1. Baln1 Balneology Balneology serves the health Prof. Dr. Dr. Helmut G. Pratzel President of the International Society of Medical Hydrology and Climatology

2. Baln 2 Overview to the following lectures ä Overview ä Video Sanfte Reize(German) ä Physical factors in Balneology ä Video Aix le Bain (French) ä Kneipp therapy ä Videos Kneipp treatment(German) ä Percutaneous Absorption ä Video Sibyllenbad Bad Nenndorf (German) ä Chemical factors in Balneology ä Video Copahue Argentinia(English) ä Creno therapy ä Video Balneorio de Alange (Spain) ä Medical Climatology

3. Baln 3 Regulates for health-conscious life by Hippokrates and Galen ä Cultured relations with light and air, waters and heat, the climate, the ground, the environment. ä Culture of the meal and drinking, the table-manners and abstinence- regulate. ä Balanced rhythm of movement and rest, work and leisure time, stress and leisure. ä Sleeping and waking state oriented at the cosmic rhythms, ä Culture of the metabolism-processes. ä Mastery of the passions, economics of the emotion-household, cultured contact with itself.

4. Baln 4 To die young, but as late as possible! PatientsTourists

5. Baln 5 Leben und Treiben an einem Jungbrunnen. Holzschnitt nach einem Bild von Hans Sebald Beham The bath a gift of the Romans

6. Baln 6 Other people with other applications

7. Baln 7 The baptism

8. Baln 8 The sweating bath

9. Baln 9 The Mud bath

10. Baln 10 The drinking cure Lithographie von Honoré Daumier

11. Baln 11 Balneotherapy in the 10 th Century by Paulos of Agina Sulphur-baths: annoy-ailments, rashes, paralyses, Sulphur-baths: annoy-ailments, rashes, paralyses, Alaun-waters: blood-cough, blood-departure from the uterus, Alaun-waters: blood-cough, blood-departure from the uterus, Copper-waters: strengthening of the eyes and ears, wholesome the guts, haemorrhoids, Copper-waters: strengthening of the eyes and ears, wholesome the guts, haemorrhoids, Iron-waters: spleen-troubles, stomach-troubles, Iron-waters: spleen-troubles, stomach-troubles,

12. Baln 12 Balneotherapy in the 11 th Century by Kanon des Avicenna Sulphur-baths: annoy-ailments, rashes, paralyses, Sulphur-baths: annoy-ailments, rashes, paralyses, Alaun-waters: blood-cough, blood-departure from the uterus, Alaun-waters: blood-cough, blood-departure from the uterus, Copper-waters: strengthening of the eyes and ears, wholesome the guts, haemorrhoids, Copper-waters: strengthening of the eyes and ears, wholesome the guts, haemorrhoids, Iron-waters: spleen-troubles, stomach-troubles, Iron-waters: spleen-troubles, stomach-troubles, Aquae salse: laxatives Aquae salse: laxatives Thermal water: pains in the joints Thermal water: pains in the joints

13. Baln 13 Bath-regulates of the 14 th Century by Pietro da Tossignano If you will go to a bath, you must take away after the advice of the doctor and have left to the vein, provided it is wholesome. If you will go to a bath, you must take away after the advice of the doctor and have left to the vein, provided it is wholesome. Whoever into the bath climbs, may not be cold or heated. Whoever into the bath climbs, may not be cold or heated. The body may have no signs to inflammations, as that is the case to all those who an acute fever survived, or disposes to fevers or are exhausted. The body may have no signs to inflammations, as that is the case to all those who an acute fever survived, or disposes to fevers or are exhausted. Before the cure, one doesn't show to frequent coitus or to big temperance, as well all other, which the strength could weaken. Before the cure, one doesn't show to frequent coitus or to big temperance, as well all other, which the strength could weaken.

