Introduction: In diabetic patients we can observe disturbance of microcirculation since the initial stage of diseases. That is the reason of many heavy complication of diabetes. Balneological procedures have most important value in complication of microcirculation treatment but there is not much science evidences. The aim of our research was to define influence of selected balneological procedures on skin microcirculation in patients with long time diabetes.
Materials: 35 diabetes type 2 patients without clinical symptoms of peripheral circulation disorders in lower extremities. Most of them (30 patients) were treated by insulin injections, rest of them only by oral antidiabetes drugs. All of our patients had good control diabetes during observation.
Methods: Treatment program consist of 3 balneological procedures applied everyday by 21 days of thermal treatment. Applied following procedures: CO₂ bath, salt bath with exercises, peat - paste poultices. Every patients gets 16-18 procedures during the time of thermal treatment program. Microcirculation examination had been done before and after treatment by using laser - doppler method in occlusion test.
  7 parameters of microcirculation had been estimated; most valuable of them were: MAX (maximal flow after occlusion), MAX/RF (relations of maximal flow after occlusion to rest flow), TL (time of vessels reaction after occlusion), TM (time to reach of maximal flow after occlusion).
Results: We receive high statistical important changes: increasing of MAX (average value; before: 0.828571 pu - perfusion unit., after: 0.950571 pu.), increasing of MAX/RF (average value; before: 1.4246, after: 1.6611), decreasing of TL (average value; before: 0.5031 s., after: 0.4058 s.), decreasing of TM (average value; before: 0.8428 s., after: 0.7811 s.)
Conclusions: Our researches are evidence on valuable influence of selected balneological procedures on microcirculation in diabetic patients.

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  Balneotherapy or Health Resort Medicine has a long tradition in Spain. This tradition is still alive today. The main indication of balneotherapy in Spain is rheumatic diseases, especially joints’ degenerative disorders.
  There are, approximately, 2,000 mineral water springs with the public utility declaration.
  There are also currently working 119 Thermal Stations, which have 19,154 hotel rooms, with 4,047,000 overnight stays in 2012. They employ 5,310 workers and 904,000 customers enjoy, although not all of them are go in sanitary programs. Total revenue of thermal stations is 255 million euros.
  Balneotherapy research in Spain takes place mainly at the Complutense University of Madrid, in the Professional School of Medical Hydrology and Department of “Physical Medicine and Rehabilitation. Medical Hydrology” (Medicine Faculty) and other Universities such as those of Extremadura, Granada, Seville, Vigo and Zaragoza. Hydrotherapy and Aquatic Therapy in Universities: Catolica San Antonio de Murcia, Extremadura, Granada and Malaga and natural mineral waters in the Complutense University of Madrid.
  Moreover, this year we celebrate 25 years of the Balneotherapy Program of the Elder’s Institute and Social Services (IMSERSO) under the Ministry of Health. The program had 12,848 beds in 28 Spas in 1989 to 209,222 in 2014 in 105 Spas, which in economic terms means moving from 4.3 million euros provided by the IMSERSO in 1989 to 34 million in 2014, with an economic impact of more than 115.2 million adding the contribution of the beneficiaries. More than 2,500,000 people have benefited the program since its implementation.

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  Balneology in Europe has a long tradition. The therapeutic effects of water or steam baths have been used in almost all its territory since early times, first as a purely empiric exercise but in our times with a remarkable progress on its scientific basis. Depending of geographic or cultural circumstances hydrotherapeutic modalities developed in different ways. However the contribution of the Greek Medicine for its roots and of the Roman Empire for the spread of its use must be enhanced.
  During the two last centuries we assisted of a growing interest and knowledge of the properties and therapeutic principles of balneology and their action mechanisms, including: physical (hydrostatic, hydrodynamic, thermal), chemical, biologic and psychological factors.
  Currently European Balneology progresses remarkably. European Medical professionals aimed several goals to build this progress. Among them we may refer: the establishment of principles and definitions; a manual of good practice; the development of research; the improvement of education on this field; the awareness of public authorities and of the population.
  We may say that in the last ten years we really got significant achievements.
  We managed to create new cooperation opportunities by the creation of a Balneology Group within the UEMS (European Union of Specialist Doctors) that is also working together with the ISMH. We start several studies trying to know the different realities of Balneology in our European countries. We are also working on the consensus for a common lexicon and taxonomy in Balneology. Some important papers on this were already published and accepted by ISMH leaders. We also assist of the publication of a significant number of scientific studies, namely randomized controlled trials. Many of them with high quality standards.
  Nevertheless the difficulties research is in fact improving. We should mention and praise the financial support of institutions specifically created to sponsor scientific studies on the thermal field, like for instance the French “AFreth” or the Italian “FoRST”.
  Balneology Education needs to be better standardised in European terms so that we may built a common curriculum and walk towards an European Medical Board that could among other tasks to be able to certify Specialized Doctors on Balneology.
  Balneology has a wide scope of interventions which include prevention, treatment and rehabilitation of a large number of health conditions.
  We hope that its progress may benefit a greater number of people. Europe should contribute to this important goal.

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  In France, several public and or private scientific investigation bodies are involved in medical balneological scientific investigation (academic or university-linked institutes in Paris, Nancy, Bordeaux, Grenoble, Clermont-Ferrand; private structures in Paris, Aix les Bains, Saujon). However, these last 10 years, the important development in medical balneology investigation could be related to the French Association for Balneotherapy Research (AFRETH). The Afreth has been created in 2004 by the French Union of SPA Contractors, the Union of the mayors of spa resorts and the French branch of the FEMTEC. The AFRETH provides every year a budget of 1 M€ for scientific investigation in balneology. The founders’ representatives, who constitute the association’s administrative committee, take the decision of supporting financially the scientifically validated projects. The scientific validity is pronounced by the scientific committee (12 independent and acknowledged doctors and scientists) on the basis of external independent experts’ advices (methodological, clinical and biological sciences from French academic institutions).
  10 calls for projects have been launched and fully implemented. They concerned mainly the actual medical benefit (cf. Table below). A global budget of 11 M€ has been engaged.
  Regarding the medical benefit have been implemented and published: STOP-TAG (treatment of generalised anxiety, 237 patients); Thermarthrose (knee osteo-arthritis, 462 patients); Maathermes (obesity and overweight, 257 patients); Pacthe (treated breast cancer patients, 250 patients) Thermes & veines (chronic venous insufficiency, 425 patients). These different randomised controlled trials have demonstrated significant results in favour of balneotherapy.
  Publication is in progress for Rotatherm (a RCT concerning shoulder cuff tendinitis, 186 patients).
  Are in progress a RCT on COPD (BPCeaux), a RCT on subacute lumbar pain (ITILO).
Pilot investigations have been implemented concerning the metabolic syndrome, Alzheimer’s disease and other ageing problems, psychotropic drugs withdrawal, therapeutic education of patients with chronic venous insufficiency.
  So scientific investigation has to come with usual balneotherapy but also with the development of new trends which have to be scientifically assessed from their initiation.
From our experience, we have to emphasize the difficulties related to the patients’ enrolment and the need of new methodological designs, alternative to usual RCT to investigate such a complex therapeutic intervention.

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  The Balneology Association of North America (BANA) announced our founding at the ISMH Congress in 2011 in Lanjaron Spain. For the 2014 ISMH Congress in Kyoto, BANA will present the work accomplished since Spain, and give a voice to the North American balneology field in the international arena.
  In the last two years we have been busy building a cohesive voice for balneology education, training, research and promotion. We are actively gaining members all across North America and even internationally, who collectively represent a vast field of interests regarding the therapeutic use of natural mineral water resources.
  Through BANA, the the many individual groups that comprise the emerging North American balneology field, now have common ground to work together in growing, networking and formalizing the practice of North American balneology.
  Balneology is little known and understood within the greater North American medical world. BANA is working with individual researchers, medical professionals, medical education institutions, private balneology health resorts, and government agencies to create a cohesive language and dialog between these individual groups on the emerging field.
  Individual researchers are joining with BANA to establish criteria for the development of balneology research in North America. BANA has proven to be useful, as our place in the international community has allowed us access to the best work in the field from across Europe, Asia and indeed the world. It is BANA’s goal to bring North American balneology research up to the international standard.
  BANA is collecting the case studies and practice models of medical professionals from across the country who are employing balneological therapy. For the first time, medical professionals in disconnected regions have a forum to exchange information and develop their practice. Through the collective conversation, the practice of balneology is gaining awareness and growing in sophistication.
  Medical education institutions are joining BANA. Within the last year, we are proud to report that the National College of Naturopathic Medicine in Portland, Oregon, has included balneology into its research agenda. Through education outreach, networking researchers with private health resort sites, and existing research resourcing, BANA is dedicated to seeing balneology research expand to many more medical education institutions in the years to come.
  BANA is working alongside major government agencies to formalize balneology in North America. The National Institutes of Health (NIH) has received submission for the assessment of balneology in North America. Through BANA, the NIH was provided with international sources, research and analysis of the field of balneology. BANA is utilizing the great international work already accomplished, to bring North American health policy up to date regarding balneology.
  Site Specific Medicine in North America is a term that encompasses not only balneology, but climatology, Shinrin-yoku, forest medicine, terrain kur, nature cure, and many others. As a melting pot of many cultures, in North America the traditions and understandings from diverse international regions are able to develop together a synthesis of traditions as Site Specific Medicine.
  BANA is looking forward to expanding our relationship with our international colleagues.
  www.balneoANA.org

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  118 papers have been published in english speaking journals with impact factor these last twenty years: 90 randomized Controlled Trials (RCT) and 28 reviews and/or meta-analysis (RMA).
  Rheumatolgy is the first topic: 63 RCT, 22 RMA. Knee osteoarthritis is the most investigated condition : 18 RCT, 5 RMA ; chronic inflammatory diseases 12 RCT, 1 RMA; Fibromyalgia 10 RCT, 2 RM ; Chronic low back pain: 11 RCT, 1 RMA. The patients with musculo-skeletal conditions have a significant actual clinical benefit on pain, function and quality of life.
  Spa therapy is beneficial for patients with psoriasis (9 RCT) and atopic dermatitis (1 RCT).
  Overweight or obese patients treated in spa resorts have a significant weight reduction according (3 RCT).
  SPA therapy is also beneficial for patients with chronic venous insufficiency (2 RCT) or chronic occlusive peripheric arterial disease (4 RCT and 2 RMA).
  Gynaecology (2 RCT) and psycho-somatic conditions (1 RCT) are more poorly investigated.
  The lack of investigation about respiratory lower tract or Ear-Nose-Throat conditions is a questionnable issue.
  Despite a significant number of trials, the level of evidence is impaired by many methodological flaws.
  The actual medico-economic benefit assessment is based on more limited data of evidence.

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  Overweight, obesity and the metabolic syndrome are usual conditions treated in french balneotherapy care facilities. 42,507 patients were treated last year in France for metabolic conditions, most of them benefiting a social security reimbursed treatment. The therapeutic intervention core is made of hydro-thermal cares: drinking mineral water (alkaline sodium bicarbonated water), individual mineral water bathing, showers, massages under mineral water, mineral water pool collective exercise; education on nutritional concepts, adapted physical activity are also essential informations delivered in group or customized sessions. AFRETH promoted two clinical studies investigating the topic.
  The randomised controlled trial Maathermes (1) assessed the benefit of the intervention on 257 overweight or obese patients randomized between balneotherapy (delivered in Brides, Capvern, Vals, Vichy, Vittel) and a control group (usual care and booklet on nutrition from the french health autorithy). At month 14th, the patients treated in the balneotherapy group showed a significant weight reduction (5.17 kg vs .54 kg ; p<.001) and they had more perspective to reach a stable weight loss of 5% (57.1% vs 18.6 % ; p<.001).
  Prisme (2), a feasability cohort study, investigated the results of the intervention in 93 patients with a metabolic syndrome treated in Eugenie les Bains. At month 12th, 67 patients could be assessed. Metabolic syndrome had disappeared in 76% of the patients (glycemia normalised in 15%, waist circumference returned to acceptable in 15%, lipidic disorders disappeared in 33% ; blood pressure had acceptable values, without increased drug intake, in 67%.). 75 % of the patients were continuing the adapted physical activity, 65 % had a correct lipid intake.
  Balneotherapy is useful for patients with overweight or obesity. Education during the stay is helpful for the weight and metabolic syndrome control. The medico-economic benefit of such an intervention remains to be established on scientific basis.

