Introduction: The maturation process of peloids has been the subject of many studies over time. Knowledge of the processes occurring during this time period, it is very interesting to know the applications of the final product.
Material and Method: For preparation of extemporaneous peloids it has been used clay Bentonite Volcangel (Benesa) supplied by Süd Chemie, a mineral water hyperthermal (42°C), sulphurated, weak mineralization (261 mg/l) from Baños Montemayor (M) and water purified obtained by distillation and ion exchange (A).
  Peloids were prepared by mixing in the ratio needed aiming to produce a product with 70% water and clay, in polymeric material containers. Water and clay were mixed slowly until total homogenization. The product was introduced into glass containers tightly closed and kept at a constant temperature of 42°C and 8°C.
  The percentage of the solid components, water and ashes was determined by gravimetric techniques, drying the sample in oven and muffle furnace (850°C). The specific heat and calorific retentivity were calculated from these data.
  　Every six weeks, the analysis of all parameters are repeated in samples maintained at 42°C and 8°C to study possible variations.
Results: In Table 1 are shown values of the parameters of the initial peloids prepared with purified water and mineromedicinal water.
Conclusion: There were no significant differences observed in the values of the analyzed parameters between the two initial peloids prepared with purified water and with medicinal mineral water of Montemayor spa and a slight diminution in the water percentage, and a small increase of the relaxation time six weeks later.

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Introduction: TVS mud index¹⁾ is a tensiometric marker for quality and maturation process control of Italian Euganean Thermal Muds (ETM) which sensitivity defined on objective basis their quality and maturation degree.
Objectives: The goal was to assess the maturation process of Biofango by TVS mud index (Sanraku-en spas centre, Japan and Osservatorio Termale Permanente-OTP, Italy), and its organic compounds by TOC analyses (University of Padova, Italy).
Materials and Methods: Biofango was prepared using KomatsuClay, MotoyamaClay, WakuraDiatomite and KasaokaBentonite giving K02 (Bentonite 1.25, Kaolinite 1.5, Diatomite 0.25) and A01 (KasaokaBentonite 1.25, Kaolinite 0.5, Diatomite 0.25). Final Biofango BFM+0%Dolomite, MAT1+10%Dolomite, MAT2+18%Dolomite, and MAT3+35%Dolomite were analyzed by TOC (Perkin-Elmer-2400) and DSA10-Krüss employing (a) PFPE, Fomblin HC/OH-1000, diiodomethane, glycerine as liquid tests and (b) Owens-Wendt mathematical model for conversion of contact angles in surface energy parameters²⁾.
Results: The behaviour of C(%) in MAT1, MAT2, and MAT3 during maturation process (20°C) showed respectively (a) MAT1t0h=1.26%, MAT1t216h=0.91%, MAT1t360=1.08%, MAT1t576h=1.23%, MAT1t720h=0.98%, (b) MAT2t0h=2.36%, MAT2t216h=1.80%, MAT2t360=1.49%, MAT2t576h=1.86%, MAT2t720h=1.68%, (c) MAT3t0h=3.29%, MAT3t216h=2.71%, MAT3t360=2.57%, MAT3t576h=2.6%, MAT3t720h=2.7%. C% decrease demonstrating the influence of Dolomite in Biofango mixtures. Dispersed energy components (DC) of MAT1, MAT2, and MAT3 showed respectively (a) MAT1t0h=3.0mN/m, MAT1t216h=3.1mN/m, MAT1t360=2.9mN/m, MAT1t576h=3.8mN/m, MAT1t720h=2.5mN/m, (b) MAT2t0h=2.1mN/m, MAT2t216h=2.2mN/m, MAT2t360=3.1mN/m, MAT2t576h=3.7mN/m, MAT2t720h=2.6mN/m, (c)MAT3t0h=2.0mN/m, MAT3t216h=2.6mN/m, MAT3t360=2.6mN/m, MAT3t576h=2.9mN/m, MAT2t720h=3.0mN/m. On the other side TVS mud index showed respectively (a) MAT1t0h=68.7mN/m, MAT1t216h=70.26mN/m, MAT1t360=71.78mN/m, MAT1t576h=64.69mN/m, MAT1t720h=71.84mN/m, (b) MAT2t0h=74.06mN/m, MAT2t216h=71.69mN/m, MAT2t360= 70.36mN/m, MAT2t576h=65.83mN/m, MAT2t720h=71.23mN/m, (c) MAT3t0h=75.9mN/m, MAT3t216h=73.05mN/m, MAT3t360=73.34mN/m, MAT3t576h=68.52mN/m, MAT3t720h=68.66mN/m proportionally inverse with DC behaviour. MAT3 with highest content in Dolomite demonstrated great capability to uptake DC during maturation process with consequently decrease of TVS mud index levels accordingly with TOC result.
Conclusions: Tensiometric investigations of Biofango underlined the links between chemical and surface energy data. The high sensitivity of TVS mud index consented to follow directly in a non invasive way the structural-surface changes in Biofango mixtures occurred during maturation process opening at new perspective for their control.

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Introduction: Sanraku-en spa started to purpose the “Shogawa biofangotherapy” using hot spring water and different kind of clays of natural origin (called Biofango) matured for three weeks during which bacterial flora develop with production of constitutive elements having therapeutic properties [4]. In collaboration with Ascendant Co. Ltd was ideated and developed the production of the first japanese Biofango supported by Toho University, University of Science and Technology of Hokuriku, and University of Hishigawa opening at new perspective in mudtherapy for therapeutic use in Japan (Biofango project).
Objectives: The goal was the assessing the surface energy of Biofango by TVS modelling and TVS mud index ^{1, 2)}. Tensiometric analyses of Biofango mixtures were performed at Sanraku-en spas centre (Tonami-Japan) and its quality control has been carried out in the Permanent Thermal Observatory (OTP) of University of Padova. Organic compounds analysis (TOC) were performed in the Department of Pharmaceutical and Pharmacological Sciences of University of Padova (Italy).
Materials and Methods: Biofango was prepared using KomatsuClay, MotoyamaClay, WakuraDiatomite and KasaokaBentonite. Pre-test mixtures were K01 (Bentonite 1.75, KomatsuClay 0.5, Diatomite 0.25) and M01 (Bentonite 1.75 MotoyamaClay 0.5 Diatomite 0.25). After were prepared K02 (Bentonite 1.25, Kaolinite 1.5, Diatomite 0.25) and A01 (KasaokaBentonite 1.25, Kaolinite 0.5, Diatomite 0.25) mixtures. Final Biofangos were BFM+0%Dolomite, MAT1+10%Dolomite, MAT2+18%Dolomite, and MAT3+35%Dolomite were analysed by XRF/XRD. TOC analyses were performed on a Perkin-Elmer-2400 analyser with Perkin-Elmer-AD-4 autobalance and tensiometric investigations were performed by DSA 10 (Krüss) tensiometer employing (a) PFPE, Fomblin HC/OH-1000, diiodomethane, glycerine as liquid tests and (b) Owens-Wendt³⁾ mathematical model to convert contact angles in surface enery parameters.
Results: XRD analyses of Biofango demonstrating presence of Kaolinite-Quartz-Feldspar in Komatsu Clay, Kaolinite-Quartz-Feldspar-Carbon in MotoyamaClay, Quartz-Montmorillonite-Feldspar-Grauconite in WakuraDiatomite, and Montmorillonite-Quartz-Feldspar-Christoballite in KasaokaBentonite while XRF showed presence of SiO₂ (KomatsuClay 53.38%, MotoyamaClay 48.86%, WakuraDiatomite 78.20%, KasaokaBentonite 66.01%) and Al₂O₃ (KomatsuClay 53.38%, MotoyamaClay 48.86%, WakuraDiatomite 78.20%, KasaokaBentonite 66.01%) as principal elements. TOC analyses demonstrated an increase of C% with production of CO₂ in relation to the amount of Dolomite in Biofango mixtures (MAT1=1.26%, MAT2=2.36%, MAT3=3.29%). Tensiometric investigations showed a correlation between C% and dispersed components (DC) measured on Biofango mixtures (MAT1=3.0 mN/m, MAT2=2.1 mN/m, MAT3=2.0 mN/m) and between C% and TVS mud index levels (MAT1=68.7 mN/m eq., MAT2=74.06 mN/m eq., MAT3=75.9 mN/m eq.).
Conclusions: Tensiometric investigations of Biofango consented to determine the correlations between chemico-mineralogical data and surface energy parameters. Thanking to the high sensitivity of TVS mud index used as integrated tensiometric marker was possible to determine directly and in a non invasive way the quality of Biofango mixtures opening at new perspective in their monitoring and control before their employment in mudtherapy in Japanese spas after their maturation process.

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Introduction: Brenta’s silt-clay consist of silt with clay containing Italian Dolomites minerals extracted from the catchment area of Brenta river. Sediments were investigated by SEM, XRD, XRF and particle size granulometer. The presence of SiO₂ (34.16%), CaO (17.12%), and Al2O3 (11.15%) as principal elements is comparable with the typical composition of Euganean Thermal Muds (ETM) of Euganean Thermal Area (ETA) which average level of SiO₂, CaO, and Al₂O₃ are respectively 38.75%, 17.74%, and 7.70%¹⁾. Tensiometric investigation of Brenta’s silt-clay were performed hypothesizing its employ in mudtherapy.
Objectives: Surface energy of natural ETM and its maturation process were monitored by TVS mud index, a tensiometric marker for the determination of the quality of a thermal mud²⁾. The aim of this work was to determine the quality of Brenta’s silt-clay by tensiometric approach introducing it in the field of thermalism.
Materials and Methods: Brenta’s silt-clayey (ie Brenta Ker) samples were collected from EGAP’s gravel pit, undergone at maturation process for 6 weeks employing thermal water, investigated using DSA10-Kruss tensiometer with diiodomethane, PFPE, glycerine as liquid tests.
  Tensiometric characterizations were performed by measurement of contact angles (deg) of different liquid tests and their conversion in surface energy (mN/m) by Owens mathematical model ³⁾. TVS mud index levels were determined trough the measurements of contact angles of PFPE ⁴⁾ by Perfluoropolyether Contact Angle Measurement Method (PCAM) for maturation process (mN/m eq./weeks) and speed (m*Nm^-1/h) evaluations.
Results: The correlation degree between ETM XRF elements data (ppm) and those of Brenta’s silt-clay (ppm) was satisfactory (R2=0.82) confirming the common origin of two kind of matrices. Considering 6 weeks of maturation, surface energy profile of Brenta’s silt-clay, expressed as dispersed component (DC) and polar component (PC), showed respectively 17.84 mN/m and 32.04 mN/m with coefficients of variations (CV%) around 22.43% and 14.29%. TVS mud index levels monitored during maturation process showed a clear decrease in the time (t0=84.02.5 mN/m eq, t1=71.01.9 mN/m eq., t2=79.80.7 mN/m eq., t3=72.63.1 mN/m eq., t4=61.22.6 mN/m eq., t5=65.12.1 mN/m eq., t6=58.81.6 mN/m eq.) underlined by the decrease of maturation speed monitored for 60 days and expressed as DC per hour (t48=0.08 m*Nm^-1/h, t120=0.03 m*Nm^-1/h, t144=0.04 m*Nm^-1/h, t384= 0.02 m*Nm^-1/h, t1416=0.005 m*Nm^-1/h).
Conclusions: Tensiometric investigations by TVS modelling and maturation speed evaluations confirmed the suitability of Brenta’s silt-clay to be employed in thermal field opening new perspectives in mudtherapy.

