu.au 
Abstract The worldwide distribution of natural hot and mineral springs has made them one of the most significant assets for the health and wellness spa industry both now and in the past. Thermal spa and bathing facilities exist in many countries and have a significant and longstanding reputation for successful treatments for a large number of health conditions. Wherever we look, the treatment methods and the health conditions benefitting most form balneology based on thermal springs are fundamentally the same worldwide and it is historically proven that the majority of countries with natural thermal springs have used these resources for healing purposes, as well as for relaxation, socialising and purifying rituals. Over the centuries thermal spas and health resorts have come and gone, but in the wake of the modern health and wellness movement many facilities, some after years of decline, have undergone modernisation and redevelopment. With prevention as one of the main aspects, health and medical spa tourism is one of the fastest growing sectors of world tourism. Moreover, the recreational use of thermal springs in health resorts and water parks combined with access to medical thermalism significantly adds to the standard attractions offered by many holiday destinations.Although there may be cultural variations related to the use of thermal springs when we are looking at ‘East’ and ‘West’ there are also a number of important similarities which will be examined in this paper/presentation. Countries such as New Zealand, Australia, Japan, Korea and China, are examples for the continued integration of natural hot and mineral springs in the prevention and rehabilitation of illness. Asian countries often combine thermalism with their own traditional medical treatments, which is comparable to the combination of thermalism, climate and other nature-based local remedies in the West. For example, treatment methods such as the ‘Fish Cure’ have been successfully imported by China, Korea and Japan where they attract visitors with their uniqueness. In countries like Australia the development of thermal spas is still at the beginning, but existing facilities have been supported by European migrants who brought the tradition of balneology from their home countries. A worldwide common perception indicates that the beneficial effects of minerals and temperature of thermal springs, often in combination with a relaxing environment, are powerful factors in regaining the focus on maintaining health and wellbeing through balneology and climatology. The global wellness focus has ignited a new awareness regarding the use of thermal springs for prevention and rehabilitation. This paper will include a number of interesting examples from individual hot spring spas, resorts and hospitals throughout the Asia / Oceania region.Keywords : Asia, Balneology, Geothermal Springs, Oceania, Prevention, Rehabilitation, Thermalism

Strategic planning for Spa / Hotel Resort developmentPatton Allison [USA]Mountainview Wellness Centre and Tranquility Resort Inc.
Patton, Dr. Allison, Mountainview Wellness Centre and Tranquility Resort Inc.3566 King George Hwy, V4P 1B5, Surrey, British Columbia CA+1 604 773 3759dr.patton@mvwc.ca
Strategic Business Plan to carry out a spa and housing development in Manitou Beach consistent with the new economic and environmental realities. This report will have a strong focus on investigating technologies that support environmental sustainability and include agriculture as a key community component. The report and research will contain a significant applied research component via focus group meetings and utilizing appreciative inquiry as a possible methodology. The participants that will be sought out are developers of similar projects and potential purchasers.

Allianoi : one of the world’s first ancient thermal therapy centres and its messages for today Cekirge Nevin1, Gurdal Hatic2 [Turkey]1 - Okan University2 - Istanbul University
Cekirge NevinOkan University, Akfirat Campus, Tuzla, 34959 Istanbul (TR)+90 216 6771630/1313 / +90 5322625641nevin.cekirge@okan.edu.tr
In the Ancient Greek, building complexes that were built for the God of Health Asklepios and which have temples and therapy centres in them, are called Asklepieion that means Asklepios’s place.The first Asklepieion found in Anatolia is a “Health Centre” at Ancient Pergamon City. Pergamon City had also a health treatment centre called Allianoi, located near Asklepieion Health Centre, which was used for thermal treatment.Ancient Allianoi Thermal Settlement was established in time of Pergamon Kingdom about 2nd century B.C. Allianoi became a famous and magnificent medical centre in time of the Roman Emperor Hadrianus near 2nd century A.C. It was also used by Byzantine Empire. Allianoi thermal settlement was used for thermal treatment efficiently until 1998 when the archeological digs were started.Allianoi has a thermomineral water which contains sodium bicarbonate and fluoride. Its temperature is between 41-43 C0 and total mineralization of the water is 2501mg/L. According to these factors this thermal water can be used for balneological applications such as thermal bath, inhalation and drinking. The bronze medical tools that were found at the digs of Allianoi prove that it was a very important medical centre in ancient times.Allianoi is also very important for urban planning and architecture. For example the perpendicular streets that are used in transportation system of Roman cities called Decumanus and Cardo were also built in Allianoi. There were transition buildings at the end and beginning of Decumanus, Nympheum (monument fountain) was on the south of the Cardo and Propylaeum (monument door) on the north of Cardo. The total area of the settlement was approximately 30.000 m2. On the 1/3 of the area, there was a Thermal Therapy Complex which consists of thermal therapy units and the surrounding buildings. There were 2-floor buildings for accommodation, common places like nympheum and peristyl building, art workshops and vault tunnels in the thermal therapy complex. Roman bath, stoa, stores with storages or workshops, insula (residential dwellings), nympheum, peristyl building, cult building, church, latrinas (public toilets), necropolis (cemetery) were placed at the south of Allianoi Settlement. Thermal Therapy Complex at the north and buildings at the south of the Ilya creek were connected with Roman Bridges. Allianoi was an important art centre. Artworks from Ceramik, glass and iron workshops were sold at Pergamon and other neighbouring cities.Asklepieion Health Centre and Allianoi were used at about the same time in ancient history. Hydrotherapy, drinking cure, peloid and herbal applications in addition to psychotherapy and musical therapy were applied at Health Centre of Pergamon. On the other hand thermal therapy, drinking cure and inhalation were applied at Allianoi. All these assesments show that the area, where two health centres were built, was a very important place for human health. Using the thermal treatment for 2000 years gives another importance to the Allianoi. This paper will give information about the history, planning principles and architectural design of these two important health centres. Pergamon Health Centre and Allianoi have a lot to teach us for our designs of new thermal settlements. After examining this important thermal therapy places, they will be compared to the contemporary thermal settlements. As a result, the messages of Allianoi about health and architecture will be thorougly discussed.

Musculo-skeletal session IRoom B012 pm - 4 pm
Lecture
Rehabilitation and spa therapy : medical issuesS Poiraudeau [France]
Papers The effects of balneotherapy on functional status and pain in symptomatic knee osteoarthritis patients Stamenkovic Bojana, Stankovic Aleksandra, Dimic Aleksandar, Nedovic Jovan, Stojanovic Sonja [Serbia]Rheumatology Clinic, Institute Niska Banja
Stamenkovic BojanaJug Bogdanova 26a, 18000 Nis (CS)+381 18 4561 777 / +381 63 301 309bojanastm@yahoo.com
Background Knee osteoarthritis (OA) is a chronic joint condition characterised by pain and muscle weakness and instability, which may affect the ability of daily functional activities. Numerous studies have shown that non pharmacological treatment should be the first choice in the management of symptomatic knee osteoarthritis patients.The aim of the study was to establish the effects of balneotherapy on pain and functional knee status in knee symptomatic OA patients using Lequesne index.Method Study was carried out on 120 patients (aged between 50-71) with symptomatic primary knee OA, according to American College of Rheumatology (ACR), with pain in at least one of the knees and grades II and III on the Kellgren Lawrence index. All the patients spent 14 days at the Institute Niska Banja, attending the balneotherapy (radioactive oligomineral baths, mud application, kinesitherapy), without pharmacological treatment. Patients were evaluated using the following assessment tool : Lequesnes functional index  for OA of the knee before and after the balneotherapy. This index includes evaluation of pain or discomfort, maximum walking distance, difficulties affecting daily routine. The Lequesne index is a questionnaire, interview style, with 3 groups of questions, scored on 0-24 scale (lower score meaning less functional impairment) given to the knee OA patients.Results After the balneotherapy, functional disability was significantly reduced. Pain was significantly reduced from 3.84±1.93 to 2.66±1.72 (p<0.05), as well as maximum walking perimeter from 1.86±1.60 to 0.58±0.81 (p<0.05). Difficulties affecting daily routine have been also reduced (from 3.51±2.14 to 1.67±2.03 (p<0.05). Lequesne index was 9.56±5.6 before the balneotherapy and it was reduced to 4.72±4.36 (p<0.05)Conclusion Our results confirm that balneotherapy was effective to reduce the pain and to improve the joint function in patients with symptomatic knee osteoarthritis and should be a compulsive recommandation to the patients.

Effects of balneotherapy and peloidotherapy on knee osteoarthritis : double blinded randomized controlled trial Barut Yasemin, Karagülle Mine, Özkuk Kağan, Berköz F Begüm, Karagülle M Zeki [Turkey]Department of Medical Ecology and Hydroclimatology Istanbul Medical Faculty, Istanbul University
MZ Karagüllemzkaragulle@tnn.net
Aim To investigate the effects of peloidotherapy and balneotherapy combination therapy on knee Osteoarthritis.Material and method Seventy patients were included in this study. They were all diagnosed as knee osteoarthritis according to the American College of Rheumatology (ACR) criteria and gave informed consent. The patients were allocated into 2 groups randomly using computer randomed numbers ; mineral water group and tap water group. 36 patients (3 males, 33 females) were included in mineral water group and 34 patients (7 males, 27 females) in tap water group. Both assessor physician and patients were blinded to the type of therapy. Both groups received the therapy ambulatory at the Balneotherapy Unit of Department of Medical Ecology and Hydroclimatology. The patients undertook either a mineral or tap water bath at about 38°C, for 20 minutes a day for two weeks (5 times per week). Thermomineral water used in the study was salty water with prevailing sodium chloride content. After bathing, the patients rested for 30 minutes. Then local peloid pack at about 43-45°C was applied on both knees for 20 minutes (clay). Assessment criteria were Patient’s Global Assessment (VAS) (0 - 100 mm), Physician’s Global Assessment (VAS) (0 - 100 mm), Pain (VAS) (0 - 100 mm), Health Assessment Questionaire (HAQ), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), Lequesne Knee Index and SF-36 (Short Form-36). The patients were assessed at the beginning (1), at the end (2) and 12 weeks after the treatment course (3).  Results In both treatment combinations, there were  significant improvements in Patient’s Global Assessment, Physician’s Global Assessment, Pain (VAS), WOMAC, Health Assesment Questionaire (HAQ), Lequesne Knee Index, SF-36 (Physical function, Physical role disability, Pain, Emotional role) parameters at the end of the treatment (2) and on week 12 (3). There was statistically significant improvement in HAQ and SF-36 (General Health) scores at the end of the treatment and at week 12 only in mineral water group. The SF-36 (Social function) results were significantly higher in mineral water group at week 12. There was not a significant difference in SF-36 (Social function) scores either at week 2 and week 12 in tap water group. In both groups no significant difference was measured in SF–36 (vitality and mental health) parameters either at the end of the treatment or on week 12.  Conclusion Balneotherapy plus mud pack treatment and tap water therapy plus mud pack treatment combinations have yielded positive effects on pain, physical function and quality of life on patients with knee osteoarthritis after the therapy lasting 12 weeks. The mineral water group was superior in HAQ and SF-36 (Social function) parameters compared to the tap water group. This study suggests that both combination treatment modalities can be used as an ambulatory treatment option in patients with knee osteoarthritis. These results must be verified with further studies including sufficient numbers of patients and longer term assessments. 

Spa therapy in the treatment of knee osteoarthritis, a large randomized multicentre trialForestier Romain1, Desfour Hugues2, Tessier Jean-Max3, Françon Alain1, Foote A4, Genty C4, Rolland C4, Roques Christian-François5, JL Bosson4 [France]1 - Centre de recherches rhumatologiques et thermales, Aix-les-Bains2 - Thermes de  Balaruc-les-Bains3 - Hôpital thermal, Dax4 - Clinical Research Centre, Inserm CIC03, Grenoble5 - Université Toulouse III
Romain Forestier15, avenue Charles de Gaulle , 73100 Aix-les-Bains (FR) romain.forestier@wanadoo.fr
Patients with knee osteoarthritis according to the American College of Rheumatology criteria were recruited by press announcement in the three main French spa centres (Aix-les-Bains, Balaruc-les-Bains & Dax). Both group were encouraged to perform daily standardized home exercises and were allowed to continue their usual treatment. The treatment group received 18 days of spa treatment (massages, showers, mud and water exercise sessions).The purpose was to determinate whether spa therapy plus home exercises and usual medical treatment provides any benefit over exercises and usual treatment in the management of knee osteoarthritis.The main endpoint was the number of patients achieving Minimal Clinically Important Improvement at six months, defined as ≥19.9 mm on the VAS pain scale and/or ≥9.1 points in a normalized WOMAC function score and no knee surgery.Zelen randomization was used so patients were ignorant of the other group and participants of the study. Spa personnel were not told which patients were participating. Most of the judgment criteria were patient self-assessment questionnaires. Allocation concealment was realized by a computer generated number.462 patients were randomized (223 in the treatment group, 228 in the control group) beween June 2006 and February 2007. Intend to treat analysis included 195 patient in the treatment group & 187 in the control group.At 6 months, 99/195 (50.8 %) spa group patients had Minimal Clinically Important Improvement and 68/187 (36.4 %) of controls (chi2=8.05 ; df=1 ; p=0.005). Standardized response mean for pain was 0.55 in the treatment group and 0.22 in the control group. The number needed to treat is 6.9 patients.There were no important adverse events or side effects.For patients with knee OA a 3-week course of spa therapy together with home exercises and usual pharmacological treatments offers benefits after 6 months compared to exercises and usual treatment alone, and is well tolerated.Trial registrationwww.clinicaltrials.gov: n° NCT00348777.FundingPrivate funding : Association Française pour la recherche thermaleInstitutionnal funding : Région Rhone-Alpes, Département de la Savoie

Components of crenobalneotherapy for knee osteoarthritis, a systematic reviewForestier Romain, Françon Alain [France]Centre de recherches rhumatologiques et thermales
Forestier Romain15 avenue Charles de Gaulle, 73100 Aix-les-Bains (FR)romain.forestier@wanadoo.fr
Objectives To conduct a systematic literature review on crenobalneotherapy for knee osteoarthritis.Methods We searched Medline using the following keywords : ‘‘spa therapy’’, ‘‘mud’’, ‘‘radon’’, ‘‘balneotherapy’’ and ‘‘hydrotherapy’’ in combination with ‘‘osteoarthritis’’, ‘‘arthrosis’’, and ‘‘gonarthrosis’’. We also reviewed the reference lists of articles retrieved by the Medline search. Studies that compared crenobalneotherapy to any other intervention or to no intervention were selected, and a checklist was used to assess their internal validity, external validity and the quality of the statistical analysis. We analyzed separately some components of crenobalneotherapy, of comparators and 4 types of judgment criteria (pain, function, stiffness and quality of life). We calculated standardized response mean.Results A publication bias is possible but probably limited and not sufficient to disable all conclusions.There is middle evidence that “multiples mineral interventions” that associates 2 or more components of crenobalneotherapy are superior to no treatment, high evidence that its association with home exercises is superior to home exercises alone and low evidence that it is superior to short wave.There is high level but conflicting evidence that water exercise is superior to no treatment. There is high level of evidence that water exercise is similar to land based exercise (but the studies noted that it is better tolerated).There is middle evidence that massage is superior to no treatment.There is low and conflicting evidence that bath in mineral water is superior or similar to bath in tap water and that mineral mud and bath in mineral water is superior to hot.The only study evaluating heat (heat sleeve vs regular sleeve) found no differences but was a pilot study with insufficient sample size.Conclusion Crenobalneotherapy seems to improve pain, function, stiffness and quality of life in lower limb osteoarthritis. As a whole treatment, its efficacy has a high level of evidence but efficacy of his component has middle (massage) and sometimes high but conflicting level of evidence (exercise in water). There is low evidence that chemical composition of water has a clinical relevant effect. More studies with higher methodology quality and sufficient sample size are needed in these fields.Keywords : Osteoarthritis, Validity, Crenobalneotherapy, Balneotherapy, Hydrotherapy, Massage, Water exercise, Mineral waters, Balneology

Role of the thermal rehabilitation of the patients subjected to surgical operations of hip and knee prosthesis Di Salvo L1, Ippolito E2, Sommaruga S2, Solimene U3 [Italy]1 - U.O. of  Rehabilitation  - ICZ of Monza2 - Foundation  Policlinico, Mangiagalli and Regina Elena IRCCS - University of Milan3 - Department of Medical Therapy and Thermal Medicine - University of Milan
Ippolito Edmondo  Viale Filippetti N° 35, 20122 Milano (IT)+39 3496043930 / +39 0258304968  edmondo.ippolito@unimi.it
Aim The purpose of this study has been to evaluate the efficacy of the thermal rehabilitation, particularly of the hydrokinesitherapy into salsobromoiodic water for patients who have been subjected to operations of hip (PTA) and a knee (PTG) prothesis.Materials and methods The study has been realised within 6 months (from January to June 2009) over 60 patients (56-80 years) subjected to PTA and PGA for arthrosis and osteoporosis. The patients are divided into two groups :A) 30 patients (15 operated of PTA and 15 operated of PTG) treated in a recovery system in our Operative Unit of specialistic rehabilitation (Clinical Institute of Monza) through individual motory reeducation, walking training, consolidation of the postural passages and tecatherapy (methodology based using low intensity indutive current which strikes the phenomenon of the moving of the intra and extracellular ions).B) 30 patients (15 operated of PTA and 15 operated of PTG) subjected to hydrokinesistherapy in thermal swimming pool with salsobromoiodic water (twelve sessions of 45 minutes) in the Center of “ Riolo Terme”.To evaluate the obtained results in the two groups we have used some indicators (evaluation scale) able to show subjective and objective aspects as 1) Analogic visive scale of the pain (VAS), 2) articulary range (ROM), 3) Functional quality of the walking (F.A.C.), 4) Evaluation scale of the activities of the daily life, 5) Evaluation of the power.Both in the A group and in the B group has been even calculated the relation cost-benefit related at the length of the treatment.Results In each group we have seen an improvement in the score of the patients at the parameters used correlated at the pre- and post-treatment phases, howewer in the group located in the thermal establishment has been underlined a major and significative reduction of the pain sintomalogy, a reduction of the normal periods to the total recovery of the patient and a lower cost to have the rehabilitation cycle (1450 euros against 2880 euros). Particulary the VAS has showed a reduction of the pain up to 70 %, the ROM an increasement of the articular range, returned in some patients to reach the normality, the F.A.C. has improved in all the patients with the autonomy and correct restarting of the deambulation (using canadian sticks), the evaluation scale of the power, has had an average increase of 2-3 points, while the B.I. has showed an increase to 90 points (out of 100), relative and the independence reached by the patient in the normal activities of daily life.Conclusions The theraupetic and biologic effects of the utilised water (the salsobromoiodic have effect antiedemic, antiseptic, antinflammatory and stimolant for the immunitary system) and the utilization of the physical properties of the water (heat, floating, pressure, etc. ) made the thermal hydrokinesistherapy, a kind of rehabilitation of great value in the operated patients of hip and knee prosthesis. The best obtained clinical results compared with patients threated with traditional rehabilitation and the lower costs of this rehabilitation, should recognize (in selected cases which need an assistential duty and technological compatibility) the thermal, as alternative to the structures of the SSN (National Health Service) of the rehabilitation of the patients with frequent orthopedic pathology as arthrosis and ostopeorotis.

What aims for spa therapy treating patients with chronic low back pain patients ? Data of the assessment of a cohort of patients Roques CF, de Boissezon X, Castel Lacanal E, Labrunie M, Felez A, Chatain M [France] Service de médecine physique, CHU de Toulouse.
Roques Christian-FrançoisService de médecine physique, CHU de Toulouse, TSA 50032 31059 Toulouse cedex 9 (FR)+33 607054037roques.cf@chu-toulouse.frThe aims of this paper was to identify the therapeutic aims of spa therapy from data of assessment particularly, differences between men and women and correlations between the different data of assessment.Thirty patients with common chronic low back pain (CLBP) - (15 males, 15 females, mean age 42 years – 22 to 54) have been assessed in this study : a) the gender, age, body mass index,  pain intensity (VAS), pain expression (Saint-Antoine Hospital Pain Questionnaire), anxiety level (STAI), depression level (BECK), disability (EFEIL – French Roland-Morris), fingertip-floor distance ; b) RIII nociceptive reflex ; c) the peak torque of the flexor and extensor muscles of the trunk (Cybex 6000) ; d) the reduction of the Quality of Life (QOL) (Dallas questionnaire) has been measured for the different items gathered in activities of daily living (ADL), social interactions (IS), professional (W), humor (AD).Comparing men and women, we observed only significant differences according to the muscular strength. Pain intensity was only correlated with lumbar stiffness. Lumbar stiffness was correlated with QOL. QOL was also correlated with disability and depression.In this population we observed an unusual link between pain intensity and lumbar stiffness. The QOL was mainly affected by the depression. The muscular impairment was poorly correlated with the other symptoms of the patients. This could lead to discuss the ability of muscular strengthening to improve the situation of the patients.Men and women with CLBP have only a different muscular impairment. CLBP patients present very different and numerous symptoms with uncertain relations. The relations between symptoms and anatomical involvement will probably have to be revised as pain intensity is only related to lumbar stiffness. Humor, stiffness, disability, muscular impairment, QOL present more relations. Therefore, pain, stiffness, mood, muscular strength have to be improved. So spa therapy has to provide the analgesic effects of thermo-mineral products, the softening effect as the mood improvement of immersion and heat, the strengthening properties of exercise (underwater or air exercises) ; but we have to emphasize the importance of education (back school) to manage the back and cope with back pain.