14. Baln 14 Bath-regulates from the 14 th Century by Pietro da Tossignano Before one climbs into the bath, one must be sober. Whoever doesn't tolerate the bath takes 2 spoons well washed raisins with 2 parts waters and 1 parts wine or some prunes softened in waters several times. One still drinks in the bath after it neither, as long as one has not yet eaten. Before one climbs into the bath, one must be sober. Whoever doesn't tolerate the bath takes 2 spoons well washed raisins with 2 parts waters and 1 parts wine or some prunes softened in waters several times. One still drinks in the bath after it neither, as long as one has not yet eaten. One must bath every day and must remain approximately 1 hour in the bath, approximately 15 days long. One must bath every day and must remain approximately 1 hour in the bath, approximately 15 days long.

15. Baln 15 Bath-regulates from the 14 th Century by Pietro da Tossignano If one has left the bath, one puts itself into the bed and waits for the perspiration-outbreak there. If one has sweat, one leaves dry off and rubs off with cloths completely. One gets dressed and goes to the fresh air for a very long time, like the heat of the bath still continues to have an effect. First then should have breakfast one. If one should have thirst previously, so takes one of white sugars or raisins or something, which deletes the thirst, but no drinks. The poor people who have no bed, should remain in the bath-room, until he has sweat well. Then he exits and does, as declared. If one has left the bath, one puts itself into the bed and waits for the perspiration-outbreak there. If one has sweat, one leaves dry off and rubs off with cloths completely. One gets dressed and goes to the fresh air for a very long time, like the heat of the bath still continues to have an effect. First then should have breakfast one. If one should have thirst previously, so takes one of white sugars or raisins or something, which deletes the thirst, but no drinks. The poor people who have no bed, should remain in the bath-room, until he has sweat well. Then he exits and does, as declared.

16. Baln 16 Bath-regulates from the 14 th Century by Pietro da Tossignano One is be careful during the time, that one is in the bath, against coldness of all type, but also still several months after it, because the strength of the bath continues to have an effect even longer time, normally 6 months. One is be careful during the time, that one is in the bath, against coldness of all type, but also still several months after it, because the strength of the bath continues to have an effect even longer time, normally 6 months.

17. Baln 17 Bath-regulates from the 14 th Century by Pietro da Tossignano If one uses the bath for the first time, one may remain in it only short time, the second time somewhat longer, the third time even somewhat longer, first at the fourth bath, one is allowed to remains in the water up to the prescribed time (1 hours). The same is valid for the drip-bath directional on the head. On the first day, one may take only 1 bath, on the second day 2 baths. Furthermore one must know, that one can take 1 tub-bath and on the same day 1 on the head directional drip-bath. It is better, to take the tub-bath before the drip-bath. If one uses the bath for the first time, one may remain in it only short time, the second time somewhat longer, the third time even somewhat longer, first at the fourth bath, one is allowed to remains in the water up to the prescribed time (1 hours). The same is valid for the drip-bath directional on the head. On the first day, one may take only 1 bath, on the second day 2 baths. Furthermore one must know, that one can take 1 tub-bath and on the same day 1 on the head directional drip-bath. It is better, to take the tub-bath before the drip-bath.

18. Baln 18 Bath-regulates from the 14 th Century by Pietro da Tossignano Whoever wants to take a drip-bath must shear or is shaved, so that the hair doesn't hinder the effect of the bath. Whoever wants to take a drip-bath must shear or is shaved, so that the hair doesn't hinder the effect of the bath. Because with these measures an inflammation of the liver or the kidneys is to be afraid, one should rub in the named positions with sandal-ointment before each bath. Because with these measures an inflammation of the liver or the kidneys is to be afraid, one should rub in the named positions with sandal-ointment before each bath.

