The studies on spa's health promotion effects on healthy or slightly unhealthy persons published in past two decades in Japan have been reviewed. Multidimensional findings from these studies have suggested that the spa resort using may have the effects of increasing and retention of skin and body temperature, improving peripheral circulation function, lowering blood pressure, improving gastrointestinal hormones secretion and increasing gastric mucosal blood flow, bettering metabolism, regulating the function of immune system, regulating the balance of autonomous nervous and internal secretion systems, relieving stress and relaxing, improving the quality of life (QOL), relieving the symptoms of those who are slightly unhealthy, promoting physical strength and fitness, promoting the well-being of the aged, reducing medical expenses of individuals or the community, keeping skin in good shape and restraining the skin's aging.
Of the 58 papers reviewed, the studies of hot spring bathing effects on increasing and retention of skin and body temperature, improving peripheral circulation function and lowering blood pressure were the most in numbers (12 papers, 20.7%), and then the studies of relieving the symptoms of those who were slightly unhealthy (10 papers, 17.2%). Case-control studies (26 papers, 44.8%) were the most used study designs, and then the clinical observation (20 papers, 34.5%). No findings from any one study reviewed in this paper showed that the spa resort using had definite evidence of health promotion effects. Probable effects were suggested from 32 studies (55.2%), but findings from the rest ones (26 papers, 44.8%) showed little evidence to support this consideration. Recently randomized controlled trials (RCT) had been used in studying the health effects of spa resort using in Japan and showed significantly better effects in the intervention group. However, the intervention methods used in the studies were comprehensive health education combing the instructions in appropriate ways of hot spring bathing and education on lifestyle and exercise. It was difficult, if not impossible, to separate the effect of hot spring bathing alone from the combination. The outcomes as effects used in the studies were blood profile, physique and other non-specific items. It may be also difficult to design and carry out a near perfect RCT study on the health promotion effects of spa resort using in field in the future. However, based on experience from past studies it is practicable and important to purse better epidemiological methods such as randomizing and crossover design. On the other side, as specific readers can be influenced marvelously by one book, the health conditions of users may be improved greatly and continuously by some spa. While evidence-based health care places emphasis on RCT, it is also extremely important to inspect the health promotion effects of spa using systematically and rapidly from the viewpoint of narrative-based health care.

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We have previously reported that a depressive mental state of the patients with rheumatoid arthritis (RA) could be improved by rehabilitation exercise and hot spring bathing. These patients noticed that their muscle stiffness decreased and that they also felt mentally refreshed. In this study, the changes in the serum inflammatory cytokine levels after rehabilitation exercise and hot spring bathing in the RA patients with an active disease were evaluated and increased levels of interleukin 6 (IL-6) were found to decrease to the nearly half of the pre exercise levels. The decreases in the IL-6 levels were not attributed to the circadian rhythm and they also did not correlate with the serum cortisole levels. Next, we chose RA patients with active disease who had not been treated with any corticosteroids or exercise therapy. After exercise, the patients tended to complain of aggravated muscle stiffness and joint pain as well as discomfort. Their IL-6 levels did not show any decrease, but instead a moderate increase was observed. IL-1 receptor antagonist (IL-1ra) showed normal levels before exercise, and they did not change substantially after the exercise. As a result, when patients with active disease achieved a decrease in muscle stiffness and also felt refreshed, then their serum IL-6 levels also decreased. Such exercise therapy should be initiated when the patients' complaints have improved owning to sufficient bed rest and small doses of corticosteroids.

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Background
Although there are several reports that electroacupuncture (EA) in the abdomen reduces fasting blood glucose and improves insulin sensitivity, the effects under a glucose load or hyperinsulinemic conditions have not yet been studied. In this study, we investigated the effect of EA at Zhongwan (CV12) under the conditions of an intravenous glucose tolerance test (IVGTT) and a hyperinsulinemic euglycemic clamp in normal Sprague-Dawlay (SD) rats.
Methods
Male SD rats were anesthetized with pentobarbital (40mg/kg i. p.) and then maintained by continuous infusion through a tail vein. Blood samples were drawn from the ventral tail artery during the fasting stage (baseline and 30min after), and at 2, 5, 10, 20, 30, 45, 60min after a glucose load (0.5g/kg). EA was performed for 30min (EA30, n=8) during the fasting stage and for 90min (EA90, n=8) during both the fasting and IVGTT periods. In the hyperinsulinemic euglycemic clamp experiments, insulin (2mU/kg/min) was infused through the tail vein, followed by infusion of 20% glucose at variable rates to maintain fasting blood glucose levels. EA was performed for 40min after a steady-state was achieved.
Results
Significant decreases in fasting blood glucose and increase in plasma insulin concentration were observed during the fasting period in rats in both the EA30 and EA90 groups, whereas rats in the control group (n=8) which did not receive any EA stimulation showed no such changes. Total glucose levels during the IVGTT were lower in the EA30 and EA90 groups compared to controls, with a significantly higher level of relative insulin secretion. During the hyperinsulinemic euglycemic clamp, glucose consumption was increased significantly by EA stimulation with a marked increase in both insulin concentration and sensitivity.
Conclusion
EA at CV12 accelerates glucose consumption during IVGTT and hyperinsulinemic conditions probably as a consequence of increased insulin sensitivity and/or increased plasma insulin concentration.