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  Six controlled clinical trials exist evaluating the effect of therapeutic radon exposure in inflammatory and degenerative rheumatic diseases applying radon by head-out radon water immersion or exposure in galleries with a high concentration of radon. Radon is taken up by inhalation or transcutaneous resorption, which may be enhanced by concomitant heat or CO₂. In these controlled clinical trials evaluating patients with osteoarthritis, degenerative spinal disorders, rheumatoid arthritis and ankylosing spondylitis, pain, mobility, drug use, daily life activities and patient assessment were positively influenced by radon treatment in baths or galleries. The difference between radon and control therapy was most striking several months after the end of treatment, indicating long-lasting changes in disease processes. Summarizingly, several clinical trials confirm the clinical experience that radon exposure can be beneficial for patients suffering from pain due to rheumatic diseases.

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  A large number of patients are treated in various countries with the traditional radon spa therapy. Adequate oxygen stress induced by radon inhalation activates chemical biological protective functions, such as induction of the synthesis of superoxide dismutase (SOD) and glutathione peroxidase. We previously reported that radon inhalation elevated antioxidant enzymes in patients with bronchial asthma and osteoarthritis ^{1), 2)}.
Objectives: Although many clinical studies have been reported, the reason why radon inhalation results in positive effects is still unclear. To elucidate the probability that activation of chemical biological protective functions alleviates various oxidation injuries, we studied the mechanisms of the effects of radon using small animals.
Methods: To examine whether radon inhalation activates antioxidative functions in mice, we developed a new facility for exposing small animals to radon and examined SOD activity, which is an antioxidative enzyme, in plasma, liver, pancreas, heart, thymus, kidney, brain, small intestine, lung, and stomach of mice. Mice were exposed to radon at a concentration of 250, 500, 1000, 2000, or 4000 Bq/m3 for 0.5, 1, 2, 4, or 8 days.
Results: It was shown that continuous exposure to radon increases SOD activity in most organs of mouse. In addition, our data suggested some new indications for radon treatment³⁾. Next, we assessed whether radon inhalation provided protection from carbon tetrachloride (CCl₄)-induced hepatic and renal damage in mice. Results showed that radon inhalation inhibited CCl₄-induced hepatic and renal damage in mice due to activation of antioxidative functions in liver and kidney⁴⁾. Although hepatic and renal damage are not the main indication for radon therapy, radon inhalation mitigates liver and kidney damage due to activation of antioxidative functions in liver and kidney. This antioxidative effect against CCl₄-induced hepatopathy is comparable to treatment with ascorbic acid (vitamin C) at a dose of 500 mg/kg weight or α-tocopherol (vitamin E) treatment at a dose of 300 mg/kg weight and is due to activation of antioxidative functions⁵⁾. We also suggested radon inhalation inhibits streptozotocin (STZ)-induced type I diabetes in mice due to activation of antioxidative functions in pancreas.
Conclusion: Thus, radon inhalation very likely activates the defense systems in the body, and therefore, contributes to preventing or reducing reactive oxygen species (ROS)-related injuries, which are thought to involve peroxidation.

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1.　What is radon
  Radon which belongs in the rare gases, is the main element of the radioactive hot spring. As radon is chemically inert, it dose not make any complex with other chemical component present in hot and mineral spring water.
  There are three kinds of radioactive radon gases in nature, even though the word radon(Rn) often means ²²²Rn. The two others are thoron(²²⁰Rn) and actinon (²¹⁹Rn) and all of the three are decay products of the natural radioactive chains of Uranium, Thorium and Actinium. Since the half-life of ²¹⁹Rn is too short (4.0 seconds) and there has been little study done on it.
  Radon research is presently being performed in environmental science, geochemical science, medical science, physics, biology and technology with many other applications.
2.　Japanese radioactive hot spring
  The Japanese Hot Spring Law defines the radon concentration in hot and mineral spring water as follows.
  Radon (Rn): 20 x 10-10 Ci/1(74 Bq/l) or over : The concentration for distinguishing mineral spring water from common waters.
  Radon (Rn): 30 x 10-10 Ci/l(111 Bq/l) or over: Therapeutic spring waters containing specific minerals (radioactive hot spring)
  However, mineral springs for medical care are not covered by the Japanese Hot Spring Law, but are considered to be the springs that are expected to have a healing effect in view of experience acquired through the medical science on hot springs.
  The hot and mineral springs distribution map of Japan indicates that the radioactive springs constitute about 8% of the total number of springs. It is well known that the hot spring phenomenon is closely related to the volcanic activity. Hot springs in the volcanic country of Japan are distributed all over the country, while so-called radioactive springs of high radon concentration are mainly distributed in the western half of the Honshu island. In Hiroshima prefecture where the largest number of springs are located, 89.1% of the springs are radioactive springs. Most of the springs in Hiroshima prefecture are cold mineral springs flowing out in the granite areas, mainly from the matrixes consisting of Hiroshima granite.
  The yield of the radioactive springs in Japan, is 1/2〜l/3 of that of the remaining types of springs and are neutral or weakly alkaline, consisting mainly of simple cold mineral springs including almost no soluble chemical components other than radon.
3.　Effects of radon
  The human body is made up of approximately 60 trillion cells, and the number of cells is known to decline with age. Recent research results show that radon bathing helps reactivate cellular function, thus helping ease symptoms of chronic illnesses and aging.
  Radon decays continuously until final stable element, Lead(Pb), producing many alpha and beta rays. When radon and its daughters decay, a very strong ionization effect occurs that strongly reboots the body cells function, as a result reactivating body organs as well and raising the physical homeostatic level thus the body system to its original normal healthy state.

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Objectives: Radon (²²²Rn) is a noble gas found in the water of hot spring spas (“onsen”). In Japan, the Hot Springs Law and the Guideline of Analytical Methods of Mineral Springs (revised) classify springs containing 74 Bq/kg of radon as “hot springs” and those with levels exceeding 111 Bq/kg as “medical springs”, also called “radioactive springs”. According to the notification article (the Nature Conservation Bureau of the Ministry of the Environment in Japan), bathing in a radioactive springs may alleviate the effects of gout, arteriosclerosis, and hypertension as well as chronic conditions such as cholecystitis, gallstones, and skin and gynecological diseases. Drinking water from these springs may treat gout, chronic digestive disorders, chronic cholecystitis, gallstones, neuralgia, muscle pain, and arthralgia. To determine exposure doses from radioactive springs, it is important to establish an easy and accurate method of measuring radon concentration in water and humid air in bathing areas.
Methods: This study measured the concentration of airborne radon using an activated charcoal detector (PICO-RAD: AccuStar Labs), desiccant (Drierite; 8 mesh of anhydrous calcium sulfate: W.A. Hammond Drierite Company, Ltd.), a liquid scintillation counter (LSC LB-5: Hitachi Aloka Medical, Ltd.), and 2,5-diphenyloxazole(DPO) + 1,4-bis (5-phenyl-2-oxazolyl) benzene(POPOP) toluene solution (Wako Pure Chemical Industries, Ltd.) were used as the liquid scintillator.
Results and Conclusions: This study evaluated radon exposure doses due to radioactive spring at a spa in Komono town, Mie prefecture. After water was piped from hot spring storage tanks into bathtubs, only 5.3-18.0% of the radon remained in the water. Two days later, only 0.25% remained, likely due to radioactive decay and increased diffusion into the air from bathing and recirculating filters. Thus, we investigated radon levels in the humid bathroom air around the radioactive hot spring and determined the total radon exposure from spa water and air. The total exposure dose was calculated assuming a two-day stay, during which customers used the bath for some number of hours. Our findings confirm the safety and efficacy of the hot spring facility. This study was supported in part by a grant from the Daido Life Welfare Foundation.

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  The aim of the lecture is to overview the single and doube blind studies related to musculoskeletal diseases. We systematically searched articles in the Pubmed, Scopus, Web of science and PEDro databeses published by blinding method, a total of 28 studies (10 double blind and 18 single blind) were identified. The randomised single or double blind studies clearly present the highest evidence, to avoid the publication bias. In balneotheray, due to technical challenges sometimes it is really diffucult to accomplish the blinding methods.

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Objectives: The purpose of this study was to investigate whether the whole body vibration (WBV) inhibits spasticity and improves motor function and walking ability in the hemiplegic legs of post-stroke patients.
Patients and Methods: This before-and-after intervention trial examined 13 post-stroke patients (11 male and 2 female; mean age, 54.3 ± 13.0 years; range, 24-72 years). The Brunnstrom Recovery Stage of the hemiplegic lower limb was stage 3 in three patients, stage 4 in 7, stage 5 in three. The modified Ashworth scale (MAS) score for the gastrocnemius muscles was 1 in one case, 1+ in 6 cases and 2 in six cases. All patients had increased muscle tonus of the affected lower limb (MAS score ≥1), and were able to walk without assistance using a T-cane or an ankle-foot orthosis. Exclusion criteria were any medical condition preventing vibratory stimulation (such as uncontrolled cardiopulmonary disease, severe joint disability and severe sensory disturbance), severe aphasia that made it impossible to follow verbal instructions, and dementia that interfered with outcome assessments. Each subjects sat on the chair with hip joint angles to approximately 90° of flexion, and with knee joint angles to 0° of extension. WBV was applied at 30 Hz (4-8 mm amplitude) for 5 min on hamstrings, gastrocnemius and soleus muscles (Figure 1). The parameters measured before and after the intervention were the MAS, the F-wave parameters as a measure of motor-neuron excitability, the active and passive range of motion (A-ROM, P-ROM) as a measure of motor function, and the 10-m walk test as a measure of walking ability.
Results: None of the subjects experienced discomfort before, during or after the intervention and all assessments were completed safely in all subjects. The MAS and F-wave parameters were significantly decreased (p < 0.05), the A-ROM and P-ROM for ankle dorsiflexion increased (p < 0.01), and the P-ROM for straight leg raising increased (p < 0.01), and walking speed improved (p < 0.01) after the 5-min intervention.
Conclusion: These findings suggest that WBV is an effective method for controlling spasticity, and improves motor function and walking ability in post-stroke patients.

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  Spinal decompression sickness including spinal cord damage is indeed a rare sickness, and in particular, there have been few reports on residual functional disorder. This case was a 39-year-old male who had been a recreational scuba diver for 13 years. While scuba diving overseas, he had suffered from decompression sickness with spinal cord involvement. As a result, imcomplete paraplegia with spasticity, sensory disturbance, neurogenic bladder and bowel disturbance occurred. Inclusive rehabilitation containing physical therapy, was provided to control the spasticity, the pain, and the improvement of the activities of daily living was thereby achieved. However, the changes of the muscle hardness, paresthesia, and hyperalgesia, and the disturbance of position and vibration sense remained. The cause of spinal decompression sickness is not clear, but a venous embolism in the spinal veins has been reported. Further observation is considered necessary.