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  Hungary is rich in thermal mineral waters. Here, we present a systematic review and meta-analysis of clinical trials conducted with Hungarian thermal mineral waters, the findings of which have been published by Hungarian authors in English. The 124 studies identified in different databases include 20 clinical trials. Seven of these evaluated the effect of hydro- and balneotherapy on chronic low back pain, four on osteoarthritis of the knee, and two on osteoarthritis of the hand and one ostheoarthrtis of shoulder. One of the remaining seven trials evaluated balneotherapy in chronic inflammatory pelvic diseases, while six studies explored its effect on various laboratory parameters. Out of the 20 studies, 9 met the predefined criteria for meta-analysis.The results confirmed the beneficial effect of balneotherapy on pain with weightbearing and at rest in patients with degenerative joint and spinal diseases. A similar effect has been found in chronic pelvic inflammatory disease. The review also revealed that balneotherapy has some beneficial effects on antioxidant status, and on metabolic and inflammatory parameters.Based on the results, we conclude that balneotherapy with Hungarian thermal-mineral waters is an effective remedy for lower back pain, as well as for knee and hand and shoulder osteoarthritis.

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  　The new developments and events in Balneology may be summarized as follows;
1.　Balneology/ISMH goes global; moving from Japan to Brazil and then to Asia to Africa so on; in recent years, interest in Medical Balneology and Hydro-climatology is being intensified all over the world. We have now a growing number of published balneological articles originated from various countries and the centers in different locations. Japan is the country of “onsen” and “ryokan” which is going to host the 39th ISMH Congress along with their national balneology congress. Brazil is being prepared for the 40th Congress of ISMH in Rio de Janeiro and ABINAM (Brazilian Association of Mineral Waters) will support the congress. Among the balneology organizations North American, Russian, Indian and Chinese associations are on the way.
2.　Effects of complexity in the balneological therapy protocols; a need for most effective combinations for certain conditions; In many countries, balneological interventions are being applied in complex character. Depending on the local natural remedies and the experience balneotherapy (thermal mineral water baths) is combined mostly with peloidotherapy (mud applications). Furthermore drinking cures, inhalations and other balneological interventions are also being combined for treating a diversity of conditions in different countries. But the most effective complex balneology treatments for certain diseases remain to be tested.
3.　Beyond the treatment of rheumatic diseases; dermatologic and other indications are being investigated: Balneotherapy and spa therapy is being increasingly considered in the evidence based treatment guidelines for rheumatic diseases, including osteoarthritis, fibromyalgia, ankylosing spondylitis, early arthritis, rheumatoid arthritis and low back pain. Among other indications of balneotherapy dermatological diseases are in the first place. The studies aiming to investigate the therapeutic effects of balneological treatments on cardiovascular, metabolic, neurological, psychiatric and respiratory conditions are being published in recent two years.
4.　The preventive effects of balneological treatments; an old remedy for contemporary health risks: Research interest in the beneficial and health effects of balneological applications is growing as a need for measures to modify the major health risks of our time. Recently published scientific balneological trials report the scientific evidence on the preventive effects of balneotherapy and spa therapy cures on metabolic syndrome, overweight and obesity as well as cognitive function and physiological status.
5.　More insights into effects of local natural spa waters and specific chemical components of balneological waters; Authors from various disciplines are publishing the studies evaluating the specific effects of local natural spa water and mud used in balneological treatments and effects of specific chemical components of balneological waters. Besides the clinical trials with biological markers measurements, some other publications reported the results obtained from cell cultures and experimental animal models studies and shed more light on the specific biological effects of a given balneological remedy and specific elements of the mineral water in particular sulfur and carbon dioxide.

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  Spa therapy has long been utilized as one of safe, effective and long-term alternative therapies of various dermatologic diseases in Korea. Among them are pruritic, xerotic, immunoinflammatory, infectious, ulcerative skin diseases. There are about 400 spas in South Korea and many of them are recognized as having specific therapeutic effects. But, the beneficial clinical effects of spa therapy as well as their underlying mechanisms are still poorly defined and understood. In Korea, the area of distribution of hot springs coincide with areas of granite and are distant from geothermal heat energy related to volcanos. Natural hot spring water in South Korea can be classified into four main hydrochemical groups, i.e., Ca(Na)-HCO₃, Na(Ca)-HCO₃, Na(Ca)-Cl, and acidic Ca-HCO₃ type. They are mostly alkaline in nature and have low chemical constituents. We performed a series of clinical and laboratory studies to have better understanding of the clinical effects as well as possible mechanisms of their beneficial effects of several hot springs having different locations and mineral concentrations. They are Haeundae(Na-Cl type), Seokmo-do(Na-Cl, Ca-Cl type), Suanbo(Na-HCO₃ type), Baekam(Na-HCO₃ type), and Dukku(Na-Cl type) areas. Utilizing human, mice models, and keratinocyte cell lines, we evaluated the effects of each hot spring water on the changes of clinical symptoms of induced dermatitis and their skin barrier functions, skin infiltrating cells and related histologic findings, proinflammatory cytokine production, helper T cell subset differentiation and proliferation. We found that studied hot spring waters, in general, have the capacity to improve skin inflammation of atopic dermatitis and tendencies to downregulate the production of skin inflammatory cytokines and to increase the Foxp3⁺ Treg cell population while to decrease the Th1, Th2, and Th17 populations.

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Objectives: To assess the quality of study reports on spa therapy based on randomized controlled trials by the spa therapy and balneotherapy checklist (SPAC), and to show the relationship between SPAC score and the characteristics of publication.
Methods: We searched the following databases from 1990 up to September 30, 2013: MEDLINE via PubMed, CINAHL, Web of Science, Ichushi Web, Global Health Library, the Western Pacific Region Index Medicus, Psyc INFO, and the Cochrane Database of Systematic Reviews. We used the SPAC to assess the quality of reports on spa therapy and balneotherapy trials (SPAC) that was developed using the Delphi consensus method.
Results: Fifty-one studies met all inclusion criteria. Forty studies (78%) were about “Diseases of the musculoskeletal system and connective”. The total SPAC score (full-mark; 19pts) was 10.8±2.3pts (mean±SD). The items for which a description was lacking (very poor; ＜50%) in many studies were as follows: “locations of spa facility where the data were collected”; “pH”; “scale of bathtub”; “presence of other facility and exposure than bathing (sauna, steam bath, etc.)”; “qualification and experience of care provider”; “Instructions about daily life” and “adherence”. We clarified that there was no relationship between the publish period, languages, and the impact factor (IF) for the SPAC score.
Conclusion: In order to prevent flawed description, SPAC could provide indispensable information for researchers who are going to design a research protocol according to each disease.

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 Scientific balneology in Russia began to develop in the late 19th century.
  Balneology for the first time began to be studied at Moscow University in 1865, at the same time it had been firmly established in medical practice.
  In July 1921 was founded Central Research Institute of Balneology in Moscow. Its first goals were to study diseases to be treated at resorts, to study therapeutic effects of physical factors, organization of health resort industry and education. Significant attention was paid to exploration and development of deposits of mineral waters and peloids.
  One of important areas for research was development of artificial mineral waters for external use (artificial hydrogen sulfide, carbon dioxide, radon, iodine-bromine bathes), that made it possible to apply them in health facilities out of resorts. Special devices allowed use of dry carbonic bathes, dry-air radon bathes, underwater spinal traction.
  Research activities were aimed to increase the effectiveness of treatment of natural factors in patients with various diseases. To achieve these goals studies of mechanism of physiological and therapeutic action of hydrobalneoprocedures were conducted.
It concerned central regulatory mechanisms, biochemical processes, microcirculation changes and permeability of membranes, immune reactions, etc. Skin penetration and distribution of active substances of mineral waters and peloids have been studied.
  Studies of specificity of reactions depending on physico-chemical composition of mineral water, study of minimal effective concentration of active ingredients were conducted.
  Optimal parameters (temperature, concentration, duration of procedure, amount of procedures per treatment) for various diseases were identified. Methods of treatment of different diseases, indications and contra-indications for their use have been developed and published. Comparative analysis of efficiency, development of rational treatment complexes were carried out.
  At present, studies of the mechanism of action balneological factors on the new methodological level, development of new approaches to applying the methods of hydro-balneotherapy, study and introduction of new balneological technology.

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  Waon therapy has been developed by Prof Tei, and currently been approved as one of advanced medical care in Japanese governmental insurance system since 2013. We are now conducting a multicenter randomized study for the establishment of efficacy and safety of Waon therapy. As one of institutes participating in the multicenter trial, I will present data from our hospital for the efficacy and safety issues of Waon therapy. We preliminarily observed that Waon therapy reduced heart rate and cardiothoracic ratio with significant improvement of 6 minutes’ walk distance. No serious adverse event was observed. Once the study concludes, we hope that Waon therapy can be reimbursed by insurance.

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Background: Our hospital is located in Beppu city, which bears the most hot spring fountainheads in the world. Here we present two studies showing the therapeutic and preventive effects of hot spring bathing. Hot spring bathing has been reported to be therapeutically useful for mentally and physically pathophysiological conditions because of its thermal and pharmacological effects. (1) The verification of the therapeutic effect of pelotherapy for the patients with fibromyalgia. (2) The epidemiological study by a questionnaire with questions of past history of hot bathing and diseases including depression and lifestyle related diseases of citizens over 65 years old of Beppu city.
Methods: (1) Seven patients with fibromyalgia (age; 60-78 y.o.) were treated by pelotherapy for 30 days. The patients took mud-bathing at 40 C for 10 minutes a day on weekday. Geriatric Dementia Scale (GDS; 15 for full score) and Face Scale (FS; 20 for full score) for systemic pain were evaluated before and after pelotherapy. (2) Twenty thousand Beppu citizens over 65 y.o. were sent the questionnaire including questions of the participants’ past history of diseases including cancers, apoplexy, ischemic heart disease, diabetes mellitus, asthma bronchiale, collagen diseases, etc. and of their habits of hot spring bathing. The logistic analysis was used for statistical analysis.
Results: (1) The mean GDS score and the mean FS score before pelotherapy were 6.6+2.5 and 12.9+5.1, and those after pelotherapy 3.3+1.3, 6.1+5.5, respectively. (2) We received filled-out questionnaires from 4,706 men and 6,352 women. Forty-eight percent of the replying participants take a hot spring bath daily. Age adjusted, hot spring users showed less rate of some diseases, All (daily % : non-daily % (p-value), Ischemic heart disease 6.2 : 7.2 (0.047), Apoplexy 2.0 : 3.1 (<0.001), Hypertension 36.2 : 38.5 (0.016), Arrhythmia 7.9 : 9.5 (0.004), Bronchial Asthma 3.0 : 4.4 (<0.001), Diabetes Mellitus 12.4 : 14.2 (0.006), Renal disease 2.9 : 3.9 (0.009), Depression 1.5 : 2.7 (<0.001)), Men (daily % : non-daily % p-value, Apoplexy 3.1 : 4.2 (0.045), Renal disease 3.8 : 5.4 (0.011)), and Women (Ischemic heart disease 3.8 : 5.1 (0.018), Apoplexy 1.1 : 2.3 (0.001), Arrhythmia 6.7 : 8.4 (0.011), Bronchial Asthma 2.9 : 4.6 (<0.001), Diabetes Mellitus 8.6 : 10.8 (0.004), Depression 1.6 : 3.3 (<0.001)).
Conclusion: Pelotherapy raises efficiently body temperature leading to relieve mental and physical stress, that is, depression and pain. The study with questionnaire showed that hot spring bathing may be beneficial for lowering incidents of some diseases with gender association. The results of both studies highlightened the physical and mental effects of hot spring bathing for disease-prevention and -therapy.