19. Baln 19 Water as elixir of the life ä Dietetic bath ä Medical bath ä cleans ä refreshes ä pleases ä enjoys ä healthy-gets ä calm ä trouble ease ä heals

20. Baln 20 The dietetic bath It serves ä The joy ä The relaxation ä The body-care ä The beauty

21. Baln 21 Water is a medical remedy and a health remedy ä It serves the health-prevention (dietetics) To drinking as food To drinking as food To bath as toiletries To bath as toiletries ä It serves the suffer-treatment (balneology) To bath because of its physical and pharmacological effects over the skin To bath because of its physical and pharmacological effects over the skin To drink because of its stimulating effects on inner organs To drink because of its stimulating effects on inner organs To inhale because of its effects on the respiration- organs To inhale because of its effects on the respiration- organs

22. Baln 22 The variety of the water-application for bathing ä Sea resorts ä River resorts ä Indoor baths ä Wave-baths ä Whirlpools ä Tub-baths ä Bubble-baths ä Shower ä Dust-baths ä Downpour ä Drip-baths ä Rain-baths

23. Baln 23 Water is the most used remedy ä Everybody is using it. ä Everybody believes its effectiveness. ä The medical experience is bigger than in any other drug. ä The private share in costs is higher than in any other medicament. ä It is the cheapest medicament. ä No other medicament was described so many times by artists than water.

24. Baln 24 In Balneology not only water is used for bathing ä Natural water baths ä Artificial baths with additions ä Sunbathes ä Air-baths ä Mud-baths ä Bog-baths ä Sand-baths

25. Baln 25 Overview of this lecture Main focuses to the topic ä History ä Definitions in Thermalism ä Health Resorts ä Therapeutic principles ä Systems, Inventory, Licenses, Education Organisation of Thermalism Organisation of Thermalism ä Statistics and economics ä Research ä Conclusion

26. Baln 26 Definitions in Thermalism I ä Balneology is the science of the remedies of the water and the ground. ä Medical balneology or Medical hydrology (French: hydrologie médicale) is the science of the medical application of the remedies of the water and the ground. (it is meant the place, the resort (Greek: balaneion, Latin: balneum, English: spa) and not the bath-tub or pool or bathing-medicine!)

27. Baln 27 Definitions in Thermalism II ä Hydrotherapy is a section of the physiotherapy. It is used tap-water or mineral water for showers, bath tubs, affusions (acc. Kneipp), packs or part- baths. ä Balneotherapy is enforced in the framework of the health resort-medicine as complex salvation- measure together with other fully organised therapy-procedures as bath-cure, drinking-cure or inhaling-cure under the influence of fixed- climatic factors (no pure bath-therapy!).

28. Baln 28 Definitions in Thermalism III ä Chemical balneology is a section of the balneology as support-science of the medical balneology to the quality-protection and -control of the remedies of the water and the ground. ä Hydro-geology is an autonomous science-area to the opening and quality-protection of the mineral resources.

29. Baln 29 Definitions in Thermalism IV ä Medical climatology or Bio-climatology is the science of the remedies of the climate. ä Meteorology and climatology are autonomous science-areas to the judgement of the climate. ä Climate-therapy is enforced in the framework of the health resort-medicine as complex salvation- measure together with other fully organised therapy-procedures with climate-cures.

30. Baln 30 Definitions in Thermalism V ä Thalasso-therapy is enforced in the framework of the health resort-medicine as complex salvation- measure together with other fully organised therapy-procedures with sea-waters, silt, sand and sun as bath-cure under the influence of the climate of the sea. ä Crenotherapy (Greek: kreno the source) is understood as drinking therapy. The concept is also used synonymously for Balneotherapy in some languages.

31. Baln 31 Thermalism ä The Roman word Thermalisme is translated in German to Kur- und Bäderwesen and is the same like Balneology. ä Thermal-baths are treatment-places with a source from deep waters, that must have over 20 °C in Europe. This is a hydro-geological definition and not a medical. ä Spa treatment during a period of 3 or 4 weeks is named cure.

32. Baln 32 Health Resort Science

33. Cure and Rehabilitation (Definitions) ä "Kur" (cure of treatment, course) is a special type of medical treatment in Health Resorts with natural remedies during a period of 3-6 weeks. It mainly use the reactivation of self-healing powers by stimulation and training by minimise the use of drugs. ä Prevention or Rehabilitation are the goal of treatment.