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Objectives: Тo compare the efficacy of two 6-month exercise programs in patients with early rheumatoid arthritis (RA).
Patients and Methods: 51 patients with early RA were randomized into 3 groups. At hospital stage 15 patients underwent 10 high-intensity dynamic exercises using gym apparatus Enraf-Nonius for 45-60 min, including aerobic part (En-Cardio) and 18-20 muscle-strengthening exercises (En-Dynamic Track), 18 patients - 10 therapeutic exercises for joints for 45 min under the supervision of a trainer. At outpatient stage the exercises lasted for 6 months 3 times a week. 18 patients received only drug therapy (control). Tender and swollen joint count, pain on 100-mm visual analogue scale (VAS), erythrocyte sedimentation rate (ESR), Disease Activity Score (DAS28), Stanford Health Assessment Questionnaire (HAQ), Rheumatology Assessment Patient Index Data (RAPID3), the average powers of knee extension and ankle flexion by EN-TreeM movement analysis were evaluated at baseline and at 6 months.
Results: After 6 months in the both exercise groups there were statistically significant differences from the control group in most parameters (p<0.05) (table). Efficacy of the intensive gym exercises was higher than the therapeutic exercises by tender joint count, HAQ, RAPID3 (p<0.05). After 6 months in the gym group tender joint count decreased by 62.0%, swollen joint count - by 56.3%, ESR - by 54.8%, pain - by 60.7%, DAS28 - by 0.99±0.14, HAQ - by 0.91±0.33, RAPID3 - by 5.22±1.25, the extension power of a weaker knee joint increased by 74.7%, the flexion power of a more affected ankle joint - by 71.8% (р<0.01). Adherence to the regular therapeutic exercises for 6 months was better (77.8%) then to the gym exercises (60.0%). Predictors of the regular high-intensity gym exercises were the young age (under 40 years) and the very early stage of RA. Most patients, who regularly did exercises, had low disease activity (66.7% in the gym group and 57.1% in the therapeutic exercises group vs 36.7% in the control group, р<0.05).
Conclusion: The both exercise programs increase functional status, quality of life and power of motion without detrimental effect on disease activity. Gym exercises should be recommended to young RA patients with the short duration of the disease.

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  Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disorder of unknown etiology. It is characterized by symmetric, polyarticular pain, swelling, morning stiffness, and fatigue. RA has a variable course, often with periods of exacerbations and, less frequently, true remissions. Outcomes are also variable, ranging from the rarely seen remitting disease to severe disease that brings disability and in some patients premature death. Without treatment, the majority of patients will experience progressive joint damage and, in some patients, this results in significant disability within just a few years. Improvement in health related quality of life is one of the most important goals in the management of rheumatoid arthritis and therefore must be pursued as a crucial aim in clinical practice. This paper draws from 49 qualitative interviews conducted with RA patients, before starting a program of Spa Therapy and aims to get an overview of their main RA related difficulties, worries, and overall understanding of quality of life. Information on the patients’ physical function was also obtained by means of the Stanford Health Assessment Questionnaire Disability Index (HAQ). Patients present a mean HAQ score of 1.42 (SD=0.69). Main findings from the interviews highlight the importance given to being autonomous and feeling independent and healthy. In addition, underlying psychological problems (e.g. depressive signs; coping with progressive dependence) and concerns with social relationships (e.g. perceived support, loneliness) emerged as significant facets of living with the disease. Despite different treatments, RA still has many deleterious consequences which from the patients’ perspective include, among other, persistent pain, functional disability, fatigue, and depression. Along with treating RA signs and associated medical evolution, medical staff should consider and deeply understand the patients’ needs, expectations and main perceived determinants of their quality of life.

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Objective: Objective of this review is to summarize the currently available information on possible chondroprotective effects of mineral waters or mineral components on chondrocyte or cartilage cultures.
Methodology: We conducted a search of the literature by PubMed and Scopus (the period examined was 1980-2013) using the terms “chondrocyte” and/or “cartilage” in combination with ”mineral water”, “hydrogen sulphide”, “sulphur hydrogen”.
Results: A chondroprotective role of mineral water or mineral components was demonstrated by some pilot studies in chondrocyte cultures. Burguera¹⁾ studied the activity of hydrogen sulphide (H₂S) in human osteoarthritic (OA) chondrocytes stimulated with Interleukin (IL)-1β. They analyzed the effects of different concentrations of a fast (NaHS) or a slow (GYY4137) release H₂S donor demonstrating a significant reduction of Nitric Oxide (NO), Prostaglandin(PG)-E₂, and Reactive Oxygen Species (ROS) levels in culture medium and of inducible Nitric Oxide Synthase (iNOS) gene expression, induced by IL-1β. These data were confirmed by Li²⁾ in normal human chondrocytes stimulated by Lipopolysaccharide(LPS). GYY4137 decreased LPS-induced production of NO, PGE₂, Tumor Necrosis Factor (TNF)-α and IL-6, reduced the levels and catalytic activity of iNOS and of Cyclooxygenase-2 (COX-2) and reduced LPS-induced NF-kB activation. Furthermore GYY4137 showed a strong inhibition on oxidative stress-induced cell death³⁾. The incubation of chondrocytes cell line C-28/I2 with another H₂S donor, Natrium Hydrogen Sulphide (NaHS), proved that constitutive as well as IL-1β-induced IL-6 and IL-8 expression was partially and transiently blocked by the NaHS⁴⁾. Fioravanti studied the chondroprotective role of highly mineralized water, strongly acidic sulfate, rich in calcium, magnesium and iron [Vetriolo’s thermal water (VW)] in human OA chondrocytes cultivated with or without IL-1β⁵⁾. For this purpose chondrocytes were cultivated in Deionized Water (DW) (DW-DMEM, controls), or in one of three different VW-DMEM media, in which DW had been totally (100%) or in part (50% or 25%) substituted with VW. The results showed that VW alone at 25% or 50% concentration did not affect the viability of cultured chondrocytes, and determined a significant survival recovery rate in cultures stimulated with IL-1β. NO levels were low both in DW-DMEM cultures and in those reconstituted with 25% or 50% of VW, and were significantly increased by IL-1β. VW at 25% or 50% concentration significantly reduced the NO production induced by IL-1β. The data of NO levels were confirmed by the immunocytochemistry assay for iNOS. Furthermore, the authors demonstrated a protective effect of VW at 25% or 50% concentration on IL-1β-induced apoptosis.
Conclusions: Presented data are stimulating, but we don’t ignore the existence of a complex series of problems and limitations. One of the critical points is the controversial problem of the absorption of the minerals dissolved in mineral waters, furthermore, extrapolation of in vitro results to in vivo should be undertaken with caution.
  Further studies are needed in vitro to confirm these preliminary findings.

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Background: Although crenobalneotherapy is used commonly for the treatment of knee osteoarthritis, scientific evidence from our previous systematic review on its efficacy was not strong enough.
Objective: To conduct an update of a previous systematic review by analyzing each component of crenobalneotherapy separately for knee osteoarthritis.
Data sources: A computerized MEDLINE literature search (1966 to October 2013) was performed and personal data and references were added. Studies that compared crenobalneotherapy to any other intervention or to no intervention were selected.
Study eligibility criteria
  Comparative studies published in English or French, evaluating one of the components of crenobalneotherapy (use of mineral water, massages, showers, baths, mud packs and/or water exercises) on patient with knee osteoarthritis were selected.
Data collection and analysis: A checklist was used to assess the internal validity, external validity and the quality of statistical analyses. We analyzed several components of crenobalneotherapy separately. We also analyzed the effect of crenobalneotherapy on 4 types of judgment criteria, pain, function, stiffness and quality of life.
Findings & conclusion: Crenobalneotherapy appears to improve pain, function, stiffness and quality of life in knee or hip osteoarthritis patients. The efficacy of multiple mineral interventions, as a whole, including water exercise, has a high level of evidence, but, when analyzed for each component the efficacy is not very well validated except for water exercise and heat application. Additional studies with higher methodological quality and larger sample sizes are needed.

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Objectives: In medical spas different spa therapy courses are offered for treating knee osteoarthritis (OA). They contain approximately 10 daily sessions of 2-3 different treatments. During the last two decades, the length of the spa therapy time in Estonia has decreased from 12 days mainly to 6 days due to the changes in the economic situation. Spa therapy courses contain different treatments: massages, thermotherapies, kinesitherapies etc. Last research (Vaht et al. 2008) focused on the effect of 6-days spa therapy course in general. At the beginning and end of spa treatment HAQ-DI, VAS and Lequesne Index were used to assess the clinical status. There were no significant differences between the results of 6- and 12-day spa therapy courses. They both had positive effects by reducing pain and improving clinical status in patients suffering from OA. This study focused on mud therapy and the aim is to compare the therapeutic effect of different spa therapy courses in knee OA.
Materials and methods: 374 patients with knee OA participated voluntarily in this controlled follow-up study, which included different medical spas of Estonia: Spa Hotel Laine, Värska Spa Hotel, Tervis Medical Spa Hotel, Fra Mare Thalasso Spa. Participants fulfilled the criteria of the American College of Rheumatology (ACR) and were at the age between 47-83. The patients with total knee prosthesis, and those who had received thermotherapy in the past three months or had started using analgesics or antidepressants in the past 2 weeks, were excluded.
  The patients were allocated to the groups in order of their admittance:
I - local mud application (40-42°C, 15-20 min, n = 52) or mud bath (41-43°C, 10 min, n = 74); massage therapy (25 min) and kinesitherapy (30 min).
II - herbal bath (37-39°C, 10 min, ) and local mud application (n = 56) or mineral water bath and mud bath (n = 82) and massage.
III - control group - herbal bath (n = 32) or mineral water bath (n = 78), massage therapy and kinesitherapy.
  All therapies were administered once a day and six times a week. All patients were evaluated before and after 6 days of spa treatments and follow-up after 10 weeks of spa treatments (VAS, HAQ-DI, Lequesne Index). Data were analysed using SPSS statistical software.
Results: After 6 days, treatment of all packages reduced pain and diminished the value of Lequesne Index. The follow-up period gave better results for the package where mineral water bath, mud bath and massage therapy were used.
Conclusions: 6-day spa therapy has a good result in the treatment of knee OA reducing pain and improving the quality of life. Better results are achieved when spa therapy course contains two thermal therapies daily in the II group. This work was supported by the Regional Competence Centre Development programme, European Regional Development Fund.

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Objective: To assess both the short-term and the long-term effectiveness of spa therapy in patients with primary knee osteoarthritis (OA) in a prospective, randomized, single blind, controlled trial.
Materials and Methods: 103 outpatients with OA of the knee according to the ACR criteria (1) were enrolled. Patients were randomized 1 : 1 and allocated into two groups: 53 patients (Group A) received in addition to usual treatment (exercise, NSAIDs and/or analgesics, established SYSADOAs) a combination of daily local mud-packs applied on both knees for 20 min at an initial temperature of 45°C and bicarbonate-sulphate-calcic mineral bath water at 38°C for 15 min, from the spa centre of Chianciano Terme (Siena, Italy) for 12 applications carried out over a period of 2 weeks. 50 patients (Group B, controls) continued routine ambulatory care. Clinical assessments were performed at basal time after 2 weeks, after 3, 6, 9 and 12 months - end of the study. The primary outcome criteria were the change from baseline to month 12 in WOMAC - Total Pain Score (W-TPS) (range 0-20)* and in WOMAC - Total Physical Function Score (W-TPFS) (range 0-68)* scored by a 5-point Likert scale. A set of secondary outcomes was also assessed such as WOMAC Total Stiffness Score (W-TSS), Physical Component Summary (PCS) and Mental Component Summary (MCS) of SF-12 (ranges 0-100) and consumption of analgesic medications (paracetamol and/or NSAIDs).
Results: Ten patients (9.5%) withdrew from the study: 2 in the spa-group and 8 (16%) in the control group. The assessment of pain showed a very significant improvement (p<0.001) in patients treated with mud-packs until 6 months and a less significant reduction (p<0.05) after 9 and 12 months. The control group showed a significant improvement after 2 weeks and 3 months, however this improvement is less expressed than in group A.
  The differences between the two groups were significant already from 2 weeks and lasted during the follow-up.
  A similar trend was observed for the WOMAC - Physical Function in the group A, group B showed a significant worsening after 6 months persisting throughout the follow-up.
  The results obtained from the quality of life, SF-12 survey showed a significant improvement (p<0.001) in Physical Component, persisting throughout the follow-up period in group A. No significant modifications were found in group B during the study period.
  On the contrary, significant improvement of the Mental Component Summary of SF-12 was shown at the end of the therapy in group A, but no significant differences were observed in the other time of the follow-up.
  These effect on pain and function were also confirmed by the observed reduction of symptomatic drugs consumption. Tolerability of spa therapy seemed to be good, with light and transitory side effects.
Conclusions: In conclusion our results, in keeping with other studies (2, 3) confirm that the beneficial effects of mud-bath therapy in patients with knee OA last over time, with significant reduction on the painful symptomatology and a significant improvement on functional capacities and on quality of life. Spa therapy can represent a useful backup to pharmacological treatment of knee OA or a valid alternative for patients who do not tolerate pharmacological treatments.