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  We used the data published recently by a team headed by the late Professor Shaul Sukenik, in order to shed light on the huge amount of work realized by this exceptional physician, who devoted his life to his family, his profession and the Dead Sea.
  Particularly, he wanted very early - and always succeeded - to apply the strictest rules of clinical studies in the fields of Balneotherapy and Spa treatment, thus lifting them up to their highest level of credibility. Thanks to his works, one can stipulate with authority that Dead Sea treatments are beneficial in several rheumatologic disease and have a good safety profile.
  The Dead Sea, the deepest and most saline lake on earth, has been known from biblical times for its healing properties. The systematic review presented critically the level of evidence for the claims of therapeutic effects of Dead Sea treatments in several rheumatologic, skin and lung diseases and, as well, reviewed these treatments’ safety.
  The authors found bona fide evidence that Dead Sea treatments are especially effective in psoriasis due to both special characteristics of solar ultraviolet radiation and Dead Sea water balneotherapy. Dead Sea mud and balneotherapy have been found to be beneficial in rheumatologic diseases, including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and knee osteoarthritis.
  In the safety analysis, no evidence was found for an increase in skin neoplasia, although skin actinic damage seems to be amplified in patients treated in the Dead Sea. Dead Sea treatments do not lead to worsening of high blood pressure. Substantial ingestion of Dead Sea water (generally in unusual near-drowning cases) is toxic and can result in cardiac rhythm disturbances because of electrolyte concentration abnormalities. Finally, laboratory analysis of Dead Sea mud did not reveal mineral concentrations that could represent a health concern for their intended use.

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  Ibusuki hotspring sand bath (SB)(Sunamushi) is a special thermal therapy using heated sands by natural hotspring gushed at the seashore of Ibusuki city. Heated heavy sands (50°C, 40-60kg) was piled on the lied body. It has traditionally been used here for 250 years to relieve muculoskeletal and neuralgic pain, and still accepts 260 thousands visitors a year. In the present study, cardiovascular and metabolic effects by SB was studied from the viewpoint of accelerated circulation.
Subjects and Methods: General physical parameters (BP, HR, sublingual temperature) and plasma chemistry were examined in 20 healthy males(36 ± 10yrs). The subjects wore thin bathrobe and a venous catheter for blood sampling were set in the forearm. They kept rest in the supine position for 30min and subjected 10min SB at the municipal SB institute with hotspring piping under the sands. In another 28 healthy subjects (44.3 ± 2.4yrs), cardiac outputs and plasma catecholamines (CA) and renin activity (PRA) were measured. In 6 subjects intracardiac study by Swan-Ganz catheterization were performed.
Results: Diastolic pressure were significantly decreased by 6mmHg, and heart rate and sublingual temperature were significantly increased by +20bpm and +1.1°C, respectively, after 10min SB. Venous blood pO₂ and pH was significantly increased by 20mm Torr and 0.03pH, and pCO₂ was significantly reduced by 5mm Torr. Lactate, pyruvate and L/P ratio were significantly reduced suggesting improved oxidative metabolism of peripheral tissues. Plasma CAs and PRA were elevated after SB. All of these results gradually returned to the resting level after 30min. Cardiac output (CO) measured by dye dilution or thermo-dilution method was significantly increased from 5.6l/min to 10.5 l/min after 10min SB, and reduced to 8.1 l/min by removing piled heavy sands. Calculated total peripheral resistance (TPR) was significantly decreaased suggesting thermal vasodilation. Although mean right atrial pressure and pulmonary arterial pressure were increased during SB, they were immediately decreased by removing piled sands.
Discussion: All of these results indicate that the basic effects of SB are derived from strong hydrostatic pressure of piled heavy sands and thermal vasodilation. Increased CO due to accelerated venous return and reduced afterload (TPR) will induce sufficient oxygen supply and increased discharge of wasted matters from peripheral tissues. These data seem to be compatible with the clinical effects of SB to relieve musculoskeletal pain and fatigue.
Conclusion: Significant clinical effects is induced by increased CO due to the increased hydrostatic pressure of piled sands and thermal vasodilation.

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  Acupuncture and moxibustion therapy in Japan has a long history, and it has developed differently from the Chinese or Korean procedures. The use of a guide tube for the insertion of a fine acupuncture needle without pain, shallow needling and use of intradermal needle without “de-qi” are known as Japanese acupuncture techniques. Our previous study clearly demonstrated variations of the point selection and methods of procedures among the Japan, Korea and Chinese traditional acupuncture therapy on the same subjects. The results obtained by three kinds of traditional acupuncture therapies were also different.
  The majority of basic research and clinical trials of acupuncture have used Chinese acupuncture procedure using thick needles with “de-qi” sensation. Participation of the endogenous opioids in relatively intense electro-acupuncture induced analgesia has been well established, but similar analgesia is also induced by stressful stimuli such as electrical foot shock, so opioid-mediated analgesia is not the specific phenomena induced by acupuncture therapy.
  Recent literature survey of the Ma Wang Dui（馬王堆）tomb clearly demonstrated the moxibustion (cauterization) was the primitive therapeutic procedure and the meridian concept was established by moxibustion not by acupuncture therapy. On the peripheral mechanisms, various sensory receptors could be activated by acupuncture but receptors responsive to moxibustion are limited. The polymodal receptors (PMRs), which responsive to mechanical, thermal and chemical stimuli, are activated by both acupuncture and moxibustion. They are also responsive to gentle skin scratching and pressure application with blunt acupuncture needle which used as sham acupuncture in recent clinical trials. Sensitization of the PMRs might be a possible cause of acupuncture point formation. These several lines of evidence suggest the PMRs are the key candidates of the action mechanisms of acupuncture and moxibustion. Figure 1 shows schematic illustration of the polymodal receptor hypothesis of action mechanisms of acupuncture and moxibustion.

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Background: Japanese loves very hot hot-spring bathing although it has some adverse reactions. Jikan-yu (timed bathing), or repeated head-out water immersion in Kusatsu hot-spring at 47C, 4 times a day, each for 3minutes, is a traditional bathing method continued since more than 200 years ago in Kusatsu spa resort, Japan. We previously reported that a very hot hot-spring bathing might result in cerebral or myocardial infarction, although appropriate hyperthermia is beneficial for human body. We summarize the effects on hemostasis after 3-minutes bathing at 47°C.
Methods and Subjects: Healthy subjects aged from 22 to 40 years old bathed up to the shoulder level in a sitting position in acidic hot-spring at 47°C for 3 minutes. Blood pressure, blood viscosity, coagulation and fibrinolytic markers, as well as ultrastructure and P-selectin of circulating platelets were analyzed before and after the bathing.
Results: Blood pressure increased during bathing but decreased after the bating. A trend toward an increase in blood viscosity after the bathing was observed. Plasma tissue plasminogen activator decreased slightly and plasminogen activator inhibitor increased transiently but markedly after the bathing at 47C. In contrast, the coagulation and fibrinolytic markers were not changed significantly after the bathing at 40 or 42C. Ultrastructural changes (folds, pseudopods, vacuoles and centralization) were increased after the bathing at 47°C. Flowcytometry demonstrated an increase in P-selectin on the surface of platelets after the bathing at 47C. See References 1-8.
Discussions: It is suggested that the bathing at 47°C leads to a thrombotic state, and further to a thrombosis when combined with endothelial dysfunction or atherosclerosis.

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  In 1989, we developed a form of thermal therapy for heart failure. In 2007, I changed the name to Waon therapy: “Wa” means soothing, and “On” means warmth, hence Waon infers soothing warmth that comfortably refreshes the mind and body.
  “Waon therapy” is defined as “therapy in which the entire body is warmed in an evenly maintained in a far infrared dry sauna at a temperature of 60°C for 15 min, and then rest supine on a bed outside the sauna where they are covered with blankets for an additional 30 min, with fluids corresponding to perspiration being supplied at the end.”
  Waon therapy has several characteristic features, that is, safe and no toxicity, gentle and cost effective. It is just a holistic medical care and gives a global optimization to the patients with refractory diseases.
  There are various clinical applications of “Waon therapy and the effects are often dramatic. In particular, a drastic recovery is often seen in severe congestive heart failure (CHF) as well as peripheral artery disease (PAD) with intractable ulcer, chronic fatigue syndrome, fibromyalgia syndrome and salivary secretion failure caused by Sjögren’s syndrome etc. In this presentation, I would like to focus the effects and mechanisms of Waon therapy on refractory CHF and PAD.
  We demonstrated that Waon therapy improved the hemodynamics, cardiac function, ventricular arrhythmias, vascular endothelial function, neurohumoral factors, sympathetic and para-sympathetic nervous system function, and also found that 2 - 4 weeks of Waon therapy (once a day, 5 days a week) significantly improved clinical symptoms, and deceased BNP and cardiac size in patients with CHF. Waon therapy improved the prognosis of CHF patients as well as CHF models of hamster and mouse. It has also been demonstrated that the molecular mechanism by which Waon therapy improves vascular flow and expression of endothelial nitric oxide synthase (eNOS) and capillary density.
  Moreover, repeated Waon therapy is effective for patients with severe PAD, as evidenced by substantial decrease in pain scores, increases in both ankle-brachial pressure index and blood flow assessed by laser Doppler perfusion imaging, and by formation of new collateral vessels on angiography. Waon therapy often heals ischemic ulcers markedly. Waon therapy upregulates heat shock protein 90 (Hsp90) and leads to angiogenesis through the akt-eNOs pathway in mouse hindlimb ischemia.
  In conclusion, Waon therapy is an innovative and highly promising strategy for cardiovascular diseases, especially treating refractory CHF and PAD.

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Objectives: Waon therapy relieves ischemic symptoms in patients with peripheral arterial disease. Waon therapy increases capillary density and blood flow in ischemic hindlimbs of mice (Circ J 2006;70:463). Moreover, we have shown that Waon therapy increases capillary densities of non-infarcted myocardium of rat with myocardial infarction in association with increases in myocardial expression of eNOS and VEGF mRNA (Am J Physiol Heart Circ Physiol 2011;301:H548). Taken together, Waon therapy may improve myocardial blood flow in patients with severe coronary artery disease. Accordingly, the purpose of the present study was to investigate whether repeated Waon therapy could improve myocardial perfusion in patients with ischemia related to chronic total occlusion (CTO) of coronary arteries.
Patients and Methods: Twenty-four patients who had myocardial ischemia in the CTO-related area were examined. The Waon group (n=16) was treated daily for 3 weeks with a 60°C far infrared-ray dry sauna bath for 15 minutes and then kept in a bed covered with blankets for 30 minutes. The severity of ischemia was quantified by thallium-201 myocardial perfusion scintigraphy with adenosine before and after 3-week Waon therapy. Treadmill exercise test, flow-mediated dilation (FMD) of the brachial artery, and the number of circulating CD34-positive bone marrow-derived cells, a putative precursor of endothelial progenitor cells, were determined. The control group (n=8) underwent myocardial perfusion scintigraphy twice with a 3-week interval.
Results: In the control group, neither summed stress score (SSS) nor summed difference score (SDS) of myocardial scintigraphy changed. However, Waon therapy improved both SSS (16±7 to 9±6, p<0.01) and SDS (7±4 to 3±2, p<0.01), and the improvement was greater in patients with higher SSS and SDS scores at the baseline. Waon therapy extended treadmill exercise time (430±185 to 511±192 sec, p<0.01) and improved FMD (4.1±1.3 to 5.9±1.8%, p<0.05), but tended to decrease the number of circulating CD34-positive cells.
Conclusions: Waon therapy improves CTO-related myocardial ischemia in association with improvement of vascular endothelial function. This therapy could be a complementary and alternative tool in patients with severe coronary lesions not suitable for coronary intervention.