34. Baln 34 Health Resorts Which kind of principles are included? Centres using methods to re-activate self-healing power by ä Salugenetic and hygiogenetic concepts of treatment ä Personally patient-oriented concepts ä Use of endogenous power stimulation and stabilising forms of treatment ä Activation of the patient's own responsibility for his health ä Use of a pleasant and culturally encouraging environment close to nature to stimulate the therapeutic acceptance. Health Resorts ?

35. Importance of Health Resorts ä Therapeutic use of classical forms of prevention and rehabilitation. ä They provide economic incentives for regional health care industries and tourist markets. ä They serve as healthy ecological location for environmental protection and appreciation.

36. Two Functions of Health Resorts ä Health Resorts are centres in treatment of chronicle diseases and to realise preventive and rehabilitative goals. ä Health Resorts are centres to get health in healthful vacations.

37. Public Health the goal of present-day Health Resort Medicine ä Prevention is better than Therapy ä Learning to Live Healthfully

38. Baln 38 Purviews of the Health Resorts Health Resort Medicine fills its tasks in the framework of prevention and medical rehabilitation under appropriate participation of the liability community and Health Resort Medicine fills its tasks in the framework of prevention and medical rehabilitation under appropriate participation of the liability community and Health Tourism fills its tasks as one itself tourism under utilisation of the offered measures in Health Resorts. Health Tourism fills its tasks as one itself tourism under utilisation of the offered measures in Health Resorts.

39. Integration of Health Resorts in the Health Care System ä Out-patient treatment by the Family Physicians ä In-patient treatment of special acute diseases in Hospitals ä In-patient or out-patient rehabilitation mainly in Health Resorts of chronic diseases of chronic diseases of acute diseases, stroke, street accidents a. o. after treatment in special hospitals of acute diseases, stroke, street accidents a. o. after treatment in special hospitals ä In-patient or out-patient prevention in Health Resorts

40. Baln 40 The cure as the 3 rd pillar of health-care-system 1. The out-patient care through the family-doctor generally as possible 2. The necessary stationary care in hospitals with certain acute- illnesses 3. The health resort-medical care in rehabilitation clinics and by out-patient cure after survived acute-illnesses, by chronic illnesses or to avoidance of illnesses with the possibilities of post-treatment, rehabilitation and prevention.

41. Baln 41 Types of Health Resorts ä Medical Treatment centres: Balneotherapeutic centres with medical useable mineral waters or mud Balneotherapeutic centres with medical useable mineral waters or mud Thermal centres with medical useable thermal water Thermal centres with medical useable thermal water Clime centres using healthy climate in the mountains Clime centres using healthy climate in the mountains Kneipp centres with equipment and experience in Kneipp therapy Kneipp centres with equipment and experience in Kneipp therapy Thalasso centres using the natural remedies of the sea Thalasso centres using the natural remedies of the sea ä Wellness centres using equipment for pleasure and fun : Spa hotels Spa hotels Sea resorts (Thalasso-wellness) Sea resorts (Thalasso-wellness) Air resorts Air resorts

42. Baln 42 Situación y competencia térapéutica ä Sano ä Agotado ä Enfermedades crónicas ä Enfermedades agudas ä Caso de emergencia Médico de familia Hospital Vacaciones de salud en spa en spa Tra- tamiento

43. Baln 43 Balneology and climatology are the science of health resorts ä it uses the therapy-principle basing on a health-science, ä it offers an integral therapy-concept, ä it applies stimulating and stabilising treatment-methods, ä it strengthens the health own-responsibility, ä it uses a culturally edifying and psychologically stress- free environment at health resort to promote of the therapeutic acceptance

44. Baln 44 Therapeutic Principles 1 stimulatio Naturopathic, reactivate of self healing power Naturopathic, reactivate of self healing power 2 substitutio Substitution for metabolic malfunctions Substitution for metabolic malfunctions 3 directio Pharmacotherapy Pharmacotherapy 4 excludio Surgery Surgery pathogenetic oriented artificial healing" hygiogenetic oriented self healing" }

45. Baln 45 1. Stimulatio ä Activation, somatic and psychic, especially by release of counter-reactions, followed by training of physiological function-systems to improve the performance-capacity (Prevention) or ä reactivation of endogenous defence-mechanisms to self overcome of pathological situations (Curation and rehabilitation by reactivation of existing self healing power).