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Background: The pathogeneses of fibromyalgia syndrome (FMS) are related with the living way of a patient, that holds biopsychosocial-existential problems. Especially existential problems are more essential; such patients are sometimes in existential vacuum. It is impossible to care the patients by onlharmacotherapy; that needs psychotherapy and physical therapy. Logotherapy and existential analysis (LTEA) was established by Prof. Viktor Frankl to save such patients, that is one of the experimental psychotherapy. Balneotherapy (BT) is popular all around the world to cure stressful patients.
Objective: We have developed Balneo-logotherapy (BLT) for patients with FMS by adding LTEA to the BT, which mainly consists of treatment carried out by taking bathes at a hot spring, a non-ordinary place. We also determined the prognosis one year after the therapy.
Method of BLT: After enough motivation and the informed consent, a patient begins BLT program. The mean duration of the therapy was 4.5±1.2 weeks. During the period from the start of the BLT until the time the patient was relieved of Yuatari phenomenon (thermal crisis, bath reaction, YP), the patient was directed to do nothing. Therapist should pay attention to help the patient to overcome YP. After this period, the patient was given free time to do things such as taking a walk. Throughout the period of BLT, patients should write in the simple diary every day and record what they became aware concerning the body and the mind.
Subjects and methods: Subjects were 65 patients with FMS (42.0 yrs±11.5, Male: Female = 24:41). Based on pathogenesis, FMS patients were classified into two groups: psychosomatic (PSD) Type (n=30) and PTSD Type (n=35). PSD type was mainly caused by loss of bodily sense (alexithymia) and hyper-adaptation. PTSD Type was mainly caused by trauma such as ill-treatment and war experience. The relationship between having YP or not and the prognosis was also determined.
Results: Overall recurrence rate was 30.8%. Recurrence rates for each type were: 23.3% for PSD Type FMS, and 37.1% for PTSD Type. Incidence of YP occurrence was: 80.0% for all cases, 86.7% for PSD Type and 74.3% for PTSD Type. The more severe YP, the better the prognosis (p<0.05). One year after the therapy, cases without recurrence accounted for 69.2% of all the cases. In PSD Type, recurrence was not seen in 73.3%. In PTSD Type, recurrence was not seen in 65.7%. Recurrence rate was lower for the group of patients with development of YP.
Discussion: Therapeutic self is most important; to create interpersonal communication to tune in the patient to get aware of intrapersonal communication (according to biopsychosocial-existential model) of the patient. Patient’s psychological movements were; Dependency ⇒ Awareness ⇒ Autonomy ⇒ Reset of the mind (through YP and ASC) ⇒ Intervention by the therapist to make change in behavior through the awareness of his own meaning of life. In this process, occurrence of YP is meaningful. A hot spa is a very suitable place to perform psychotherapy like logotherapy.

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Objectives: The study was conducted from 10.11.2012 - 20.03. 2013 aimed both to research and analyze tolerance of mineral water VALCELE and the therapeutic effects of the water.
  At the same time we aimed to identify potential clinical manifestations or adverse effects induced by the ingestion of this specific type of mineral water.
Material and method: The study included 87 patients. Following informed consent they received water, used in internal cure.
  Patients in the study had various musculoskeletal suffering, being hospitalized for rehabilitation program for rheumatic diseases - coxarthrosis and gonarthrosis, disco-vertebral sufferings, post trauma, a small number of patients with stroke and patients with manifestations of dysfunctionality of the reno-urinary tract.
  There were administered to each patient 2 liters of bottled water per day ad libitum, depending on the condition and needs of hydration.
  We followed the presence of specific or non-specific digestive symptoms, urinary flow rate, urinating dynamics and biological dynamics for key blood parameters (hemoleucogram, ESR, glucose, urea, creatinine, SGPT and SGOT, uric acid, electrolytes) and urine.
  Following ingestion of mineral water "VALCELE" during two weeks of hospitalization in the IIIrd Rehabilitation Clinic of National Institute of Rehabilitation, there were not registered the emergence or exacerbation of clinical symptoms digestive type (gastrointestinal tract, hepatobiliary activity) urinary, metabolic or electrolyte type.
Conclusions: During internal cure with mineral water “VALCELE” has been found satisfactory water tolerance, correction of some digestive symptoms or functional disorders (heartburn, esophageal reflux, constipation, flatulence or feeling distended abdomen) and a part of patients with significant variations in the level improvement of glucose has been found its dynamics.
  Clinical trial results conducted on a group of patients (87) showed favorable tolerance, improvement of clinical and functional digestive and urinary symptoms in patients with associated locomotory diseases.

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  Scientifically, healthy aging requires long-term complex and meaningful processes that will empower aging people to make healthy choices. Our genes¹⁾ put us on the path of aging but they become inter-related with: gender, age-related non-communicable diseases, environments, social participation and support²⁾, cultural fulfillment, healthy eating, injury prevention, physical activities, financial abilities, optimism for the future and tobacco cessation. The United Nations general assembly in New York (2011) along with the W.H.O. focused on four non communicable conditions, that is: 1. Cardiovascular disease 2. Diabetes 3. Cancer and 4. Chronic Respiratory Diseases. These conditions are responsible for most premature mortalities. The other focus was on four life-style risk factors, that is: 1. Smoking 2. Heavy and harmful alcohol use 3. Lack of physical activity and 4. High salt, high fat diets. Environmental conditions play a major role in neurodegenerative processes. Recent research works have shown that gene changes occur through epigenesis³⁾ due to pathological environmental conditions. The underlying mechanism of epigenesis thus involves noninterpreted genes induced by environmentally modified gene expression without altering DNA sequences³⁾. People all over the world are living longer and aging at a faster rate. Hence, protective factors which promote healthy living are a priority. Therefore creating a beneficial, physiological, and scientific pathway becomes vital for healthy aging. This paper will describe the beneficial, physiological and scientific pathway for healthy aging so that aging brings pleasure and enjoyment in life, rather than discontent and pain.

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  French balneotherapy is highly dependent on public regulations and finance. State and public bodies have a major say on cares delivered, in both nature and number, on required qualifications of therapists, on a fixed 3-week’s duration, on hygiene and safety. At the same time, public financing of cares is by far more important than the contribution of complementary private health insurances and out-of-pocket payments by the patient.
  Some 10 years ago, the National Health Insurance Fund openly stated that hypothesized health benefits of spa therapy were no longer good enough to keep the subsidizing of thermal treatments. Clinical research with flawless methodology had to be organized to prove thermalism has a true medical interest.
  Years later the challenge has been met and fewer opponents question any longer the virtues of hydrotherapy. The actual medical benefit of spa treatments is now well established in such fields as generalized anxiety disorders, knee osteoarthritis, obesity and overweight, post-breast cancer rehabilitation, healthy ageing, ...
  This financial effort of more than 10 million euros proved to be fruitful as the National Health Insurance Fund recently renewed the subsidyzing of thermal treatments.
  However, in the wake of spiralling health costs putting a strain on public spending, a new requirement is set on spa center operators. Nowadays, they also have to prove that balneotherapy is cost-efficient in comparison with other therapies. The yet to be proved economic relevance of spa therapy as well as new expectations are set to bring about a dramatic shake-up by which alongside the traditional treatment of chronic diseases, spa companies will have to address new fields of competences, such as prevention, rehabilitation, quitting of addictions, postponing of age-associated loss of autonomy, etc.

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  Heat shock proteins (HSPs) are present in all organisms from E. coli to humans and have been preserved very well over species. HSPs are then found to be induced by various types of stress, not only by heat stress, and repair the stress-induced misfolded proteins, thus protecting the body from stress. HSPs come in various sizes according to their molecular weights, of which HSP70 (70 kDa) is especially well known for being induced by heat stress. HSP70 is efficiently induced by mild hyperthermia and has the important physiologic function of biophylaxis action (protection from stresses), an immunoenhancing effect (activation of NK cells), and a molecular chaperone action (folding of proteins).
  We confirmed that HSP70 was induced by mild hyperthermic living (Kaon Seikatsu) such as bath and hot-spring, and established the HSP bathing method (that had taken a bath for 10-20 min. at 40-42°C, keep it warm for 15 minutes after that) to increase HSP70. In the HSP bathing method, HSP70 and NK cells activity increased significantly on two days after bathing. About five minutes could be shortened by using bath additive including the carbonic acid at the bathing time. The rise of the heartbeats with the step going up and down was decreased by HSP bathing, and the physical index increased significantly. In the results of the questionnaire concerning health, tiredness and muscular pain were reduced, the confusion of feelings was controlled, and the result of the improvement mentally and physically was obtained in the HSP bathing.
  On the other hand, various functions of whole body decrease with aging.
  Also, the induction of HSP70 rapidly decrease on the sixties, the senior citizen become weakening to the stresses and the immunity. In this report, it was shown about the relationship between the benefits of bathing, hot springs and HSP70.
  Japan is the best country of long life expectancy in the world, and a lot of Japanese like bath. It seems that one of the reasons of a Japanese long life is the induction of HSP70 by a certain daily activity like bathing, and this would be helpful in reducing medical expenses in the elderly.
  Moreover, there are some reports that HSP70 is related to long life. As for recent high-profile folding diseases caused by misfolded proteins, such as Alzheimer disease, and Parkinson disease, HSP70 induced by bathing can be expected to be supplementary remedy through the molecular chaperone effect of HSP70. Especially, bath and hot-spring (40-42°C) in Japan is suitable for inducing HSP70. It seems that the hot-spring hopping is the most reasonable ecological way to keep fit as the healthy method in the old age.