Biology & physiologyRoom Actes4.30 pm - 6 pm
Lectures
Experimental in vivo and in vitro approach of spa and thermal research,a recent bibliographic survey (2005-2008)Jean Cambar [France]Institut du Thermalisme de Dax - Université Victor Ségalen Bordeaux 2
Use of experimental animal or cellular models is a necessary ethically preliminary step to all products in development for future prescription in clinics. The aim of this presentation is to point out some recent examples of such experimental approach, as well in vivo as in vitro, to evidence the efficacy and to explain the action mechanisms of mineral (MW) or thermal (TW) waters. It will be reported some very recent studies (2007-2009) showing clearly in rats, the main experimental animal used, the effects of different MW and TW in some pathologies, as gastro-intestinal, cardio-vascular, rheumatic  or metabolic ones.In normal rats, TW (chloride-sulphur-bicarbonate) reduced plasma ROS (hydroperoxides) production, evidencing the potential anti-oxidant role of thermal water in intestinal physiopathology. Beneficial effect of a TW therapy in the polyethylene cuff on femoral arteries model is shown by attenuate infiltration of inflammatory cells in adventitia, by suppression of neo-intimal thickening in arteries, accompanied by biological marker changes as enhancement of HSP72 expression and oxidative stress suppression. The interest of thermal therapy is confirmed in cardiovascular diseases, especially against the development of atherosclerosis.In the classical experimental model of adjuvant-induced arthritis rat, magnesium rich waters can prevent partly the development of paw edema. Likewise, in the same model, Mg-rich water co-administration with indomethacin can decrease the ulcerogenic response to indomethacin assessed by the total area of gastric mucosa lesions. Mg administration in TM can reduce pain, inflammation and joint damage in rheumatoid arthritis patients.Another experimental study on inflammatory gastro-intestinal disorders demonstrates that a bicarbonate-alkaline MW enhanced gastric emptying and increased small-intestinal and colonic transit. So, thermal water exerts beneficial effects on gastro-intestinal motility in inflammatory agents induced bowel motor dysfunction. Such holistic experimental models permit clearly to precise the cell targets and molecular mechanisms of effects of MW or TW.It is interesting to study the effects of mineral water at both levels, in the whole animal and at cellular level ex vivo. A recent study reports, in rats fed a cholesterol-rich diet, that sulfurous mineral water (versus tap control water) drinking significantly decreases as well plasma total as plasma membrane erythrocyte cholesterol.In vitro models, especially cell cultures, have already provided large validated recognized contributions in toxicology, pharmacology and therapeutics. Fair correlations have been established between in vitro, in vivo and clinical studies. But, the major interest of such in vitro approach remains to precisely study the cell targets and molecular effects of an exogenous substance.  In the literature, some studies have already reported the cellular effects of MW and TW in different in vitro models as human skin, fibroblasts, muscle, bone or cartilage cells. Fair correlations have been established with plasma inflammation circulating markers in arthrosic  patients or with differenciation markers in skin cells  in psoriasic patients.Some recent papers (2005-2009) relating interesting results using in vitro models, especially cell cultures, in thermal research will be presented. These models used different human cell types, as cutaneous (fibroblasts or kératinocytes), immunological (leucocytes or lymphocytes) or articular (chondrocytes or sinoviocytes) for example, permitting so to precise the cellular and molecular targets, and also the mechanisms of MW or TW.  All these in vitro studies demonstrate an indisputable effect of MW and TW on signalisation ways or markers in pathologies. In conclusion, such experimental in vivo, ex vivo or in vitro studies open a complementary way to explain the benefic effects of MW and TW in many acute, chronic or degenerative pathologies as asthma, arthritis and rheumatism, psoriasis or cardio-vascular and gastro-intestinal diseases for example. Such investigative innovative approaches need to be developed and encouraged in parallel and complement to clinical investigations to contribute for the demonstration and explanation of the efficacy of MW and TW.

 Immuno-allergological issues in balneologyM Vitale [Italy]

PapersThe benefits of the Natrium-hydrogencarbonate thermal water on sexual activityAndits Tamas1, Horvath Agnes2 [Hungary]1 - Daily Hospital, Szombathely2 - Markusovsky Hospital, Szombathely
Dr Andits Tamas
Fő utca 7, 9700 Szombathely (HU)+36 94-506-116tomcat43@freemail.hu
The following research draws attention to so far neglected aspects of the thermal water’s effects. Patients with locomotor disorders have been treated since 1985 in the Daily Hospital in Szombathely, Hungary, with complex physiotherapy. One of the effective segments of the therapy is the 33°C thermal water containing Natrium-hydrocarbonate. According to the reports of the patients, the thermal water has increased their sexual activity. In the research we have examined 10 female and 16 male patients with active sexual life. The change in sexual activity has been tested with the Sexual Activity Questionnaire (SAQ). The patients filled out the questionnaire before and after the treatment. The treatment consisted of 15 bathing sessions, each 30 minutes. The data was evaluated by using statistical methods. The results confirm the hypothesis that the Natrium-hydrocarbonate thermal water enhances sexual activity.

Micro-bubble bathing increases the production of insulin-like growth factor-I in the hippocampus, thereby improving cognitive function in miceHarada Naoaki, Okajima Kenji, Ueno Naoto, Nakatsuka Yuji [Japan]Department of Translational Medical Science Research, Nagoya City University Graduate School of Medical Sciences, Nagoya (NH, KO), and Noritz Corporation, Akashi (NU and YN)
Harada NaoakiKawasumi 1, Mizuho-cho, Mizuho-ku, 467-8601 Nagoya (JP)naoha@med.nagoya-cu.ac.jp
Stimulation of peripheral sensory neurons enhances release of calcitonin gene-related peptide (CGRP) from nerve endings, thereby increasing the production of insulin-like growth factor-I (IGF-I) systemically in mice. IGF-I has beneficial effects on the cognitive function and plays an important role in the maintenance of normal skin morphology. Micro-bubbles generated by swirl-type generator has been shown to increase the growth of oysters in the sea, we hypothesized that micro-bubble bathing (MB) increases the production of IGF-I by stimulating sensory neurons. In the present study, we examined this possibility using wild-type (WT) and CGRP knockout (CGRP-/-) mice.Tissue levels of CGRP, IGF-I, and the immunohistochemical expression of IGF-I were increased in the skin and hippocampus in WT mice subjected to 10-min MB at 40°C. Significant enhancement of angiogenesis and neurogenesis was observed in the dentate gyrus of the hippocampus of the WT mice subjected to MB (p<0.01). WT mice subjected to 10-min MB resulted in an increase in the expression of c-fos in the spinal dorsal horn, the parabrachial nuclei, solitary tract nucleus, and the hippocampus. Significant improvement of spatial learning in the Morris water maze was observed in the WT mice subjected to MB. MB also increased dermal levels of CGRP and IGF-I in WT mice. None of the effects were observed in CGRP-/- mice subjected to MB.These observations strongly suggest that MB may increase the hippocampal IGF-I production via sensory neuron stimulation in the skin, thereby improving the cognitive function in mice. Furthermore, these observations raised the possibility that MB might contribute to maintain normal skin morphology by increasing the dermal production of IGF-I.

Aberrant patterns of thermal change in fingers after cold exposure in patients with connective tissue diseasesInokuma Shigeko1, Hagiwara Kiyofumi 1, Yonaha Tomoki 1, Nakachi Shinichiro1, Kobayashi Shoko1, Akiyama Osamu1, Kijima Yasuo2
[Japan]1 - Department of Allergy and Rheumatology2 - Department of Laboratory, Japanese Red Cross Medical Center, Tokyo
Inokuma Shigeko4-1-22 Hiroo, Shibuya-ku, 150-8935 Tokyo (JP)inokuma_shigeko@med.jrc.or.jp
Objectives To elucidate the aberrant response of vasculature in the fingers to thermal stimulus in patients with connective tissue diseases (CTDs).Methods The CTD patients who visited our hospital between Jun. 2008 and Oct. 2009, whose finger temperatures were tested before and after cold stimulus were included in this study. The temperature was determined by infrared thermography. After relaxing in a 25°C room for 15 minutes, skin temperatures at the site proximal to the nailfold (nailfold) and the dorsum of the metacarpophalangeal joint (MCP) of 10 fingers were measured before, immediately after, and 3, 5, 10, 15, 20 and 30 minutes after bilateral hand immersion into 10°C water for 10 seconds. Observed results were globally classified into patterns, mainly on the basis of evaluation of the nailfold temperature level. The normal reference pattern was based on our previous study.Results 132 CTD patients, 122 females and 10 males aged 56.6±15.3 (21-81) were examined. All of these patients had either any complaint suggestive of peripheral perfusion disturbance including Raynaud phenomenon, or anti-RNP antibody, scl-70 antibody or anti-centromere antibody. The classified patterns and patient numbers showing each were I) normal : 27, II) apparently normal : 17, III) rebound : 4, IV) progressive decline : 8, V) delayed recovery : 43, and VI) persistently low : 33, respectively. When comparing the nailfold temperature level among patterns other than III which included only small numbers, that before the immersion was more and more lowered from that in pattern I to that in pattern VI (33.8±0.2℃, 33.2 ±0.6°C, 31.6±1.3°C,  31.4±1.6°C, and 27.6±2.4°C, respectively). In addition, the temperature varied more and more among fingers from in pattern I to in pattern VI. This was also the case for those 3 to 30 minutes after the immersion. Just after the immersion, pattern VI showed the lowest (20.6±1.3°C), but the other patterns had similar levels. The naifold temperature was higher than that of MCP, at any point except for just after the immersion, in pattern I. In contrast, lower temperature of the nailfold at any point was observed in all the patients with other patterns. In contrast to the least temperature variation among fingers in pattern I, it varied much (maximum : >3°C) in all the patients with patterns II, III, IV and V. However, in pattern VI, temperature variation among fingers was even smaller than that in pattern V.Conclusion Aberrant cutaneous thermal change before and after 10°C stimulus at a site proximal to the nailfold in CTD patients included low temperature, lower temperature than that at MCP, delayed recovery, and broken equality of temperature among fingers. The progressively changing patterns could be classified into II) apparently normal, III) rebound, IV) progressive decline, V) delayed recovery, and persistently low patterns ; these may develop one after another, or may be increasingly severe.
References Inokuma, S. et al. Thermal changes of fingers after cold stimulus exposure in normal volunteers. 36th International Society of Medical Hydrology and Climatology, Porto, 2008.

Body core and skin temperature after whole-body cryotherapyZalewski Pawel1, Klawe Jacek J1, Tafil-Klawe Małgorzata2, Weber Piotr2, Peplowski Piotr3, Osinski Grzegorz4 [Poland]1 - Department of Hygiene and Epidemiology, Collegium Medicum UMK2 - Department of Physiology, Collegium Medicum UMK3 - Department of Physics, Nicolaus Copernicus University4 - Nicolaus Copernicus University
Zalewski PawelM. Sklodowskiej-Curie 9, 85-094 Bydgoszcz (PL)+48 525853616 / +48 515447267p.zalewski@cm.umk.pl
Background Body exposure to acute whole-body cryotherapy (WBC) facilitates rapid heat loss which definitely reduces skin temperature. There is a limited bibliographic data which demonstrate empirical research concerning changes of body core temperature after whole-body cryotherapy. The study was undertaken to determine an influence of whole-body cryotherapy on body core temperature.Material and Methods Twenty-five healthy subjects (25 men) participated in this study. The average age was 31,50±5,61 yr, height 1,79±0,05 m, weight 83,70±10,10 kg, BMI 25,90± 2,82 kg/m2, BSA 2,00±0,12 m2, sBP 123,60±11,58 mm/Hg, dBP 77,80±7,30 mm/Hg. All subjects were exposed to whole-body cryotherapy (- 115°C) for 3-minutes. Each subject was provided with a Vital Sense® telemetric monitor – an ingestible pill telemetry system was used to record body core temperature. Registered body core temperature changes were analyzed within the period from 40 min prior to whole-body cryotherapy up to maximum peak of body core temperature circadian rhythm. Body core temperature measurements were collected at 1-min epochs, for statistical purposes whole recording period was divided into 5-minutes intervals and mean value was calculated. During temperature measurements subjects sat quietly in unchanging thermal and humidity conditions.Additionally body skin temperature was measured by using thermographic camera Flir® systems P640. Thermographic registrations were made before ; within first minute after ; 40 minutes, 3 hours and 6 hours after exposure to whole-body cryotherapy. All thermographic measurements were made in normothermic and adequate humidity conditions. Analyzed body thermograms were divided into 28 anatomical areas (marked R01-R28), mean values of each area were calculated by using special software.No anatomical localizationR01 chestR02 abdomenR03 front of right upper-armR09 front of right thighR15 upper backR20 back of right upper armR26 back of right thighR28 back of right calfResultsTemperature mean values [°C]        
AreaBefore WBCUp to 1 minuteAfter WBC 40 minutesAfter WBC3 hoursAfter WBC6 hoursR0132,2814,6930,4733,7534,15R0231,8814,4129,5233,3333,98R0331,6111,0229,5733,1333,58R0931,2614,2929,8431,6131,91R1533,1819,9531,7033,9534,16R2031,3214,9929,1231,7832,79R2632,3118,7030,7532,8432,87R2832,0617,3031,2232,0831,93Core37,1937,1936,7637,1837,36

Observed changes of skin surface and core body temperature were statistically significant (p<0,05). The minimal values of skin surface temperatures were observed just after WBC exposure; minimal body core temperature was recorded 40 minutes after WBC exposure.Conclusion Exposure to whole-body cryotherapy cause rapid decrease in skin temperature, and slight, but significant decrease in core body temperature.

New trends session IIRoom B014.30 pm - 6 pm
LecturePsychosomatic issues and thermal medicineBases, clinical applications, evidenceOlivier Dubois [France] Établissement thermal Saujon 
The main existing references are proposed here to sum up the links between balneotherapy, hydrotherapy and psychiatry.With information on the powerful existing historic reports in hippocratic medicine linking balneotherapy, and medical psychology (therapeutic synergy actions described by the author), topical research work has been carried out over these last years with supposed mechanisms of action, which form here the subject to a synthetic collection of facts.We are setting out the elements of scientific evidence collected concerning the effectiveness of balneotherapy, not to mention hydrotherapy and more generally spa therapy in different areas in the field of psychiatry, along with the DSM-IV, the classification manual, which is the international reference in psychiatry, which, as yet, have barely been subject to assessment.In the field of assessed psychiatric pathologies, particular interest is shown in anxiety disorders, depressive disorders, certain affections said to be psychosomatic, at least in their links with psychiatric affections (stress, anxiety, depression, quality of life,…), as well as sleeping disorders and also benzodiazepine withdrawal. Lastly, we will focus on psychoses and syndromes particularly attributed to agitation, delirium, hallucinations and other behavioral disorders. Similarly, we will   take a bearing of dementia in its evolutive phase with almost similar symptoms (agitation, aggressiveness,…) and have a look at the stress endured by the caregivers who look after these chronically dependent patients.

PapersGynaecological rehabilitation : recent experiences with sulphuric thermal spa water in Harkany, HungaryVarga Peter1,2 & Malmer N1 [Hungary]1 - Dept. of Gynaecology, Harkany Medicinal Spa Hospital  2 - Faculty of Health Sciences, University of Pecs
Varga PeterDept. of Gynaecology, Harkany Medicinal Spa HospitalZsigmondy s.1, 7815 Harkany (HU)+36 72580900 / +36 302170704petervar@t-online.hu
Introduction Thermal medicinal spa waters are known to be beneficial for many gynaecological disorders potentially deteriorating the quality of life of women. The medicinal thermal spa water of Harkany (Southern region of Hungary), discovered in 1823, contains especially well absorbable gaseous compound : carbonyl sulphide (COS) which turns to hydrogen sulphide (H2S) a recently recognised gasotransmitter. Earlier decades’ observations on balneotherapy with this sulphuric spa water alone or in combination with other therapeutic modalities (e.g. mud packing, gymnastic, massage) showed beneficial effects on chronic pelvic symptoms, chronic pelvic inflammatory diseases (PID), postoperative adhaesions, tubal factor infertility or menopause associated vaginal complaints or incontinence. These were reported on an empirical retrospective basis. We, therefore, carried out a prospective controlled clinical trial to measure and compare the efficacy of the medicinal sulphuric water of Harkany (study group) with that of a common salt (sodium chloride) containing bath water (controls) in the treatment of women enrolled into four main diagnostic specialities : 1/ infertility (N=14 study, n=9 control), 2/ endometriosis (N=21 study, n=12 control), 3/ postoperative and chronic pelvic inflammatory disease (chronic PID) or pain (N=53 study, n=31 control), and 4/ menopause associated (urinary incontinence, descended vaginal wall or atrophic inflammation, etc.) (N=32 study, n=14 control) problems. During cure with the exception of water applied all other regimens were identical in both treatment groups. Cumulative Visual Analogue Scale (VAS) scores (from score 0 to 10) based on both the patient’s and the gynaecologist’s (examination findings, US, laboratory tests included) evaluation were registered in the two groups. The changes in patients’ VAS scores were compared and statistically analysed at the time of entering and finishing treatment protocol (in average of 18 days) and at three months check-up.Results The need for pharmaceutical drugs decreased significantly (p<0.001) in the Harkany sulphuric water treated group compared to that of salt water group. In all four diagnostic groups the falls in VAS scores judged by both the patients and examiners showing relief of symptoms or complaints after treatment were significantly more expressed in the medicinal water treated test groups in comparison to controls. This efficacy could also be observed at the three months post-treatment check-up. More than one third of infertile patients with patent tube got pregnant within six months following treatment. During the treatments no side effects were observed and there was no remarkable shift in the investigated laboratory or ultra-sonographic parameters.Discussion Our results confirmed the previous observations and demonstrate the beneficial activity of the medicinal water of Harkany in rehabilitation of gynaecological patients, too. Being familiar with the properties of the water (i.e. it smells) we were aware of the fact that a semi placebo salt-water treatment served as controls. Even though, the balneotherapy with the anti-inflammatory and vasodilatatory effects of Harkany medicinal water, alone or as part of combined therapeutic regimens could be used efficiently for the rehabilitation of these gynaecological disorders but further research is needed to disclose the exact mechanism of its action. It can be presumed, however, beyond the thermal effects, the special effects of   biologically active carbonyl sulphide (COS) turning to hydrogen sulphide (H2S), a sulphide donor agent may play a key role in its immunological, vasoactive, gasotransmitter and anti-oxidant action and thus beneficial health improving effect.

Potentiality of the heat inhalation as the novel method of the whole body warming through the respiratory tract and the lungIiyama Junichi, Miyazaki Shinji [Japan]Kumamoto Health Science University Graduate School of Health SciencesDivision of Health Sciences
Iiyama Junichi325 izumi, 861-5598 Kumamoto city (JP)+81 962752148 / +81 08052437979iiyama@kumamoto-hsu.ac.jp
Thermal stimulation is one of the important factors of hydrology. We can use thermal therapy to treat patients even in case with problems such as severe heart failure.Although, low temperature sauna is a very useful tool to treat such patients, there is no device which is convenient and low cost.We are developing the new device of thermal air inhalation as the novel method of the whole body warming through the respiratory tract and the lungs.Ten healthy male subjects inhaled thermal air at 43~44°C for 12 min. They were covered with cloth material to prevent heat loss from the body surface. We measured sublingual temperature, tympanic temperature, blood pressure and heart rate. Though, sublingual temperature rose up significantly 0.5°C and declined immediately after the inhalation, tympanic temperature rose up by only 0.1°C while inhaling and rose up by 0.2°C after the inhalation. There were no significant changes in blood pressure and heart rate. This time lag between sublingual and tympanic temperature was probably due to the difference of heat diffusion. It was suggested that there was potentiality of the heat inhalation as the novel method of the whole body warming through the respiratory tract and the lungs.

New clinical development in hydrotherapyLoufti Joseph [Canada]
Loufti Joseph12774 Bvd Gouin Ouest, H8Z1W5 Pierrefond, Québecgastromed@hotmail.com
This new trend in hydrotherapy is to explore different ways to use water in the treatment of bodily aches and anxiety. The idea is to gain a sense of relaxation and wellbeing.Some will use the senses of touch like in watsu, while others will use music and colour like in liquid sounds or yoga in water to facilitate the movements and to increase endurance. The last resort is to treat anxiety by sensory deprivation and to see if someone can completely detach himself from surroundings.So we see different approaches ; one relies on the senses to give a feeling of wellbeing and another which cuts completely all contact with the senses and the outside world… So which one is the best approach, it’s very difficult to say, each one is different and some approaches will appeal to people differently depending of their mood, character and personality.In my presentation, I will address these 4 topics :• yoga in water,• watsu is a massage in water,• liquid sound where the music is transmitted through water and colour light is transmitted through air and water, this is the association between colour and sound,• sensory deprivation in a floating tank.In conclusion where are we heading : sensitive deprivation or using our senses to give us a sense of wellbeing ; it is very hard to say, at this stage, which way might be going, both ways perhaps. 

