Is balneotherapy more effective than hydrotherapy?

M. Zeki Karagülle IV. TURKISH - HUNGARIAN BALNEOLOGICAL MEETING

18-22 January 2006 Balçova, Turkey

Confusion

• Balneotherapy

• Hydrotherapy

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.

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

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

What is common in balneotherapy and hydrotherapy ?

“Hot Water Immersion” in Balneotherapy and Hydrotherapy

Factors Effects

Temperature Thermal effects; analgesic, muscle relaxation, anti-inflammatory ie.

Hydrostatic Pressure

Cardiovascular and urinary effects; central blood redistribution, ANF secretion, diuresis,

Buoyancy Mechanical relaxation, ability to float, easily lying position

Viscosity Resistance of motion through water

(during walking and exercising)

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

Some provocative remarks

• Does balneotherapy using thermal mineral water offer any benefits that hydrotherapy with tap water does not?

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

Main Ions and Combinations in Mineral waters

Main Ions

Na+ Ca++ Mg++

Cl-

HCO3-

SO4--

Specific Chemical Ingredients

ChemicalChemical IngredientIngredient Minimum concentration Minimum concentration

Sulfur (S2-) 1mg/L

CO2 500 or 1000mg/L

Radon (222Rn) 666Bq/L (α-particle)

Salt (NaCl) 1g/L (Salty), 14g/L (Brine)

Na+ 500mg/L

Cl- 800g/L

Does chemical ingredients make any sense?

ChemicalChemical IngredientIngredient Minimum concentration Minimum concentration

Thermomineral water1g/L ≤ total mineralization,

20°C ≤ natural temperature

Sulfur water 1mg/L ≤ S2-

Sulfur baths versus tap water; animal study

Artificial sulfur waterS2- concentration: 10mg/L

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.

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.

Natural Sulfur WaterS2- concentration: 59.3mg/L

Sulfur water versus tap water; experimental study

Natural Sulfur Water

S2- concentration: 2.4mg/L

Sulfur baths versus tap water; clinical study

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

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.

Sulfur baths versus control; meta-analysis of clinical studies

Natural Sulfur Water

S2- concentration: 16mg/L

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.

Sulfur baths versus control; meta-analysis of clinical studies

Natural Sulfur Water

S2- concentration: 16mg/L

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)

Comparison of the effects of taking bath in thermomineral versus tap water on the pain threshold ; Karagülle MZ, Dönmez A, Odabaşı E, Karagülle MZ, Dönmez A, Odabaşı E, Karagülle M, Eşref AKaragülle M, Eşref A

33rd World Congress of ISMH33rd World Congress of ISMHOctober 4-11 1998, Karlovy Vary, Prague, LuhacoviceOctober 4-11 1998, Karlovy Vary, Prague, Luhacovice

Natural Thermomineral waterTotal Mineral Concentration; 2600mg/L

Thermomineral versus tap water;

Physiological study

0

5

10

15

20

25

30

% Increase inPressure Pain

Threshold

Thermalwater36ºC

Tapwater36ºC

p<0,001

Thermomineral baths versus tap water; clinical study

Natural Thermomineral waterTotal Mineral Concentration 1675mg/L

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.

Does chemical ingredients make any sense?

ChemicalChemical

IngredientIngredientMinimum Minimum cconcentrationoncentration

Effective Effective concconceentrationntration

Sulfur (H2S, S2-) 1 mg/L Higher

Total Mineral 1 g/L Higher

Biological EffectsSulfur Water

BalneotherapyThermomineral Balneotherapy

Tap Water Hydrotherapy

Immuno-modulatory,

+ + ? ?

Anti-imflammatory

+ + + + +

Antioxdidant, + + ?

Release of β endorphin

? + ?

Analgesic + + + + + +

Muscle relaxant

+ + + + + +

Therapeutic Effectiveness

Sulfur Water Balneotherapy

Thermomineral Balneotherapy

Tap Water Hydrotherapy

Rheumatoid Arthritis

↑ ↑ ↑ ↑ ?↑

Knee Osteoarthritis

↑ ↑ ↑ ↑ ↑ ↑

Low back pain

↑ ↑ ↑ ↑ ↑ ↑

Fibromyalgia↑ ↑ ↑ ↑ ↑ ? ↑

Balneotherapy (Mineral water Immersion)

Mineral composition

Causes biologic effects

Mechanisms Not completely understood

Probably Involved

“NICE” systems;

Neuro-Immuno-Cutaneous-Endocrine

There is some There is some evidence, but we evidence, but we

still can not still can not answer clearlyanswer clearly

• Does balneotherapy have any advantages over hydrotherapy?

• Is balneotherapy more effective than hydrotherapy?