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  Ageing is the major biomedical challenge of our society, considered as a progressive and irreversible set of structural and functional changes for a living organism, in relation with both genes and environmental factors. The percentage of elderly people and the incidence of age-related diseases such as cardio-vascular diseases, cancer and neurodegenerative diseases are main concerns for many scientists from worldwide.
  Discovering the biological basis of ageing is one of the greatest remaining challenges for science. Findings from model organisms have revealed that ageing is a surprisingly modifiable process that can be manipulated by both genetic and environmental factors.
  One well-studied dietary manipulation of ageing is caloric restriction, which consists of restricting the food intake of organisms without triggering malnutrition and has been shown to retard ageing in model organisms. Ageing is intrinsically complex, being driven by multiple causal mechanisms. Each mechanism tends to be partially supported by data indicating that it has a role in the overall cellular and molecular pathways underlying the ageing process. Pharmacological intervention to decelerate ageing and age-related diseases is highly attractive because it would target all the population during many years. If successful, healthy ageing therapy will be more efficient in reducing mortality than to fight separately each age-related disease. Research on healthy ageing interventions has evolved along the main theories of ageing.
  Caloric restriction is already being used as a paradigm for developing compounds that mimic its life-extension effects and might therefore have therapeutic value. The potential for further advances in this field is immense; hundreds of genes in several pathways have recently emerged as regulators of ageing and caloric restriction in model organisms. Some of these genes, such as IGF1R and FOXO3, have also been associated with human longevity in genetic association studies. The parallel emergence of network approaches offers prospects to develop multitarget drugs and combinatorial therapies. Understanding how the environment modulates ageing-related genes may lead to human applications and disease therapies through diet, lifestyle, or pharmacological interventions. Unlocking the capacity to manipulate human ageing would result in unprecedented health benefits. Currently, health is understood as the removal of diseases in a defensive manner to the pathological process and with higher costs. Would be more effective the maintenance of health through prevention mechanisms identified by modern science. The study of the mechanisms by which various natural or health factors can influence the ageing process positively or negatively opens the path to design and obtain new products for the benefit of elderly people to maintain health for a long time and enabling a socially active role.
  Combining the balneotherapy with using healthy-ageing products, provides a significant advantage and represents the sustainability of the research in the context of which spas are the ideal place for the application of new treatments. Peloids and plants, used in balneotherapy, in the treatment of various rheumatic, endocrine, dermatological or gynecological diseases, because of many biological, biochemical, physical, chemical and physico-chemical actions that have in the body - represent the support for the design of new geroprotectives.

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  Increasing ratio of elderly population calls not only attention to the common health problems related to ageing and but the necessity to fight against these problems more effectively and protect the health and wellbeing of elderly population and keep them healthy as long as possible.
  Balneological treatments have been being used widely in many countries for treating certain pathologies mostly the rheumatic diseases for centuries. Recently, beyond the therapeutic effects of diverse balneotherapeutic factors and interventions, their possible preventive effects are being more intensively considered by the investigators. With the expectation that they might play a preventative role on human health in general, beneficial effects of balneotherapy, mud therapy, thalassotherapy and hydrotherapy are being increasingly investigated and documented. Even though the studies reporting these beneficial effects are not directly related to the biological and physiological processes which are predominant in the elderly population, some results reported in the publications might be considered as anti-aging effects. With this perspective a review of existing literature obtained after a comprehensive database search relieved that balneology interventions seem to attenuate a remarkable range of aging processes and phenotypes in apparently with their proven effects on attenuation of inflammatory and oxidative processes.
  The evidence on the positive effects of investigated balneological and climatological factors and interventions on the conserved aging phenotypes indicates that balneology and spa tradition could be a tool for healthy and graceful ageing.

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  In developped countries ageing is a major challenge. In France, the AFRETH promoted several studies investigating the role of balneotherapy on ageing.
  The (Multimodal Prevention Alzheimer Trial) MAPT programme is made of nutritional education, adapted physical activity, cognitive stimulation. The programme was proposed to patients of 70 years and more attending spa resorts. 35 % estimated to be concerned, 70% accepted to be included in the programme with remarkable levels of compliance (97%) and satisfaction (90%). Every year about 50,000 persons could be involved in such a programme in the French spa resorts. It has been established that 800,000 French persons complain with the disease for a global yearly coast of € 22,000 by patient (55% family supported) ; a 4 year delay on the onset of the disease could reduce by 50% the prevalence of the disease.
  In the« TCap study »we could observe that adapted physical activity education delivered in spa resorts during a spa treatment was an effective way to promote adapted physical activity in old persons.
  « Prevention consultation »: the time-span of the spa treatment could be used to perform a relevant clinical investigation to detect predictive factors of frailty and propose an accurate stategy of prevention, obtain public health useful relevant data.
  The« Parenthese study »designed a complex programme to prevent or treat the burn-out of Alzheimer patients’ care givers: i)The care givers could receive an intervention made of hydro-thermal cares aiming to the treatment of the burn-out and musculo-skeletal conditions associated with the emotional and physical burden of the care-giving; an educational intervention would help the care-givers to manage every day life of the patients ; ii) the patients, when accompanying the care-giver, could be attended in a geriatric day facility; iii) when the patients would be unable to stay in ordinary venues, accommodation could be organised in an adapted night facility (eventually with the care-giver).

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  New ways to attend patients and pathologies are developing due to scientific results and evolution of installations, techniques, aparatology at water treatment centers.
  We present a way to understand changes in mentality and patients needs. Our model proposes a combination of water centers, spa, balneary and thalassotherapy.
  The first center is a Spa with medical wellness clinic in the city of Marbella. A favorite holiday destination in Spain. Objective of clients is having a holidays plus some spa programs, mostly, relaxing with psychological concerns. Slimming programs to lose weight are indicated along with individualized diet and a complete special physical exercise program based on aquagym and some attractive sports. Beauty programs are demanded by the female public that can be completed with small non invasive aesthetical procedures. Bioenergy medicine and natural treatments based in bioelectricity, electromagnetic fields and oriental techniques.
  Programs recommended at Carratraca Balneary:
  The balneotherapy center is located in the mountains of Malaga. Climatological conditions are special and the thermal waters rich in sulfur, bicarbonate, calcium, magnesium and radon.
  Traditional programs as rheumatological treatments, rehabilitation, respiratory, dermatological and digestive by hydropinic cure, but there is a new concept: The medical offer can be extended and divided in several units:
- Fertility and women unity. Due to the excellent results as antinflamatory and endocrine stimulation.
- Cardiovascular unit: most of the patients present some risk factors as high blood pressure, diabetes, obesity, tabaquism, cholesterol…that have indication for a deeper approach.
- Healthy Aging and preventive medicine by the antioxidant properties of water and also because the genetic unit can provide early detection of potential genetic variants and information about the oncotest, cardiogenetic test, and nutritional genetic test.
- The traditional slimming programs can also be implemented by new devices for physical activity; this allows the specialists to control the type of exercise and results, not only at the stay but by distance through several on line and video applications. This way responsible specialists have a complete control of the patient over the time, fidelization, coming back to our centers for periodical controls.
- Detoxification programs.
  The third option is the thalasso therapy center, due to the benefits of sea water and climatology of the coast are ideal for several programs:
- Dermatological problems
- Osteoarticular pathologies, with physiotherapy and osteopathy specialists.
- Psychological and psychosomatic problems.
- Retreat treatments where not only physical and psychological helps are provided by spiritual approach by the specialist and group techniques and individual coaching.
- Oncological diseases, as useful to help syntomathology and quality of life.
  Finally all the compounds of sea water are part of thalassotherapy such as micro and macroorganisms. Assisted therapy with sea lions and dolphins (otaridotherapy and dolphintherapy) could be part of the programs. A complete team of professionals with psychologist, physiotherapist, special educators, doctors, nurses and animal trainers are necessary.
  Pathologies such as hyperactivity, autism, Down’s Syndrome for children can be treated. Families can participate not forgetting pathologies such as rheumatic fibromyalgia, Parkinson’s disease, multiple sclerosis and so on with scientific results published in the last years.

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  China is one of the countries abundant in hot spring resources. There are more than 4,000 hot spring resources consisting of two types: the natural hot spring and the developed hot spring. Yet, there are still many more hot spring resources to be explored and developed.
  To the end of 2013, there were around 1,000 hot spring tourism facilities or projects in operation. The yearly number of visitors to hot spring tourism facilities reached over 60,000,000 by the end of 2012.
  Although China has a long history of taking hot spring as a gift the Nature for bathing and healing, in ancient China, hot spring was never integrated into the mainstream traditional Chinese medicine (TCM), medication and practices.
  Thermalism and balneotherapy was introduced into China in 1920s.
  In 1940, Professor Chen Yanbing (1903-1996), the founder of the modern thermalism and hot spring medicine of China (thanks to Japan, Prof. Chen Yanbing used to study in medical college where he studied hot spring medicine, Keio University during 1928-1932) published a book on hot spring and medicine. It was the first book of its kind in China. In 1959, he established the first medical institute on hot spring study at the medical school of Sun Yat- Sen University, Canton province.
  Around the year of 1949, the concept of hot spring hospital (sanatorium) and thermalism was officially introduced into China from former Soviet Union and Eastern European socialist countries, and regarded as an important part of national healthcare system. The first hot spring sanatorium, now named Tanggangzi hot spring hospital, was soon opened in 1950, modeled after the hot spring sanatorium of Soviet Union.
  At its heyday of the sanatorium business in 1980s, there were more than 300 hot spring sanatoria and hospitals all over China. Under the centralized social and economical plan system during 1950s to 1980s, all the sanatoria were state-owned and state-run.
  When most of the sanatoria were falling down rapidly in mid 1990s, a new business model of hot spring so called hot spring tourism was rising and developing rapidly.
  The hot spring tourism is a new product type that consists of different kinds and sizes of indoor and outdoor hot spring pools in man-made garden or natural landscaping surroundings, and it usually combines with hotel, restaurant, massage house, theaters, KARAOKE, water park, ski field and other entertainment facilities. The main purposes that visitors come to hot springs are relaxation, social activity, entertainment and health keeping.
  Almost all the hot spring tourism facilities are commercially invested and operated, and none of them is integrated into social health system, or even commercial health system, thus they cannot be reimbursed at all.
  During 1997 to 2012, hot spring tourism developed rapidly all over the country and became the mainstay of hot spring industry in China.
  In 2009, China Hot Spring Tourism Association (CHSTA) was established under the China Tourism Association. Soon after the establishment, the association applied for joining FEMTEC and being approved in a short time, and became the vice chairman membership country of FEMTEC.
  So far, CHSTA has co-organized together with the FEMTEC through two annual congresses of FEMTEC separately held in 2008 and 2012 in China. Because of the influences of the two congresses and CHSTA’s continuing promotion, the concept of modern Thermalism especially balneotherapy and climatology has been widely accepted by scholars, professionals, investors and managers from the whole hot spring industry.

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  Humans have enjoyed forest environments for ages because of the quiet atmosphere, beautiful scenery, mild climate, pleasant aromas, and fresh, clean air.
  In Japan, since 2004, serial studies have been conducted to investigate the effects of forest environments on human health (1-13).
  We have established a new science called Forest Medicine. Forest Medicine is a new interdisciplinary science, falling under the categories of alternative medicine, environmental medicine, and preventive medicine, which encompasses the effects of forest environments on human health (11).
  It has been reported that forest environments have the following beneficial effects on human health:
  1. Increase human natural killer (NK) activity, the number of NK cells, and the intracellular levels of anti-cancer proteins in NK cells, suggesting a preventive effect on cancers (1-9, 11).
  2. Reduce blood pressure (Fig. 1), heart rate, and stress hormones, such as urinary adrenaline and noradrenaline and salivary cortisol (3, 4, 7, 10-13). Decreases of urinary adrenaline and noradrenaline contributed to the lower blood pressure (10, 11).
  3. Increase the activity of parasympathetic nerves and reduce the activity of sympathetic nerves (12-13). These effects indirectly influence the endocrine and immune systems via the psycho-neuro-endocrino-immune network (11).
  4. Increase the levels of serum adiponectin and dehydroepiandrosterone sulfate (DHEA-S). Adiponectin is a serum protein hormone specifi cally produced by adipose tissue. Studies have shown that lower than normal blood adiponectin concentrations are associated with several metabolic disorders, including obesity, type 2 diabetes mellitus, cardiovascular disease, and metabolic syndrome. Epidemiological evidence in humans suggests that DHEA-S has cardioprotective, anti-obesity, and anti-diabetic properties (10, 11).
  5. In the Profile of Mood States (POMS) test, reduce the scores for anxiety, depression, anger, fatigue, and confusion, and increase the score for vigor, showing psychological effects as well (2, 4, 7, 10, 11).
  These findings suggest that forest environments may have preventive effects on lifestyle-related diseases (9-11).