Health benefit of Cacica resort in Romanian area - speleotherapy and hydrotherapy in functional rehabilitationStratulat Ioan Sorin1, Ieţcu Ioan2, Simionca Gheorghe3, Zup Corneliu4, Rădăşanu Vlad1, Andries Angela1 [Romania]1 - Gr. T. Popa University of Medicine and Pharmacy Iasi, CF Clinical Hospital, Rehabilitation, Physical Medicine and Balneoclimatology Department2 - Suceava County Hospital3 - Medical Rehabilitation National Institute4 - Cacica salt mine
Stratulat Ioan Sorin
Universitatea de Medicina si Farmacie Gr.T. Popa Str. Universitatii nr.16, 700115 Iasi (RO)dr_sorin_stratulat@yahoo.com
In this study we present natural factors with proven therapeutic value speleotherapeutic andhydrotherapeutic, from the north-eastern part of Romania – Cacica, Suceava country. The village, only 40 km from the city of Suceava, was founded in 1791 with the putting into operation of the salt mine by the Habsburg Empire.Speleotherapy is done in spaces left open by the salt mine – Horizon I (40 m) and Horizon II (61 m), pathologies treated being those of the respiratory tract (alergic and chronic diseases). Hydrotherapy is performed with saline water resulting from the mixture between 2/3 water from probe 250-300 g/1000 with 1/3 sweet water heated by solar batteries. External pool is used in therapy of chronic rheumatic diseases, post-traumathic sequelae of the myoarthrokinetic system and peripheral neurological diseases. The sedative climate from the base of the mountain covered with conifers and opportunities around the pool are completing in a pleasant and useful way the balneology treatment.The therapeutic effect was certified in 2009 by the National Institute of Balneology from Bucharest which confirmed the quality of physical, chemical and radioactive parameters compatible with the utilization of all therapeutic factors from surface and underground as curative medical indications, functional rehabilitation but also as wellness and reconnecting with the anti-stress natural means.We are presenting the data obtained from a group of patients with traumatic and degenerative osteoarticular diseases investigated in Suceava County Hospital and University of Medicine and Pharmacy Iasi - Rehabilitation and Balneology Clinic in CF Hospital. All this prove that resort Cacica successfully integrates in internal tourism and as hope for the future in the European one as well.

National epidemiologic concerning patients who are excessive BZD consumers so as to undergo an experiment in spa therapySalamon R, Doussau A, Maurice-Tison S, Dubois Olivier [France] Établissement thermal Saujon 
thermes.odubois@wanadoo.fr
Benzodiazepines are by far the most prescribed medicines encountered in the over-consumption of psychotropics in France. This type of medication is efficient, but is not devoid of side-effects especially with the elderly who are particularly likely to engender dependence and iatrogenic effects.On the initiative of the Afreth (French Association for Spa Research) and in collaboration with the Research Unit of the Isped at Bordeaux University, a study has been carried out aiming at assessing patients’ needs in France when over-consuming benzodiazepines by obtaining general practitioners’ opinions on both the needs and therapeutic means which appear to be the most appropriate.The transverse epidemiologic survey was carried out in 2008 through a sample of 2,000 doctors who had been lot-drawn from the National file.286 general practitioners brought information concerning 997 of their patients being treated with BZD on a regular basis.Information concerning the mode and age of their prescriptions were recorded. Cases were examined to decide on the necessity or not whether to offer therapeutic withdrawal or else alternative forms to the seemingly most suitable medication that had been prescribed.Here, we present the results of the survey concerning the general practitioners, making a synthetic analysis.

Protocol for psycho-instructive in-care in spa therapy for therapeutic withdrawal from benzodiazepinesGorwood P, Olié JP, Hergueta T, Dubois Olivier [France] Établissement thermal Saujon 
thermes.odubois@wanadoo.fr
It is a well-known fact in France there is a problem with over-consumption mainly with regards to Benzodiazepines. 11 % of the French are regular consumers of this kind of therapeutics (Cnam 2003). Despite these medicines being efficient, they are not devoid of side-effects particularly as far as elderly subjects are concerned with risks of dependency and iatrogenic effects at stake.From the epidemiologic survey carried out with 300 doctors who assessed their practice towards this excessive consumption of medicine, a group of university experts was formed so as to conceptualize and structure a proposal of specifically adapted care for a 3-week stay in a spa cure for patients presenting excessive medicinal consumption (in quantity and duration) associated with anxiety disorder and confirmation in writing of their determination to stop medicinal consumption.At the same time, a protocol for taking care of excessive BZD consumers was drawn up and submitted to the Afreth (French Association for Spa Research). Its principles shown during this intervention consist in :• Making groups of 6 to 12 patients, excessive BZD consumers,• Structuring and medically supervising the programme to reduce therapeutics,• Carrying out programmes in psychological training by psychologists involved in comportment and behavioural therapy (CBT) based on psychological and informative workshops, relaxation sessions, documents handed out, etc…• Individual follow-up programme with interviews in assessment and motivation,• 6-month telephone follow-up after the cure treatment.The 5 French psychiatric spa resorts decided to integrate this experimental protocol which was set up in 2010 by the AFRETh. The global achievement as foreseen is to be about 8 to 10 groups of 6 to 12 patients in each and a global assessment with as main criterion the evolution in consumption of BZD 6 months after the end of the cure compared to that of the start of the cure.
Friday June 25
Clinical investigationRoom Actes8.30 am – 10 am

Lectures
Clinical investigation in spa therapyPh Ravaud [France]
Quality of life in crenobalneotherapy. A systematic reviewForestier R*, Françon A*, Roques CF** [France]*Centre de recherches rhumatologiques et thermales, Aix-les-Bains* *Service de Médecine physique & de RéadaptationUniversité Paul-Sabatier, Toulouse
Background Many patients across the world use crenobalneotherapy to treat their rheumatic diseases but no synthesis exists on his effect on quality of lifeObjectives  To conduct a systematic literature review on the effect of crenobalneotherapy on quality of life (QOL) in rheumatic diseasesData sources We searched Medline using the following keywords : “quality of life”, “trial” combined with ‘‘spa therapy’’, ‘‘mud’’, “water”, ‘‘radon’’, ‘‘balneotherapy’’, and ‘‘hydrotherapy’’, “shower” and “massage”. We also reviewed the reference lists of articles retrieved by the Medline search and added personnel data. All studies before January 2010 were examined.Study selection Studies that compared crenobalneotherapy or one of his components to any other intervention or to no intervention were selected,Data extraction Quality of life data were extracted by one reviewer from 37 studies (41 publications). Study quality was assessed by a 10-item checklist for internal validity and a 6-item one for external and statistical validity.Data synthesis There is no evidence that a publication bias can influence conclusions.In osteoarthritis, there is high evidence that multiple mineral interventions have a significant effect in people without concomitant treatment but no significant effect in people continuing usual treatment and performing home exercise. Massages are superior to no treatment.In low back pain, there is high evidence that massages and multiple mineral interventions are superior to no treatment.In fibromyalgia, there is high evidence that exercise in tap water + usual care is superior to usual care alone and that thalassotherapy is superior to no treatment.In ankylosing spondylitis, there is high evidence that multiple mineral intervention + home exercise are superior to home exercise alone. In juvenile idiopathic arthritis there is high evidence that water and land based exercises have a similar low effect than land based exercise alone. In RA, there is high evidence than exercise in tap water and land based exercise have no effect and that natural carbon dioxide is superior to artificial carbon dioxide in people receiving multiple mineral intervention and rehabilitation program.Weighed standardized response mean in rheumatic diseases is 0.5, indicating a moderate effect of crenobalneotherapy and his evaluated components.Limitation of the studyMost of the studies are enabled to detect clinical change in pain and function and QOL is rarely the main outcome. QOL outcome have mainly been developed for severe illness and may be not the best tool to evaluate rheumatic diseases.ConclusionCrenobalneotherapy (multiple mineral interventions) seem to improve QOL in most of the evaluated rheumatic diseases (lower limb osteoarthritis, low back pain, fibromyalgia, ankylosing spondylitis, rheumatoid arthritis).Massages and water exercises seem also to have a significant effect. None of the others component of crenobalneotherapy were separately evaluated for QOL.

Drug consumption and crenobalneotherapy in rheumatologyFrançon A*, Forestier R*, Queneau ** [France]*Centre de recherches rhumatologiques et thermales, Aix-les-Bains** Académie nationale de médecine et Université de Saint-Étienne
Objective To conduct a systematic literature review on the effect of crenobalneotherapy on reduction of drugs consumption in rheumatology.MethodsWe searched in Medline using the following keywords : “non-steroidal anti-inflammatory drugs (NSAIDs)”, “analgesics”, “randomized clinical trial (RCT)”, ‘‘spa therapy’’, ‘‘mud therapy’’, “mineral water”, ‘‘balneotherapy’’ and ‘‘hydrotherapy’’. We have selected randomized clinical trials in rheumatologic pathologies that compared crenobalneotherapy or one of its components to any other intervention or to no intervention. ResultsWe found 14 RCTs with assessment of analgesics or/and NSAIDs consumption. In one RCT, on both lumbar spine, knee and hip osteoarthritis, spa therapy versus waiting list significantly reduce at 24 weeks the intake of analgesics and NSAIDs (significant statistical between-group difference). Six RCTs assess analgesics and/or NSAIDs consumption in knee osteoarthritis. Among them, four RCTs show a significant reduction of analgesic and NSAID consumption in spa therapy group compared to control group (significant statistical between-group difference) : spa therapy versus waiting-list, mud pack group versus nylon versus covered mud pack, intermittent balneotherapy versus control group and spa therapy versus ambulatory care. In one RCT, the absence of statistical between-group calculated doesn’t allow to conclude. One RCT with high statistical power shows at 6 months a significant reduction of number of patients with analgesic treatment in the control group (physical exercises alone) versus the study group (both spa therapy and physical exercises). In spite of a better improvement in the pain and function in favour spa therapy, the result of this RCT is conflicting with the results of the other RCTs.In chronic low back pain, two RCTs comparing spa therapy versus waiting list show in favour of spa therapy a reduction of intake of analgesics and NSAIDs (significant statistical between-group difference). In a third RCT the absence of statistical between-group calculated doesn’t allow to conclude.  One RCT in chronic neck pain shows no difference between spa therapy and pulsed electromagnetic field in intake of paracetamol, NSAID or morphinic drugs.In ankylosing spondylitis, two RCTs indicate a significant between-group reduction of intake of analgesics or NSAIDs in favour of spa therapy versus control group.In fibromyalgia, no RCT assess drugs consumption.In rheumatoid arthritis, one RCT shows than baths with radon and natural carbon dioxide are superior to baths without radon and with artificial carbon dioxide significantly to reduce at 9 and 12 months the NSAIDs and analgesics consumption (significant statistical between-group difference).ConclusionMost of the results of RCTs indicate that crenobalneotherapy reduces the analgesics and NSAIDs consumption versus control group in knee osteoarthritis, chronic lumbar pain, ankylosing spondylitis and rheumatoid arthritis. However one RCT shows an opposite result in knee osteoarthritis.

PapersA meta-analysis of spa-therapy for chronic low back pain Roques CF1, Nony P2, Pereira M2, Cucherat M2, Boissel JP2 [France]1 - Service de Médecine physique, Toulouse et Afreth, Paris 2 - cric@t, faculté de Médecine Laennec, Lyon
Roques Christian-FrançoisService de Médecine Physique, CHU de Toulouse, TSA 50032 Toulouse cedex 9 (FR)+33 607054037roques.cf@chu-toulouse.fr
A bibliographical enquiry performed in April 2006 found 48 relevant randomized controlled clinical trials concerning SPA Therapy (i.e. medical balneology using thermo-mineral waters, muds, gases, steams) published in English-speaking journals ; 7 trials gathering 716 patients concerned Chronic Low Back Pain (CLBP).All the patients received mineral balneotherapy in a spa resort ; the treatment was delivered 6 days a week during three weeks in 3 papers, two weeks in the others. The control group received the usual treatment of chronic low back pain except for one paper; in this case the patients received balneotherapy with tap-water. The follow-up survey of the different studies was respectively of 1, 2, 3, 3, 6, 9, 12 months. The assessment was blind in all the papers.The statistical data of the meta-analysis were obtained from the EasyMA programme. The therapeutic effect was assessed using the Relative Risk for binary criteria and the effect size for the continuous data ; an association test was performed and the Cochran Q test was used to assess the heterogeneity.The quality of these 7 papers was assessed using the Jadad’s score (score 1:1 ; 2:3 ; 3:2 ; 4:0 ; 5:1). 4 of the papers had been published in reviews without impact factor ; for the 3 others, the impact factor was respectively : 2.9, 3.74, 5.7.No study was found to be a well achieved trial.40 criteria were statistically assessed, of which 8 concerned several trials.For these 8 criteria we found a relevant effect size and a significant association. A lack of heterogeneity was observed for the reduction of the drug consumption (es=-0.45) and the improvement of the opinion of the patient on his health (es=1.02) ; an heterogeneity was found for the six other criteria : decrease of the pain intensity (es=-0.77), decrease of the pain duration (es=-1.02), decrease of the fingertip-floor distance (es=-0.58), increase of the right (es=-0.42) and left latero-flexion (es=-0.50), increase of the Schöber’s index (es=0.24). Among data obtained from only one trial, 23 criteria showed significant modification and 9 criteria were found without any significant difference.From these data the efficiency of spa therapy for CLBP remains a questionable issue but the relevant data observed could emphasize the need for further conclusive well achieved trials.

Balneological research in HungaryBender Tamás [Hungary]Hospitaller Brothers of St John of God, Budapest
Tamás BenderFrankel L  31, 1013 Budapest (HU)bender@mail.datanet.hu
During the past decades several balneological articles were published in Hungary. About arthrosis there were three double-blinded and one self-controlled studies, about low back pain two double-blinded, in the field of dermatology one study was performed, concerning balneophototherapy. Two basic science balneological studies were published as well (about free radicals and the autonomic nervous system) and another two studies about radon therapy. Four studies were published from Hungary about hydrotraction therapy which is a Hungarian speciality. One study was performed in internal medicine (double-blinded RTC study) and one in gynecology (RTC study). Several Hungarian universities are involved in balneological research. In Hungary there is a Balneological Research Foundation (HBRS) which organises the scientific work in the field of balneology and sometimes covers the express of the research. Now HBRS is going to set up a new Balneological Institute to organise balneological courses, multicentric studies and to keep the connection with international societies. Hungary is very rich in mineral waters, balneological research can be useful not only for the science but also for the economy.

Clinical investigation in France : the AFRETHRoques-Latrille CF1, Tabone W2, Mancret RC3 [France]1 - Scientific committee president2 - Managing director3 - Administrative committee president, Association française pour la recherche thermale (Afreth), ParisCF Roques-Latrille cf.roques@orange.frSPA Therapy is based, in France, on three pillars : the thermal cares delivered to the patients in the spa resorts, the development in new trends, the scientific investigation.The Afreth was created on December 2004 by the union of the representatives of the French SPA Therapy (contractors, spa city mayors, federation of professional associations) ; they supply an annual budget for research of 1,300,000 € and constitute the administrative committee of the association which takes the decision of financial support to the projects declared scientifically relevant. 4 calls for projects have been fully implemented; the studies concerned mainly the actual medical benefit (table 1). The scientific validity was pronounced by the scientific committee (independent and acknowledged doctors and scientists) on the basis of external independent experts’ advices (methodological, clinical and biological sciences from French academic institutions).

AbstractsreceivedEligible projectsFull protocols receivedScientific validityFinancial supportActual Medical Benefit8265603430Security43332Biology73331TOTAL9371664033

Concerning the medical benefit, have been published : RCT on the spa treatment of generalized anxiety (1 trial, 237 patients enrolled) and of knee osteo-arthritis (a multicentric RCT, 462 patients enrolled) with significant results in favour of spa therapy. Are fully implemented and still to publish : pilot RCT on children’s otitis (30 patients) ; overweight (1 trial, 308 patients enrolled) ; pilot cohort medico-economic study (632/720 patients enrolled). Are in progress RCT on the treatment of adults’ rhinosinusitis (1 trial 52 patients enrolled), Rotatherm (shoulder cuff, 190 patients enlisted), Therm&Veine (RCT on venous insufficiency, 400 patients), Pacthe (treated breast cancer, 270 patients), Prisme (metabolic syndrome 170 patients). Is in preparation RCT on venous insufficiency. Are implemented also pilot studies on the spa treatment therapeutic education of the venous patients, psychotropic drugs withdrawal, helpers of patients with Alzheimer’s disease, MAPT programme. The enlistment of the patients could be difficult : public hospitals were not efficient centres for enlisting the patients ;  doctors with a private practice showed a limited power of enlistment ; the best efficient way was to recruit local patients (living near a resort) using the local mass media (papers, radio, TV, posters, ..). So, scientific investigation is essential to demonstrate the medical benefit of spa therapy, have a better knowledge of the thermo-mineral products and of their security. But scientific investigation has to come also with the development of new trends which have to be scientifically assessed since their initiation. France has engaged a significant endeavour in the field of thermal scientific investigation, but now a large and international cooperation in the scientific investigation of spa therapy is needed.

Safety & techniques session IIRoom B018.30 am – 10 am
A new method to produce Legionella pneumophila biofilmsPécastaings Sophie1, Dubourg Karine2, Bergé M3, Roques C1 [France]1 - Laboratoire de Microbiologie industrielle, Université Paul Sabatier Toulouse 3, 35 chemin des Maraîchers, 31062 Toulouse cedex 92 - Institut du thermalisme, 8 rue Sainte-Ursule, 40100 Dax3 - Laboratoire de Microbiologie et Génétique moléculaires, 118 route de Narbonne, Bât. IBCG, CNRS, 31062 Toulouse cedex 9
Pécastaings Sophie Laboratoire de Microbiologie Industrielle, Université Paul Sabatier Toulouse 3 chemin des maraîchers, 31062 Toulouse cedex 9 (FR)+33 562256860 / +33 662334072sophie@pecastaings.net
Introduction Biofilms in water pipes represent a medical hazard. Because of the occasional detachment of cell clusters of mature biofilms, microorganisms, including potential virulent pathogens, are released in the water flow thus causing water quality to deteriorate. Since its identification in 1979, Legionella pneumophila has been frequently isolated in hot water systems (residential water systems, hospitals, air cooling systems). When present in water droplets or aerosols, Legionella can be inhaled and infect the lung macrophages of immuno-depressed patients, thus causing potentially lethal pneumonia. High prevalence of Legionella in water samples often correlates with the presence of biofilms in pipes and storage systems. At this time, little is known about L. pneumophila surface colonization and biofilm formation. Previous studies have shown that in oligotrophic conditions L. pneumophila is able to colonize multispecies biofilms from water systems. However, some authors argue that other microbial species are indispensable for L. pneumophila to multiply in a biofilm in such conditions. Hence, these models involve interactions among multiple species, making them poorly reproducible in vitro for subsequent analysis. More recently, L. pneumophila biofilm formation was studied in a model using a rich growth medium to produce monospecies L. pneumophila biofilms. However, Mampel et al. showed that growth was mostly due to planktonic rather than sessile growth. Also, growth conditions used in these studies could have led to a different biofilm structure compared to that developed in less nutritious conditions. The aim of the present study was to develop a method to grow adherent L. pneumophila as a monospecies biofilm. Methods Three environmental isolates of L. pneumophila were inoculated in 24-well microplates containing the tested growth media. To eliminate planktonic bacteria, the media were frequently renewed. Fixed population of L. pneumophila was monitored by growth on Buffered Charcoal Yeast Extract plates or by quantitative PCR, in order to establish biofilm formation kinetics. Confocal laser scanning microscopy (CLSM) was used to determine the 3-D structure of biofilms. Results Among 9 growth media tested, a medium consisting of a mix of mineral salts and a low concentration carbon source was selected. After 7 days of incubation, biofilms were constituted of 5.75±0.12 log CFU/cm2 and the fixed population remained stable up to 3 weeks after initial inoculation, whichever strain was tested. Quantification was similar by numeration on BCYE or q-PCR, and subsequent analysis showed that inoculum size or medium renewal frequency had no significant effect on L. pneumophila biofilm development.In situ CSLM observations of fixed L. pneumophila stained with Syto9 revealed a typical biofilm structure, comprising cell clusters ranging up to 300 µm. Staining the carbohydrates with a fluorescent lectin indicated that the L. pneumophila biofilm matrix had a specific make-up : clusters or sheets of carbohydrates were scattered between cells instead of constituting a slime in which cells were embedded.