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Background: Transient severe myocardial ischemia in patients with coronary vasospasm impairs regional left ventricular (LV) relaxation which persists for several weeks.
Methods: We studied 40 consecutive patients (17 women, 52±8) with vasospastic angina (VA) who had recurrent angina despite treatment with the conventional calcium channel blockers (CCBs) during the follow-up period. These 40 patients were registered and randomly assigned to either Waon therapy group or the high dose of CCBs therapy. In Waon therapy, the patients were treated with a far infrared-ray dry sauna at 60 degrees centigrade for 15 minutes and then kept on bed rest with a blanket for 30 minutes for 2 weeks. Strain imaging (SI) was acquired in the LV mid-papillary short-axis view and radial strain was measured using 2D speckle tracking echocardiography. The peak values of stain at the closure of aortic valve (A) and at the one third diastole duration (B) were measured. The SI-diastolic index (SI-DI) was determined as (A-B)/A 100%. The repeated SI study was conducted 1 weeks and 2 weeks in Waon therapy. Chest pain was scored by a numeric pain intensity rating scale.
Results: The mean SI-DIs was 20±17% in the 45 territories perfused by the coronary arteries with spasm at baseline. The SI-DI significantly improved at 1 weeks (50±14%, p<0.001), and further improved after 2 weeks (77±10%, p<0.001). In contrast, the index did not improve in the high-dose CCBs therapy group. The pain score significantly decreased after 2 weeks of Waon therapy.
Conclusion: The repeated Waon therapy improved the LV postischemic diastolic dysfunction and chest pain in patients with VA.

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Objective: Myalgic Encephalomyelitis/Chronic fatigue syndrome (ME/CFS) is an illness characterized by disabling fatigue lasting for at least 6 months. There are many controlled trials and case-control treatment studies that utilized immunological substances, pharmacological products, nutritional supplements, physical therapies, and cognitive behavioral therapy. Because of the unclear etiology, diagnostic uncertainty, and the resultant heterologeneity of the ME/CFS population, there are no firmly established treatment recommendation for ME/CFS. Recently Tei et al reported 2 CFS cases in whom thermal therapy improved the subjective symptoms. Thermal therapy has been reported to increase stroke volume and cardiac output in patients and improve the quality of life, sleep quality, and general well-being of these subjects. Thermal therapy using far-infrared ray dry sauna may be a promising method for the treatment of ME/CFS. We examined the applicability of Waon therapy (soothing warmth therapy) as a new treatment for patients with ME/CFS.
Methods: Nine female ME/CFS patients (mean age, 38.4±11.2 years old; range, 21-60) who fulfilled the criteria of the Ministry of Health, Labor and Welfare of Japan and Canadian clinical case definition of ME/CFS participated in this study. The mean illness duration was 3.1±1.8 years (range, 1-6). The mean performance state was 6.9±0.9. The patients were placed in the sitting position in a infrared-ray dry sauna maintained at an even temperature of 45°C for 15 minutes, and then transferred to a room maintained at 26-27°C where they were covered with a warm blanket from the neck down to keep them warm for 30 minutes. They received thermal therapy twice a day for 3 weeks in hospital or once a day at the outpatient clinic for 5weeks. Their functional health and well-being scores were determined using SF-36 before treatment, after 30 treatments and during follow-up (mean follow-up period, 27.9±10.5 months; range 7-40).
Results: Seven patients experienced a significant improvement in physical and mental condition by Waon therapy, and the effect continued throughout the observation period.
In two patients, no improvement of symptoms was observed. Waon therapy brought the improvement in the score of Physical functioning(p<0.05), Role physical(RP)(p<0.05), Bodily pain(p<0.001), General health perceptions(p<0.03) and Role emotional(RE)(p<0.005) of FS-36 in good responders. However, the therapy did not bring any improvement in the score of Vitality, Social functioning and Mental health.
  In poor responders, no improvement was observed in the score of FS-36. Mean duration of illness in poor responders was longer than in good responders (4.5±0.7ys:2.7±1.9ys, p<0.09). The performance state at the admission was almost same between poor responders and good responders (7±0:6.9±1.1).
Conclusion: Waon therapy is effective for the treatment of ME/CFS. Although the present study included only 10 patients, the effects observed in our patients were dramatic. Further clinical studies in larger ME/CFS patient populations are required to confirm the effects of this method of treatment.

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Objectives: Many patients with chronic pain and fibromyalgia (FM) consult health care clinics continually, and move from hospital to hospital without gaining pain relief. In some patients, prolonged refractory pain affects their daily life and social function despite various treatments. The purpose of this study was to clarify the effects of Waon therapy in patients with chronic pain and FM.
Patients and Methods:
Study A: 46 patients with chronic pain were assigned to Waon therapy group (n = 22) or non-Waon therapy group (n = 24). All patients were admitted to our hospital for 5 weeks. In non-Waon therapy group, cognitive behavior therapy (CBT), rehabilitation, and exercise therapy were performed during hospitalization. Waon therapy was started 2 weeks after admission in addition to CBT, rehabilitation, and exercise therapy. And the therapy was performed for 4 weeks. Pain was evaluated by the visual analog scale (VAS). Pain behavior was assessed based on the 11 items and the number per day was counted. Anger score was evaluated using the mentral complaints in the Cornell Medical Index. The degree of satisfaction with treatment was evaluated at discharge.
Study B: 12 patients who fulfilled the FM criteria of the American College of Rheumatology. All patients received 20 sessions of Waon Therapy at our outpatients clinic. The VAS pain scale and the Fibromyalgia Impact Questionnaire (FIQ), Profile of Mood State (POMS) were evaluated before and after 10 and 20 sessions of Waon Therapy.
Results:
Study A: The differences in number of pain behavior and anger scores before and after treatment were significantly larger in Waon therapy group than those in non-Waon therapy group. The treatment was rated as ‘satisfactory’ or ‘very satisfactory’ by 55% in non-Waon-therapy group and 82% in Waon Therapy group.
Study B: The VAS pain scores and FIQ scores were improved after the 10 and 20 sessions of Waon therapy. In the POMS, depression and anger, anxiety, confusion scales were sigificantly decresed and vigor score was elevated.
Conclusion: Waon therapy may be a promising method for treatment of chronic pain and fibromyalgia.

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Objectives: Peripheral artery disease (PAD) is a major health problem; however, no satisfactory intervention is available for its treatment. This study was undertaken to investigate the effects as well as mechanisms of the CO₂-enriched water bath (CEWB) treatment on blood flow in the ischemic hind limb.
Experimental Model: For inducing PAD, the femoral artery was occluded for 5 weeks in rats. The animals were treated with or without CEWB at 37°C for 4 weeks (20 min daily; 5 days per week) starting one week after the artery occlusion. CEWB was prepared by using Carbothera (Mitsubishi Rayon Engineering Tokyo). The blood flow was measured by Pulse Wave Doppler Ultrasound technique before and after the ligation as well as at the end of 4 weeks treatment. The angiogenesis (formation of new blood vessels) in the skeletal muscle was studied by histological examination.
Results: The peak, mean or minimal blood flow was not detected in the untreated ischemic hind limb animals due to arterial ligation. However, the values for blood flow were about 50% of the control values upon treatment with CEWB; 67% of the ligated animals showed positive blood flow by CO₂ treatment. Morphological examination of the treated ischemic skeletal muscle revealed a 3-fold increase in small artery count. Although plasma triglycerides were decreased and plasma NO concentration was increased in the ischemic animals, CEWB treatment produced no effects on these parameters. No mortality or changes in body wt, heart rate and plasma glucose, cholesterol or high density lipoproteins were seen in the control and experimental animals.
Conclusion: This study demonstrates the beneficial effect of CEWB treatment on blood flow in hind limb PAD. Furthermore, it is suggested that this beneficial action of CO₂ therapy may be due to the formation of new blood vessels in the ischemic skeletal muscle.

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  Balneotherapy for humans has a long tradition in Germany. Carbonated water or CO₂ containing spring water has been known for ancient times, not only in spas for bathing but also for drinking. In 1845 the German spa physician Dr. F. Bodo from Bad Nauheim noted a “congested, velvety reddened skin” after taking a bath in warm CO₂ enriched water. Conducting absorption experiments Hediger in 1928 demonstrated for the first time that CO₂ is absorbed into the body by passing through the intact skin. In Germany 80% of the natural mineral spas contain the minimum concentration of 400mg/kg CO₂ required for treatment and 50% of all spas have a CO₂ content higher than 1000 mg/kg which is required for the designation as carbon dioxide enriched water. The spa resorts Bad Nauheim and Bad Krozingen harbor natural mineral springs with the world wide highest CO₂ concentrations containing 2600 mg/kg and 2200 mg/kg, respectively. These springs belong to artesian wells which means the spring water is under a hydrostatic pressure that is high enough to well up to the surface without any pumps.
  The beneficial effects of CO₂ balneotherapy are not known in detail yet. However, animal studies have shown that bathing in carbon dioxide rich water enhances collateral blood flow in ischemic hindlimb through mobilization of endothelial progenitor cells and activation of NO system. Daily CO₂ bathing for 28 days induced a 4 fold increase in collateral vessel density which was prevented by the administration of L-NAME a NO inhibitor. In humans CO₂ bathing improves arteriolar blood flow in patients with arterial occlusive diseases. Patients with necrosis of skin and soft tissue due to disturbed blood flow showed profound improvement of the skin defects with decrease of the necrosis area. To the skin CO₂ enriched water has topical effects. Ten days of rinsing detergent-damaged skin with CO₂ enriched water enhanced clinical skin regeneration, enhanced epidermal lipid synthesis and enhanced barrier repair. Taking together CO₂ balneotherapy has different beneficial effects on human diseases. This review presents the effects of CO₂ enriched water on humans diseases and discusses its clinical indications.