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  The human species have existed for 6-7 million years. Because over 99.99% of our evolutionary history has been spent in natural environments, it is considered that we are adaptive to nature¹⁾. However, we now live in a society that is characterized by urbanization and artificiality, despite our physiological functions still being adapted to nature.
  We conducted experiments involving 420 subjects at 35 different forests throughout Japan²⁾. Participants in natural surroundings showed the following physiological decreases compared with those in an urban control group: 12.4% decrease in cortisol level, 7.0% decrease in sympathetic nervous activity, 1.4% decrease in systolic blood pressure, and 5.8% decrease in heart rate. This suggests that stressful states can be relieved by forest therapy. In addition, parasympathetic nervous activity was enhanced by 55.0%, indicating a relaxed state. The results of similar experiments that involved walking in forests were equivalent. Li et al. demonstrated that immune function was enhanced by forest therapy in middle-aged employees who volunteered to participate in these experiments. Natural killer cell activity, an indicator of immune function, was enhanced by 56% on the second day and returned to normal levels. A significant increase of 23% was maintained for 1 month even after returning to urban life, clearly illustrating the preventive benefits of forest therapy³⁾.
  In conclusion, forest therapy had preventive benefits and facilitated physiological relaxation and immune recovery⁴⁾ (Figure 1).

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Objectives: To investigate the stress-relief and mood-change effects of extractives from the leaves of Abies sachalinensis
Methods: The essential oil was steam-distilled from the leaves of Abies sachalinensis (Todomatsu) and it was a generous gift from Japan Aroma Laboratory. Ten healthy university students (male 8, female 2) participated in the present study. After informed consent was obtained, the subject sat on a chair in a climatic chamber in which temperature and relative humidity were kept at 24°C and 50%, respectively. After ten min rest in a room, first salivary collection for cortisol, amylase and questionnaire with mood check list short form 2 (MCL-S.2) were performed. Second measurement was done after 20 min rest without aroma and then further 20 min later with aroma, third measurement was done. None felt discomfort during the experiment. Differences between the three measurements were examined using Friedman test, then if there is any significant differences, Scheffe’ test was performed.
Results and Conclusion: Regarding the emotional changes, higher “relaxation” score and lower “anxiety” score were observed in the cases with aroma (third measurement) than those without aroma (second measurement, p<0.05). “Pleasantness” score did not show significant changes. No significant differences between first and second measurements.
  Salivary stress parameter such as cortisol decreased significantly in the subjects with aroma (first vs. third, p=0.001). There was also significant difference between second and third measurements (p<0.05). Salivary amylase activity showed lower value with aroma than the resting value (first vs. third, p<0.05).
  From these findings, essential oil from the leaves of Abies sachalinensis (Todomatsu) assumed to improve mood status and have a stress-relief activity.

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Objectives: In our investigation we had a goal to present and measure the effect of the authentic outdoor medical SPA programs “Shumadian Forest hammam”, “Cigota Cross SPA golden pine forest hammam” and “Tara hammam as 75+, ageing well program” that combine phytoncides, heliotherapy, mineral springs water, zero distance food, tradition and heritage of the Serbian people, on the health of the people
Material and Methods: Our investigation was designed to measure the effects of Medical SPA programs proposed by experts team of Medical SPA Association of Serbia. One of the programs “Cigota Cross SPA Golden pine forest hammam” has been designed for the healthy women age 50 + for the promotion of healthy life style, better quality of life and preventing disease.
Program encompass several leisure activities: 1 hour walking through the wild nature (woods and fields, collecting herbs and flowers), 10 minutes of kneipp therapy, (walking through the spring water) 30 minutes of meditation below the oak three, listening birds song, 10 minutes of breath excercise, 10 minutes of folk dance therapy along with music therapy from shepards pipe, Next 30 minutes takes time to prepare and consume the brunch tailored by zero distance food protocols and according the mood food questionnaire, Natural spring water (4 x 200 ml or more) has been consumed during the program protocol. At the end the attendants were involved in selfness workshop (how to make their own herbal ball from collected herbs and flowers, for self massage during additional 30 minutes.
  The traveling by bus to the destination from the meeting point, and backward was 45-50 minutes.
  The measurement of physiological parameters was conducted by pulse oxymeter device twice before entering the bus from the meeting point and from the program destination.
  The Manchester colour wheel test and aromadiagnostic test, as nonverbal mood profile state tests were performed after the pulse oxymeter measurement
  The GHQ has been performed the day before the program, to select healthy attendants.
  The Burn out test, Life satisfaction test, stress scale, and POMS24 scale were performed the day before the program and before entering the bus after the program.
  All of 30 participants have completed the program procedure.
Results: We have calculated overall score from the tests before and after the program and we have found that there are higher scores of overall oxygen saturation after the program, lower score of Burn out tests, lower score of stress test. POMS24 test shows lower score of TMD,
  The Manchester colour wheel, and aromadiagnostic tests indicate the changes towards more balanced emotional state.
Conclusion: Our pilot investigation showed that there is measurable positive effect of authentic forest hammam medical SPA programs on the holistic health of the attendants.
Summarizing the results of our pilot investigation we did not explore them by comprehensive statistical methods. That part of investigation will be organized after more thorough investigation in our future work.

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Objectives: Mud Therapy or peloidotherapy is implemented to treat various diseases; rheumatic gynecological, dermatologic, gastrointestinal disorders etc. It is mostly used for treating rheumatic diseases in Turkey. We summarize the results of our studies that aimed to investigate the effects of mud therapy in rheumatic conditions.
Materials and Methods: In last five years (2008-2013) we conducted 6 study to investigate the beneficial effect of mud therapy in rheumatic diseases. These rheumatic conditions are knee osteoarthritis (two studies) ankylosing spondylitis, rheumatoid arthritis, hand osteoarthritis and fibromyalgia. The same mud was applied in all diseases and it is a kind of clay contains mineral water. Patients who participated to studies were recruited from among patients seeking medical advice in Outpatient Clinic of Medical Ecology and Hydroclimatology Department of Istanbul Medical Faculty. They are randomized to two groups with a computer method in each study. Research procedures were set according to property of each disease. Temperature of mud and water, treatments of control groups, number of application and application area showed differences. Outcome measures were carried out a blinded physician in certain measurement times (week 0, week 2, week 12, week 24). Results of studies were calculated and analyzed with SPSS statistical program.
Results: Ankylosing Spondilitis: Patients in Group 1(Hydrotherapy + mud therapy + home exercises) showed superior improvement on pain and Group 2(supervised exercises +home exercise) had superior development of flexibility and mobility comparing each other.
Knee osteoarthritis 1: Patients in group 1 (traditional group, had hydrotherapy + mud therapy five times per week for 2 weeks) and patients in group 2 (had hydrotherapy + mud therapy two or three times weekly for four consecutive weeks) showed similar improvements on patients with knee osteoarthritis.
Knee osteoarthritis 2: Patients in Group 1 (mineral water bath +mud therapy) and group 2 (tap water bath +mud therapy) showed statistically significant improvement on pain and WOMAC parameters besides Group 1 showed significant improvement on HAQ and SF-36 parameters at the end of therapy period and at week 12 comparing to baseline.
Fibromyalgia: Group 1 (hydrotherapy + mud therapy; consecutively) and group 2 (hydrotherapy + mud therapy; intermittently) had treatment totally same amount. The consecutive or intermittent delivery of ambulatory balneotherapy programs, both are affective in the treatment of fibromyalgia.
Hand Osteoarthritis: Group 1 (had balneotherapy with thermo mineral water) and Group 2 (had mud therapy) assessed as measuring pain, grip strength by hand dynamometer and hand functional indexes. They showed similar improvement after therapy period and it lasts 6 months in both groups.
Rheumathoid arthritis: Group 1 (mud pack therapy + conventional medication) showed superiror improvement on pain and HAQ compared to Group 2 (conventional medication). Mud therapy is an adjuvant therapy for rheumatoid artrhritis and it is an effective treatment modality to relieve pain and improve quality of life in short and middle term up to 12 weeks.
Conclusions: These results indicate that mud therapy has beneficial effects on these varius originated rheumatic diseases.

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  The study was designed to distinguish the skin response after the continuous application (three months) of two different osmotic dermatologic products: a Moisturizing Emulsion and a Facial Mask, both elaborated from Lanjarón-Capuchina mineral water« dry residue: 19.871 mg/l; chloride (Cl^-): 8.867 mg/l; sodium (Na₂⁺): 3.941 mg/l; calcium (Ca²⁺): 1.423 mg/l; magnesium (Mg²⁺): 235 mg/l; sulphate (SO₄^2-): 448 mg/l; bicarbonate (HCO₃^-): 1.732 mg/l and iron (Fe²⁺): 28 mg/l ».
Objectives: The main objective of the present study was to determine the in situ biomechanical behaviour of skin in response to the use of two dermatologic products manufactured from the sediments (saline muds) of Capuchina water. The impact of the osmotic products on the biomechanical behaviour of human skin, its pH, sebum output, barrier function and dermal density was quantified in healthy volunteers using several non-invasive approaches.
Material and Method: Experimental data were obtained in 38 healthy women aged 32 to 58 years (41.4±5.9 years) with no prior skin problems of any relevance. Written informed consent was obtained from each participant.
  Subjects were instructed to apply the moisturizing cream (Emulsión Hidratante del Balneario de Lanjarón) to the face each day after a cleaning routine in the morning and evening. Once a week, the participants applied the face mask (Máscara Facial del Balneario de Lanjarón) for 20 minutes.
  The biological response was registered by means of five non invasive techniques: Cutometer, Sebumeter, pH-meter, Reviscometer and Tewameter (TEWL).
  Formerly safety tests were performed on cosmetic.
Results: The results suggest that skin response may be modified and/or controlled, significantly reducing skin sebum (6%), TEWL (21%) and skin fatigue due to repeted suction (30%) after 15 days of treatment and stabilized after approximately 60 days.
  On the other hand, a considerable increase of total skin elasticity Ua/Uf (19%), skin resistance to maximum extension Uf (5%), and dermal redensification evaluated by means of the Reviscometer (6%) was observed.
  The pH and cutaneous viscoelasticity (Uv/Ue) determinations have resulted irrelevant and not significant.
Conclusions: We can conclude that:
1. Dermatological products prepared with Lanjarón-Capuchina sediment are safe and healthy for the skin.
2. Sebum without affecting the skin barrier function is regulated.
3. After 30 days of treatment significantly reduces transepidermal water loss. That is, the skin barrier function is enhanced.
4. Skin pH is not affected after treatment implantation.
5. There is a significant increase in dermal density, which begins to occur after a month of treatment.
6. Increased skin resistance to suction (firmness) from 15 days occurs and rises slightly to 90 days.
7. Considerably increases the elasticity of the skin, which at 30 days of treatment is estimated at 20%, remaining at these values until the end of the study.
8. By repeated skin suction, skin fatigue considerably decreased, 30% from baseline.
  Overall treatment application normalizes the amount of sebum, without greatly altering the ecology and skin barrier function, clearly favouring the biomechanical properties of the skin, especially the parameters that are modified by time.