Cyanobacterial production potency as an ecotoxicity test – Application to aquatic toxicology and public healthVarga Csaba [Hungary]Department of Environmental Health, University of Pécs
Varga CsabaSzigeti 12, 7624 Pécs (HU)+36 72 536 394 / +36 20 475 0391chemsafety@freemail.hu
The cyanobacterial overproduction in the natural recreational (surface) waters has widely been studied nowadays by the hydrobiologists. These photosynthetic prokaryotic organisms (formerly : “blue-green algae”) can produce several types of biologically active compounds (toxins) causing health problems in the exposed population. There are no data on the cyanobacterial biomass and toxin production in spa waters, but the possibility cannot be disclosed, predominantly in outdoor basins and pools containing thermal waters. The well-known and most common toxins (cyclic peptides, neurotoxic and cytotoxic alkaloids, and irritant toxins can be determined by chemical analyses or in mammalian (mouse) toxicity test. In order to determine possible hazards of thermal waters under outdoor conditions, a new test is under development.The “challenge”-type test is based on cultivation of cyanobacterial strains in the particular spa waters, under controlled circumstances. Thermotolerant or thermophilic strains with high toxin-production capacity are grown in monocultures supplied with the particular sample of the water in use. (However, mineral content of spa waters will have great impact on the growth rate of cyanobacterial populations). Cultivation is stopped by a standard disinfection process to deliberate intracellular toxins via lyses of cells. The biomass (and toxin-) producing potency of different spa waters can be qualified as compared to the positive control (that is completely supplied) cultures. Decreasing health hazards of the patients/guests, spa waters with high capacity of cyanobacterial (or toxin-) production should be restricted to indoor use.The system developed for spa water samples and described here may also be suitable as an ecotoxicity test in other fields of environmental and human toxicological risk assessment, involving qualification of waste or sewage waters, ground waters or extracts of solid wastes, contaminated sludge, peloid or soil samples.

Microbial ecology of deep hot aquifers in the Aquitaine BasinGregoire P1,3, Fardeau ML1, Guasco S2, Michotey V2, Dubourg K3, Cambar J3, Bonin P2, Ollivier B1 [France]1 – Laboratoire de microbiologie et de biotechnologie des environnements chauds, UMR 180, IRD, Universités de Provence et de la Méditerranée, ESIL case 925, 163 Avenue de Luminy, 13288 Marseille Cedex 092 - LMGEM, UMR 6117, Centre d’océanologie de Marseille, Université Aix-Marseille 2, Campus de Luminy - Case 901, 163 Avenue de Luminy, 13288 Marseille Cedex 093 - Institut du Thermalisme - Université Victor Segalen Bordeaux 2, 8 rue Sainte Ursule, 40100 Dax
Gregoire Patrick Institut du thermalisme 8 rue Sainte-Ursule, 40100 Dax (FR)+33 558561942 / +33 683951723patrick.gregoire@u-bordeaux2.fr
Extremophilic micro-organisms are known to live in harsh physico-chemical conditions including high salt concentrations (halophiles), low or high pH (acidophiles or alcaliphiles), high pressure (piezophiles), cold or hot temperatures (psychrophiles or thermophiles). Most of the ecosystems, in which these organisms are found, are marine salterns, acidic and alkaline springs, together with marine, terrestrial or subterrestrial geothermally heated ecosystems like hot springs, deep-sea hydrothermal vents, oil reservoirs, and deep hot aquifers etc….In France, there are few reports on micro-organisms inhabiting thermals minerals waters and particularly the deep ones. Our research aims to analyse both by molecular and microbiological approaches the microbial diversity of deep thermal waters within the Aquitaine Basin in South-West France (Saint-Christophe spring, depth -149 m, temperature 60.5°C ; SPDX spring, depth -1570 m, temperature 59.5°C).Molecular studies (Bacteria and Archaea) of these springs were performed by cloning and DGGE analysis (Denaturing gradient gel electrophoresis) of 16S rDNA gene. From Saint-Christophe spring, twenty-one DGGE-bands in DGGE (four Bacteria and seventeen Archaea) were obtained and seven clones (six Bacteria and one Archaea) were sequenced whereas from SPDX spring, eighteen DGGE-bands (five Bacteria and thirteen Archaea) were observed and six clones (five Bacteria and one Archaea) were sequenced. Analysis of clones indicated that for both springs, a predominance of aerobic and micro-aerobic bacteria was observed with a peculiar emphasis for hydrogenotrophic organisms pertaining to the genus Hydrogenophilus spp. Anaerobic thermophiles identified by molecular analysis were representatives of the orders Thermotogales, Thermococcales or Archaeoglobales comprising thermophilic / hyperthermophilic microorganisms inhabiting shallow / deep hot environments (e.g. deep-sea hydrothermal vents or oil reservoirs). Besides molecular studies, microbiological approaches revealed the presence of three bacteria which have been already isolated from terrestrial and subterrestrial hydrothermal springs: an aerobic strain closely related to Thermus scotoductus, an anaerobic sulphate-reducing bacterium Desulfotomaculum kuznetsovii isolated from Saint-Christophe spring and an aerobic strain closely related to Geobacillus stearothermophilus isolated from SPDX spring.Three bacteria pertaining to novel genera were also isolated : a thermophilic anaerobic sulphite-reducing bacterium (strain SPDX02-08), and two fermentative strictly anaerobic bacteria (strains D1-25-10-4 and strain GNS-1) belonging to the Chloroflexi phylum.Finally, our results extend the knowledge on microbial diversity existing in deep thermal waters. They should help us in understanding the geomicrobiological processes occurring in deep hot environments and indicate that new thermophilic inhabitants with novel metabolic properties may be still discovered in these extreme ecosystems.Keywords : Extremophilic micro-organisms, microbial ecology, thermal natural mineral water, Aquitaine Basin

Thermophysical and rheological characterization of peloids from several mineral watersMourelle M-Lourdes1, Gómez-Pardo Carmen1, Medina Carlos1, Legido J Luis1, Navia Paloma1, Roman Luis1, Meijide Rosa2 [Spain]1 - Department of Applied Physics, University of Vigo2 - Department of Medicine, University of A Coruña


Mourelle M-LourdesDepartment of Applied Physics, University of Vigo Campus Lagoas-Marcosende s/n, 36310 Vigo (ES)+34 986818701 / +34 696413531lmourelle@uvigo.es
Purpose The applications of the muds in therapies depend on their thermophysical properties. Among theses, those that have bigger influence are the heat capacity, the thermal conductivity and the density. Their rheological properties must be also taken into account as they will determine the easiness of local application in form of hot cataplasms.The main objective of this work is to analyze the thermophysical behaviour of different mixtures of sodium bentonite clay type with several thermal mineral waters and seawater.Materials In previous works we have analyzed the thermal and rheological behaviour of mixtures of several clays with tridistilled water. We have concluded that these properties depend strongly on the water content of the mixture, agreeing with other authors. In this sense, the best results have been obtained for the bentonite that are monomineral clays of the type of the smectites and that possess a great absorptive capacity of water and a high swelling index. In this work we analyze the effect of the mineralization of the water on the thermophysical properties as well as the rheological properties of a peloid. We have mixed a sodium bentonite clay type with different types of water with different mineralization :  thermal water and seawater.Results The results show that the rheological properties of peloids depend strongly on the mineralization of the thermal water. Other thermophysical properties as the heat capacity and the density are less dependent on mineralization but more on the water content of the mixture.

Methods of peat use in balneotherapyUosukainen Harry [Finland]
Turveruukki Oy
Uosukainen HarryP.O. Box 75, 90451 Kempele 2 (FI) +358 400580665harry.uosukainen@turveruukki.fi
This paper contains basic information on the therapeutic uses of peat in baths and in local applications. Peat is formed of plant remains representing the organic soil layer of a mire or bog.The effect of peat therapy is based on the combined influence of physical uplift and high temperature of baths, the antiseptic effects of peat and its biologically active components. Of particular importance in the treatment are the organic, humic substances, which penetrate the skin, influencing enzymatic and hormone activity. The therapeutic effects of peat can be summed up as relaxation of the muscles, purification of the skin and stimulation of metabolic and hormonal activity. The modes of use suggested here are based on practices utilized in Central and Northern Europe. The principal targets for peat therapy treatments are : rheumatism and locomotory problems, neurodermatitis, eczema, degenerative diseases, dermatological diseases, hormonal cellulitis, chronic inflammatory diseases, inflammatory venous thrombosis, prevention of local inflammation, complications of surgery or trauma, gastric ulcer and hyperacidity, infertility and gynecological and urological complaints. People who find slimming difficult for hormonal reasons may benefit from peat therapy as a means of losing weight. Peat therapy also has a general relaxing and stress-reducing effect. Cosmetological peat treatments are usually targeted at dry or rough skin and ageing skin, cases of cellulitis, acne or sebaceous secretion imbalance and other flushing or irritations of the skin, and the outcome should be a more elastic, softer, moister skin. Peat-based hairdressing products are intended to render the hair more elastic and deepen its natural colour. Relief for scalp conditions such as dandruff can also be achieved in this way. Peat can be used by several kind of treatments. Spas have specially constructed bath tubs which can be filled with a suspension of peat and water. The German tradition is to use a mixture of 1/3 water and 2/3 peat. A bath tub will take between 30 and 100 kg of peat, depending on its size and design, the modern trend being to use a bath tub that follows the outlines of the body as closely as possible in order to reduce the quantity of peat consumed. A suitable temperature for a peat bath would be 38–40°C. The recommended bathing time is 20-30 minutes. The temperature of the mixture will drop by only few degrees within that time, on account of the good heat retention properties of peat. A therapeutic effect can be obtained by taking peat baths 2-3 times a week over periods of 3–5 weeks. The patient should take a shower after the bath and then rest for at least half an hour. For body mask the peat mixture should be heated to 42–44°C. About one kilogram of peat is needed to cover the whole body. Before peat treatment the skin should be cleaned and peeled. A thickness of 1–2 mm is sufficient in practice if the peat in fine-grained and easy to spread. Sauna can be used for peat body mask treatment as well. Patient should stay in the sauna for 15–20 minutes in temperature around 60 °C.In cases of degenerative arthritis, rheumatic pains, sports injuries, psoriasis, haematoma etc., a local poultice can be applied. The peat can be spread on the area concerned in a thick layer, so that it will remain warm for a long time. A treatment will normally last 20 minutes, but in some cases, e.g. for arthritic pains, the poultice can be left in position for several hours if well protected with plastic foil, even overnight. When the feet and hands peat are applied, the treatment area should be wrapped in plastic bags for protection and placed in a 40–43°C water bath. Face masks need peat supplied especially for this purpose. Warm water can be added to the peat if necessary to make it easier to spread, and the skin should be cleaned or peeled beforehand. The peat should then be spread on the face and neck and covered with a cloth or with a thin plastic film. Peat can also be used as an eye poultice, for relieving stress to the eyes and surrounding musculature.For hair rub peat vigorously into the hair and scalp and allow it to stay preferably for 30–40 minutes. Rinse off with water alone. The treatment is more effective if the peat is heated to 40–44°C or if the whole process takes place in sauna. Peat shampoos are available on the market, but it is always possible to use peat alone. The hair will be just as clean, light and well-washed as with the finest chemical shampoos. Other methods of peat cure are peat tampons used in the treatment of infertility, for post-operative gynecological purposes and for eliminating vaginal yeasts in cases of inflammation. Peat can also be used for cryotherapy, e.g. in cases of acute inflammation, tendon injuries, swellings and rheumatic pains. The compress should then be at a temperature of around +2 °C and be applied for 20–30 minutes.

Clay and clay minerals in medical hydrologyGomes Celso [Portugal]Research Centre “GeoBioTec” of FCT (Foundation for Science and Technology), University of Aveiro
Gomes CelsoUniversity of Aveiro, 3810-193 Aveiro (PT)+351 370200 / +351 917554675cgomes@ua.pt
The use of minerals by humans for medicinal and wellness purposes is most probably as old as mankind, and within minerals clay due to its ubiquitous occurrence in nature and easy availability was the first to be used, and is still used worldwide. Clay minerals, hydrous phyllosilicates, are the fundamental constituents of clay, and the varied typology of the existing clays, in terms of properties and applications, essentially depends upon the structural and chemical specificities of the various existing clay mineral species.Within the various naturotherapy processes and methods some involve minerals (latu sensu), such as geophagy, mudtherapy, peloidtherapy or pelotherapy (in short), halotherapy or salt therapy, psammotherapy or arenotherapy, and oligotherapy. Geophagy, deliberate soil-eating, has been observed in all regions of the world since antiquity. Also the consumption of edible clays suspended in water is a common practice in some communities to combat digestive diseases such as : diarrhoea, enterocolitis, colopathy, and gastrointestinal ulcers, and still as source of bio-essential trace elements. Mudtherapy and pelotherapy, in particular, involve the use of clay mineral-bearing materials called mud and peloid.There is a close relationship between the natural resources, clay and water, the latter being essential, through the interaction with the rock-forming minerals, for the formation of the former. On the other hand, water acts as the vehicle that transports in suspension, the fine clay particles and provides their deposit. Also, there is an ionic interchange between clay and water, in a degree dependent upon clay global electric charge and ion exchange capacity, and water chemical composition. Clay and clay minerals are fundamental constituents of the so-called mud and peloids. Mud (mixture of fine grained and plastic geologic material and water from spring, lake or sea, able to exhibit more or less plasticity) is used for topical applications as it occurs in certain geosites of the natural environment. As a rule mud applications do not involve medical counselling and accompanying.Peloid is a term of current use in Medical Hydrology, peloids being of common use inside Thalassotherapy Centres, Thermal Centres and SPAs, for the therapy or healing of certain dermatological and muscular-skeletal affections. Peloid is a final product (as a rule it is the result of a preparation process called maturation) and is constituted of a solid component (inorganic or mineral and organic) and of a liquid component (sea water, salted lake water, spring water, either thermal or not thermal), and certain additives, inorganic or organic, could be added. Peloids can be classified into two major groups ; essentially inorganic peloids and essentially organic peloids, depending upon the relative content of the inorganic and organic components.Clay and clay minerals are fundamental constituents, particularly of the essentially inorganic peloids, and their therapeutic functions mainly depend upon particle size distribution and composition (mineral and chemical). Clay minerals typology is a major conditioning factor of peloid relevant properties : capacity of adsorbed/absorbed water retaining, capacity of heat retaining and heat diffusiveness, plasticity, adhesiveness, and spreading capacity. Maturation improves the properties of the natural peloid.The nomenclature of the essentially inorganic peloids, based on their geological origin, mineralogical and chemical composition, and physical properties, comprises the following terms : clay, mud, fango or thermal mud, and slime or lodo. The specificities of each one of the peloids referred to will be discussed.Clay and clay minerals also participate, although in small quantities, in the essentially organic peloids. Such happens in the case of the natural products named turf, sapropel, and biofilm or bioglea.Peloids are used to accomplish the following purposes : 1. Thermal treatment - peloids are considered natural medicines having analgesic and anti-inflammatory actions that should be applied under medical prescription ; 2. Cosmetic treatment - peloids are interesting for cosmetic applications due to their concentration in oligoelements and biologic substances, and to their hydrating and absorbing capacities. Naturally, dermal absorption is the pathway for the incorporation of those bioactive elements and compounds into the human body.Finally, only in the last two decades researchers have been looking for scientific explanations for the relevant properties (physical and chemical), application methodologies, health benefits, and counter-indications of peloids whose healing properties had been empirically recognized. There is no doubt that the well informed use of the appropriate clay, mud, fango, and slime or lodo (each one of these material is unique, different types can respond differently in the human body, and differently from body to body), for internal or external applications, can provide cure or temporary and satisfactory health benefits.

Specificity, legislation and control of natural mineral waters used in thermalism (French medical hydrotherapy centres) Popoff Georges [France]
Georges Popoff138 avenue Victor Hugo, 92140 Clamart (FR)+33 1 79 46 86 80 / +33 6 21 43 03 21gepopoff@numericable.fr
Waters used for hydrotherapy in French medical hydrotherapy centres are legally called Natural Mineral Waters (NMW). Sometimes they are called Thermal Waters but this denomination is a little confusing with hot (drinking) waters.There is no legal specific definition of NMW used in spas ; the only definition is the European definition for bottled NMW (directive EC 2009/54).Natural mineral waters have their own specificity that leads to differentiate them from any ordinary water. A NMW must have properties beneficial to health and meet certain stability requirements of chemical composition, groundwater origin and have a great original purity.This is not the chemical composition of water that determines whether or not it will be classified as mineral water, but the clinical record assessed according to strict rules developed by the Academy of Medicine. Water should be a characterization and a thorough study of its components. Those waters are very complex, the various dissolved species remaining in balance against each other.It is also clear those certain types of mineral waters, as sulphide waters, chloride waters and sulphate waters, because their components predispose for use in thermal treatment of respiratory or metabolic disorders internal. But it appears only as a presumption of efficiency.Strict control of water and sanitation facilities in their care provides a high level of safety.

Drinking mineral watersRoom Actes10.30 am – 12.30 am

Lectures
Drinking mineral waters - State of the artChristoph Gutenbrunner [Germany]Department for rehabilitation medicineInstitute for balneology and medical climatology, Hannover
Mineral water drinking is one of the main modalities to use natural resources in health resorts but outside health resorts too. Looking at the concepts behind this intervention, the following mechanisms have to be taken into consideration :• effects of water and minerals on the mucosal surface of the gastro-intestinal tract,• secondary reaction of gastro-intestinal motility and release of gastro-intestinal hormones and mediators,• pharmacological actions of minerals after absorption influencing acid-base-balance and other metabolic functions,• substitution or supplementation of trace-elements and minerals,• effects on kidney function as well as on mucosa and motility of the urinary system,• effects and urinary composition with respect to the risk of stone formation and other urinary diseases.For drinking mostly mineral waters with medium and high electrolyte concentration are used. In Germany, threshold of the minimum content of effective minerals have been defined, these include Calcium, Magnesium, Sulfate, Bicarbonate and Carbon dioxyde as well as some trace-elements.Many studies show that many functions, functional adaptation, can be evoked by periodical drinking of mineral water e.g. in renal and intestinal functions as well as in circulatory regulation and metabolic functions. However, the clinical relevance still is unclear. Most studies published in the eighties and nineties of the last century deal with mechanisms and short-term physiological effects. Searching for clinical evidence for the efficacy of mineral water drinking cures, there are only a few studies published on the effects of drinking cures as such, and most of them do not refer to randomized controlled studies. In Medline from 2000-2009 a total of 18 papers reporting about clinical studies are available (some of them with more than one parameter) dealing with functional bowel syndromes and gastric motility (8 papers), effects on lipid metabolism (4), Calcium, Iron and Fluoride-substitution (3) as well as on renal stone formation risk (4). As the knowledge on physiologic effects of mineral water drinking is high and at least some clinical studies are available, it is promising to evaluate clinical effects in randomized controlled trials. 