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Objectives: Spasticity is defined as a pathological increase in muscle tonus, and increased muscle tonus of lower limbs is a major obstacle to the stroke rehabilitation. Foot baths are considered to provide beneficial thermal therapy for post-stroke patients with spasticity, but their anti-spastic effects have not been investigated comprehensively. The present study aimed to evaluate alterations in spasticity and motor function using foot baths in post-stroke patients with spastic hemiplegia.
Methods: We underwent two separate experiments each consisting of immersion in warm water up to the knee joint level, and measuring spasticity, physiological examination and motor function.
Experiment 1; Fourteen post-stroke patients with lower limb spasticity were enrolled in this study (nine males and five females; mean age 50.4±12.9 years; range, 28-65 years). The subjects’ legs from below the knee joint were immersed in water at 41°C for 15 min. Measurements of F-waves and a physiological examination were carried out immediately (within 5 min) after the foot-bath session, and again 30 min later, while the subject remained wrapped in blankets on the lift-bath stretcher.
Experiment 2; Six post-stroke patients with lower limb spasticity were enrolled in this study (five males and one female; mean age 55.2±14.6 years; range, 39-68 years). The subjects’ legs from below the knee joint were immersed in the artificial high concentration carbon-dioxide (CO₂) water or tap water foot bath at 38°C for 30 min. Measurements of muscle stiffness, motor function (active range of motion: A-ROM) and a physiological examination were carried out immediately (within 5 min) after the foot-bath session, and again 10 min later, while the subject remained wrapped in blankets.
Results: None of the subjects experienced discomfort before, during or after the foot-bath treatment. The physiological examination was completed safely in all subjects.
Experiment 1; The mean values of F-wave parameters were significantly reduced after foot-bath treatment (P<0.01). The anti-spastic effects of foot-bath treatment were indicated by decreased F-wave parameters, in parallel with decreases in modified Ashworth scale (MAS) score. The body temperature was significantly increased both immediately after, and 30 min following foot-bath treatment.
Experiment 2; The changes both in the body and surface skin temperature were higher in the artificial high concentration CO₂ water foot bath compared with the tap water foot bath. The changes in the MAS score, muscle stiffness and A-ROM were also higher in the high concentration CO₂ water foot bath than in the tap water foot bath.
Conclusion: These findings demonstrate that the use of foot baths is an effective non-pharmacological anti-spastic treatment that might facilitate stroke rehabilitation. In addition, the high concentration CO₂ water foot baths appeared to play an important role in decreased spasticity.

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  The impairment of vasodilatory function is common symptom in elderly especially among those who have arteriosclerosis and diabetic merits. In the 19th-century Europe, CO₂-enriched water had been used as naturopathy for hypertensions, exclusively. In 1997 Japan, the CO₂-enriched water could be adopted as a clinical application, since the device was developed to produce artificial CO₂-water easier.
  Thereafter, artificial CO₂-water had been comparable effect of natural CO₂-hot spring water in experimental animal models (Hashimoto, 1999), and the efficacy has been studied in various disease states of human. In the therapy of peripheral arterial disease (PAD), several reports demonstrated the effects for intermittent claudication including the improved hemodynamic status of immersion part (Hartmann et al, 1997).
  Based on these findings, we focused on microcirculatory effects of topical application of artificial CO₂-enriched water, and studied clinical efficacy in patients with PAD especially critical limb ischemia (CLI). Initially, we showed that immersion of feet in artificial CO₂-water (CO₂ immersion) increased the blood flow of feet much higher than the plain water even in the patients with CLI, and it improved the limb preservation rate in patients without indication of revascularization (Toriyama et al, 2002). Furthermore, we clarified that CO₂ immersion accelerated wound healing after lower extremities bypass surgery in CLI patients with ulcer/gangrene as an adjuvant therapy (Hayashi et al, 2008).
  We summarize the clinical studies for artificial CO₂-water foot bathing in PAD, and clarify the therapeutic usefulness of CO₂ immersion in CLI patients.

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Introduction: The World Health Organization (WHO) is in the process of updating the "Guidelines for safe recreational water environments, volume 2: swimming pools and similar environments (2006). The update plans to contain a chapter on the health benefits of immersion and therapeutic aquatic exercise in pools and spas.
Methods: In order to write a narrative review, searches in PubMed, Embase, Cinahl, Sportdiscus, PEDro and Cochrane central were conducted in May-October 2012.
  The group of 8 experts focused on persons with a medical diagnosis as described in the ICD-10 and their resultants effects (as described in the ICF)., but has been restricted to diseases, which have been presented in aquatic research literature sufficiently.
  Keywords about the interventions included “Hydrotherapy Or Water exercise Or Aquatic exercise Or Aquatic therapy Or Water rehabilitation Or Aquatic physical therapy Or Aquatic rehabilitation Or Aquatics”, as well as the appropriate keywords for the pathologies.
  References were restricted to Level 1-3 evidence papers as defined by the Oxford Centre of Evidence Based Medicine.
Results: In summary, across musculoskeletal disorders (low back and neck pain, osteoarthritis, joint replacement, fibromyalgia, rheumatoid arthritis and ankylosing spondylitis), both active and passive interventions have low to high clinical effects on outcome parameters at the various ICF levels and on quality of life. Adverse effects have not been reported.
  The evidence across neurological diseases (stroke, Parkinson disease, multiple sclerosis) is limited in comparison to musculoskeletal ones and mainly focuses on balance, gait, functional independence and quality of life. Moderate to high clinical effects have been found for these parameters. Effects on fatigue are conflicting. No adverse effects have been reported.
Discussion: This narrative review didn’t allow a comparison with other interventions and only focuses on the health benefits of aquatic interventions themselves. Description of intervention and the applied doses were often insufficient, therefore the exact parameters of the intervention tactics still have to be established. Many studies were underpowered and would need follow-up studies that are more rigorous in order to establish the health benefits with higher effects sizes and statistical significance.
Conclusion: The average - level 2 - evidence of therapeutic aquatic exercise and balneotherapy in neuro-musculoskeletal diseases have moderate to high beneficial effects on variables at the levels if function (primarily pain) and activity of the ICF, as well as on quality of life. These benefits seem to comparable across the diseases.

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  TRP (transient receptor potential) channels were first described in Drosophila in 1989, and in mammals, TRP channels comprise six related protein families (TRPC, TRPV, TRPM, TRPA, TRPML, TRPP). One subunit of the TRP channel is composed of six transmembrane domains and a putative pore region with both amino and carboxyl termini on the cytosolic side. It is thought that the subunits form functional channels as homo- or hetero-tetramers. TRP channels are best recognized for their contributions to sensory transduction, responding to temperature, nociceptive stimuli, touch, osmolarity, pheromones and other stimuli from both within and outside the cell. Among the huge TRP super family of ion channels, some have been proven to be involved in thermosensation detecting ambient temperatures from cold to hot. There are now ten thermosensitive TRP channels (TRPV1, TRPV2, TRPV3, TRPV4, TRPM2, TRPM3, TRPM4, TRPM5, TRPM8 and TRPA1) with distinct temperature thresholds for their activation. Because temperature ranges above 43 degree C or below 15 degree C are considered to cause pain sensation in our body, thermosensitive TRP channels whose temperature thresholds are in the range can be viewed as nocicpetive receptors as well. Thermosensitive TRP channels work as ‘multimodal receptors’ which respond to various chemical and physical stimuli. TRPV1, the first identified thermosensitive TRP channel, was found as a receptor for capsaicin, and later was found to have thermosensitivity. I would like to talk about the physiological significance of the thermosensitive TRP channels (TRPV1, TRPA1, TRPV4 and TRPM2). Some of the thermosensitive TRP channels are expressed in the tissues not exposed to the dynamic changes in the ambient temperature and activated by warm temperature around our body temperature, suggesting that they have some specific physiological functuions. In addition, how structure and functions of thermosensitive TRP channels were changed dynamically in the process of evolution will also be discussed.

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  Ibusuki hot spring sand bath (SB) (Sunamushi) has traditionally been used for the relief of musculoskeletal pain. It is specified by piling up heavy (40-60 kg) and hot (50°C) sands on the lied body heated by the hot spring water gushed at the seashore of Ibusuki. In this study, remarkable circulatory activation and metabolic improvements probably due to thermal vasodilation and higher hydrostatic pressure is examined.
Subjects: The subjects examined were 20 healthy males (34.3±10.5 yrs) who accepted informed consents.
Methods: The subjects were thin bathrobe and kept rest for 30 min in the supine position. BP, HR and sublingual temperature measurements and venous blood sampling from the indwelling catheter was done. Blood counts, blood gas pressure and plasma chemistry were examined. Then sand bath carried out for 10 min and 30 min rest under keeping sufficient warmth by blankets.
Results: Systolic blood pressure was significantly increased though diastolic blood pressure was significantly reduced. HR and sublingual temperature were significantly increased by +22 bpm and +1.1°C, respectively, just after 10 min SB. Venous blood pO₂ and pH were significantly increased by +18.3 mm Torr and +0.03pH, and pCO₂ was significantly reduced by -5.8 mm Torr. Lactate and pyruvate were significantly reduced after 10 min and 30 min after sand bath suggesting the improved peripheral oxidative metabolism.
Conclusion: Increase in blood pressure and heart rate indicating cardiac acceleration was considered to be induced by hydrostatic pressure with heavy sands and thermal vasodilation. Improved peripheral circulation and oxidative metabolism were also suggested by increased pO₂, decreased pCO₂ and decreased lactate and pyruvate level. Sufficient O₂ supply and removal of wasted substances due to activated circulation was considered to be the basic mechanism of the effects of sand bath.

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Objectives: The early local vasodilator response to local warming is predominantly dependent on neural reflexes. However, it is suggested that systemic vasomotor activities are unaffected by a local warming at early stage. The purposes of this study were to assess the hypothesis that systemic vasomotor activities might make an adjustment at early stage of hand warming.
Materials and Methods: Thirty-nine young volunteers who were healthy were recruited. Each participant received a right hand bathing at 40°C for 10 minutes. Doppler ultrasound technique was used to monitor the brachial artery mean blood velocity (aMBV) at the heated arm, and changes in aMBV were used to evaluate local vasodilator response to hand warming. Photoplethysmographic technique was used to monitor digital volume pulse (DVP) at the unheated finger, and changes in the DVP derived peak amplitude (DVPampl), reflection index (DVPRI), stiffness index (DVPSI), and heart rate (HR) were used to evaluate vascular distensibility of the unheated upper limb, small artery tone in the lower body, large artery stiffness, and cardiac regulation respectively. The data collected in each minute were averaged as an interval. Comparisons of aMBV, DVPRI, DVPSI, and HR at each interval with their respective baseline values were performed using one-way ANOVA.
Results: Plots of one-minute intervals versus aMBV, DVPampl, DVPRI, DVPSI, and HR were shown in Figure. aMBV values presented significant increases with a early peak at the third minute. DVPampl presented significant decrease in the first minute and then reversed to a significant increase at the sixth minute. DVPRI presented a significant increase in the first three minutes, and then returned to the level of baseline. DVPSI and HR did not present any significant changes.
Conclusion: At the period of early local vasodilator response to hand warming, systemic vasomotor activities did make a significant adjustment by decreasing vascular distensibility of the unheated upper limb and increasing small artery tone of the lower body, though the activities in heart rate and large artery tone were unaffected. Later, vascular distensibility of the unheated upper limb made a reverse adjustment and reached a significant increase.

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Background: Peripheral circulation is often disturbed in patients with connective tissue diseases (CTDs) and its objective evaluation is an important issue. Infrared thermography has been used for the purpose for decades [1]. Raynaud phenomenon (RP) is prevalent in and considerably characteristic of CTDs and we have long noticed colour unevenness among fingers in patients during RP attacks. We hypothesized that temperature unevenness among fingers detected by thermography would be a useful parameter to evaluate peripheral circulation.
Objectives: To evaluate temperature unevenness among fingers as a thermographic parameter by comparing it with other parameters validated in previous studies.
Methods: Patients who visited our hospital and had been diagnosed as having RP by their attending physicians and underwent thermographic examinations were included and compared with healthy volunteers. Skin temperatures of dorsum of hands at 10 fingers’ nail folds and MCP joints were measured at baseline. Then hands were immersed in 10°C water for 10 seconds. Skin temperatures were measured at 0, 3, 5, 10, 15, 20, and 30 min after immersion. Mean temperature, recovery rate (temperature recovery from immersion/decrease by immersion), and coefficient of variation (standard deviation/mean temperature) of nail fold temperature were calculated. Higher coefficient of variation means temperature among fingers is more uneven. Distal-dorsal difference (DDD: measured by subtracting mean temperature of MCP from that of nail fold) was also calculated and these parameters were compared between the two groups. Receiver operating characteristic (ROC) curve was generated to compare these parameters in terms of their capability of differentiating patients with RP from HCs.
Results: Thirty-one patients with RP (10 with primary Raynaud, 11 with systemic sclerosis (SSc), 11 with other CTDs) were included and compared with 25 healthy controls (HCs). Baseline nail fold temperature was significantly lower in patients of RP than in HC (30.8±3.1 °C vs. 33.2±1.8 °C, p=0.0002). Cold-water immersion of hands revealed patients with RP had lower recovery rate, lower DDD, and higher coefficient of variation than did HCs. The differences in these parameters were the most evident at 5 min after immersion (patients with RP vs HCs: recovery rate; 49.6±27.7 vs 71.5±26.8, p=0.004 DDD; -1.4±2.8 vs 0.85±2.7, p=0.0008 coefficient of variation; 0.053±0.024 vs 0.021±0.015, p=1.2x10^-6). On the basis of ROC curve analyses for these parameters, coefficient of variation of nail fold temperature most effectively differentiated patients with RP from HCs (Area under the curve; recovery rate: 0.64 DDD: 0.79 coefficient of variation: 0.88).
Conclusions: Unevenness of temperature among fingers was the most useful thermographic parameter to evaluate disturbed peripheral circulation.