46. Baln 46 2. Substitutio ä Substitute and supplement of lacking substances and abilities, if these cannot be mobilised sufficiently by stimulation (insulin, vitamins, prostheses, glasses, etc).

47. Baln 47 3. Direktio ä Steering of patho-physiologic functions by drugs, if it is not possible to reactivate endogenous self healing power by stimulation, by the goal to develop stabilised physiological functions again, and to avoid long-term dependence.

48. Baln 48 4. Exklusio Endogenous: elimination of not repairable systems by surgical intervention, if other measures seem unsuccessful. Endogenous: elimination of not repairable systems by surgical intervention, if other measures seem unsuccessful. ä Exogenous: relief of sick-doing noxe and behaviour (wrong nutrition, drug addiction, medicament abuse, insufficient inurity).

49. Baln 49 Primary prevention l to contribute the avoidance of a damage through activation of defence-strengths in one still healthy assuming organism by construction of a healthy behaviour. The organism has an elevated risk through certain habits or a special occupation and would take early or late damage without prevention measure.

50. Baln 50 Secondary prevention l Elimination of risk factors by early-treatment of existing illnesses, to reach a decrease of the pathogen or pathoplastic appearing influence-sizes and to stabilise one still remained rest-health by elimination of illness- stabilising habits.

51. Baln 51 Ternary prevention or medical rehabilitation l to reach an improvement of the health-condition and one progressing of the illness-process, to detain and to enable the concerned, to handle his illness adequately, and despite hindrance to perceive his function in occupation, family and company as wide as possibly.

52. Baln 52 Cure systems ä Free (out-patient) cure ä Compact cure (group treatment) ä In-patient cure in sanatorium or clinics

53. Course of Treatment depending on impairment, malfunctions, disability or handicap ä Out-patient treatment (Patients stay in pensions or special hotels) ä In-patient treatment (Patients stay in sanatorium or rehabilitation clinics)

54. Baln 54 Compact cure ä Led group-therapy ä Indication oriented contractual treatment- concept ä Estimated-emolument

55. Baln 55 Guidelines for health resorts § 1 type-terms § 2 natural remedies § 3 analysis-guidelines § 4 medical norms

56. Baln 56 General rules for effective bathing ä Chemical effects of water can be used only in bath tubs No disinfections No disinfections Concentration in bath tub Concentration in bath tub ä H 2 S > 10 mg/l ä Radon > 1 kBq/l ä CO 2 > 1 g/l ä Brine 10-150 g/l (in case of indication) ä Physical effects of water can be uses in pools With disinfections (chemical substances are destroyed With disinfections (chemical substances are destroyed Temperature >30 °C (in case of application) Temperature >30 °C (in case of application)

57. Baln 57 ä Baths ä Bath-additions ä Warmly-packets ä Kryotherapie ä Inhaling ä Hydrotherapy ä Massages ä Kinesitherapy ä Physiotherapy ä Electro-therapy ä UV-Irradiation ä Radon-treatment ä Psoriasis-treatment ä Night-silence Performance-description for physical therapy in health resorts

58. Baln 58 Quality in Health Resort Medicine Quality control - of the remedies at the health resorts - of the treatment-strategies at the health resort Quality control - of the remedies at the health resorts - of the treatment-strategies at the health resort l Quality protection - by technical measures - by protection of the resources - by establishing of the performance-standard

59. Baln 59 Medical licences of physicians with relevancy in the treatment in Health Resorts ä Balneology and medical climatology ä Physical medicine ä Rehabilitative medicine ä Nature-treatments ä Environment-medicine

60. Baln 60 Specialities of Physicians in the EC ä Physikalische und Rehabilitative Medizin (Germany) ä Rééducation et Réadaptation Fonctionnelles (France) ä Rehabilitación (Spain) ä Fisiatria (Portugal) ä Fisioterapia (Italy)