From drinking mineral water to the modern nephrology :the exemple of EvianViviane de la Gueronnière [France]
PapersBottled natural mineral water and health Maraver Francisco, Morer C [Spain]Chair of Medical Hydrology – School of Medicine, UCM, Madrid 
Maraver Francisco
Chair of Medical Hydrology – School of Medicine, UCM, 28040 Madrid (ES)hidromed@med.ucm.es
Introduction The per capita bottled water consumption in Spain reached the 123 litres in 2008, a total of 5.562.506.291 litres, of which 5.330.134.101 (95,8 %) were natural mineral water. The water regulations by the European Commission Directive 2003/40/CE of 16th May, 2003 and RD1.744/2.003 of 19th December, establish not only the biological healthiness but also the underground stratum or deposit origin of this water. This later characteristic makes the difference with regards to tap water because it means that its nature is invariable thoughout time due to the fact that external conditions do not affect the nature of the water. The law demands the protection of the original purity of the aquifer against any contaminating risks. The bottling process is done at origin and may not undergo any chemical or microbiological treatment. Only under certain conditions and always with prior authorization may physical procedures be applied to separate unstable elements. For this reason, only natural mineral water is authorized by law to have the physico-chemical composition on the label.Objectives The object of this paper has been to study the physical chemical composition of Spain’s most common natural mineral bottled waters paying special attention to its dry residue and ionic content : Sodium (Na2+), Calcium (Ca2+) and Magnesium (Mg2+) and Sulphate (SO42-) and Bicarbonate (CO3H1-) as well as its possible interest from a nutritional or health point of view.Material and Method One hundred analytical studies of different Spanish natural mineral waters have been the studied material. The methodology has been to sort them out from the highest content to the lowest (according to the specific requirements for the labelling of natural mineral water) : first the dry residue and then bicarbonate, sulphate, calcium, magnesium and sodium.Results The waters’ ionic composition and their total mineralization is determined by the analytical studies :• Nine of the 100 waters studied, according to the dry residue, are of high mineralization (more than 1.500 mg/L dry residue) ; sixty six are oligometallic or low mineralization (less than 500 mg/L dry residue) and five are very low mineralization (less than 50 mg/L dry residue).• Ten are bicarbonated (more than 600 mg/L bicarbonate).• Eleven are sulphated (more than 200 mg/L sulphate).• Six are calcium waters (more than 150 mg/L calcium).• Seven are magnesium waters (more than 50 mg/L magnesium).• Twelve are sodium waters (more than 200 mg/L sodium).• Sixty four contain less than 20 mg/L sodium and therefore may be indicated in low sodium diets.Conclusion Bottled natural mineral waters in Spain are very different and offer a wide range of possibilities due to their different sources and composition. The consumer can choose the natural mineral water most beneficial to his/her health according to the mineral nutrients and oligoelements that appear in the chemical analysis on the label.Key words : natural mineral water, drinking mineral water, minerals, health

Scientific investigation and drinking mineral water in France Viviane de la Gueronnière [France]

Chronic ingestion of a hypersaline sodium-rich carbonated natural mineral water on an animal model of the metabolic syndrome - effects on blood pressure and plasma metabolic profileAlmeida C1, Araújo JR1, Monteiro R1, Severo M2, Guimarães JT1, Azevedo I1, Martins MJ1 [Portugal]1 - Department of Biochemistry 2 - Department of Epidemiology, Faculty of Medicine, University of Porto
Martins Maria Jo,
Alameda Professor Hernani Monteiro, 4200-319 Porto (PT)+351 225513624 / +351 914052353mmartins@med.up.pt

The metabolic syndrome (MetSyn) consists of a constellation of co-associated metabolic abnormalities such as insulin resistance, type 2 diabetes, dyslipidaemia, hypertension and visceral obesity. This syndrome occurs worldwide, at an epidemic rate, with frightful consequences for human health.Its exact aetiology remains unclear, but seems to result from complex interactions of genetic, metabolic and environmental factors ; diet is of central importance. Some minerals, in which the current western diet is deficient, have been proposed as protective onto the MetSyn. Mineral waters are rich in some of these minerals, which are highly bioavailable. On the other hand, there is a substantial increase in dietary fructose consumption, which has been associated to some adverse metabolic changes observed in the MetSyn.In this regard, the fructose-fed rat is a common animal model of diet-induced MetSyn.  Different rat strains, with distinct fructose ingestion protocols, have been used, but all of them were successful to induce (some of the) MetSyn features.In the present study, the effect of a hypersaline sodium-rich carbonated natural mineral water (HSRCNMINwater) was tested in Sprague-Dawley fructose-fed rats (10 % fructose in drinking solution) for 8 weeks. Three animal groups (n=7 in each) were included in the study: a) rats drinking tap water (CONT), b) rats drinking 10 % fructose in tap water (FRUCT) and c) rats drinking 10 % fructose in a HSRCNMINwater (FRUCTMIN). All animals had ad libitum access to control standard laboratory chow diet and to one of the 3 different drinking solutions.The following parameters were evaluated for each animal group : • a) body weight, food and fluid ingestion (once a week) ; • b) blood pressure and heart rate (once a week) ; • c) plasma glucose, insulin, lipid profile and C-reactive protein (at the end of the protocol).Animal body weight increased over the 8 weeks-period in both FRUCT and FRUCTMIN when compared to CONT (p<0.001), without differences between FRUCT and FRUCTMIN.Time evolution of fluid ingestion revealed an increase for FRUCTMIN and a decrease for FRUCT : only FRUCTMIN values [with (p=0.047) and without (p=0.015) body weight adjustment] were significantly different from CONT values. FRUCTMIN fluid ingestion values were higher than FRUCT values [with (p=0.002) and without (p=0.003) body weight adjustment]. Food intake during the experimental protocol was similar between CONT and FRUCT animals groups ; FRUCTMIN rats showed a tendency to reduce their food ingestion when compared to CONT (p=0.119 and p=0.033) and to FRUCT (p=0.049 and p=0.077) animals, with and without body weight adjustment. However, altogether, these time evolution patterns for both parameters did not induce, week by week, significant differences in fructose ingestion [(fructose in fluid + fructose in food)/animal body weight)] between FRUCT and FRUCTMIN rats.Systolic blood pressure increased with time in both FRUCT [with (p=0.006) and without (p=0.004) body weight adjustment] and FRUCTMIN [with (p=0.051) and without (p=0.047) body weight adjustment] groups when compared to CONT. Heart rate was elevated in FRUCTMIN when compared to CONT [with (p=0.056) and without (p=0.038) body weight adjustment] with time. A tendency to increased diastolic blood pressure values over CONT was observed for FRUCTMIN [with (p=0.065) and without (p=0.057) body weight adjustment] with time. For these 3 parameters no significant differences were observed between the two FRUCT groups. Interestingly, fructose increased plasma insulin, glucose and triglyceride levels and mineral water supplementation reduced that effect, with body weight adjustment ; although statistical significances were not always reached for all parameters and treatments. Plasma insulin and glucose levels were similar for CONT and FRUCTMIN groups. Plasma total cholesterol and C-reactive protein levels were not modified by treatments. FRUCT group showed plasma insulin levels higher than CONT (11.317 vs 7.472 µg/L ; p=0.033) and a trend to be higher than FRUCTMIN (11.317 vs 7.969 µg/L ; p=0.066) groups. Although not statistically significant, plasma glucose doubled in FRUCT relative to CONT (3.24 vs 1.61 g/L). Plasma triglycerides were elevated in FRUCT when compared to CONT (2.61 vs 1.46 g/L ; p=0.023), but not with FRUCTMIN (2.61 vs 2.17 g/L ; p=0.364).Interestingly, (liver weight)/(body weight) ratio was elevated in FRUCT when compared to both CONT (0.040783 vs 0.031780 ; p<0.001) and to FRUCTMIN (0.040783 vs 0.035480 ; p=0.004). FRUCTMIN (liver weight)/(body weight) ratio was higher than CONT (p=0.053).In conclusion, FRUCT rats exhibited some of the metabolic syndrome features such as increased blood pressure, (liver weight)/(body weight) ratio, plasma insulin and triglyceride levels when compared to CONT rats. Ingestion of HSRCNMINwater did not aggravate any of these metabolic syndrome features. In fact, some of them were improved by HSRCNMINwater ingestion.

Effects of bicarbonate-alkaline mineral water Cabreiro Única in functional dyspepsiaMeijide-Failde Rosa1, Blanco-Lobeiras Mª Sinda2, Rivas-Lombardero Enriqueta2, Pazo-Paniagua Concepción2, Suarez-Alén José2, Martínez-Bravo Julián2, Suarez-Quiroga Mª Jesús2, Bugallo-Rivas Mª José2 [Spain]1 -  Medical Hydrology. Department of Medicine - University of Coruña2 -  Physical doctor Health Galician Service Coruña  
Meijide-Failde RosaUniversity of Coruña, Campus de Oza s/n, 15006 Coruña (ES)+34 606967694rmf@udc.es
Background Dyspepsia is a chronic disorder of the digestive tract that affects 25 % of the population and causes large numbers of medical consultations with a significant decline in the quality of life. The results of drug treatment are unsatisfactory, with very limited effectiveness, partly to improve symptoms in most cases. Antidyspeptic properties of mineral waters have been based on empirical data but clinical studies suggest that ingestion of water rich in minerals, notably the alkaline bicarbonate improves gastric secretory functions, stimulates gastric emptying and improves motor and secretory activity of the gastrointestinal tract decreasing dyspeptic symptoms and improving quality of life of patients. The mineral water Cabreiro Única® (Spain) is an alkaline bicarbonate water, characterized by a relatively high content of bicarbonate, sodium, carbon dioxide, silicon ions besides calcium, magnesium, lithium and fluoride. That mineral water has been used in an empirical way for over 100 years to improve the functional gastroduodenal disorders.The aim of this study was to assess the influence of the ingestion of a natural mineral water from Cabreiro Única® sodium bicarbonate strong mineralization on digestive symptoms and quality of life in patients with functional dyspepsia.Patients and method We conducted a randomized, masked, controlled in 36 patients (19 treatment, 17 control) of mean age 49 years diagnosed with functional dyspepsia according to Rome II criteria were randomized to treatment group who ingested for 12 weeks 750 -1000 Ml of water daily Cabreiro Única® (Dry residue : 1518 mg/L, Bicarbonate : 1616 mg/L, Sodium : 545 mg/L, Potassium : 50 mg/L, Calcium : 21 mg/L, Carbon : 1200 mg/L) and control group of low spring water slightly carbonated mineralization (Dry residue : 96 mg/L, Bicarbonate : 23 mg/L, Sodium : 6 mg/L, Potassium : 1 mg/L, Calcium : 4 mg/L). We studied the severity of dyspeptic symptoms evaluated from 1 to 5 : epigastric pain, retrosternal heartburn, postprandial heaviness, bloating, gastric alitosis, nausea. Using the validated questionnaire of quality of life associated with dyspepsia, “Dyspepsia Related Health Scales” studied the impact on quality of life before and after 12 weeks of intervention included in a scale of 1-10 current pain intensity compared with the last three months due to inability to perform activities of daily living, to relate and work, and satisfaction with health with four items rated 1-5.Statistical analysis A descriptive study of the variables included in the study. Qualitative variables are expressed as absolute values and the estimated percentage of 95 % confidence interval. Quantitative variables were expressed as mean ± SD. The comparison of means test was performed with the Student t-test or Mann-Whitney U as appropriate after testing for normality with the Kolmogorov-Smirnov test. The association of a qualitative variable with chi square. To determine the clinical relevance relative risk was calculated.Results Clinical results All analyzed symptoms improved significantly in the group treated with Cabreiro Única® water after treatment. In the control group was also observed a decrease in the score given to different symptoms, but this decline has been significantly lower this more apparent still in pain (-44.6 % treatment group -25.5 % control group, p=0.029), followed by retrosternal heartburn (-39.2 % treatment group, +3.04 % control, p=0.039).Quality of life results In the current pain intensity with respect to that suffered in the last 3 months, there is improvement in the two groups this decrease was more marked in the intervention group (-70.6 % versus -53.0 %. P=0.029). As for disability due to pain, there is a decrease of -64.3 % in the intervention group and -7.2 % in the control group (p=0.066). Regarding satisfaction with health, there is an improvement in both groups, the difference being more marked in the intervention group (-64.3 %) than in the control group (-7.3 %), being also the difference close to statistical significance (p=0.09).Conclusion Our results indicate that regular intake of 750 cc/day Cabreiro Única® cause an improvement of dyspeptic symptoms and quality of life in patients with functional dyspepsia.

Fiber and L-Carnitine enriched mineral water intake in weight control therapy :  Effects on body composition and metabolic parameters in overweight patientsRomera Cristina1, Torres Juan M1, De La Fuente Pedro1, Serrano Pilar1, Larrarte Eider2, Cantera Itiziar2, Sanz Emilio2, Brandao Tiago3 [Spain]1 - Clinical Trials. Quantum Experimental. Madrid 2 - Clinical Trials. LEIA CDT  Foundation. Txagorritxu Hospital. Vitoria   3 - Grupo UNICER
Romera CristinaAvda. M-40, Portal 17. Of 69. Alcorc 8925 Madrid (ES)+34 914855347 / +34 653 95 92 40cromera@quantumexperimental.es
Overweight and obesity are metabolic disorders characterized by an excessive energy accumulation in the organism in the form of fat, which leads to an increase in body weight according to sex, age and height. These disorders are usually linked to different pathologies, such as diabetes, dyslipemia, hypertension, etc. In last years, the incidence of these disorders has reached 50 % of adult population in Spain, according to SEEDO data. This relationship between obesity and the increase of pathology risk has caused an increase in consumer’s demand of products or drugs that allow them to overcome this situation and improve not only their appearance but their health. In that context is interesting the development of products that, together with a modification in diet and life style, allow getting a decrease in BMI and an improvement in parameters associated to overweight and obesity.In this context, water intake has been proven to play a main role in a healthy life way of life, being capable of modify some risk factor of cardiovascular diseases as has been demonstrated in some clinical studies. The addition of functional ingredients with proven effects over cardiovascular risk factors to water could improve the beneficial effects of water alone.Objective The aim of this study was to evaluate the effect of a fiber and L-Carnitine enriched mineral water – Vitalis Elegante - as adjuvant of a weight-control therapy on overweight patients.Methodology A double-blinded, placebo-controlled, randomized clinical trial was carried out, in which 40 overweight persons were enrolled. They were indicated to follow a hypocaloric diet during 56 days, supplemented, in one group, with 1L per day of Vitalis Elegante, while the other group was supplemented with 1L per day of mineral water. During the intervention, changes in weight, waist perimeter, glycaemia variability and LDL-cholesterol, were determinate.An Intention to Trear analysis was carried out, and differences were considered statistically significant if p<0.05.Results and Discussion 40 overweight volunteers (BMI values between 25,1 and 29,9 kg/m2) were included in this trial, 17 women and 23 men. The average age was 37.25±4.97 years old.The volunteers were randomly assigned to two experimental groups. One of the groups received placebo (mineral water), while the other one received enriched mineral water. In the placebo group 3 drop-outs were reported, and a volunteer was withdrawn by the investigator due to non-compliance to treatment, while in the Vitalis Elegante group 3 exclusions were reported. All the volunteers were excluded for not following the treatment.Both, Vitalis Elegante and placebo were effective in the reduction of several measures related to overweight, not having found statistically significant differences between them as regard to evolution of parameters during the treatment, not being possible to determine the effect of active ingredients (fiber and L-carnitin). However, we found some interesting results.Only the group supplemented with Vitalis Elegante was able to decrease the waist perimeter and the tricipital fold in comparison with basal values, what did not happen in the group supplemented with placebo.Other interesting results were related to the downward tendency observed in fasting glycemia values and the quick statistically significant decrease of LDL levels, faster in Vitalis Elegante group than in Placebo group.Regarding to safety of both experimental treatments, it was evaluated through the assessment of hepatic and renal function, not showing differences between treatments, neither between initial and final values in each group.Taken together, these data show that Vitalis Elegante could contribute to the improvement of weight control used at the moment.

Bottled mineral waters in Turkey : friend or foe ? Karagülle Mine, Gürdal Hatice, Aldinç Fulya, Karagülle M Zeki [Turkey]Department of Medical Ecology and Hydroclimatology, Istanbul Medical Faculty, Istanbul UniversityZeki Karagüllemzkaragulle@tnn.netObjective The belief on positive health effects of drinking mineral waters is recently being counter balanced with the fear of adverse effects of their mineral ingredients especially sodium in Turkey. On the other hand it is observed that the mineral water consumption in Turkey has increased in recent years. The amount of consumed mineral water has increased from 2.2 L/year/person (in 2001) to 6 L/year/person (in 2007). We aimed to evaluate the bottled mineral waters produced in Turkey in terms of mineral composition and main mineral levels and to review their possible beneficial effects on human health. Methods Licensed bottled mineral waters produced in Turkey were analyzed in terms of 11 chemical parameters at Balneology Laboratory in Istanbul Medical Faculty, Medical Ecology and Hydroclimatology Department. Based on internationally accepted criteria, the results were evaluated and the waters have been classified according to their mineral ingredients. In the light of the published scientific studies with similar types of mineral waters their potential health effects have been reviewed. Results Total 35 brands of mineral waters are being bottled in Turkey and 24 of them have been included in this review. 19 of them have a total mineral content higher than 1000 mg per litre while 5 have less than 1000 mg per litre.  Calcium content of 5 of the brands is higher than 300 mg/L, the amount determined as the level for Calcium-containing water. Moreover, 6 of the 24 brands contain more than 100 mg/L magnesium, the upper limit for magnesium content. Most of the mineral waters are having low sodium content ; sodium-free (4 waters), very low sodium (6) and low sodium (12) types. 6 of the analyzed bottled mineral water types have fluoride levels higher than 1 mg/L, and 3 have more than 2 mg/L. Bicarbonate levels are higher than 1300 mg/L in 12 bottled mineral waters. Only 1 of bottled mineral waters have high sulfate content (>800 mg/L). The carbon dioxide content of the water types varies between 5280 mg/L and 9812 mg/L. Conclusion Bottled mineral waters in Turkey may have beneficial effects on human health considering their rich chemical ingredients, namely calcium, magnesium and bicarbonate. There is a need to inform and educate the different population segments about the potential health effects of consuming mineral waters. Public relation campaigns may play a significant role to increase the awareness of people about the healthy characteristics of mineral waters bottled in Turkey hence the increase of mineral water consumption of Turkish population.
Corporate communicationThermes d’Évian (Danone company)
This session receives the support of thermes d’Évian

Musculo-skeletal session IIRoom Actes2 pm – 4 pm

LectureSpa therapy and inflammatory rheumatic diseasesState of the art Shaul Sukenik [Israel]Soroka University Medical Center, Faculty of Health Sciences Ben - Gurion University of the Negev
Rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) are the most common inflammatory rheumatic diseases. The introduction of new disease modifying drugs, in particular the biologic agents, has improved the prognosis of patients significantly. In this lecture, I shall review randomized prospective controlled studies that have been published in the English literature,The lecture will focus on conclusions based on these studies, relating to the effectiveness of balneotherapy in the treatment of these diseases. Future studies that can help fortify these conclusions will be proposed.Rheumatoid Arthritis RA is the most common inflammatory arthritis, affecting approximately 1 % of the adult population worldwide. This potentially crippling disease reduces survival and most importantly compromises quality of life in most patients. The 5 prospective randomized controlled studies reported in the English literature are summarized in Table 1. 
Table 1. Rheumatoid arthritis : prospective randomized controlled studies

OutcomePrimary end pointsFollow-upmonthsDurationdays
N
Mode of therapy
Author
PositiveVas-pain AIMS Scale
6
15
60
Radon baths vs CO2 baths
Franke (5)

PositiveRichie indexNo active joints

3

14

30
Dead Sea vs table salt (NaCl)
Sukenik (2)
PositiveRichie indexNo active joints

3

14

40
Mud vs sulfur vs mud + sulfur
Sukenik (1)Mild ImprovementRichie index
6
14
41Mineral baths + mud vs tap waterElkayam (3)

PositiveRichie indexNo active joints

3

12

36
Dead Sea water vs sulfur vs Dead Sea + sulfur
Sukenik (4)



199



The most important conclusions that can be drawn from these studies are : A. Clinical improvement lasting up to six months was observed in most of the clinical parameters assessed. B. The number of patients in most studies is relatively small and the clinical parameters used to assess disease activity are outdated and unacceptable for present and future studies. None of the patients received any of the new biologic agents, which are the most effective medications available today for RA patients C. There is no way to determine the preferred duration of therapy, the optimal treatment modality, or whether combination therapy is necessary to achieve a maximal effect.  D. Balneotherapy is safe and can be used even during periods of severe and active inflammation. E. Clinical improvement is usually not associated with concomitant improvement in laboratory indices of inflammation such as ESR and CRP. F. The mechanism/s of action of balneotherapy is/are basically unknown and there are no basic science studies that assess the effect of balneotherapy or animal models of arthritis. G. Cost-effective studies comparing balneotherapy to therapy based on the new biologic agent are needed. H. Clinical trials on patient populations with relatively early disease, before the occurrence of permanent damage, are needed. Early spa therapy may improve the outcomes.   
Ankylosing SpondylitisAS is a chronic inflammatory disorder that primarily affect the spine, the axial skeleton and the large proximal joints of the body. The prevalence of AS in the general population is between 0.1 % and 0.6 %. A distinctive feature of AS is its tendency for ossification and ankylosis of the spine and involved joints. The typical presentation is inflammatory back pain of insidious onset and morning stiffness that improves with physical activity. Until recently therapy was based on non-steroidal anti-inflammatory drugs (NSAIDs) and old disease modifying anti-rheumatic drugs (DMARDs) such as sulphasalazine. The introduction of biologic agents, especially anti-tumor necrosis factor (anti-TNF) agents, has improved dramatically the prognosis of patients. Five randomized controlled studies will be included in my lecture and are summarized in Table 2.
Table 2. Ankylosing spondylitis : randomized controlled studies

OutcomePrimary end pointsFollow-upmonths
Durationdays
N
Mode of therapy
AuthorPositiveFunctional abilityPatients global wellbeing

10

21

120

Spa exercise
Van Tubergen(6)PositiveASAS core set
6
21
61Balneotherapy vs balneotherapy + NSAIDS
Yurtkuran(7)Weakly positiveBASDAI, VAS PAIN, SF-36
3
14
28
Mud + sulfur vs tap water
Codish(8)PositiveBASDAI, BAFSI, DFI and others
6
21
60
Balneotherapy vs control
Altan(9)Weakly positiveBASFI, VAS (EQ-5DVAS)
6
7
60Etanercept vs etanercept + spa therapy
Colina(10)



329



The most important conclusions from these studies are : A. Clinical improvement lasting 3-6 months was achieved in only 3 of these studies. B. Van Tubergen showed, for the first time, that balneotherapy is not only effective but also cost-effective. C. The study of Colina [10] is the first one that compared the efficacy of combination therapy (balneotherapy plus biologic therapy) versus monotherapy (biologic agent alone). No definite conclusions can be drawn from this study because of the very short duration (one week) of the spa therapy.Psoriatic ArthritisPsA is a chronic inflammatory arthritis that occurs in approximately 26 % of patients with psoriasis, leading to a prevalence rate in the population of 0.3 % to 1 %. There are a few clinical subsets of PsA including oligoarthritis (the most common subset), distal joint disease, arthritis mutilans, rheumatoid arthritis like (symmetrical polyarthritis) and spondylitis. The diagnosis is made on clinical grounds in patients with psoriasis who have skin, scalp or nail changes.The only two studies evaluating the effect of balneotherapy on patients with PsA were conducted in Israel (Table 3). Treatment for psoriasis at the Dead Sea has been proven in many studies to be highly efficacious. The treatment regimen is based mainly on exposure of the skin to both Dead Sea water and the sun’s ultraviolet rays.
Table 3. Randomized controlled studies