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Objectives: Ceramic bathing is a kind of sauna on which visitors lie and enjoy hot stimulus. Our aim in this study was to examine whether an intensive exposure of ceramic bathing improves physical and psychological functions or not.
Methods: The study design is a non-randomized single-arm before-after trial. The 38 subjects (6 males and 32 females) were enrolled in Yachiyo city, Chiba, Japan and bathing 8 times in 2 months from November 2009 to May 2010. Physiological, physical and psychological functions were examined when participants were bathing first and last time. We measured systolic blood pressure, diastolic blood pressure, pulse rate and body mass index (BMI) as physiological functions and SF-8, Profile of Mood States (POMS), and Cornell Medical Index (CMI) questionnaire score for examining subjective changes of physical and psychological functions. The results were compared by paired t test.
Results: Physiological functions were not changed considerably by intensive bathing, excepting a slight decline of diastolic blood pressure. Concerning subjective physical functions, we observed statistically-significant improvement in 11 items: eyes/ears, cardiovascular, digestive, skin, nervous, physical component summary, general health, role physical, bodily pain, vitality, and physical functioning. Regarding subjective psychological functions, 9 items were significantly improved: sensitivity, anger, psychological component summary, role emotional, mental health, tension-anxiety, anger-hostility, fatigue, and confusion. We observed certain but not-significant improvements in 6 items of subjective physical functions (respiratory, musculo-skeletal, genito-urinary, fatigability, frequency of illness, and social functioning) and 5 items of subjective psychological functions (depression in CMI and POMS, maladaptation, anxiety, and tension). There observed little change in only 1 item in subjective psychological function (vigor in POMS). There were no items showing significant deterioration after intensive bathing.
Conclusion: An intensive exposure of ceramic bathing might be effective in improving physical and psychological functions without changing physiological status.

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Introduction: Long-term cardiac hypertrophy causes heart failure. One of the mechanisms of this transition from hypertrophy to heart failure is collapse of hypoxic response and angiogenesis. Heat shock protein 27 (HSP27) was found to act as an anti-apoptotic protein and its phosphorylation is responsible for the protection of cells against heat stress. HSP27 has been reported to regulate p53 expression, which contributes to down-regulate angiogenic factors through hypoxia inducible factor-1α(HIF-1α). We have reported that thermal therapy, namely Waon therapy, improves cardiac and vascular function in patients with chronic heart failure. However, the effect of this therapy on cardiac hypertrophy due to pressure overload is unknown. The purpose of this study is to investigate the effects and mechanisms of thermal therapy (Waon therapy) on the transition from cardiac hypertrophy to heart failure after pressure overload.
Methods: Cardiac hypertrophy was induced by transverse aortic constriction (TAC) in C57BL/6 mice. At 2 weeks after TAC, all mice were examined by echocardiography and showed left ventricular hypertrophy. Then, mice were randomly divided into thermal therapy or untreated group. Thermal therapy group received thermal therapy using an experimental far infrared ray dry sauna, which elevates the core temperature by 1 degree Celsius for 30 minutes, daily for 4 weeks. Sham operated mice were used as control. At 6 weeks after TAC, we measured body weight, heart rate and blood pressure before sacrifice, and eviscerated heart and leg muscle. Western blot analysis of p53, phosphorylated HSP27, HIF-1α and vascular endothelial growth factor (VEGF) was performed using extracted protein form heart.
Results: At 6 weeks after TAC, body weight, heart rate and blood pressure did not differ in three groups. Echocardiography showed that left ventricular fractional shortening of thermal therapy group was significantly larger than that of untreated group (Sham vs. Untreated vs. Thermal; 50.0±1.7 vs. 36.7±1.3 vs. 46.2±0.5, P<0.01, n=6 each). Heart weight/tibia length ratio of thermal therapy group was significantly smaller than that of untreated group (6.7±0.1 vs. 9.7±0.5 vs. 7.9±0.2, P<0.01, n=9 each). Western blot showed that thermal therapy increased phosphorylation of HSP27 and reduced p53. Thermal therapy also increased HIF-1α and VEGF at 6 weeks after TAC. Capillary/myofiber ratio was larger in thermal therapy group than that in untreated group (1.71±0.05 vs. 2.04±0.04 vs. 2.41±0.10, P<0.01, n=4 each).
Conclusion: Thermal therapy, namely Waon therapy, prevented the transition from cardiac hypertrophy to heart failure induced by pressure overload in mice. As the mechanism, thermal therapy amplified the phosphorylation of HSP27 and inhibited p53, increased HIF-1α and VEGF, and then increased angiogenesis.

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Objectives: To evaluate the efficacy of complex rehabilitation program for patients with early rheumatoid arthritis (RA) within 6 months.
Patients and Methods: 64 patients with early RA were included. 34 study group patients underwent drug therapy and complex rehabilitation. The rehabilitation program consisted of hospital stage (2 weeks): local air cryotherapy (-60°C, Criojet Air С600) for hand, knee or ankle joints for 15 min, 45-min therapeutic exercises under the supervision of a trainer, 45-min occupational therapy (joint protection strategies, methods for shaping a correct functional stereotype, use of assistive devices and adaptive equipment for personal care, mobility and household), 10 sessions, education program (4 daily 90-min studies) and outpatient stage (6 months): 45-min home-based exercises 3 times a week, orthoses (functional wrist and knee orthoses, individual orthopedic insoles). 30 patients received only drug therapy (control). Tender and swollen joint count, erythrocyte sedimentation rate (ESR), joint pain on 100-mm visual analogue scale (VAS), Disease Activity Score (DAS28), Stanford Health Assessment Questionnaire (HAQ), Rheumatology Assessment Patient Index Data (RAPID3), hand grip strength, the average powers of knee extension and ankle flexion by EN-TreeM movement analysis were evaluated at baseline, at 2 weeks and at 6 months.
Results: 2-week stationary stage of rehabilitation program relieved pain, improved parameters of functional status and motor activity, but did not influence on the parameters of inflammatory diseases activity (swollen joint count, ESR, DAS28) (table). After 6-month complex rehabilitation program tender joint count decreased by 72.3%, swollen joint count - by 74.1%, ESR - by 58.2%, joint pain by 70.4%, DAS28 - by 1.38±0.2, HAQ - by 0.97±0.56, RAPID3 - by 5.98±1.25 (p<0.01). The grip strength of a more affected hand elevated by 44.9%, the average extension power of a weaker knee joint - by 88.7%, the average flexion power of a more affected ankle joint - by 81.6% (p<0.01). The changes in the control group were less pronounced, which determined statistically significant differences between the groups in all parameters (p<0.05).
Conclusion: 6-month complex rehabilitation program increases functional ability and motion activity, relieves pain, helps to control diseases activity and improves quality of life in patients with early RA.

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Introduction: Human body has systems that preserve its homeostasis, corresponding to a spectrum of stimuli. As for thermal stimuli, vasculatures would react most, and changes in blood flow could be observed as skin temperature measured by thermography. In case that vasculature gets sickened, its response may change. We have observed that temperature unevenness/disparity among fingers is the most useful finding to see disturbed peripheral circulation in connective tissue diseases (CTDs) patients, although low temperatures prior to immersion and their delayed recovery after immersion are distinguished.
Objectives: To examine whether warm stimulus ameliorates temperature disparity, and if it works, whether any differences are between warm tap water and warm water containing CO₂.
Patients and methods: CTD patients with signs or symptoms of circulatory disturbance in periphery of extremities were tested for thermo-loading test. Loading was hands immersion in 42C tap water or water containing CO₂ (1000 ppm) for 10’’. Coefficient of variation (CV, mean of right & left SD/mean of 5 nailfolds’ temperature) was calculated at each measuring point (baseline, 0, 3, 5, 10, 15, 20, 30 minutes after the immersion), its change from baseline was examined, and the CV change was compared between tap and CO₂ warm water.
Results: Twenty-one (F:20, M:1, 60.0±17.1 year-old) , and 24 (F:22, M:2 58.3±19.4 y) patients were tested for tap and CO₂ water immersion, respectively. Before warm bathing, varying levels of CV was observed from patient to patient (tap, 0.020+/-0.014; CO₂ 0.029+/-0.029, p<0.05). Just after the immersion, CV decreased in all of the patients (0.010+/-0.003, p<0.05 vs. baseline; 0.013+/-0.005, p<0.05). Then, afterward, CV gradually re-increased toward the level at baseline prior to bathing; however, until 20’ after, CV was still lower than that at baseline, in both immersions (data not shown). Thirty minutes after the immersion, CV re-increased to a level not statistically different from that at baseline in tap water immersion (0.018+/-0.011, ns); however, CV was still statistically lower in CO₂ water immersion (0.016+/-0.014, p<0.05).
Conclusion: Hands immersion in warm tap water and warm CO₂ water both once ameliorated varied temperature, evaluated by CV. Amelioration was dissolved 30’ after the immersion in tap water, but sustained even 30’ after the immersion in CO₂ water, in spite of higher CV in CO₂ group

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Introduction: As a child, I was repeatedly subjected to a cupping therapy and perhaps with good results, because I live for today. As a young doctor I used cupping in the 80 - th century. Today in my country is relatively rarely used by qualified medical personnel, although still officially approved for the treatment, and also quite widely practiced outside of official medicine.
  The aim of the study was to analyze the medical literature cupping therapy.
Method: A review of the literature available on PubMed and Google Scholar, clinicaltrials.gov and EU Clinical Trials Register.
Results: After entering the phrase “cupping therapy” obtained information about more than 800 publications and 10 clinical trials. It seems much more probably located in the journals outside these databases of literature, including unreviewed, books and websites.
  Cupping are a medical device used in physical medicine for hundreds, perhaps even thousands of years quite different indications and in different modifications. On the one hand it can be considered as related acupressure, in a sense acupuncture, because the pressure changes affect the skin and subcutaneous tissue, the other as a form of heat treatment, and thus akin to moxibustion. The scope of the described indications for cupping therapy is quite broad and includes fibromyalgia, neuralgia, Persistent non- specific low back pain, neck pain, mechanical / motor problems with neck and trunk, osteoarthritis, carpal tunnel syndrome, facial paresis, but also insomia, asthma, cough, bronchtis, dyslipdemia, laryngitis, erysipelas, hypertension and pneumothorax and.. constipation.
  Unfortunately the available data do not allow for strong recommendations of their use, but can be considered as a method of supplementing or even basic for patients with contraindications to other forms of treatment (medication or operating). However, further research to these recommendations could be verified.
  Cupping is also not free from the risk of complications, especially dermatological and hematology. The biggest risk, however, is probably omission or delay the necessary diagnosis and/or therapy, such as surgery, when cupping lead to a subjective improvement, but it can not cure serious diseases such as cancer.
Conclusion: Available data do not allow for strong support of cupping therapy, but may be considered as a complementary method or even basic for patients with contraindications to other forms of treatment (medication or operating). However, further research to verify these recommendations must be done.