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Aims
Yufuin is one of the most famous spa resorts in Japan. However, little attention has been paid to public spa facilities from the viewpoint of their roles in health promotions for the residents. The Yufuin Onsenkan (spa facility) is located in the central portion of the Yufuin spa and has a complete set of spa baths and pools. The aim of this study is to assess the effect of spa-aqua therapy on various lifestyle-related diseases in collaboration with this public spa facility.
Methods
We have introduced spa-aqua therapy to patients who had been diagnosed and treated as having certain lifestyle-related diseases (diabetes, hypertension, hyperlipidemia, etc) in our outpatient clinic. One hundred and twenty-four patients consented to participate in the program of aqua exercises (30 minute walk) at least three times a week for more than three months under the supervision of medical doctors, aqua therapists, and public health nurses. These patients were assessed for clinical symptoms and laboratory data at 12 months following the spa-aqua therapy. Subsequently, brachial-ankle pulse wave velocity (baPWV) was measured on 92 healthy volunteers, 21 diabetes patients, and 39 hypertension patients to evaluate the effect of aqua-therapy on arteriosclerosis caused by lifestyle-related diseases.
Results
Decreases in clinical symptoms, improvement of laboratory data, and decreases in frequency and dosage of medical prescription were observed in 89 of 124 patients. Specifically, lowered levels of fasting blood sugar and hemoglobin Alc were observed in 20 of 24 diabetic patients and remarkable effects such as lowered blood pressure and decreased dosage of medicine and frequency of medical prescription were observed in 16 out of 20 hypertensive patients. As an index of arteriosclerosis caused by some lifestyle-related diseases, we also measured baPWV on 92 healthy volunteers, 21 diabetes patients, and 39 hypertensive patients before and after introduction of aqua-exercise. From the viewpoint of health insurance, annual medical fees of 35 patients, who were randomly selected from among 124 patients, decreased significantly after receiving aqua therapy combined with medicines. The baPWV values of diabetic and hypertensive patients were significantly higher than those of healthy volunteers before commencing aqua-exercise, and the baPWV values of diabetic and hypertensive patients did not improve significantly after six months of aqua-exercise, suggesting that a longer period of exercise is required.
Conclusion & Discussion
In collaboration with a public spa facility used daily by many residents, we succeeded in naturally introducing aqua-spa exercise to the usual habitual behavior of patients with lifestyle-related diseases. This kind of preliminary trial may have future potential not only of promoting health care for local residents but also providing prospects for health care businesses in spa resort areas.

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Balneotherapy includes several modalities of treatments and wellness programs, such as physiological and pharmacological effects of hot spring bathing and aqua-exercise, relaxing and biorhythm adjusting effects of staying in the urban climates and educational instruction for healthier life style. We examined health promoting effects of the comprehensive balneotherapy as a whole by the randomized controlled study. 89 women, who had no medical care, and were aged 40-65 years (mean +/- SD age: 59.0 +/- 8.0 years), volunteered for this investigation. Subjects were assigned at random to three groups; group 1 was the control group without any intervention; group 2 with exercise for 60min and educational guidance; group 3 with exercise for 30min and balneotherapy including aquaexercise for 30min and bathing in hot spring for 30min in addition to educational guidance. Each group followed the prescribed program twice a week for 3 months. There was no significant difference in age, body mass index (BMI), blood pressure, heart rate, %FAT, diet/exercise custom and psychological conditions among the three groups. Before and after the program, the physiological, biochemical and psychological measurements were performed: body weight, blood pressure, heart rate, physical strength using ergometer, serum lipids, liver function and questionnaires with profile of mood state (POMS) and self relating depression scale (SDS). After excluding 4 subjects who were dropped out because of their convenience, the results were compared. In group 2 (N=28) and 3 (N=28), body weight, BMI, blood pressure and heart rate were significantly decreased and their physical strength and psychological condition were improved significantly (p<0.05). Furthermore only in group 3, serum total cholesterol, atherogenic index and triglyceride were significantly decreased (p<0.05). The difference between these two groups was not due to changing of their diet and estimated energy consumption by daily activities during 3 months. These data suggest the efficacy of balneotherapy with hot spring bathing and aqua-exercise for health promotion.

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To clarify problems in the cardio-pulmonary arrest (CPA) cases that occurred in a bathroom, we investigated the medical care and results in 32 cases of CPA (14%) out of the 215 patients carried into our emergency center with CPA from August 2002 to July 2003.
The ages of patients ranged from 43 to 91, indicating a high incidence of CPA in ages over 70 but with no difference between sexes. Most of the cases (21/32, 65.6%) occurred from November to February. Through the exact time of onset was unknown because it was in a bathroom, it took an average of 8.4 minutes from receiving a 119 call until arrival of the ambulance. Average time at the site was 17.4 minutes, and it took an average of 11.0 minutes to transport the patients from the site to the hospital. Out of 32 patients, only six patients (18.8%) received cardiopulmonary resuscitation immediately after the onset. Advanced treatment (mainly airway management) was applied by paramedics on 23 out of 32 patients (71.9%). When carried into the hospital, patients were in CPA and electrocardiogram indicated asystole. Though advanced cardiovascular lifesaving means were applied promptly, most patients (31 cases) were already dead when carried in with one exception whose heartbeats resumed. Causes of onset estimated from clinical findings included 14 drowned, three with subarachnoid hemorrhage, one with trauma, one with aortic disease, one with respiratory disease, and 12 with suspected heart disease and/or unknown causes. In four cases in which subarachnoid hemorrhage or aortic disruption was detected, CT diagnosis clearly indicated that the cause of CPA was an internal disease
It is important to perform a sequence of lifesaving measures consisting of early access, early basic life support, early defibrillation and early advanced cardiovascular life support (ACLS). In the case of onset in a bathroom, in particular, it is highly probable that detection is delayed and that prognosis might be poor. However, it is possible to resuscitate patients with CPA that occurred due to an internal disease without any accompanying lethal influence on the respiratory and circulatory system, so it is important to provide training in cardiopulmonary resuscitation techniques. In addition, prudent bathing is required in winter seasons for the elderly who have some disorders.

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