OutcomePrimary end pointsFollow-upmonthsDurationdays
N
Mode of therapy
AuthorPositive for peripheral joints, spine pain & mobilityRichie index, VAS pain, Spine mobility

No

21

166
Dead Sea + sun vs Dead Sea + sun + mud + sulfur
Sukenik(11)Positive for peripheral joints, spinal pain & mobilityTender & swollen joints, Schöber test, VAS for pain

6

28

42
Dead Sea + sun vs Dead Sea + sun + mud + sulfur
Elkayam(12)



208



The main conclusions of these two studies are that bathing in Dead Sea water and exposure of the skin to the unique ultraviolet rays at the Dead Sea area have a beneficial effect on both the skin and the peripheral joints. The addition of mud and sulfur therapy reduces spinal pain and improves spinal mobility.Further studies are needed to clarify which of the modalities have a greater effect, balneotherapy or climatotherapy.
References1. Sukenik S, Buskila D, Neumann L et al. Sulphur bath and mud pack treatment for rheumatoid arthritis at the Dead Sea area. Ann Rheum Dis 1990;49:99-102.2. Sukenik S, Neumann L, Buskila D et al. Dead Sea salts for the treatment of rheumatoid arthritis. Clin Exp Rheumatol 1990;8:353-357.3. Elkayam O, Wigler, I Tishler M et al. Effect of spa therapy in Tiberias on patients with rheumatoid arthritis and osteoarthritis. J Rheumatol 1991;18:1799-1803.4. Sukenik S, Neumann L, Flusser D et al. Balneotherapy for rheumatoid arthritis at the Dead Sea. Isr J Med Sci 1995;31:210-214.5. Franke A, Reiner L, Pratzel HG et al. Long–term efficacy of radon spa therapy in rheumatoid arthritis – a randomized controlled study and follow-up. Rheumatology (Oxford) 2000;39:894-902.6. Van Tubergen A, Landewe R, Van der Heijde D et al. Combined spoa-exercise therapy is effective in patients with ankylosing spondylitis : a randomized controlled trial. Arthritis Care Res 2001;45:430-438.7.Yurkuran M, Ay A & Karakoc Y. Improvement of the clinical outcome in ankylosing spondylitis by balneothdrapy. Joint Bone Spine 2005;72:303-308.8. Codish S, Dobrovinsky S, Abu Shakra M et al. Spa therapy for ankylosing spondylitis at the Dead Sea. IMAJ 2005;7:431-434.9. Altan L, Bingol U, Aslan M et al. The effect of balneothrerapy on patients with ankylosing spondylitis. Scand J Rheumatol 2006;35:283-289.10. Colina M, Ciancio G, Garavini R et al. Combination treatment with Etanercept and an intensive spa rehabilitation program in active ankylosing spondylitis. Int J Immunopathol Pharmacol 2009;22:1125-1129.11. Sukenik S, Giryes H, Halevy S et al. Treatment of psoriatic arthritis at the Dead Sea. J Rheumatol 1994;21:1305-1309.12. Elkayam O, Ophir J, Brener S et al. Immediate and delayed effects of treatment at the Dead Sea in patients with psoriatic arthritis. Rheumatol Int 2000;19:77-82PapersEffects of Spa therapy on serum leptin and adiponectin levels in patients with knee osteoarthritisFioravanti Antonella1, Cantarini Luca1, Bacarelli Maria Romana1, de Lalla Arianna2, Ceccatelli Linda2, Blardi Patrizia2 [Italy]1 - Rheumatology Unit, Department of Clinical Medicine and Immunological Sciences, University of Siena2 - Center of Clinical Pharmacology, University of Siena
Antonella FioravantiUniversity of Siena, Viale Bracci, 1, 53100 Siena, Italyfioravanti7@virgilio.it
Adipocytokine, including leptin and adiponectin, may play an important role in the pathophysiology of osteoarthritis (OA) [1,2]. Spa therapy is one of the most commonly used non-pharmacological approaches for OA, but its mechanisms of action are not completely known. The effects of thermal baths are, in part, related to temperature, and balneotherapy also induces a neuroendocrine reaction which causes an increase in serum levels of corticosteroids and catecholamines [3] and a reduction in circulation levels of tumour necrosis factor α (TNF-α) and Interleukin-1β (IL-1 β) [4].Since serum levels of leptin and adiponectin are influenced by temperature [5,6], catecholamines [7], corticosteroids [8] and TNF-α and IL-1 β [9,10], we evaluated whether Spa therapy modifies plasma levels of leptin and adiponectin in thirty patients with OA treated with a cycle of a combination of daily locally-applied mud packs and bicarbonate-sulphate mineral bath water. Leptin and adiponectin plasma levels were assessed at baseline and after two weeks, upon completion of the spa treatment period. The concentrations of leptin and adiponectin were measured by ELISA. At basal time, plasma leptin levels were significantly correlated with body mass index (BMI) (r=0.41, p<0.001) and gender (r=0.61, p<0.001), but no significant correlation was found with patient age, duration of disease, radiographic severity of knee OA, VAS score or Lequesne index. There was no correlation between plasma adiponectin level and BMI, gender and age, duration of the disease, radiographic severity of knee OA, and VAS score. A significant correlation of plasma adiponectin levels was found only with the Lequesne index (r=0.34, p=0.03).At the end of the mud-bath therapy cycle, serum leptin levels showed a slight but not significant increase, while a significant decrease (p<0.05) of serum adiponectin levels was found. However, leptin and adiponectin concentrations after treatment were not correlated with other clinical parameters. There is some evidence that leptin increases the stimulatory effects of pro-inflammatory cytokines on nitric oxide (NO) production in chondrocytes [11,12] and may also trigger cartilage destruction by increasing matrix metalloproteases (MMP)-9 and MMP-13 [12].In skeletal joints, adiponectin may act as a pro-inflammatory agent and may be involved in matrix degradation [4].  Adiponectin induced the expression of type-2 nitric oxide synthase (NOS) and stimulated IL-6, MMP-3, MMP-9 and monocyte chemoattractant protein-1 (MCP-1) release [2]. In view of these recent findings, the decrease of adiponectin after spa therapy demonstrated in our study may play a protective role in OA. However, adiponectin presents metabolic properties as it increases insulin sensitivity, improves glucose metabolism and decreases plasma triglycerides, and has antiatherogenetic actions [13]. Because obesity and cardiometabolic syndrome are frequently associated with OA [14], it is important to study the effects of spa therapy on certain cardiovascular risk factors.  Finally, it remains to be clarified which of the mechanisms of action of spa therapy may have determined the changes in plasma levels of leptin and adiponectin that we observed. In conclusion, our data shows that spa therapy can modify plasma levels of the adipocytokines leptin and adiponectin, important mediators of cartilage metabolism. Whether this effect may play a potential role in OA needs further investigations.Keywords : Osteoarthritis, Leptin, Adiponectin, Spa therapy
References1. Loeser RF. Systemic and local regulation of articular cartilage metabolism : where does leptin fit in the puzzle ? Arthritis Rheum 2003;48:3009-12.2. Lago R, Gomez R, Otero M, Lago F, Gallego R, Dieguez C et al. A new player in cartilage homeostasis : adiponectin induces nitric oxide synthase type II and pro-inflammatory cytokines in chondrocytes. Osteoarthritis Cartilage 2008;16:1101-9.3. Laatikainen T, Salminen K, Kohvakka A, Pettersson J. Response of plasma endorphins, prolactin and catecholamines in women to intense heat in a sauna. Eur J Appl Physiol Occup Physiol 1988;57:98-102.4. Cozzi F, Carrara M, Sfriso P, Todesco S, Cima L. Anti-inflammatory effect of mud-bath application on adjuvant arthritis in rats. Clin Exp Rheumatol 2004;22:763-66.5. Zeyl A, Stocks JM, Taylor NAS, Jenkins AB. Interactions between temperature and human leptin physiology in vivo and in vitro.  Eur J Appl Physiol 2004;92: 571-8.6. Imbeault P, Dépault I, Haman F. Cold exposure increases adiponectin levels in men. Metabolism 2009;58:552-9.7. Trayhurn P, Duncan JS, Hoggard N, Rayner DV. Regulation of leptin production : a dominant role for the sympathetic nervous system ? Proc Nutr Soc 1998;57:413-9.8. Miell JP, Englaro P, Blum WF. Dexamethasone induces an acute and sustained rise in circulating leptin levels in normal human subjects. Horm Metab Res 1996;28:704-7.9. Zumback MS, Boehme MW, Wahl P, Stremmel W, Zeigler R, Nawroth PP. Tumour necrosis factor increases serum leptin levels in humans. J Clin Endocrinol Metab 1997;82:4080-2.10. Delaigle AM, Jonas JC, Bauche IB, Cornu O, Brichard SM. Induction of adiponectin in skeletal muscle by inflammatory cytochines : in vivo and in vitro studies. Endocrinology 2004;145:5589-97.11. Otero M, Lago R, Lago F, Reino JJ, Gualillo O. Signalling pathway involved in nitric oxide synthase type II activation in chondrocytes : synergistic effect of leptin with interleukin-1. Arthritis Res Ther 2005;7:R581-91.12. Simopoulou T, Malizos KN, Iliopoulos D, Stefanou N, Papatheodorou L, Ioannou M, Tsezou A. Differential expression of leptin and leptin’s receptor isoform (Ob-Rb) mRNA between advanced and minimally affected osteoarthritic cartilage ; effect on cartilage metabolism. Osteoarthritis Cartilage 2007;15:872-83.13. Ouchi N, Shibata R, Walsh K. Cardioprotection by adiponectin. Trends Cardiovasc Med 2006;16:141-6.14. Puenpatom RA, Victor TW. Increased prevalence of metabolic syndrome in individuals with osteoarthritis : an analysis of NHANES III data. Postgrad Med 2009;121:9-20.

The effect of mud pack treatment on neopterin levels in knee osteoarthritisTuran Mustafa¹, Odabasi Ersin¹, Yaman Halil² [Turkey] 1 - Gulhane School of Medicine, Department of Medical Ecology and Hydroclimatology, Ankara2 - Gulhane School of Medicine, Department of Biochemistry, Ankara
Turan MustafaGulhane School of Medicine, Department of Medical Ecology and Hydroclimatology06018 Ankara (TR)mturan@tr.net
Objective In recent years there is a resurgence of interest in studies concerning the role of mud pack treatment on some inflammatory parameters in osteoarthritis. Neopterin molecule is an indicator of pro-inflammatory status. Its synthesis is stimulated by IFN γ. The aim of the present study is to explore whether mud pack treatment affects plasma neopterin level in patients with knee osteoarthritis.Methods Twenty-one patients with bilateral primary OA of the knee were enrolled in the study. All patients were subjected to daily mud pack treatment, applied to both knees for 30 min. at 43°C, 15 days. Baseline and end-of-treatment neopterin level analysis were made.Results The median neopterin level before the treatment was 19.12 (IQR=5) nmol/L whereas end of the treatment level was 20.39 (IQR=6) nmol/L. Comparison of these two values were not found to be statistically significant (u=220 ; p>0.05, Mann-Whitney U test). Plasma neopterin level was found not to be affected with mud pack application.Conclusion Seemingly mud pack treatment does not affect plasma neopterin level. Observed anti-inflammatory effects of mud pack treatment have to be occurred through a different mediator.

Variation of inflammatory cytokines levels after mud therapy in patients with ankylosing spondylitisProfir Daniela, Marin Viorica, Surdu Olga, Muja Liviu Ion [Romania]Balnealy and Rehabilitation Sanatorium Techirghiol
Profir DanielaSos. Mangaliei nr.72, bl.A, sc.4, ap.10, 900116 Constanta (RO)+40 241582019 / +40 723632180danaprofir@hotmail.com
Ankylosing spondylitis (AS, from Greek ankylos, bent ; spondylos, vertebrae), previously known as Bechterew's disease, Bechterew syndrome, and Marie-Strümpell disease, a form of spondyloarthritis, is a chronic, inflammatory arthritis and autoimmune disease. It mainly affects joints in the spine and the sacroilium in the pelvis, and can cause eventual fusion of the spine. It is a member of the group of the spondyloarthropathies with a strong genetic predisposition. Complete fusion results in a complete rigidity of the spine, a condition known as bamboo spine.The typical patient is a young male, aged 18–30, when symptoms of the disease first appear, with chronic pain and stiffness in the lower part of the spine or sometimes the entire spine, often with pain referred to one or other buttock or the back of thigh from the sacroiliac joint.Men are affected more than women by a ratio about of 3:1, with the disease usually taking a more painful course in men than women. Pain is often severe on rest, and improves with physical activity, but many experience inflammation and pain to varying degrees regardless of rest and movement. AS is one of a cluster of conditions known as seronegative spondyloarthropathies, in which the characteristic pathological lesion is an inflammation of the enthesis (the insertion of tensile connective tissue into bone). Other forms of spondyloarthropathy are associated with ulcerative colitis, Crohn’s disease, psoriasis and Reiter’s syndrome (reactive arthritis).Objective The study aims to evaluate anti-inflammatory activity of cold mud ointment using specific natural factors in patients with ankylosing spondylitis.Material and method  • The main prescribed treatment was progressive heliotherapy, followed by cold mud ointment and swim into the salted water of Techirghiol Lake ; in addition we used electrotherapy, kinetics and massage. • The studied group included 15 patients (2 females and 13 males) with AS (following ACR criteria for diagnosis). All patients received cold mud therapy as explained above. • The patients were clinically evaluated and have been taken blood samples before and after mud treatment. Serum level of TNF-α, IL-1β and IL-6 were determined at the Research Center for Microscopically Morphology and Immunology from Craiova University and the rest of the blood tests were performed at Techirghiol Analysis Laboratory.Results  After cold mud ointment we observe an important decrease of IL-1β serum level in the studied group, which can be correlated with clinical improvement shown by the patients. It can be seen certain changes in the others’ two types of cytokines levels, but not statistically significant.Conclusions Complex variation of inflammatory cytokines serum levels after mud therapy suggests that the saprogenic mud of Techirghiol Lake is beneficial for the progression of the disease in patients with AS.
References1. Galzigna L, Ceschi-Berrini C, Moschin E, Tolomio C. Thermal mud-pack as an anti-inflammatory treatment. Clinical Trial. PMID : 9856289 Fortschr Med 1989 Aug 10; 107(23):24-5 Biomed Pharmacother 1998;52(9):408-9.2. Bellometti S, Galzigna L, Richelmi P, Gregotti C, Berte F. Both serum receptors of tumor necrosis factor are influenced by mudpack treatment in osteoarthrotic patients. Pietrod’Abano Research Centre, Padova, Italy, Int J Tissue React 2002;24(2):57-64.3. Basili S, Martini F, Ferroni P, Grassi M, Sili Scavalli A, Streva P, Cusumano G, Musca A, Battista Rini G. Effects of mud-pack treatment on plasma cytokine and soluble adhesion molecule levels in healthy volunteers. Department of Medical Therapy, University of Rome La Sapienza, Viale Del Policlinico, 155 00161 Rome, Italy. Clin Chim Acta 2001 Dec;314(1-2):209-14.

The hydro-traction therapy, theoretical explanation and practical experiencesBender Tamás, Oláh Mihály, Oláh Csaba, Kurutz Márta [Hungary]Hospital St John of God, Budapest
Tamás Benderbender@mail.datanet.hu
Introduction Underwater traction (“weight bath”) was invented by Károly Moll, a Hungarian physician, in 1953. Suspension of the submerged body by the neck or using armpit supports is intended to relieve the spine, primarily, or less frequently, the large joints of the lower extremities. Extension of the body is also intended to relieve compression of nerve roots, intervertebral discs, etc. Weight bath therapy in warm water accomplishes relaxation of skeletal muscle and extension of the spinal column, and this promotes retraction of a herniated nucleus pulposus—also facilitated by the hydrostatic pressure exerted onto the body. The pleasant subjective experience of being suspended in warm water greatly enhances therapeutic efficacy through muscle relaxation. Materials and methods In underwater cervical suspension of a human body of standard parameters, about 25 N stretching load occurs in the cervical spine, and about 11 N occurs in the lumbar spine. By applying extra weights, the above tensile forces along the spinal column can be increased. Thus, the traction effect can be controlled by applying extra loads during the treatment. Elongations of segments L3–L4, L4–L5, and L5–S1 were measured during the usual WHT of patients suspended cervically in water for 20 minutes, loaded by 20–20 N lead weights on the ankles. The study population comprised 72 subjects. Two groups of 18 patients each received underwater traction therapy of the cervical or lumbar spine with add-on McKenzie exercises and iontophoresis. The remaining two groups, treated with exercises and iontophoresis, served as controls. VAS and SF36 scores, range of motion were monitored to appraise therapeutic efficacy in cervical discopathy, whereas these parameters were supplemented by the Oswestry index in lumbar discopathy. A MRI scan was done at baseline and after 3 months of follow-up. Results Experimantal examination: The mean initial elastic elongations of segments were about 0.8 mm for patients aged less than 40 years, 0.5 mm between 40–60 years, and 0.2 mm over 60 years. The mean final viscoelastic elongations were 1.5 mm, 1.2 mm and 0.6 mm for the same age classes, respectively. No significant difference was found between the sexes regarding age-dependence in tension. Underwater traction therapy for discopathy showed significant improvement of clinical parameters, which was still evident three months later, as demonstrated by using a controlled pilot study. Clinical examination Underwater cervical or lumbar traction therapy for discopathy achieved significant improvement of all study parameters, which was still evident 3 months later. Among the controls, significant improvement of just a single parameter was seen in patients with lumbar, and of two parameters in those with cervical discopathy. Conclusion Underwater traction therapy effectively mitigates pain, enhances joint flexibility, and improves the quality of life of patients. The equipment is easy to install and the treatment technique is simple. The authors were the first to determine the biomechanical effects of underwater traction using an in vivo-measuring method and biomechanical calculations and verified the beneficial clinical effects by a controlled pilot study. 

Thermographic aspects of CRPS during mud-therapyDemirgian Sibel1, Surdu Olga1, 2, Surdu TV1, Minea  Mihaela1, Ionescu Elena Valentina1 [Romania]1 - Balneal and Rehabilitation Sanatorium Techirghiol 2 - Ovidius University Constanta
Demirgian SibelBld. Tomis nr. 236 bl.TD16, sc.E apt.80, 90140 Constanta (RO)+40 241481744 / +40 752129149sibeldemirgian@yahoo.com 
Introduction Reflex sympathetic dystrophy (RSD) is a syndrome that usually affects the limbs, characterized by pain and/or other sensitive anomalies, swelling, motor (limit ROM) and vascular abnormalities (vasomotor instability) and changes in the superficial and deep tissues "trophic changes" (skin changes, patchy bone demineralization). Not all these elements are necessarily present at the same time. RSD is a syndrome that usually affects one or more extremities, but can affect virtually any part of the body.In 1995, IASP (International Association for the Study of Pain) recommended use of the term CRPS type 1 for RSD and CRPS type 2 for causalgia. The “complex” term express a wide range of signs and symptoms.Objectives • 1.To evaluate the benefits of peloidotherapy on RSD ;  • 2. To evaluate the variation of skin temperature during mud therapy on RSD ; • 3. To correlate the inflammatory phenomenon with skin temperature during mud therapy.Materials • 1. Sapropelic mud and mineral water from Techirghiol Lake ; • 2. Thermograph ; • 3. Laboratory additives.Methods • 1. 10 patients who received mud therapy during 12 days and 10 patients who did not receive any treatment, suffering of RSD in stage II, with or without surgical intervention ; • 2. Inclusion and exclusion criteria were applied upon the two batches ;  • 3. In the blood samples were determined parameters of inflammation before the beginning of treatment, at 24 hours after first mud application and at the end of the cure. All patients were clinically and biologically evaluated ; • 4. Inclusion criteria refers to traumatic conditions (fractures of limbs) and to stage of evolution (stage II) ; • 5. Exclusion criteria refers to cardiovascular conditions, other inflammatory diseases, cancers and organs failure that forbid mud application ; • 6. Treatment applied consists in : hydro-thermo-therapy (mud bath at 380°C for 20 minutes), electro-therapy (reflex electrotherapy, antialgic and resorptive electrotherapy), massage and kinetotherapy in the gym room or hydro-kineto-therapy in the swimming pool with salt water from Techirghiol Lake.Results Clinical signs and symptoms improved, local inflammation decreased, pain perception decreased, local blood circulation improved. Mathematical analysis and biostatistics interpretation are yet processing.Discussion & conclusion • 1. Mud application within the frame of thermoneutralism parameters decreased skin temperature in damaged area and improved peripheral blood circulation ;  • 2. Using peloidotherapy in thermoneutralism field the local inflammatory phenomenon decreased ; • 3. At the end of balneal cure, we obtained the remission of algo-neuro-dystrophyc symptoms.Key words : Thermography, complex regional pain syndrome, peloidotheraphy
References1. Uceyler N, Eberle T, Rolke R et al. Differential expression patterns of cytokines in complex regional pain syndrome. Pain Sep 2007; [Medline].2. Wasner G, Heckmann K, Maier C et al. Vascular abnormalities in acute reflex sympathetic dystrophy (CRPS I) : complete inhibition of sympathetic nerve activity with recovery. Arch Neurol May 1999;56(5):613-20. [Medline].3. Blaes F, Tschernatsch M, Braeu ME, Matz O, Schmitz K, Nascimento D. Autoimmunity in complex-regional pain syndrome. Ann N Y Acad Sci Jun 2007;1107:168-73. [Medline].4. Schürmann M, Zaspel J, Löhr P, et al. Imaging in early posttraumatic complex regional pain syndrome : a comparison of diagnostic methods. Clin J Pain Jun 2007;23,5:449-57. [Medline].5. Hsu ES. Practical management of complex regional pain syndrome. Am J Ther Mar-Apr 2009;16,2:147-54. [Medline].