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Objective: We investigated the effects and the mechanism of the acupuncture.
Methods: Nishijo/Mori and colleagues studied the function of the autonomic nervous system (ANS) with the instantaneous heart rate (IHR) as indicator. With the ANS blockers we also revealed the response of ANS when we insert needles to human body. For example, in our study of 1991, we conducted an experimental study on humans and elucidated that the physical stimulation promoted the resilience and the homeostasis of our body. Our recent study (2013) showed the physical stimulation (not acupuncture) on the lower thighs (mainly the bottom of the feet) also enhanced the above mentioned effects.
Results and Discussion:
1.　The subjects sat on the chairs and they were given the acupuncture stimulation on their wrists (the skin and subcutaneous tissues) at the expiration. The stimulation for the duration of 15 consecutive breaths increased the function of the parasympathetic nerve (PN). At the same time that of the sympathetic nerve (SN) also enhanced. In short, firstly that of PN enhanced and secondly that of SN followed. Thus, it was observed that the physical stimulations promoted the resilience and the homeostasis of our body and we may regard that this is the first mechanisms.
2.　In our recent study (2013) the subjects sat on the chairs and there were given the stimulation (50 times of fist-strikes) on the sole of the feet. Immediately after the stimulation the result of Floor Finger Distance test （FFD) was improved. At the same time IHR, the indicator of the function of ANS, showed that those of SN (adrenaline β stimulus) and PN were simultaneously increased as soon as the stimulation started. The same result was obtained from the study of the body vibration (the SOUND healing). This process of 2013 was different from that of 1991, however, both of them provided the effect; the promotion of the resilience and the homeostasis of our body. Therefore, we could regard it as the second mechanism of the physical stimulations which promotes the resilience and the homeostasis of our body.
Conclusion: In this way, there are two mechanisms of the physical stimulation in promoting the resilience and the homeostasis of our body.

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Introduction: In Japan, onsen, or hot springs, has traditionally been associated with good quality natural water baths surrounded by beautiful nature, meals made from local products, hospitality at hot spring hotels, and massage. I would like to introduce Anma massage therapy, the massage technique most widely practiced by nationally certified massage therapists in Japan.
Origin and treatment characteristics: Ancient Chinese medicine, which involves Ankyo, Doin, acupuncture, moxibustion, and herbal medicine was introduced to Japan from China via the Korean Peninsula in the 6th century. Ankyo was a massage therapy that considered acupuncture meridians. Ankyo was modified to meet the preferences of Japanese people and subsequently developed into the modern-day Anma massage therapy. Anma derives its name from its two main manual techniques; an, which is the Japanese term for applying pressure, and ma, the Japanese term for stroking.
  Today, Anma massage is generally applied over the whole body, focusing not on meridians but instead on anatomy, especially muscles. Standard Anma massage techniques involve mainly kneading, with lesser amounts of stroking and pressing through clothing using rhythmic massaging motions, and occasionally, brief joint exercises. The intensity of stimulation is adjusted according to each patient’s comfort level.
Results of our studies: We administered a single 40-minute full-body Anma massage session to 15 healthy women. After this session, we observed significantly reduced visual analog scale scores for their subjective symptom of muscle stiffness in the neck and shoulders, state anxiety scores, and salivary cortisol concentrations, as well as significantly increased secretory immunoglobulin A concentrations.
  Next, changes in gene expression were investigated to clarify the mechanisms of the clinical effects of Anma massage therapy. Subjects were two healthy female volunteers. Blood was taken before and after a 40-minute Anma massage session and analyzed by microarray. The analysis revealed the gene ontology terms selected by both participants after the Anma massage were “immune response” and “immune system”. Although the sample size was very small, these results imply that Anma massage therapy may affect immune function.
  Moreover, in our studies on outpatients with Parkinson’s disease, Anma massage therapy significantly alleviated severity of patients’ subjective symptoms of muscle stiffness, movement difficulties, pain, and fatigue, and also improved motor functions of the upper and lower limbs.
Future challenges in Anma massage research: After completing a preliminary study, we are now conducting a 2-year randomized controlled trial of the efficacy of Anma massage therapy among cancer survivors.
  Because Anma is a full-body massage tailored to meet the physical and mental state of individuals, it is difficult to develop standardized therapy protocols for studies. However, we aim to incorporate the unique merits of Anma massage into therapy protocols in studies to produce results that are appropriately rigorous for the global scientific community.

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Fangotherapy is one of four medical treatments used under a medical doctor’s supervision at a hot spring. This treatment is conducted in Europe, especially in Italy, using peloids maturated with natural hot spring water. The maturated peloids have factors of concentrated hot spring and biological extract -glycolipids- from thermophilic algae.
  There are many kinds of hot springs in Japan, but they are almost always used for “taking a bath” only. Our research focused on Fango found in Abano Italy, and modified into “Japanese style Fango” made with maturated peloids by hot spring water.
Methods: The original Japanese Fango, which we made in a hot spring in Japan, has been named Biofango^®. The original and first Biofango^® was made from the Sanrakuen Hotel’s hot spring water in Toyama, and treated in the hotel as in the Abano style. The benefits of Biofango^® were checked using the following methods;
1.　Hyperthermia and some medical effects were checked under treatment with maturated peloids, and the effects were compared with hot spring water only and with boiled tap water.
2.　The double-blind method was used comparing Biofango^® (True Fango) and imitation Fango. Two kinds of Fango were made using either hot spring water or hot tap water, and some medical effects were checked. After treatment of Fangotherapy, a medical questionnaire was provided for each test subject.
Results: Fango (Biofango^®) is the best treatment among three bathing methods for keeping normal responses of blood flow and blood pressure at the thigh, and for keeping good thermal effects on the body, especially for the back of the body after 50 min.
  The results of the double-blind method, deep body temperature increase and diastolic blood pressure decrease in True Fango showed a significant difference. Pulse increase and SIV decrease in True Fango shows a reduced load on the vessel, while still showing a high thermal effect. Functions of the body showed an improved friend in True Fango, according to the questionnaire survey.
Conclusion: Traditional use of hot spring water in Japan was hot spring bathing in the mainstream. But, according to these results, Fango is the best method for a body-friendly treatment by hot spring water. Further, the questionnaire about body functions after Fango treatment shows that the hot spring Fango (True Fango) is more effective than hot tap water Fango (imitation Fango).
  In Italy, glycolipids from thermophilic algae are an important factor for reducing inflammation by Fango therapy. Growth of thermophilic algae also has been confirmed in Fango maturation in Japan, and was cultured in the laboratory. We also found such glycolipids from Japanese algae, and have evidence, in situ, of the glycolipids remaining between particles of peloids. In the future, Biofango^® should have a useful biological factor similar to Abano Fango for treatment.

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Introduction: To evaluate the influence of the skin aging critical level on the development of objective thermal protocols, an improved integrated tensiometric approach was developed named as Tensiometric Versus Skin (TVS) modeling.
  TVS modeling: (i) exploits the structure-surface correlations which are characteristic of all systems; (ii) applies the principle of permutability of the tensiometric technique, according to which unknown solids can be characterized by their known surface characteristics, and vice versa; (iii) is carried out in a non-invasive way by a tensiometric contact angle method.
  TVS modeling involves TVS skin test as an objective evaluation marker of the epidermal functional state, and TVS mud index as an evaluation marker of thermal matrices.
Objectives: On the basis of these scientific evidences, the combined action of TVS mud index with TVS skin test was investigated to develop objective dose-response thermal protocols.
  The first “OTP-TVS thermal protocol” was developed in the Euganean thermal area where fangotherapy is widely practiced.
Materials and Methods: Native Euganean thermal mud was firstly characterized from the chemical and mineralogical point of view. After maturation in controlled conditions, TVS mud index was obtained by contact angle method using PFPE as reference standard liquid, and finally, by repeated TVS skin test before and after a dose of fango application, the fango effectiveness was performed.
Results: The schematic OTP-TVS protocol pathway is shown in Figure 1.

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Introduction: The link between the hydration state and the functional effects of formulations and natural systems is been demonstrated by several studies. Measurement of skin hydration has been used to assess barrier function integrity in vivo and stratum corneum (SC), hydration may increase after the topical application of natural or formulate systems. Thermal muds have great hydration properties thanking at its high water contain due to presence of clays minerals¹⁾. Our work was focused on the evaluation of skin’s hydration potentialities of Japanese Biofango^®.
Objectives: Mudtherapy increase the hydration state of skin and modify its selective permeability favouring the permeation of therapeutic substances product by maturation process. Our goal was the development of a tensiometric model for assessment and optimisation of Japanese Biofango mudtherapy protocol by the evaluation of skin hydration measuring water contact angles on skin surface²⁾. Our work was performed at Sanraku-en spas centre (Tonami-Japan).
Materials and Methods: Biofango was constituted by Kunigel, Kaolinite, and WakuraDiatomite contains montmorillonite. BFM mixture was prepared and collected from Sanraku-en maturation plant. Samples were stored at -25°C. Skin’s hydration state analysis were performed before and after treatment by contact angle method (CA) using DSA 2-Kruss Dynamic Tenskinmeter³⁾ water as liquid test and accordingly to traditional Sanraku-en/Biofango protocol. Four subjects with differents age, sex and weights (KS, YS, MO, and KM) were considered as test. Sanraku-en mudtherapy protocol’s steps were (a) first blood pressure measurement, (b) water’s CA measurements on left and right arm before treatment, (c) thermal bath (8’), (d) water’s CA measurements, (e) BFM mudtherapy (20’), (f) water’s CA measurements on polish skin, (g) shower (3’), (h) water’s CA measurements, and (i) final blood pressure measurement.
Results: CA of water on subject KS skin showed elevated levels before (CAt0>89.5 deg) and after (CAtf>89.5 deg) treatment. YS subject showed increases of skin hydration after treatment (CAt0>89.5 deg, CAtf=40.27 deg), MO showed more increase of skin hydration than YS (CAt0>89.5 deg, CAtf=20.12 deg), and KM (CAt0>89.5 deg, CAtf=41.30 deg) showed an hydration state similar to YS. Regarding YS subject, we optimized its mudtherapy by the inversion of bath (CAt0>89.5 deg, CAtf>89.5 deg) with mudtherapy phases. As results a major increase of hydration state respect normal protocol (CAt0>89.5 deg, CAtf =30.4 deg) reflecting on skin moisturize after bath phase also (CAt0>89.5 deg, CAtf=87.43 deg).
Conclusions: Analyses of hydration state of skin by measurement of water’s contact angles consented to evaluate the capability of Biofango BFM to modify the selective permeability of stratum corneum. Thanking to the method developed was possible to optimise and personalize Sanraku-en protocol.