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  The main objective of the present study was to determine the in situ biomechanical behaviour of skin in response to the use of three muds manufactured with a hyperosmotic Spring “Hervederos de Cofrentes” water, Valencia, Spain. The impact of the osmotic muds on the biomechanical behaviour of human skin, its pH, blood flow, barrier function and dermal density was quantified in healthy volunteers using several non-invasive approaches.
Materials and Method: This study was designed to assess the skin response to daily use for 10 and 20 days on volar forearms of 33 healthy volunteers aged between 18 and 40 years (23.3 ± 4.4) when applied 3 extemporaneous peloides with 0 (P0), 30 (P3) and 60 (P6) days of maturation.
  Peloids daily placed on volar forearm on panellist and variables were determined at baseline before starting treatment (day 0), and 10 and 20 days after the start of treatment. Day zero values are considered normal skin pattern.
  After a descriptive statistical analysis (mean and standard deviation), a paired Student’s t-test was used to compare data. The level of significance was set at p<0.05.
Results and Conclusions: Our results also suggest a direct relationship between the actions of the muds used and the following changes in the in vivo characteristics of human skin.
  P3 peloid gradually decreases blood flow (p<0.05) whitout affetation TEWL and there is a general increase in pH with the implementation of treatment. Increases skin firmness (p<0, 05) and elasticity (p<0.05).
  All peloids P0, P3 and P6 had an increase in dermal density (p<0.05), and was recorded reaching significance after 10 days of treatment and increased resistance towards repeated suction (reduced fatigue) after 10 days of treatment too, rising gradually up to 20 days was observed (p<0.05).
  As an overall conclusion, our findings indicate that the skin treatment proposed, P3 peloid mainly, decrease blood flow without modifying the barrier function of the skin, does not change TEWL, and clearly improves its biomechanical properties, improving skin density, skin firmness, increasing the elasticity and decreasing the fatigue of the skin, up minimally modifying the pH.
  All these circumstances make it very compatible with scaly process type psoriasis, atopic dermatitis, ichthyosis or cutaneous process that curse with an increase in skin cell turn-over.

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Objectives: To conduct a pilot study assessing the impact of a peat mud pack therapy (PMPT) protocol on patients with osteoarthritis (OA) of the knee.
Design: Quasi-experimental, repeated measures design
Patients: Ten participants with previously diagnosed bilateral OA of the knees.
Methods: Participants will receive PMPT twice a week for six weeks. Single-use peat mud packs heated to 42°C will be placed on the knees of seated participants for 20 minutes. Blood biomarkers will be collected at the beginning and end of the first, the sixth and the last treatment visits. Serum biomarkers TNF-a and hsCRP will assess changes in inflammation, and IGF-1 will be measured to assess potential chondroprotective effects. Questionnaires will be given at the screening visit, and the first, third, sixth, and last treatment visits to assess subjective levels of pain, stiffness, and mobility throughout the study.
Significance: The majority of balneotherapy studies involve a 10-14 day course of daily spa therapy. Practical limitations (e.g. participants’ busy daily schedules, a lack of affordable access, insurance coverage to safe and effective spa therapies) in America make this type of approach infeasible. The current study is designed to reflect a more limited but realistic spa therapy schedule, given American cultural norms. Results will help researchers assess compliance to the proposed therapy regimen, and may improve understanding of the therapeutic activity of peat mud.

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  The wide spectrum of therapies offered in the Dead Sea region includes the use of the natural mud, which has an unique composition reflecting the magnesium and mineral richness of the Dead Sea waters. Mud pack therapy applied to the whole body, alone, or in combination with other modalities of balneotherapy has been shown to improve many rheumatologic symptoms. The “Ahava Laboratories Ltd.” company located in the Dead Sea area, recently developed mud compresses that can be used in patients’ homes.
  The aim of the present study was to assess the efficacy of home application of such mud compresses onto the back of patients suffering from chronic low back pain (LBP).
  All patients were above age of 18 and had LBP for more than a year. The pain was localized to the region below the 12th rib and above the gluteal line. Exclusion criteria included acute back pain, inflammatory LBP, malignant disease, disk herniation, patients under narcotics, sensitivity to mud, Spa treatment in the last 6 months, scoliosis, pregnancy, infections, heart failure and osteoporosis.
  The patients were randomized into two groups: group 1 treated with mineral-rich mud compresses, and group 2 treated with mineral depleted compresses, serving as a control group. The study was double blinded, neither patients nor physicians were aware of which type of compresses a patient received. Heated mud compresses were applied 5 times a week (from Sunday to Thursday), for three consecutive weeks totaling 15 treatments; the duration of each treatment was 20 minutes.
  The study showed an improvement in patients suffering from chronic LBP self-treated at home with natural-mineral-rich mud packs. This improvement was demonstrated by the self-assessment of pain severity, based on a visual analog scale and by the score obtained through a functional questionnaire. The improvement in pain severity and functional score in the treatment group maintained one month after completing the therapy. In the control group, no improvement in the visual analog scale score was seen in any assessment, except for the Ronald & Morris score.

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Objective: The purpose of this study was to clarify the chronic effects of bathtub bathing (BB), whole body warming after bathtub bathing (BBW), and bathtub bathing with herbal extracts (BBH) on the mental condition of healthy young persons.
Subjects and Methods:
Experiment 1: Eighteen (6 male and 12 female; age: 19.6±0.7 years, mean ± SD) healthy young persons who were taking a shower habitually but not bathtub bathing participated in this study.
  From November 2012 to December 2012, subjects were randomly assigned into two groups (each 3 male, 6 female): those who had BB or 30-min BBW 14 times for 14 consecutive nights during a 2-week period. After a 2-week washout period, subjects were asked to switch their bathing conditions (a cross-over design).
Experiment 2: Twenty (8 male and 12 female; age: 21.3±1.6 years, mean ± SD) healthy young persons who were taking a shower habitually but not bathtub bathing participated in this study.
  From October 2013 to November 2013, subejects (4male and 6 female) were randomly assigned to undergo BB or BBH.
  The herbal extract contained Dong dang gui (Japanese Angelica Root), Chimpi (Citrus Unshiu peel), Chamomilla recutita, and ginger extracts.
  After a 2-week washout period, subjects were asked switch to the other bathing condition (a cross-over design).
  All participants provided informed consent for participation in these studies, and these studies were approved by the Ethics Committee of the Kumamoto Health Science University.
  The subjects immersed their bodies up to the supraclavian for 10 min, in tap water adjusted to a temperature of 41 °C in their bathtub at home.
The subjects’ mental conditions were assessed using Profile of Mood States short version questionnaire.
  The differences in the effect of BB and BBW, as well as those of BB and BBH on the subjects’ mental conditions and their mental conditions pre-BB and post-BB, pre-BBW and post-BBW, pre-BBH and post-BBH were analyzed using Wilcoxon’s signed-rank sum test.
Results: The points for depression-dejection, fatigue, and confusion in those who had BBH significantly converged to the median average (50 points) compared to the points in those who had BB.
  The points for anger-hostility before BBW and BBH significantly converged to the median average (50 points) after BBW and BBH, and there were no significant differences in points before and after BB.
Conclusions: The subjects’ anger-hostility was influenced by body warming in BBW and the vasodilatory components of the herbal extracts.
  The subjects’ depression-dejection and fatigue was influenced by the fragrance and color of herbal extracts.

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Introduction: The health-related QOL is important for an index to prescribe health condition, but there is little analysis that what kind of bathing method the person whom this index has good performs. In this study, health-related QOL and habitual bathing was intended to clarify relationship, correlation.
Methods: The participants were 198 employees of a quasi-drug manufacturing company and their family members who could and cooperated in the present study. The study was conducted as a self-report survey from October 1-30, 2010, with questionnaires being distributed to and collected from subjects before and after this period. Participants were asked about their sex, age, bathing number of times in week, frequency of bath additive use in week, temperature of bathing, bathing duration, and water level when in the bath, health, and sleep quality. Health-Related Quality of Life was assessed using the Short-Form Health Survey (SF-36v2) , and self-rated health and quality of sleep were assessed using a Visual Analog Scale (VAS).
Results: When I divided it at the average age concerning a bathing method and the age, there was much frequency of bathing per week in late debut as an entertainer 45 years old or older, and under 45 years old had a short bathing time, and water level when in the bath was shallow. The shallow tendency that water level when in the bath was observed in that level in female. Relationship SF-36v2 and bathing method, it was suggested that a Social functioning significantly (p<0.01) increases so that temperature of bathing was low, a Role physical significantly (p<0.05) increases so that there was much bathing number of times in week, a General health significantly (p<0.05) increases so that there was much frequency of use of bath additives per week. Each of subjective self-rated health, quality of sleep by VAS, it was good in conjunction with frequency of use of bath additives per week.
Discussion: This study applied to an authorized company employee, and there was a limit that the external validity was weak, but was related to General health, social functioning, Role physical and bathing method. The influence of bathing habits such as full-bath bathing and the use of bath additives on a person’s physical and psychological state as found by our study can be regarded as a way of maintaining health among those in the prime of life. Because our study uses a cross-sectional design, interpretation had a limit, and it was thought that a prospective study would be necessary in future.

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Introduction: Some students take showers instead of baths for economic reasons or because they dislike cleaning the bathtub. The purpose of this study was to examine the effect of bathing routines on students’ working efficiency.
Subjects: Seventeen (six male and 11 female) healthy young students (19.6 ± 0.7 years old, mean ± SD) who habitually took showers instead of baths participated in this study. Informed consent was obtained from all the subjects and the study was approved by the Ethics Committee of Kumamoto Health Science University.
Method: Subjects were randomly assigned into two groups. The subjects in the first group (bathtub bathing [BB]) were immersed to the supraclavicular level in their home bathtub and instructed to rest for 10 minutes with the temperature regulated at 41°C. The subjects of the second group (whole-body warming after BB [BBW]) followed the same bathing protocol and then rested in a sleeping bag and sheet for 30 minutes to keep their bodies warm. Each period was carried out over 2 weeks in a cross-over design. Washout periods were 2 weeks long. The evaluation items of this study included the obstructive sleep apnea (OSA) sleep inventory MA version (OSA-MA), a questionnaire containing a visual analog scale (VAS) to judge the subjective bathing effect, profile of mood states, salivary stress marker (α-amylase), and the Purdue Pegboard test. These tests were evaluated before and after the BB sessions, BBW sessions, and washout interval for a total of four times in a 6-week period.
Result: Participants tended to report a better sleep feeling on the OSA-MA after the BB or BBW sessions than after showering. There were significantly better changes in both the BB and BBW in the VAS for bathing effect in terms of “Sense of deep sleep,” “Body fatigue,” “Light feeling of the body” than after a shower. The mean α-amylase value in the saliva of the BBW group participants was significantly lower than that after showering. The mean Purdue Pegboard test scores of both the BB and BBW sessions were significantly higher than that after the shower.
Discussion: Sleep quality seemed to be more improved after BB or BBW than after showering, perhaps due to reduced stress. Work efficiency also increased in the BB and BBW groups.