Balneological hypertermal procedures in patients with osteopeniaPonikowska Irena, Kalmus Piotr, Chojnowski Jacek [Poland]Department of Balneology and Physical Medicine Collegium Medicum Copernicus University in Torun
Ponikowska IrenaLeśna 3, 87-720 Ciechocinek (PL)+48 542833945 / +48 606184821iponikowska@poczta.onet.pl
Introduction Information about increasing bone turnover and tissue metabolism in patients with osteopenia and osteoporsis, during hyperthermal procedures, is very scarce. In general opinion, there is a lack of proven efficacy in research studies. As a result of this opinion, the hyperthermal therapy is not applied in those patients.The aim of our study was to investigate the influence of balneological hyperthermal procedures on the bone turnover markers in patients with osteopenia.Material and Methods Two groups of patients (53 women) with osteopenia and osteoarthritis were examined. The study group (31 patients) was treated by hyperthermal balneological procedures (brine bath, peat poltices, paraffintherapy). Control group (22 patients) received balneological procedures without hyperthermal agent.Results There were no significant changes in the level/activity of the bone turnover markers in both groups of patients, neither just after the end of the therapy, nor after the follow up observation.Conclusion The hyperthermal procedures are not contraindicated in patients with osteopenia during balneological therapy in thermal stations.

Skin conditions & balneologyRoom B012 pm - 4 pm
Hydrogen Sulphide inhibits IL-8 expression in human keratinocytesMirandola Prisco1, Gobbi Giuliana1, Di Marcantonio Daniela1, Micheloni Cristina1, Vitale Marco1,2 [Italy]1 - Department of Anatomy, Pharmacology & Forensic Medicine, Human Anatomy Section, University of Parma, Parma2 - Fondazione per la Ricerca Scientifica Termale, Rome
Marco VitaleVia Gramsci 14, 43126 Parma (IT)+39 521033034  marco.vitale@unipr.it
Psoriasis, a chronic inflammatory skin condition that has important implications in terms of medical costs and treatment strategies, is characterized by hyperproliferation and abnormal differentiation of epidermal keratinocytes, and also by neutrophil and lymphocyte infiltration (T reg cells) of epidermal and dermal layers [J Cutan Med Surg 2002;6:2-7 ; J Am Acad Dermatol 2005;53:S94-100]On the basis of the biochemical analyses and in vitro studies, it has become evident that IL-8 greatly contributes to the major pathologic changes seen in psoriasis [J Invest Dermatol 1991;96:26-30 ; J Dermatol Sci 2001;26:119–24]. However, its biological mechanisms remain incompletely defined.Furthermore, others cytokines secreted by T reg cells, have an emerging role in the pathogenesis of this disease : in particular, IL-17 and IL-22 activate keratinocytes, interfere with keratinocyte and lymphocyte differentiation and proliferation, promote the secretion of inflammatory cytokines [J Immunol 2005; 174:3695–702 ; J Exp Med 2006; 203:2271–9].Recently, it has been reported that IL-8 released by keratinocytes in IL-17-injected skin may be responsible for accumulation of neutrophils [J Invest Dermatol 2009;129:650-6]. The signalling pathway downstream IL-17 receptor appears to involve ERK activation : however additional molecular mediators may be recruited as PI3K and Akt [Arthritis Res Ther 2004;6:R120–8 ; J Invest Dermatol 2009;129:650–56].Hydrogen sulfide is a component of several natural compounds known to be effective in many inflammatory pathologies [Nat Rev Drug Discov 2007;6:917-935]. We have recently demonstrated that : • i) exogenous H2S can delay the onset of apoptosis of granulocytes in vitro, initially contributing to acute inflammatory and bactericidal defence and subsequently preventing the development of chronic inflammatory processes [Rinaldi et al., Lab Invest 2006;86:391-7.] ; • ii) H2S exerts a subset-specific toxicity on peripheral blood lymphocytes in terms of cell survival and cytokine production [Mirandola et al., J Cell Physiol 2007;213:826-33] ; • iii) H2S impairs adhesion and proliferation of human keratinocytes by preventing the activation of Raf-MEK-ERK signalling pathway. Moreover, performing in vivo experiments we have observed that NaHS-treatment reduced pERK levels in the epidermis of patients affected by psoriasis [Lab Invest 2009;89:994-1006].On this basis, we have now studied the ability of NaHS to affect IL-8 transcription and secretion in human normal keratinocyte NCTC cell line, that secretes IL-8 upon different stimuli as PMA and UV stimulation [Cytokine 2005;29:197-07]. IL-8 expression was analyzed both at transcriptional and protein level by RT-PCR and ELISA, respectively. Studies have been performed in resting and IL-17 or IL-22-stimulated cell cultures. The ability of NaHS to suppress IL-8 expression in vivo was also studied by immunohistochemistry on biopsies from a patient affected by psoriasis, treated for 1 week with NaHS. Results show that NaHS, blocking ERK activation, interferes with IL-8 production. Sulfurs are able to penetrate the skin, and a sulfur-rich balneotherapy is known to be effective in the treatment of psoriasis [Dermatol Ther 2003;16:132-140]. These data suggest that H2S might be useful to limit the proliferation of keratinoblasts in skin diseases like psoriasis, dermatitis, skin iperplasia and basaliomas, where a functional modification of keratinocyte behaviour plays a major pathogenetic role.

Evaluation of the effects on the skin of three peloids by cutaneous bio-engineering methodsMeijide-Failde Rosa1, Salgado-Somoza Teresa1, LLanes-Gómez Ana1, Mourelle-Mosqueira Lourdes2, Gómez-Pardo Carmen2, Legido-Soto José-Luis2, Teijeiro-Vidal Jorge 1 [Spain]1 - Department of Medicine, University of Coruña2 - Department of Applied physics. University of Vigo
Meijide-Failde RosaUniversity of Coruña. Campus de Oza s/n, 15006 Coruña (ES)+34 981167000 / +34 606967694rmf@udc.es
Background In medical hydrology, peloids are called natural products consisting of a mixture of mineral water, lake or sea salt with organic and inorganic materials resulting from geological processes and / or biological used for a therapeutic purpose in the form of wraps, poultices or baths to be the clay in the solid substrate is used more often. The peloids are used in different pathologies of the locomotor both inflammatory and degenerative skin changes by its moisturizing effects, healing, regenerating and antioxidant on the skin being used for therapeutic purposes to treat skin disorders, both pathological conditions such as psoriasis, atopic dermatitis, seborrheic or acne, or cosmetic purposes in the alterations of the secretions and hydration. There are few data on the optimal implementation of the mud and their effects on skin and tolerance in relation to their physicochemical characteristics.The aim of this study was the evaluation of its effects on intact skin after application of three "peloids untimely" consisting of a mixture of sodium bentonite with 3 different types of water from the study of the mechanical and functional skin.Methods We conducted a pilot study that assessed the following parameters : skin microrelief (scaling, roughness, texture, volume), hydration and elasticity of the skin before and after application of peloids in 57 healthy volunteers distributed in two age groups : 28 with a mean age of 18 years old and 29 with a mean age of 74 years old. The three extemporaneous peloids have been prepared with a mixture of sodium bentonite with 3 types of water : tridistilled 15 %, sodium sulfide mineral-Cuntis Hot Springs (Spain) to 22 %, seawater to 33 %. They were applied in the anterior forearm at room temperature (26ºC) for 20 minutes. The measurements were made using skin bioengineering methods such as measuring instrument using the Visioscan® VC 98, Courage & Khazaka brand. The measurement principle is based on the distribution of gray level image using a video sensor in black and white high resolution and a source of UV-A. The data were obtained using software version 1.9.0.1 and compared the effects of the three peloids with a control zone. Statistical analysis : a descriptive study of the variables included in the study. Quantitative variables were expressed as mean ± SD. The comparison of means test was performed with the Student t-test or Mann-Whitney U as appropriate after testing for normality with the Kolmogorov-Smirnov test. The data analysis was done through SPSS 16.0 statistical package.Results At baseline the skin of young people has less scaling and better texture and moisturizing the skin of the elderly. After applying the 3 peloids, parameters related to the microrelief of the skin and scaling, roughness, and roughness was produced with the three peloids increased all of which was significant in both older and younger in preparations mineral water with very significant and peloids with sea water. With regard to hydration of the skin, measured in an indirect manner by two parameters, show that both young and older resulted in improvement of hydration remained significant with values tridistilled prepared with water. And the values of smoothness of the skin show that all preparations decrease the smoothness remained significant with sea water.Conclusions There was an increase in the level of hydration of the skin, moisturizing factor being water, increased roughness and scaling with the formulation based on mineral water and sea water and above all had a good handling peloids, cohesion and adhesion, with the formulation with mineral water for best performance.

New and rational use of spa treatment in psoriasis vulgaris : clinical-experimental study Costantino Maria1,2,4, Contaldi Emilia1, Norel Xavier3, Filippelli Amelia4 [Italy - France]
1 - Association no profit Firs Thermae (Interdisciplinary Formation, Researches and SPA Therapies Sciences), Naples2 - Cerist (Center of Thermal Researches and Studies srl), Naples3 - Inserm U 698, Haemostasis, Bio-engineering and Cardiovascular Remodeling,CHU X. Bichat, 46 rue Henri Huchard, 75877 Paris Cedex 184 - Department of Experimental Medicine–Pharmacological Division II, University of Naples
Costantino Maria Via Marziale, 21, 80070 Bacoli, Naples (IT)+39  0813047978 / +39  3388260800mariacostantino@katamail.com
Objective Psoriasis is a chronic disease characterized by an acceleration of the cell proliferation kinetic in epidermis. Plaque psoriasis or psoriasis vulgaris is the most common form of psoriasis (incidence 80 to 90 % of people with psoriasis). Plaque psoriasis typically appears as raised areas of inflamed skin covered with silvery white scaly skin. Treatment of the psoriasis includes topic or systemic drugs, photo or thermal (SPA) therapy. In spite of the empirical evidence of benefits of thermal therapy in the psoriasis, the clinical-experimental studies are insufficient, especially those regarding the mud-bath therapy with mineral water for which until now there are no standardized methods. The aim of our study has been to evaluate the best application of the mud-bath thermal treatment in patients affected from psoriasis vulgaris of moderate degree in base to the criterions of the Efficacy Working Party EMEA.Materials and Methods The study was carried out on 60 patients, randomized in three groups. Each of them was treated for 12 days as follows : A group : pharmacological therapy ; B group : mud-bath thermal therapy with chlorine-sulphur-bicarbonate mineral water of the Thermal Baths Stabia in Castellammare (Naples-Italy) ; C group : pharmacological therapy + mud-bath thermal therapy. Before and after these treatments, we have valued or measured : • 1) the PASI Index Score (Psoriasis Area Severity Index) ; • 2) the pruriginous symptomatology ; • 3) the plasmatic concentration of reactive oxygen metabolites [ROM], compounds involved in psoriatic processes, expressed in CARR.U. (1 CARR.U.= 0.08mg/dl of H2O2) by the use of d-ROMs test (Diacron International srl-Grosseto Italy) ; • 4) photographic relief for a clinical follow-up ; • 5) impact of the SPA treatment considered on the quality of life using Dermatology Life Quality Index (DLQI) ; • 6) the adverse reactions. Statistical analysis of the data was performed by determining the mean ± SD. The results were compared with the Student “t” test. A p value ≤0.05 was considered significant.Results In comparison to the basal value (To) is observed in A and B groups a significant (P< 0.05) reduction of the PASI-index (A group : 11±10->5±7 ; B group : 11±9->8±8) and the pruriginous symptomatology (A group : 1.2±1.1->0.7±0.6 ; B group : 1.4±1.3->0.6±0.7). Therapeutic synergism is observed when SPA and pharmacological treatment are associated (pruriginous symptomatology : C group : 1.1±1.2->0.3±0.5 ; PASI-index : C group : 9±7.6->5±4.7). These beneficial effects, as demonstrated by the questionnaire DLQI, administered before and after the considered treatments, result in the improvement of the quality of life in the psoriatic subjects examined with the reduction of the interferences of the disease with daily activities and with social relationships. Finally, a reduction of the [ROM] was detected and a good tolerability to the SPA therapy has been observed.Conclusions The results of this study show that the mud-bath treatment, in the application by our standardized method, can be considered, in the care of the psoriasis vulgaris, as an important phase of the therapeutic strategy directed at the optimization and integration of therapeutic options currently available.

Use of Avene thermal spring water in the management of skin disorders. A review of clinical studies in medical indications and dermo-cosmetic proceduresGuerrero Didier [France] 
Didier Guerrero, Laboratoires Pierre Fabre - Avènedidier.guerrero@pierre-fabre.com
Avene thermal spring water (ATSW) is used since 1743 in the management of inflammatory skin disorders (eczema, atopic dermatitis, psoriasis, chronic pruritus) and also to improve burns or wound healing. In these indications, different cares are given in the hydrotherapy centre of Avene.ATSW is a low mineralized water, with a specific ratio between calcium and magnesium. Since 1990, a specific range of dermo-cosmetic products (sprays of thermal water, skin cares for sensitive skin) has been developed around this mineral water.ATSW is worldwide available by using sprays. It was very interesting to know wether it was possible to improve skin disorders and wound healing process with this spray.We report the results of some clinical studies carried with ATSW sprays in different dermatological indications : atopic dermatitis, combination with some topical treatments, sensitive skin, dermatological procedures (post-laser and also after photodynamic therapy).The conclusion of these studies is a significant benefit on inflammatory symptoms including pruritus, an improvement of the skin comfort and finally a better quality of life for the patients. Purified ocean water as a cosmetic and a therapeutic solutionSoto Jose [USA]
Soto Jose1571 Stillwater Drive, 33141 Miami Beach (US)+1 305-940-5007 / +1 786-417-3165sotomedical@doctor.com
The presentation explains the uses of purified ocean water as a cosmetic and a natural therapeutic solution. The presentation reviews different dermatological and non dermatological uses of salt containing waters. Benefits of seawater on psoriasis and dermatitis are cited. Mechanisms of action are discussed including the immune response, the aquaporins activation and protein cleavage of sialic acid present in the sputum. A system is described to use a purified ocean water solution (Sea-Mar®) as a calming lotion, toner and a pharmacological vehicle. The solution is also used to transport radioisotopic molecules (Tecnetium 99m) for a ventilation scan. The solution can also be used as a pharmacological delivery vehicle and as expectorant. Clinical, radiological and anatomo-pathological evidences are presented. Method of application is a fine mist spray for dermatological purposes or through a conventional aerosol using a regular jet nebulizers or ultrasonic devices for respiratory and facial applications. The six keys elements of the solution are Chloride, Sodium, Magnesium, Calcium, Potassium and Sulfate. The elements are present in ionic state or forming pharmacologically active salts. The key elements distribution in the periodic table provides the solution with additional chemical stability and prolonged shelf life. There are not significant side effects associated with the use of purified ocean water. The solution obtained is 100 % natural, fragrance free, oil free, non staining, non commedogenic, alcohol free and preservative free.Keywords : sea, skincare, respiratory, psoriasis, eczema, ventilation scan

Musculo-skeletal session IIIRoom Actes4.30 pm - 6 pm
LectureBalneology and the clinical guidelines and recommendations for treatment of rheumatic diseases Mine Karagülle [Turkey]Department of Medical Ecology and HydroclimatologyIstanbul Medical Faculty of Istanbul University, Istanbul
The numbers of published scientific papers mainly focusing on the efficacy of balneotherapeutic methods on rheumatic diseases are being increased within the last decades. Furthermore the number of systematic reviews and meta-analyses and papers on effects of mechanisms are also increasing. Based on this increasing evidence, there have been efforts by scientific and medical associations and health authorities to generate evidence-based recommendations for the management of rheumatic diseases. We searched MEDLINE for recommendations for the treatment of rheumatic conditions namely knee, hip and hand osteoarthritis, ankylosing spondylitis, rheumatoid arthritis, early arthritis, fibromyalgia syndrome and low back pain. We found that the European League Against Rheumatism (EULAR), the Osteoarthritis Research Society International (OARSI), the Association of the Scientific Medical Societies in Germany (AWMF), French National Authority for Health (HAS), the American Pain Society (APS) have published such treatment guidelines since last decade. Later we checked them if they included “balneotherapy, hydrotherapy and/or spa therapy” among the interventions to evaluate and reviewed in which rheumatic indications these therapies have been recommended. EULAR [2007], APS [2005] and AWMF [2008] suggest that spa therapy reduces pain and improves quality of life in patients with fibromyalgia. They conclude that spa therapy may be one first line non-pharmacological treatment modality in these patients living near spa resorts.According to the ASAS/EULAR [2006] recommendations for ankylosing spondylitis, level Ib evidence supports spa therapy for physical functioning in patients with AS over 3 months and was shown to be cost-effective. Spa therapy is recommended by HAS [2005] for stabilized rheumatoid arthritis, rank C, since some of the non-pharmaceutical interventions — such as dynamic exercises, occupational therapy and hydrotherapy — have shown indisputable, often symptom relieving effects in established rheumatoid arthritis states. With regard to EULAR [2007] recommendations for early rheumatoid arthritis, evidence level of spa therapy/hydrotherapy is Ia and strength of recommendation is B.EULAR [2000 and 2003] included spa therapy to evaluate for the treatment of knee osteoarthritis and found evidence with an effect size 1.0 and level of evidence 1b, but rather a low recommendation level C. EULAR [2005 and 2007] does not recommend spa or balneotherapy for the treatment of hip and hand osteoarthritis. OARSI [2007, 2008 and 2010] has published recommendations for the management of hip and knee osteoarthritis in three parts consequently, and evaluated the evidence of balneo-hydrological methods (spa therapy, balneotherapy, hydrotherapy) for the treatment of patients with hip and knee osteoarthritis but did not include them in recommendations.Spa therapy is recommended for chronic low back pain by only HAS [2005], while available evidence coming from 3 RCTs and a Meta-analyze results a recommendation rank B.As a conclusion, the available evidence according to the published recommendations and clinical practice guidelines suggests that balneotherapy may help patients with various rheumatologic diseases : osteoarthritis, fibromyalgia, ankylosing spondylitis, rheumatoid arthritis and chronic low back pain.
PapersSpa therapy in the treatment of generalized osteoarthritis, a subgroup analysis of a large randomized trialForestier Romain1, Desfour Hugues2, Tessier Jean-Max3, Françon Alain1, Foote A4, Genty C4, Rolland C4, Roques Christian-François5, JL Bosson4 [France]1- Centre de recherches rhumatologiques et thermales, Aix-les-Bains 2 - Thermes de Balaruc-les-Bains3 -  Hôpital Thermal, Dax4 - Clinical Research Centre, Inserm CIC03, Grenoble,5 - Université Toulouse III
Forestier Romain15, avenue Charles de Gaulle, 73100 Aix-les-Bains (FR) +33 4 79 35 14 87romain.forestier@wanadoo.fr
Trial design Subgroup analysis of a randomized multicentre trialMethod Participants. Patients with knee osteoarthritis according to the American College of Rheumatology (ACR) criteria were recruited by press announcement in the three main French spa centre (Aix-les-Bains, Balaruc-les-Bains & Dax). This study is focused on the patients satisfying one of the three definitions of generalized osteoarthritis according to the Kellgren or ACR or Dougados criteria.Interventions Both groups were encouraged to perform daily standardized home exercises and were allowed to continue their usual treatment. The treatment group received 18 days of spa treatment (massages, showers, mud and water exercise sessions).Objective To determine whether spa therapy plus home exercises and usual medical treatment provides any benefit over exercises and usual treatment, in the management of knee osteoarthritis.Main outcome Number of patients achieving Minimal Clinically Important Improvement (MCII) at six months, defined as ≥19.9 mm on the VAS pain scale and/or ≥9.1 points in a normalized WOMAC function score and no knee surgery.Randomization Zelen randomization was used so patients were ignorant of the other group and participants of the study. Spa personnel were not told which patients were participating. Most of the judgment criteria were patient self-assessment questionnaires. Allocation concealment was realized by a computer generated number.Results Number of patients. 462 patients suffering of knee osteoarthritis were randomized. 399 of them had precise information on osteoarthritis diffusion. 201 of them had generalized osteoarthritis, 85 were analysed in the control group, 89 in the spa therapy group.Outcome • Main criteria : at six months, 31/85 patients have a clinically significant improvement in the control group, 48/89 in the Spa therapy group (p=0.021, OR : 2.04 [1.11-3.74].) • Secondary criteria : MCII at 3 months is 30/80 in the control group and 51/82 in the spa group (p=0.028), MCII at 9 months is 27/75 in the control group, 45/78 in the spa group (p=0.011). Pain improves more in the spa group (-10.6±26) than in the control group (-3.9±23). Standardized response mean is 0.23 [-0.07 – 0.53] in the control group and 0.54 [0.25 – 0.84] in the spa group.Harms There were no important adverse events or side effects.Conclusions For patients with generalized OA a 3-week course of spa therapy together with home exercises and usual pharmacological treatments offers clinical benefits on pain & function after 6 months compared to exercises and usual treatment alone, and is well tolerated.Trial registrationwww.clinicaltrials.gov: n° NCT00348777.FundingPrivate funding : Association française pour la recherche thermaleInstitutionnal funding : Rhône-Alpes, Conseil général de la Savoie