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Introduction: Brenta’s silt-clay (BrentaKer^®, EGAP, Italy) is a natural sediment containing minerals pertaining to Italian Dolomite Alps mountains, which is extracted from the catchment area of Brenta river. Particle-size distribution, mineralogical, chemical, tensiometric investigations with some observational findings open to new perspectives for its application in beauty & wellness field. On these basis, surface energy evaluations of tensiometric affinity with the skin by TVS modelling¹⁾ and in-vivo clinical studies of anti-cellulite properties of Brenta’s silt-clay were performed.
Objectives: The aim of this work was to evaluate the properties of the Brenta’s silt-clay in anti-cellulite cosmetic treatments. These properties were hypothesized on the basis of its tensiometric affinity for the skin, as determined by the Bio-adhesive TVS index¹⁾.
Materials and Methods: Surface energy studies were performed by contact angle method, using the DSA10-Kruss tensiometer (diiodomethane, FomblinHC/25^®PFPE, glycerine as liquid tests). Bio-adhesive TVS index levels were originated from overlapping Brenta’s silt-clay and skin’s tensiometric prints. γ-rays irradiated Brenta’s silt-clay (Oroscare, EGAP, Italy) was inserted in a formulation composed by demineralised water, diazolidinyl urea, carboxymethyl cellulose, carbomer, glycerine, phenoxyethanol. Clinical efficacy of Brenta’s silt-clay was tested versus placebo in 10 females with cellulite on their thighs and/or gluteus (degree 1-3, Nurberger and Muller scale) for 8 weeks considering (a) skin hydration value (Corneometer CM825, C&K, Germany), (b) vertical deformation, elasticity, skin extensibility (Cutometer MPA580, C&K, Germany), (c) thigh circumference (measuring tape), (d) microcirculatory flow (Flowmeter Periflux PF4001, Perimed, UK, (e) length of dermo-hypodermic junction (Ultrasound Scanner Dermascan C^®Ver.3, Cortex Technology, Germany), (f) skin smoothness (Skin replicas image analysis, Monaderm, France).
Results: In three subjects the Bio-adhesive TVS index showed maximal affinity between Brenta’s silt-clay (DC=17.8±4 mN/m, PC=32.0±4.6 mN/m, SFE=49.8 mN/m) and untreated skin (DC=13.5±4.1, PC=19.67±13.4, SFE=33.2±16.2), indicating that the surface energy of Brenta’s silt-clay was higher than that of the skin and suggesting its capability to modify skin’s selective permeability. After 4 (T1) and 8 (T2) weeks, the subjects treated with Brenta’s silt-clay were compared with respect to placebo. Derma-hypodermal junction length significantly decreased (-10.7%, p<0.05) in T1, whereas an increase of skin microcirculatory flow (+26.0%, p<0.05) and a decrease of the derma-hypodermal junction length (-16.8%, p=0.052) and of skin maximum average roughness (-4.2%, p=0.057) were observed in T2.
Conclusions: In subjects with cellulite blemish, the application of Brenta’s silt-clay is capable to increase skin blood micro-flow, improve dermo-hypodermal junction length and decrease skin maximum average roughness, suggesting its efficacy in anti-cellulite treatments. Bio-adhesive TVS index analysis suggests that this efficacy is probably related to its capability to modify skin’s selective permeability.

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Introduction: Brenta’s silt-clay (BrentaKer^®, EGAP, Italy) is a natural sediment containing minerals pertaining to Italian Dolomite Alps mountains, which is extracted from the catchment area of Brenta river. Particle-size distribution, mineralogical, chemical, tensiometric investigations with some observational findings open to new perspectives for its application in beauty & wellness field. On these basis, surface energy evaluations of tensiometric affinity with the skin by TVS modelling [1] and in-vivo clinical studies of anti-acne properties of Brenta’s silt-clay were performed.
Objectives: The aim of this work was to evaluate the properties of the Brenta’s silt-clay in anti-acne cosmetic treatments. These properties were hypothesized on the basis of its tensiometric affinity for the skin, as determined by the Bio-adhesive TVS index [1].
Materials and Methods: Surface energy studies were performed by contact angle method, using the DSA10-Kruss tensiometer (diiodomethane, FomblinHC/25^®PFPE, glycerine as liquid tests). Bio-adhesive TVS index levels were originated from overlapping Brenta’s silt-clay and skin’s tensiometric prints. 10 healthy volunteers with mild-moderate facial acne vulgaris with a maximum of 20 comedones, 50 papules and pustules, without nodules or cysts were enrolled [2]. A mud composed by 15g of γ-rays irradiated Brenta’s silt-clay (Oroscare, EGAP, Italy) and 10g of water was prepared and applied on the areas of the face to be treated (15 minutes, twice a week, 30 days). Number of a) comedones, papules and pustules, (b) quantity of sebum (Sebumeter-CK), (c) pH (pH-Meter-CK), and (d) soothing effect evaluated by skin’s colour (Mexameter-CK) were analysed at baseline (T0), after 15 (T15) and 30 (T30) days.
Results: In three subjects, the Bio-adhesive TVS index showed maximal affinity between Brenta’s silt-clay (DC=17.8±4 mN/m, PC=32.0±4.6 mN/m, SFE=49.8 mN/m) and untreated skin (DC=13.5±4.1, PC=19.67±13.4, SFE=33.2±16.2), indicating that the surface energy of Brenta’s silt-clay was higher than that of the skin and suggesting its capability to modify skin’s selective permeability. In T0-T30 period the number of papules significantly decreased from 11.3±3, 83 to 10.6±3, 74 (p=0.033). In the same period, the number of postules decreased from to 2.5±1.5 to 1.9±2.02 (p=0.055) whereas the papular colorimetric measurement diminished from 618±13.5 to 613.0±6.80 (p=0.046). Sebum values significantly decreased both in T0-T15 (-28.7%, p=0.027) and in T0-T30 (-32.7%, p=0.017) periods. Finally, significant changing of pH and colorimetric measurements on healthy skin were not observed.
Conclusions: In subjects with mild to moderated facial acne vulgaris, a mask based on Brenta’s silt-clay regulates the sebum, reduces papular inflammatory, maintains cutaneous physiological conditions, suggesting its efficacy in anti-acne treatment. Bio-adhesive TVS index analysis suggests that this efficacy is probably related to its capability to modify skin’s selective permeability.

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  Carhue is the largest thermal center of the province of Buenos Aires, located 520 kilometers from the state capital. The thermal baths and the treatments with the lake’s peloids have become an emblem of the city. Since 1920 visitors from around the world have come to this place to enjoy the benefits of the mineral waters from Epecuen Lake.
Objective: The objective of this work is the physicochemical study of the Carhue peloid.
Material and Method: A commercial peloid sample, The percentage of the solid components, water and ashes was determined by gravimetric techniques drying the sample in oven and mufla. The specific heat, thermal conductivity coefficient and calorific retentivity were calculated from these data.
  The particle size was determined by laser diffraction, using the model 3000 of Malvern Instruments Mastersizer.
  The instrumental texture was determined with the Brookfield LFRA, Texture Analyzer, model 1000 LFRA LRFA. The Rambaud method was the technic used to obtain the cooling curve, with thermostatic baths, Lauda, RA 8 Alpha and E-100 and thermocouple Cole-Parmer, model 91100-50.
Results: (Table 1)
Conclusions: Its water percentage (47.4%) allow us classify this product as a true peloid.
  From the relation ash / solid (0.90) it follows that is a peloid rich in inorganic products.
  The particle size indicates that there are particles ranging 0.6 to 120 microns, with Dv(50) of 10.5 microns but with scarce uniformity.
  Specific heat and retentivity values are agree with the obtained percentage values of water and ashes.
  The value tr (8.7 minutes) shows a peloid with slow release of heat, matching up with the data of their retentivity 7.74 106 s/m².
  According to its texture is a soft peloid (64.7 g) with good cohesion capacity (0.96) so it is an easy product to use.

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  There is little doubt that the main therapeutic action of the peloid’s, therapy depends on their thermal properties. For this reason is quite of interest getting to know the thermal properties of the materials that form peloids.
Objective: Study the thermal properties of three inorganic solids that can be used in the preparation of therapeutic peloids.
Materials and Method: The products used are aluminic Bentonite, Kerolita (Süd Chemie) and SPLF ELITE (Tolsa).
  From the thermal point of view the specific heat was determined using a Scanning Calorimetry equipment, model DSC1, cooled by air of Mettler Toledo and it was used the software STARe for the collection and processing of data.
  An extemporaneous product was prepared with a liquid phase of 60%, using distilled deionized water. Its cooling curves their relaxation and inertia times were studied.
  For the determination of the cooling curves we have followed the Rambaud technique, obtaining graphs and equations that best fit the experimental curve, using the ORIGIN program 8. We used Thermostatic baths, models Lauda RA Alpha 8 and E-100 and a thermocouple Cole-Parmer, model 91100-50.
Results and Discussion: The following Table 1 shows the results of the specific heat measures of the three studied products, in the range of 45-36°C and its corresponding average value. We also include the inertia and relaxation time of peloids.
Conclusions: The SPLF, a sepiolite, presents the highest value of the specific heat, whose corresponding peloid with an equal percentage of water would provide the greatest amount of heat. The specific heat of the bentonite and kerolita is very similar.
  Bentonite Al shows the most relaxation time of the three products, releasing therefore the heat more slowly.

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Introduction: Mineralogical, granulometrical and chemical investigations of Brenta’s silt-clay confirmed its common origin with natural Euganean Thermal Muds (ETM)¹⁾ opening perspectives in the treatment of inflammatory pathologies as rheumatic diseases. Basing on these evidences, surface energy investigations of Brenta’s silt-clay and ETM by TVS modelling were considered within correlation studies between physic-chemical and tensiometric data.
Objectives: Basing on Brenta’s silt-clay and ETM common origin, the aim of this work was to confirm the suitability of Brenta’s silt-clay in thermal field by comparative analyses of their matrices and on these basis hypothesize the potentialities of Brenta’s silt-clay in mudtherapy and cosmetic field.
Materials and Methods: Brenta’s silt-clay (BrentaKerÒ) samples and ETM were collected respectively from EGAP’s gravel pit and Euganean thermal spa’s maturation plant, undergone at maturation process employing thermal water at different temperature, investigated using (a) DSA10-Kruss tensiometer (diiodomethane, PFPE, glycerine as liquid tests) for surface energy characterization, and (b) Perkin Elmer TOC Analyser for C (%) and H (%) detection. Tensiometric characterizations were performed by measurement of contact angles (deg) of different liquid tests converted successively in surface energy (mN/m) by Owens mathematical model ²⁾. Contact angles of PFPE were performed by Perfluoropolyether Contact Angle Measurement Method (PCAM).
Results: Correlation degree between dispersed surface energy component (DC) of Brenta’s silt-clay and contact angles of PFPE (deg) measured during 6 weeks of maturation resulted satisfactory (R2=0.90). Considering the typical maturation’s temperature measured from third week to sixth (40°Ct3, 41°Ct4, 42°Ct5, 43°Ct6), the correlation degree between them and values of DC (mN/m) of Brenta’s silt-clay (DCt3=18.9 mN/m, DCt4=20.3 mN/m, DCt5=19.9 mN/m, DCt6=20.6 mN/m) resulted maximal (R2=1). Brenta silt-clay and ETM DC levels (DCt3=21.2 mN/m, DCt4=20.4 mN/m, DCt5=20.9 mN/m, DCt6=20.7 mN/m) demonstrated optimally correlated (R2=0.97). TOC analyses performed on Brenta’s silt-clay and ETM after maturation showed an increase of C% respectively +1.4% and +4.3% and percentage loss of H of -37.8% and -10.7% with an increase of DC and PC of +17.8 mN/m and +21.0 mN/m confirming the great affinity between the two geomaterials. Regarding ETM it demonstrated also the capability to deliver DC (-44.8%) uptaking PC (+50%) during mudtherapy as result of the modification of selective permeability of skin.
Conclusions: Chemical-mineralogical analyses, tensiometric investigations, and studies of correlations between Brenta’s silt-clay and ETM demonstrated a great affinity between them. Surface energy evaluations of ETM, its capability to deliver DC to skin uptaking PC during mudtherapy modifying skin’s selective permeability and favouring the permeation of therapeutic substances product during maturation process, suggest new perspectives for the employment of Brenta’s silt-clay in thermal field as anti-inflammatory agent for rheumatic diseases and in cosmetic sector.

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