1. Is balneotherapy more effective than hydrotherapy? M. Zeki Karagülle IV. TURKISH - HUNGARIAN BALNEOLOGICAL MEETING 18-22 January 2006 Balçova, Turkey

2. Confusion Balneotherapy Hydrotherapy

3. Water Therapies In fact, both hydrotherapy and balneotherapy involve the use of water in any form or at any temperature for the purpose of healing.

4. Balneotherapy Comprehensively defined as; “the therapeutic use of balneological agents (mineral and thermal waters, muds and gases); usually through water or gas (not so often) immersion of part or all of the body, through mud applications (total or local baths or packs or even tampons) also through drinking mineral and thermal water but also inhaling the vaporized or dispersed mineral and thermal water

5. Hydrotherapy Broadly defined as; “the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes” may include immersion in a bath (bath tube) or body of water (such as a pool), aquatic exercise (exercise in water in a pool), use of water jets, douches, application of wet towels to the skin, or water birth

6. What is common in balneotherapy and hydrotherapy ?

8. “Hot Water Immersion” in Balneotherapy and Hydrotherapy FactorsEffects TemperatureThermal effects; analgesic, muscle relaxation, anti-inflammatory ie. Hydrostatic Pressure Cardiovascular and urinary effects; central blood redistribution, ANF secretion, diuresis, BuoyancyMechanical relaxation, ability to float, easily lying position ViscosityResistance of motion through water (during walking and exercising)

9. What is the difference? Balneotherapy employs generally natural thermal mineral water, mostly at a spa Hydrotherapy on the other hand consists of the use of ordinary water (tap or very low mineralized), whether at a spa or not

10. Some provocative remarks Does balneotherapy using thermal mineral water offer any benefits that hydrotherapy with tap water does not?

11. Thermal and Mineral Waters Mineral Water Minimum 1g/L total mineralization Thermal Water Minimum 20°C natural temperature “Specific” Mineral Waters Minimum levels for minerals; Bromide, Chloride, Fluoride, Ferro, Iodide, Sodium, Sulfur Minimum levels for dissolved gases; Radon, Carbon dioxide, Hydrogen Sulfide

12. Main Ions and Combinations in Mineral waters Main Ions Na + Ca ++ Mg ++ Cl -  HCO 3 - SO 4 -- 

13. Specific Chemical Ingredients Chemical Ingredient Minimum concentration Sulfur (S 2- )1mg/L CO 2 500 or 1000mg/L Radon ( 222 Rn)666Bq/L (α-particle) Salt (NaCl)1g/L (Salty), 14g/L (Brine) Na + 500mg/L Cl - 800g/L

14. Does chemical ingredients make any sense? Chemical Ingredient Minimum concentration Thermomineral water 1g/L ≤ total mineralization, 20°C ≤ natural temperature Sulfur water1mg/L ≤ S 2-

15. Sulfur baths versus tap water; animal study Artificial sulfur water S 2- concentration: 10mg/L

16. The chronic arthritis which developed in the non-injected left hind paws reached maximum severity on the 9th day after CFA injection in tap water and control groups and not before the 19th day in the sulfur group. Later on, edema in the sulfur group decreased statistically more rapidly (p <0.001) compared to the other two groups.

17. The decrease in paw volume in adjuvant injected paws at the end of the experiment was the greatest in the sulfur group followed by tap water group. There was not any significant difference between the two experiment and the control groups.

18. Natural Sulfur Water S 2- concentration: 59.3mg/L Sulfur water versus tap water; experimental study

20. Natural Sulfur Water S 2- concentration: 2.4mg/L Sulfur baths versus tap water; clinical study

21. Prior to treatment, the groups were statistically similar. After treatment, there was evidence of a statistically significant effect of spa water compared with tap water

22. Testing for Association between Water Properties and Improvement in Clinical Status The statistical test yields an empirical chi square statistics of X2emp=40.7465 (degrees of freedom: 1) within associated value of p < 0.0001. This proves the true association between the two qualitative variables. Therefore, the statistical analysis demonstrated the favorable influence of balneotherapy with Kehidakustany mineral water on the patients' clinical status.

23. Sulfur baths versus control; meta- analysis of clinical studies Natural Sulfur Water S 2- concentration: 16mg/L

24. Hot sulphur baths vs control for pain severity (0–10 scale: 0=none, 10=severe) and for function (Lequesne index of knee OA severity). resulted in favor of sulphur baths, but no statistically significant outcomes for pain and function regardless of time frame post-treatment differences were found.

25. Sulfur baths versus control; meta-analysis of clinical studies Natural Sulfur Water S 2- concentration: 16mg/L

26. A clinically important benefit for hot sulphur baths versus control was found for both the improvement of swollen/tender joints (10 and 46% relative difference) and global patient (5 and 19% relative difference) in patients with RA (definite or classical RA, chronic stage)

27. Karagülle MZ, Dönmez A, Odabaşı E, Karagülle M, Eşref A Comparison of the effects of taking bath in thermomineral versus tap water on the pain threshold ; Karagülle MZ, Dönmez A, Odabaşı E, Karagülle M, Eşref A 33rd World Congress of ISMH October 4-11 1998, Karlovy Vary, Prague, Luhacovice Natural Thermomineral water Total Mineral Concentration; 2600mg/L Thermomineral versus tap water; Physiological study

28. p<0,001

29. Thermomineral baths versus tap water; clinical study Natural Thermomineral water Total Mineral Concentration 1675mg/L

30. Subjective rating of therapeutic efficacy by patients reflected a significant improvement immediately after treatment in both groups. Paradoxically, 3 months later, this improvement was present only in the control group. After balneotherapy, medical assessment revealed significant improvement exclusively in the actively treated group. After 3 months, however, there was no difference between the two groups.

31. Does chemical ingredients make any sense? ChemicalIngredient Minimum concentration Effective concentration Sulfur (H 2 S, S 2- )1 mg/LHigher Total Mineral1 g/LHigher

32. Biological Effects Sulfur Water Balneotherapy Thermomineral Balneotherapy Tap Water Hydrotherapy Immuno- modulatory, + ?? Anti- imflammatory + ++ + Antioxdidant,++? Release of β endorphin ?+? Analgesic+ + ++ + Muscle relaxant + + ++ +

33. Therapeutic Effectiveness Sulfur Water Balneotherapy Thermomineral Balneotherapy Tap Water Hydrotherapy Rheumatoid Arthritis ↑ ↑ ↑↑?↑ Knee Osteoarthritis ↑ ↑ ↑↑ ↑ Low back pain ↑ ↑ ↑↑ ↑ Fibromyalgia ↑ ↑ ↑↑ ? ↑

34. Balneotherapy (Mineral water Immersion) Mineral composition Causes biologic effects MechanismsNot completely understood Probably Involved “NICE” systems; Neuro-Immuno-Cutaneous- Endocrine

35. There is some evidence, but we still can not answer clearly Does balneotherapy have any advantages over hydrotherapy? Is balneotherapy more effective than hydrotherapy?