Does peloidotherapy improve the quality of life of the patients with osteoarthritis ?Ionescu Elena2, Minea Mihaela2, Surdu Olga1,2, Muja Liviu2, Marin Victoria2, Demirgeam Sibel2, Profir Dana2 [Romania]1 – Ovidius University Constanta2 – Balneal and Rehabilitation Sanatorium Techirghiol
Ionescu Elena Victor Climescu str. 34-40, 906100 Techirghiol (RO)+40 241481713 / +40 744495602mihaela_minea_2005@yahoo.com
Introduction The patients with Osteoarthritis return every year to Balneal and Rehabilitation Sanatorium Techirghiol (B.R.S.T.) for treatment. Usual treatment applied in BRST consists in :  • 1. hydro-(kineto)-thermo-therapy once a day ; • 2. kinetotherapy in the gym room : 1-2 time a day ; • 3. 2 – 4 adjuvant electrotherapy procedures ; • 4. Massage : one session daily.Objectives First objective of the study was to evaluate the quality of life of patients undergoing peloidotherapy. Second main objective was to evaluate the clinical benefits of balneal cure using natural factors : climate, sapropelic mud, salty-water of the lake, applied to patients with Osteoarthritis.Material • Sapropelic mud, from the deposit of the bottom of Techirghiol lake ; • Salted water of the lake ; • All the device from the electrotherapy, massage and kinetotherapy rooms; • Health Assessment Questionnaire, VAS (visual analogous scale for pain).Method The study batch was composed of 64 patients hospitalised in B.R.S.T. between 01.08.2009-31.08.2009, diagnosed with Osteoarthritis (knee, hip or spine located) according to ACR criteria. Inclusion and exclusion criteria were applied and all patients were clinical and biological evaluated in order to avoid the contraindication of cure. The treatments received by patients were chosen according to the biological shape. The prescription of balneotherapy consisted in : • Cold mud ointment (antique Egyptian method), or • Mud bath at 38°C, • Mud wrapping (pack) at 42°C.Cold mud ointment is a complex procedure consisting in : progressive heliotherapy, swimming into the lake and mud application (20°C). The mud wrapping (42°C) and mud bath (38°C) were applied alternatively with salted bath in bath tub (37°C) or in swimming pool (35°C) with individual or group hydrokinetotherapy. Length/duration of cure was of 12 days (two weeks).Study batch presentation : 63 patients aged between 35 and 73 years old, from which 39 women (61,9 %) and 24 men (38,09 %). Most of them (80 - 95 %) were from urban areas. Almost a half of them (50 - 79 %) received cold mud ointment, 41 - 26 % received warm or hot mud application and for 3 - 17 % the prescription did not contain mud or salted water but plant extract.All patients were questioned using the Health Assessment Questionnaire–Disability Index (HAQ-DI) which was developed as a comprehensive measure of outcome in patients with a wide variety of rheumatic diseases [1]. The patients were questioned at the beginning and at the end of their hospitalisation and also after three months and the scores were compared. After three months only 35 patients sent us the questionnaire.During this study also were evaluated the climate conditions of the residence place of patients : temperature and humidity.Results After two weeks of treatment 29,6 % of patients improved the HAQ score and 60 % of them improved VAS for pain. From the patients who sent their answers at three months, 22,85 % had better HAQ score and 57,11 % had VAS better than at the time of their admittance.The persistence of an improved HAQ-score was inversely correlated (index “r” of correlation =-0,26) with the humidity of the residential area of patients. The temperature was directly correlated (r=0,20) with a better HAQ-score.Conclusions The patients with Osteoarthritis following the complex treatment of Techirghiol, improve their quality of life at the end of hospitalization but also after three months. The maintenance of these benefits is correlated with the humidity and the temperature in the areas that they live in.Key words : peloidotherapy, quality of life, humidity, temperature.
References1.  http://aramis.stanford.edu/HAQ.html.

Evaluation of the clinical efficiency of the thermal mineral water of Gunaras on patients with primary hand osteoarthritisHorvath Katalin1, Kulisch Gota2, Nemeth Andras3, BenderTamás4 [Hungary]1 - Gunaras Spa, Gunaras2 – Spa Hévíz and St Andrew Hospital for Rheumatic Diseases3 - NK Medicor Kft, Keszthely4 - Polyclinic of the Hospitaller Brothers of St John of God, Budapest
Katalin HorvathMore Fulop street 1/a IV/15. 7623 Pécs (HU)+36 70-380-1658hkatya@freemail.hu
Objective The aim of this study was to evaluate the efficacy of the thermal mineral water of Gunaras Spa, Hungary, in the treatment of patients with primary hand osteoarthritis.Methods This randomized, single-blinded, controlled, follow-up study examined 60 patients, diagnosed according to the American College of Rheumatology (ACR) criteria for hand osteoarthritis. The patients were divided into three groups : the treatment groups (group I, n= 20 ; group II, n=21) received a combination of thermal mineral water therapy at different temperatures, namely group I at 36°C respectively group II at 38°C for 20 minutes a day, 5 days a week, for a period of 3 consecutive weeks and electrotherapy for 3 days a week ; while the control group (n=19) received only electrotherapy for 3 days a week. The content of the thermal mineral water from two different fountains of Gunaras was slightly different. The outcome measures were visual analogue scale scores (VAS), grip strength, pinch grip, joint stiffness, swollen and tender joints of the hand, Health Assessment Questionnaire and Short Form-36 questionnaire. The study parameters were administered at baseline and immediately after treatment, the follow-up is in progress.Results After the treatment, we observed statistically significant improvement in almost all evaluated parameters in all groups ; however, the significance was detected in more parameters in the groups treated with thermal mineral water, than in the control group, and the 38°C thermal mineral water seemed to be superior to the 36°C thermal mineral water.Conclusion The results of our study confirm that spa therapy combined with electrotherapy has, compared with electrotherapy alone, positive effects on patients with hand osteoarthritis, further that warmer thermal mineral water is more effective in the treatment of hand osteoarthritis, including positive effects on the patients’ quality of life and functional capacities.

Efficacy of the Aix-les-Bains’ “Berthollet” on functional symptoms of hand osteoarthritis. A randomized clinical trialGraber-Duvernay Bernard, Forestier Romain, Françon Alain [France] Centre de recherches rhumatologiques et thermales, Aix-les-Bains
Romain Forestier15 avenue Charles de Gaulle, 73100 Aix-les-Bains (FR)romain.forestier@wanadoo.fr
Method  Participants. Patients with hand osteoarthritis (ACR criteria) with Dreiser score more than 5/30. Data collected by an independent reviewer.Intervention The spa group received 18 session of 15’ of heated cloud pulsed on the hands by the Berthollet technique. The control group applied, 3 times a day, an Ibuprofen topic on their hands.Objective To compare efficacy of Berthollet with a validated Ibuprofen topic on hand osteoarthritis.Outcome  Primary outcome : Dreiser index for hand osteoarthritis. Secondary outcome : Pain (VAS), strength, topographic index (pain, deformities, limitation), fingers circumferences.Randomization The patients are randomized by throwing a coin in front of them. No blinding of randomization.Blinding Blinding of the practitioner assessing the patientsResults Number of analyzed patientsAt 3 weeks 59 patients were analyzed in the Berthollet group and 57 in the Ibuprofen topic group in the winter 1995. At 6 months 54 vs 53 patients were analyzed.Results For the Dreiser index, improvement is superior in the Berthollet group : -4.34 vs -1.53 (p<0.001) at three week, but not at 6 months : -1.14 vs -0.24 (NS). All the secondary outcomes are more improved in the Berthollet group at 3 weeks and 3 of them at six months (strength, topographic index and fingers circumferences).Conclusion Berthollet is superior to Ibuprofen topic at three week for all the judgment criteria and for three of the secondary judgments criteria at six months.

Indications and contraindications in use of sulphuric peloid of Banja Koviljaca in treating some disorders of locomotor system in children Stojkovic Negosava, Jokic Aleksandar, Sremcevic Nikola, Jevtic Nada [Serbia]The Specialized Rehabilitation Hospital, Banja Koviljca
Stojkovic NegosavaPark 4, 15316 Banja Koviljaca (CS)+381 638469194 / +381 15818270lekari@banjakoviljaca.rs
Aims The aim of this work is to present therapeutical effect of sulphuric peloid of Banja Koviljaca in the treatment of injuries and disorders of locomotor system in children.Method Between 1989 and 2009 at Children ward of the Specialized Rehabilitation Hospital Banja Koviljaca, 23 754 children were treated, both stationery and non-stationery. Standard physical procedures and peloid were applied. Indications for application of peloid are: locomotor system anomalies and deformities, aseptic bone necrosis, epiphysiolyses of femoral head, fractures of locomotor system, conditions after osteotomies, slight lesions of CNS, lesions of peripheral nerves, rheumatic diseases in the period of remission, contractures of joints, spastic forms of cerebral paralyses. Contraindications are dystrophy, myiotonia, spinal muscular atrophy, muscles hypotonia, polyradiculoneuritis, malignant diseases, fever, coagulation disorders, thyroid gland diseases, heart failure, anemia, bleeding. The peloid was applied locally or by segments, 20 minutes, for 20 days, and after that, series were repeated. In some conditions, kinesitherapy in peloid was applied.Results The results were good in fractures and conditions after osteotomies and epiphysiolyses of femoral head, contractures, rheumatic diseases and slight lesions of peripheral nerves.Conclusion The authors suggest application of sulphuric peloid of Banja Koviljaca in the treatment of above-mentioned diseases because it gives extraordinary results.Keywords : peloid, children, Banja Koviljaca

Poster Session Day IIRoom B094.30 pm - 6 pm

Palais du LuxembourgClosure session 
Saturday June 26
Scientific session ageing9 am – 10.30 am
Lectures
Balneological treatments (Crenotherapy) and AgeingM Zeki Karagülle [Turkey]Department of Medical Ecology and Hydroclimatology Istanbul Medical Faculty, Istanbul University, Istanbul
At the turn of the 2nd millennium, increase in elderly population became an emerging characteristic in developed and developing countries. This phenomenon calls to attention not only common health problems encountered in advanced age and the need to deal with them more effectively, but also requires more efforts to protect the health of the elderly and provide new health services and effective treatments for a “healthy aging”. Geriatrics is defined as a medical discipline in maintaining the quality of life and lower rates of disability of elderly and to cope with health problems of elderly population by studying and implementing different medical procedures and interventions. Gerontology is a branch of science studying the aging processes and emerging biological and physiological changes related to aging. Another recently developed concept, so called Anti-Aging Medicine focuses on stopping the aging process, with intensive efforts and methods that aim at reversing the aging processes to develop “the young elderly”.“Appearing or staying young with aging” may be considered as a subject of plastic surgery and cosmetology or complementary and alternative medicine, since elderly is rarely been a topic of balneology so far. Traditionally patient age has been considered one of the most important “individual differences” that must be taken into account when balneotherapy, climatotherapy and spa treatments are being prescribed for elderly people. It is emphasized that more frequency of “thermal crisis or reaction” must be kept in mind. Furthermore, the expected therapeutic effects may differ in elderly and the types of modalities and dosage of treatments as well. In advanced age, balneo-climatological interventions may be considered especially in three aspects. First, the positive or therapeutic effects of these therapies that may be classified as “anti-aging effects” on the development of biological and physiological changes due to aging itself, even a preventive role may be involved here in preventing these changes lead pathological levels. The observed empiric health effects of balneotherapy, climatotherapy and spa therapy in elderly population need to be tested with scientific methods. Understanding the mechanisms of effects of spa therapy on brain, skin and neurological systems may create a deeper insight in understanding the long term favourable effects on general well-being and wellness of this “anti-aging” intervention.Recently, it has been demonstrated that a number of balneological agents and methods may exert a series of well known “anti-aging” effects such as anti-oxidant and anti-inflammatory. Furthermore healthy skin functions, DNA repair, strengthening or modulation of immune function, regulation of lipid metabolism and other endocrinal processes can also be achieved by balneology applications. Secondly, balneotherapeutic treatments and spa therapy courses can be used as effective tools for prevention, therapy and rehabilitation of common health problems and system disorders in elderly. Balneology can create effective non-pharmacologic treatment options in pulmonary, cardiovascular, metabolic, endocrinal and musculoskeletal conditions and problems in advanced age. And finally to be used in the sense complementary or supportive manner, combining balneological methods with treatment modalities which are shown effective in the management of aging can be increasingly prevalent. 


ICF Concept and BalneologyPedro Cantista [Portugal]Universidade do Porto – Instituto de Ciências Biomédicas Abel SalazarProfessor Auxiliar Convidado de Hidrologia Médica
The bio-psycho-social approach of the health concept got a significant evolution with the approval of the International Classification of Functioning, Disability and Health (ICF) in May of 2001, during the 54th WHO General Assembly in Geneva. It was shown that “Health” probably relies more on function and quality of life that simply on a disease diagnostic classification (ICD), although of course this procedure is of an extraordinary importance.  The relevance of the ICF “Contextual Factors” (both personal and environmental) in the development of a defined health condition was definitively recognized.These personal and environmental factors interact with the considered domains of the ICF Model (Body Structures and Function, Activities and Participation) and determine the true “state of health”. If we think of the Balneology principles, we immediately may link them with this kind of model. In fact, probably there is no better example of interaction of our body structures and functions with the environment than what happens in a thermal spa ambience. In such an “environment” that interaction may lead to an increment of “activities” and facilitate “participation”. Personal factors of course play here a major role. Circumstantial factors such as specific climate characteristics (temperature, humidity, winds), geographic influence (altitude and atmospheric pressure, sun radiation exposure), thermal water treatments, adequate health behaviour and social interaction may modify the final results of a therapeutic strategy allowing better outcomes. Although the evaluation methodology of these results is not easy, we have already good indicators of the benefits of the so called “Health Resort Medicine”. The concept of Health Resort Medicine emphasizes the search for an “ideal place to treat” or at least a “proper or good place to promote, treat or rehabilitate” a health condition. Either in the presence of an established disease (with their consequent impairments and disabilities) or when dealing with a potential health problem that we want to prevent, what is really important to achieve is to get the circumstances that may facilitate our action and help us to reach our goals. Health education programs find here excellent locations to be implemented.If we look back in the history and tradition of this medical practice we conclude that this model was already present since Hippocrates. The correct behaviour of those who were under “resort treatments” included diet, exercise, baths and other physical modalities (such as massage) in a comprehensive program that can be consider an equivalent of those we prescribe today.So, we are not doing more than continuing an essential logic of health care which was updated today through the wise implementation of the ICF Model, allowing a better understanding and a rational systematization of our medical attitudes.

PapersThe influence of Ai Chi on balance and fear of falling among older adults : a randomized clinical trialTeixeira Rita1, Lambeck Johan2, Neto Francisco1 [Portugal, Belgium]1 - Formaterapia Cursos, Porto, Portugal2 - Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Belgium
Lambeck Johan Tervuursevest 101, 3001 Heverlee, Louvain (BE)+41 223014044 / +31 610947125lambeck@freeler.nl
Objective The purpose of this randomized, assessor blinded, experimental study was to examine the effect of an Ai Chi program on balance and fear of falling among community dwelling older adults.Methods Thirty older adults were randomly allocated to either an experimental or a control group. The experimental group (n=16) received 16 Ai Chi sessions in the period of 6 weeks. Participants in the control group (n=16) did not participate in any exercise program and were asked not to change their usual pattern of activities during the study. All participants were assessed with the Tinetti Performance-Oriented Mobility Assessment (POMA) to measure balance capabilities and the Falls Efficacy Scale (FES) to measure fear of falling at 0 and 6 weeks.Results The experimental group had a statistically significant increase in balance (Wilcoxon Z=-3,289 ; p=0.001) but not in fear of falling (Wilcoxon Z=-1,024 ; p=0,306), whereas the control group showed no significant change in balance (Wilcoxon Z=-1,140 ; p=0,254) and a significant increase in fear of falling (Wilcoxon Z=-2,528 ; p=0,011). The effect sizes (Cohen’s d) showed values of 1.3 for the POMA and 1.5 for the FESConclusion This investigation’s findings suggest that an Ai Chi program leads to a clinical relevant increase of balance in older people. There is a tendency to decrease fear of falling, although statistical significance has not been reached, but since fear of falling increased in the control group, a clinical relevant difference could be shown.

Thermal treatment for elderly in a Spanish and French balnearyCerrada A1, Casado JM1, Sánchez A1, Maraver F1, Ribera JM2, Diestro P3 Herisson C4, Carbonnel R5 [Spain, France]1 - Department of Hydrology Complutense University, Madrid, Spain2 - Geriatric Department Hospital Clínico San Carlos Madrid, Spain 3 - Department of Hydrology, Balneary of Baños de Montemayor, Cáceres, Spain4 - Functional Reeducation Department, Hopital Lapeyronie, Montpellier, France 5 - Service of Thermal Medicine, Balaruc-les-Bains, France
Alberto Cerrada Fernandez alatriste28@yahoo.es
Objective To assess the characteristics of the patients, main pathologies, number of drugs before and after the cure and their objective and subjective evolution, in two groups of  elderly patients attending a Balneary of Cáceres (Spain) and Balaruc-les-Bains (France).Materials and methods We have made a randomized selection of the elderly attended at the balneary. The sample studied covered 52 patients in Spain and 76 in France. Informations were obtained through an interview with the doctor the first and the last day of the cure. The questionnaire evaluates : sex, age, social statement, main pathology, medication before and after the cure and subjective and objective evolution of the disease. We have performed a descriptive statistical analysis comparing results between Spanish and French group of patients. Result In Spain 67 % of the patients were women, 67 % married, 27 % widowed. Mean age was 71 years (58 % more than 70 years old). Rheumathological problems are the first cause of attendance (98 %) respiratory diseases was present in 33 %. Main number of drug intake : 3.2, after the cure there was a 6 % reduction and 2 % had total supression. Mobility increased in 85 % of the cases and 80 % improved the respiratory sintomatology. Subjective evolution in terms of sintomatology and general welfare was perceived as moderate increase nearly 100 % of the patients as well as the satisfaction and repetition of the program. In France 63 % of the patients were women, 79 % married, 9 % widowed, 9 % divorced. Mean age was 61.4 years (71 % less than 65 years old). 100 % had rheumathological problems. Main number of drug intake : 2.1, after the cure there was a 4 % increase. Objective evolution in terms of mobility increased in 61 % of the cases. Subjective evolution was perceived as increased in 64 % (29 % great majority).Conclusions Patients who attend the Spanish balneary are older, with a greater drug compsumption and higher percentage of widowed. Respiratory problems are also frequent and treated. Subjective and objective evolution is reported as higher in this group with no increase of drug intake. Social statement differs slightly in the French thermal station with a higher percentage of married and divorced patients. We do not find significative differences between patients attending either two balnearies in terms of sex and main pathology ; female with chronic rheumathological problems, although French balnearies are focused on one pathology.

The “Programa de termalismo social del IMSERSO” in spain and old peopleSaz Peiro Pablo, Ortiz Lucas Mar, Martinez Moure Olga [Spain]Facultad de Medicina de la Universidad de Zaragoza
Saz Peiro PabloFacultad de Medicina de la Universidad de Zaragoza. Calle Domingo Miral , s/n  50009 Zaragoza (ES)+34 610250461 / +34 657148710olga.m.moure2006@hotmail.com
In this text we analyse the “Programa de Termalismo Social del IMSERSO”, as a tourist form posted to old people.On the other hand, Spain is a country with a population very aged (in relation with European reality).Thermal baths can be seen as a right, related with the health belief model. We talk about the proportion places in the programme-old people.
Scientific conclusion of the congress
Discussion of the blog of terminology10.30 am – 11.30 am

Social session11.30 am – 12.30 am
ISMH General assembly Presentation of the venue of the next congress

General conclusion – End of the congress