61. Baln 61 Courses to get special licences and specialities l Licences Nature healing (4 months) Balneology and Medical Climatology (1 year) Physical Medicine (2 years) Rehabilitative Medicine (1 year) Environmental medicine (1,5 years) l Specialities the EC (3 years) Germany:Physikalische und Rehabilitative Medizin (Facharztanerkennung) France:Rééducation et réadaptation fonctionnelles (Attestation de médecin spécialiste qualifié) Spain:Rehabilitación (Título de Especialista) Portugal:Fisiatria (Tìtulo de Especialista) Italy:Fisioterapia (Diploma die medico specialista) l Specialities Specialist in physiotherapy in the EC (3 years) Germany:Physikalische und Rehabilitative Medizin (Facharztanerkennung) France:Rééducation et réadaptation fonctionnelles (Attestation de médecin spécialiste qualifié) Spain:Rehabilitación (Título de Especialista) Portugal:Fisiatria (Tìtulo de Especialista) Italy:Fisioterapia (Diploma die medico specialista)

62. Baln 62 Course to get Physiotherapist (3 years) 2900 h theoretical and practical education 500 h Gymnastics 380 h Anatomy and Physiology 440 h Pathology and Hygiene + 100 h Diagnostic 160 h Massage 120 h Physiotherapy + 580 h practice 100 h Kinesitherapy + 120 h practice 60 h Physical Therapy + 60 h practice 60 h Social medicine 40 h Applied Physic 40 h Occupation + 40 h first aid 100 h Kinesitherapy + 120 h practice 60 h Physical Therapy + 60 h practice 60 h Social medicine 40 h Applied Physic 40 h Occupation + 40 h first aid 1600 h Practice ever 240 h in: Surgery, Inner Medicine, Orthopaedics, Neurology 160 h Paediatrics ever 80 h in: Psychiatrics and Gynaecology ever 80 h in: Psychiatrics and Gynaecology

63. Baln 63 Education-principles of physicians The treatment chronically sick person can be learned only there, where ä these patients are treated, ä efficient therapy-centres existing, ä Teachers with enough experience practice.

64. Baln 64 Topics of the high-school-training l Application of active and reactive methods l Technologies and methods of the classic nature-treatments l Bases over autonomous functions in the biochemistry, physiology and psychology. Adaptive and regulative processes especially in the context with inflammation- processes and pains. l Diagnostic and therapeutic concepts with chronic illnesses l Manuals technologies of the diagnosis l Functional diagnosis l Acute rehabilitation in the area of the neurology, inner medicine, orthopaedics, geriatrics,

65. Baln 65 Health Resort Organisation

66. Baln 66 Medical Societies in Germany ä Scientific Society of physicians: Deutsche Gesellschaft für Physikalische Medizin und Rehabilitation e.V. ä Section of the I.S.M.H.: Deutsche Sektion der Internationalen Gesellschaft für Medizinische Balneologie und Klimatologie e. V. ä Occupation Society of spa physicians: Verband Deutscher Badeärzte e. V. ä Occupation society of physicians: Berufsverband der Ärzte für Physikalische und rehabilitative Medizin e.V. ä Society of physicians: Kneippärztebund e.V. ä Society of sciences in balneology: Vereinigung für Bäder- und Klimakunde e.V

67. Baln 67 Economic Association of Health Resorts ä In all European states economic national associations of the spas are working. In Germany: Wirtschaftsverband Deutscher Heilbäder und Kurorte.

68. Baln 68 World Organisations of Health Resort Science ä I.S.M.H. (since 1921) Medicine International Society of Medical Hydrology and Climatology International Society of Medical Hydrology and Climatology ä FITEC (since 1947-2000) Federation of National Health Resort Associations Fédération Internationale du Thermalisme et du Climatisme Fédération Internationale du Thermalisme et du Climatisme ä SITH (since 1955) Spa technique Société Internationale des Techniques Hydrothermales Société Internationale des Techniques Hydrothermales ä OMTh (since 1977) Economic, Management Organisation Mondiale du Thermalisme Organisation Mondiale du Thermalisme ä FEMTEC (since 2000) before FITEC

69. Baln 69 European Organisations ä EHV (since 1995) European Federation of National Health Resort Europäischer-Heilbäder-Verband Europäischer-Heilbäder-Verband ä ESCNM (since 1996) Medicine European Society for Classical Natural Medicine European Society for Classical Natural Medicine

70. World-Organisations of Health Resort Science

71. Baln 71 Common Congresses of the I.S.M.H. and founding the International League of Rheumatology

72. Baln 72 Congresses of the International League of Rheumatology

73. Baln 73 International Congresses of the I.S.M.H.

74. Baln 74 Committees of the I.S.M.H. l Rheumatology l Cardiology, circulation and vessel diseases l Gastroenterology and Endocrinology l Gynaecology l Dermatology l Respiratory diseases l Prevention l Paediatrics l Cure of the old person l Radon-applications

75. Baln 75 Objectives of international Committees l Preparing of uniform indication-listings for the treatment at health resorts l Preparing of a catalogue of checked and acknowledgement-appreciates treatment-strategies at health resorts. l Formulation of the priority health resort-medical research-demand and the criteria suitable for clinical questions.

76. Baln 76 Objectives of national Sections l Delegation of representatives for health resort- specific application-strategies into the international committees l Organisation of the exchange of scientific works l Reconnaissance and patronage of national structures to the research-transaction l Use of national subventions and organisation of global research-projects

77. European Health Resorts

78. Statistics of Health Resort Treatment 1992 53 % Diseases of the locomotoric system 14 % Diseases of the circulatory system 13 % Psycho-social diseases 5 % Metabolic diseases 5 % Metabolic diseases 5 % Tumours 5 % Tumours 5 % Respiratory tract diseases 5 % Respiratory tract diseases 5 % others 5 % others

79. Costs of Chronic Back Pain in Germany 1994 ä 1989 2,3 million cases of back pain resulted 43 million non-working days ä 1994 about 25.000 million$ treatment costs for disorders of spine and back pain and about 15.000 million$ non-working salary total about 40.000 million$

80. Costs of Treatment in Health Resorts ä Out-patient treatment $2000 during 3 weeks insurance pays $10 per night and 90% of treatment costs insurance pays $10 per night and 90% of treatment costs ä In-patient treatment $2500 during 3 weeks patients pay about $10 per day patients pay about $10 per day

81. Health Costs in Germany ä 1969 46.000 million$ ä 1992 286.000 million$ ä payment of the State Health Insurance 138.400 million$ in-patient treatment in hospitals37,1 % in-patient treatment in hospitals37,1 % out-patient treatments29,0 % out-patient treatments29,0 % administration6,0 % administration6,0 % health resort and spa treatment2,3 % health resort and spa treatment2,3 % ä payment of the Retirement Insurance 19.300 million$

82. German Health Resort Industry ä 329 Health Resorts and Spas ä annual increment value 13.300 million $ ä Work force 310.000 persons (=$42.903 per person) ä 118 million overnights 1993 in 726.000 beds (=44,5%) ä 9.8 million visitors 1993 (=12 days per visitor) ä 8.2 million patients privately financed (=83,6%) ä 1.6 million patients social financed (=16,4%)

83. Baln 83 Number of German Health Resorts Mineral- water and Mud- Resorts Clime- Resorts Thalasso- Resorts Kneipp- Resorts total 166415450311

84. Baln 84 Guests in German Health Resorts Mineral- water and Mud- Resorts Clime- Resorts Thalasso- Resorts Kneipp- Resorts total 19985.364.7463.243.4754.390.8421.786.22814.785.391 19995.700.8573.312.4424.788.9091.837.14815.639.356 20006.099.6053.534.5885.964.1241.970.47516.668.793

85. Baln 85 Overnight in German Health Resorts Mineral- water and Mud- Resorts Clime- Resorts Thalasso- Resorts Kneipp- Resorts total 199837.327.69717.498.886..29.879.32010.124.42794.830.330 1999 3999.238.94 7 17.534.35231.342.37210.347.39198.463.062 200041.549.36118.296.50733.141.16810.840.043103.827.079

86. Baln 86 Mean days overnight in German Health Resorts Mineral- water and Mud- Resorts Clime- Resorts Thalasso- Resorts Kneipp- Resorts total 19986,965,406,805,676,41 19996,885,296,545,636,30 20006,815,186,545,506,23

87. Baln 87 Patients in German Health Resorts

88. Research Three levels of research goals are important: ä medical treatment effect during the course of treatment ä long-term medical and social-medical effectiveness ä difference between expense and success: the efficacy. The following methods are suitable: ä clinical comparison ä comparison of costs before and after treatment ä comparison of non-working time

89. Baln 89 Criterions for evidence of the efficiency how is the treatment success? how is the treatment success? how is the follow up success ? how is the follow up success ? which relevancy does the singles-measure have at the total-success? which relevancy does the singles-measure have at the total-success?

90. Baln 90 Quality protection by clinical research Observation of applications Risks and benefits are recognized by big collectives by long observation times. Controlled trials Risks and benefits are recognized by small collectives by short observation times. Traditional evaluated inductive medicine (Naturopathic treatments) By free market rules evaluated deductive medicine (Pharmaceutical research)

91. Clinical Research as evidence the effectiveness and recognition of risks Fundamental Research to understand the principle of effectiveness Trial with low evidence (Observation of applications) Risks are recognized by long observation times Trials with high evidence (Controlled trials) Risks are recognized by rules of drug law Effect and effectiveness have to be in plausible context Exploration of effectiveness is of academic interest and to recognize of the rest-risk

92. Baln 92 Reliability of clinical research Long experience by big collectives Controlled research by small collectives

93. Baln 93 Clinical Trial Protocol by the Guidelines for Good Clinical Practice (GCP) of the European Community Trial objectives and purpose Trial objectives and purpose Trial design Trial design Randomisation, Blinding Randomisation, Blinding Selection and withdrawal of subjects Selection and withdrawal of subjects inclusion and exclusion criteria inclusion and exclusion criteria Treatment of subjects and control medication Treatment of subjects and control medication Assessment of efficacy Assessment of efficacy Assessment of safety Control of side effects and interactions Control of Compliance Statistics Direct Access to Source Data/Documents Quality control and Quality Assurance Procedures Ethics

94. Baln 94 Primary Efficacy Variable ä Only validated parameters should be used. ä Only one efficacy parameter is to defined. ä Endpoints used to determine efficacy should be clearly specified. ä Multiple parameters should be assembled to one score parameter. An efficacy threshold is to defined. An efficacy threshold is to defined.

95. Baln 95 Physical Medicine and Health Resort Medicine Cumulative Number of Congress lectures in specific fields

96. Baln 96 Main focuses of the physical medicine and health resort- medicine frequency of the topics of 100 congresses 1879-1995

97. Thermalism low Profit Pharmaceutical industry high Profit research promotion ContributionsContributions Co-operationCo-operation Public research promotion Public research promotion Research, education Use of professionalism Goal of interests Development of Political opinions Use of professionalism Goal of interests Development of Political opinions No promotion Lack of comprehension Lack of comprehension Circulation of contributions in free market systems

98. Baln 98 Conclusion ä Most medical bath application were evaluated by traditional experiences. ä Critical check-ups by drug-legal criterions have confirmed these experiences largely. ä Treatment in Health Resorts are important to enjoy and well-being both in the medicine as well as in the culture. ä The quality-requests in therapeutic and dietetic use of natural remedies are different. The difference is included in governmental certifications of medical health resorts or health resorts to use in health tourism. ä Water as the elixir of life. It has useful scientific qualities without spiritual imaginations.

99. Conclusion Chronically ill patients are dependent on the possibilities offered at the Health Resorts. But healthy tourists learn in Health Resorts too. The goal of both groups in treatment and prevention is the same: To die young, but as late as possible.