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Purpose: Our previous study compared the characteristics of middle-aged persons who regularly take hot bathtub baths with those who do not and found taking hot bathtub baths helped to have good sleep and increase self-rated health. However, few studies have focused on this habit among young people. This study therefore compared the characteristics of young persons who regularly take hot bathtub baths with those who do not and clarify the potential effects of habitual bathtub bathing on their health.
Methods: In this cross-sectional study, a self-reported questionnaire on bathtub bathing habits and general health and lifestyle was distributed to 483 university students between May and June 2013. Respondents were divided into two groups: those who took 3 or more bathtub baths per week (high-frequency group) and those who took 2 or fewer bathtub baths per week (low-frequency group). Differences between the groups were determined for sex, age, living with or apart from one’s family, quality of sleep, sense of fatigue, and self-rated health. Prior to conducting the study, the study protocol was approved by the Institutional Review Board of Daito Bunka University.
Results: We obtained 394 responses (response rate: 81.6%) and analyzed 376 valid responses. Those who answered the question on bathtub bathing habits were divided into a high-frequency group (176 persons, 47%) and a low-frequency group (200 persons, 53%). The high-frequency group (52% men, 43% women, 5% sex was unknown) had a slightly greater proportion of men than in the low-frequency group (p=0.07). The two bathing frequency groups did not significantly differ by age group(p=0.43), and the age distribution in the high-frequency group age was 51% among 18 year olds, 45% among 19 year olds, 39% among 20 year olds, 48% among 21 year olds, and 61% among 22 year olds and older. Significantly more of the high-frequency group lived with their family (70% versus 23% living alone) than the low-frequency group (p<0.001). In terms of quality of sleep, 62% of the high-frequency group and 60% of the low-frequency group reported having good sleep (p=0.72). For sense of fatigue, 27% of the high-frequency group and 23% of the low-frequency group reported they did not experience fatigue (p=0.36), and for self-rated health, 81% of the high frequency group and 76% of the low-frequency group reported they were healthy (p=0.30). While there were no significant differences between the two groups, the findings suggest that those in the high-frequency group experienced good health. Results of logistic regression analysis adjusted for living with or apart from family showed the following odds ratios (95% confidence intervals) in the high-frequency group: good quality of sleep 1.02 (0.63-1.66), no fatigue 1.37 (0.76-2.46), and self-rated health 1.61 (0.90-2.89).
Conclusion: Among university students in this study, men and persons living with their families were highly likely to take hot bathtub baths regularly. While there were no significant differences between the high and low frequency bathers, taking hot bathtub baths may marginally help to reduce fatigue and increase self-rated health.
Competing interests: The authors declare no conflicts of interest.

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Objects: Bathing is unavoidable activity in our daily life. The influence of bathing for asthma patients is yet not fully known till now. In Japanese Guideline for Asthma Prevention and Management, the vapor inhalation during bathing is counted for one of the triggering factors for asthma exacerbation, and its mechanism is thought to be due to the bronchoconstriction triggered by the stimulation of hypotonic aerosols to the airway. We conducted the observational study to investigate the situation concerning of the change of the symptoms and its degree by bathing in asthmatic patients.
Patients and methods: The questionnaire focusing on the bathing-induced symptom change and its degree, the contributing factors was made and asked to the asthmatic patients in outpatient department of our institute from January 2012 to November 2013.
Results: Total of 215 cases were recruited. Sixty cases（27.9%）experienced the appearance of the asthmatic symptom. The extent of the symptoms included 20 cases of chest discomfort (33.3%), 19 cases of cough (31.7%), and 21 cases of wheezing (35.0%). In 38 cases (63.3%) the symptoms was seen only when they had asthma exacerbation, and in 22 cases (36.7%) the symptoms appeared even their asthma status was stable. There were no relationship between asthma severity and the appearance of the bathing-induced symptoms and its degree. The triggering factors included vapor inhalation (32 cases, 53.3%), water pressure to the thorax (26 cases, 43.3%), followed by sudden change of the air temperature (16 cases, 26.7%). In 9 cases who had bating-induced asthmatic symptoms, the timing of regular inhalation of inhaled corticosteroid and long-acting beta-agonist combination was shifted from after to before bathing, and in 8 cases the appearance of the symptoms was prevented successfully. In 38 cases (17.7%), the asthmatic symptoms were improved by bathing. The vapor inhalation was the most common contributing factor (34 cases, 89.5%), followed by warming whole body (13 cases, 34.2%). In 27 cases (71.1%) the improvement of the symptoms was partial and symptoms did not disappear completely, and in 11 cases (28.9%) the wheezing disappeared completely. There was no relationship between asthma severity and improvement of the symptoms.
Conclusion: The effects of bathing to asthmatic patients widely differed from patient to patient and its etiology includes several factors. The vapor inhalation worked as triggering factor in some and as reliever in the others, thus suggested the heterogeneous nature of bronchial asthma. In the patients who suffer from appearance of the asthmatic symptoms from bathing, the preventive method such as beta-agonist pre-inhalation should be taken into consideration. Those whose symptoms are improved by bathing might be expected to respond better than the rest by hot spring therapy of asthma.

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  In Japan, sudden death in the bathroom (‘bath-related death’) occurs particularly in the elderly population in winter. Previously, we showed that bath-related death in Kagoshima Prefecture occurs at similar frequency as that in other prefectures, despite its warm environment. In this study, we performed a retrospective review of the inquest records in Kagoshima from between 2006 and 2013 in order to compare the demographic and circumstantial factors of the following 3 groups classified by the location where the death occurred: home bathroom, spa, and nursing home bathroom. The total number of the deaths was 1533 (759 males and 774 females), which corresponds to a crude mortality rate of 11.3 per 100,000 person-years. Most of the deaths occurred at home (1319; 86.0%), followed by spa (159; 10.4%), nursing home (18; 1.2%), and others (37; 2.4%). In all 3 groups, most of the deceased were over 65 years old and were found sinking in the bathtub. The greatest number of deaths occurred in the winter at home (52.6%) and at a spa (54.7%) compared to other seasons. In contrast, death occurred most frequently in the spring at nursing homes (44.4%), when unexperienced staff begin to work in Japan. There was no significant difference in gender between home and nursing home cases, whereas significant more men died at a spa (p=0.0014). Although most deaths occurred at home between 16:00 and 20:00, a time when the elderly usually take a bath in Japan (49.4%), those at a spa and nursing home occurred earlier (12:00-16:00). The most common past history of illness was hypertension in home and spa cases, and that in nursing home cases was cardiovascular disease. Cardiac events leading to tragic results may occur more frequently in people with these illnesses than in healthy individuals while bathing. A history of drinking alcohol before bathing was observed in minor populations in home and spa cases, although it is also a known risk factor for death. However, the positive rate of spa cases was higher than that of home cases (8.2% vs. 3.3%). In all 3 groups, the most common cause of death indicated on the death certificate was heart disease such as myocardial infarction and arrhythmia (about 50%), followed by drowning. Except for 10 cases in which autopsy was performed, the cause of death in most cases was determined by only external examinations. Instead of autopsy, postmortem computed tomography (PMCT) scanning was performed in 44.9% of cases from 2010 to 2013. Cases that were diagnosed as drowning based on the findings by PMCT imaging have increased in recent years. However, PMCT is inferior to autopsy in detecting intrinsic disease and in elucidating a pathophysiological mechanism leading to drowning. In order to reduce the number of bath-related deaths, it is necessary to accumulate further evidence by increasing the number of cases undergoing autopsy, and to prompt the government and society to develop protective activities not only for known risk factors for death, but also for those peculiar to the bathing location.

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Objective: It has been believed that hot spring bathing has therapeutic effect for certain life style-associated diseases. In addition, medical preventive effect of hot spring bathing to diseases has not been well known. In order to investigate preventive effect for life style associated diseases, we performed an epidemiological study about the relationship between personal habits of hot spring bathing and past history of diseases of aged population over 64 years old in Beppu city, which has the most hot spring fountainheads in the world. Beppu city also bear 10 kinds of spa of all except radioactivity hot spring.
Materials and Methods: There are about 35,000 Beppu citizens over 64 years old. We sent the questionnaires to randomly chosen 20,000 people among them, asking the personal history of hot-spring-bathing and disease-history in Nov 2012. We received 11,146 replies filled in Jan 2013.
Results: 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. The age distribution of the respondents was comparable admittably to that of all Beppu citizens registered over 64 years old. Age adjusted, hot spring user showed less rate of some diseases. The results showed that daily hot spring bathing was associated with past history of less diseases of some, such as ischemic heart disease, apoplexy, hypertension, bronchial asthma, diabetes mellitus, chronic renal disease, and depression. As for this tendency, the difference was seen among men and women (Figure 1). Moreover, the medical effect of the hot spring had the higher one where a hot spring use period is longer.
Conclusion: This observation suggests that daily hot spring bathing contributes to lessen the susceptibility of some of life style associated diseases.

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Objectives: To reveal a relationship between bathing and sleep quality making for healthy aging.
Materials and Methods: A population based self-administered mail survey was conducted for randomly selected or all independent people without long-term care needs aged 65 and over in 31 municipalities of Japan in 2010. This data is a part of the Japan Gerontological Evaluation Study (JAGES) project. Frequency of bathing using bathtub in summer and winter was asked. Logistic regression analyses were applied to estimate univariate and multivariate odds ratios of bad sleep quality by regular bathing (7 times or more per week for average of summer and winter) adjusting sex, age, equivalized household income, self-rated health, depression, working status, and region.
Results: Response rate of the mail survey was 66.3%. The number of people who made a valid answer for bathing was 18,090. Among them, 53.0% did bathing 7 times a week, 44.6% did less than 7 times, and 2.4% did more than 7 times. Odds ratios by regular bathing were shown on the tables. Most of them indicated significantly low risk for sleeping problems.
Conclusion: Regular bathing would be helpful to better sleep quality. After the survey, we are now following up the participants for incidence of long-term care needs and death.

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  Balneotherapy is defined as a group of treatment modalities using natural remedies. The term also is used to describe complex multimodal interventions for the prevention, treatment and rehabilitation of (chronic) health conditions. The use of the term rehabilitation also is dual: on one hand it is used for a health strategy to overcome disability and to improve functioning. On the other hand it is defined as a set of measures used in multidisciplinary teams. Thus, the definitions of balneotherapy and rehabilitation are different but have some overlap too. It needs to be discussed, how balneotherpy can be used for rehabilitation of chronic health conditions and what the evidence of the added value is. Secondly, the tradition of comprehensive treatments in health resorts should be analysed using the criteria of rehabilitation measures and also here the added value must be demonstrated.

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Objectives: The purposes of this study were to determine whether men and women differ in risk factors for acute myocardial infarction (AMI) during the four seasons of the year.
Materials and methods: Medical records of 2,086 (women: 693) patients hospitalized with a confirmed AMI were reviewed retrospectively from the region’s only medical center in eastern Taiwan. The onset date of 544 patients (women: 178) was in spring, 493 patients (women: 165) in summer, 474 patients (women: 155) in autumn, and 575 patients (women: 195) in winter. Risk factors of age, percentage of smoking (smoking%), percentage of diabetes (diabetes%), percentage of hypertension (hypertension%), total cholesterol, and body mass index were assessed. In each season, logistic regression model was used to calculate the odds ratio (OR) and 95% conference interval (CI) of women compared to men by risk factors.
Results: In spring, women presented significantly higher values in age (OR 1.022; 95%CI 1.012-1.031 ) and diabetes% (OR2.373；95%CI 1.554-3.625), significantly lower in smoking% (OR 0.187；95%CI 0.145-0.240). In summer, women presented significantly lower values in body mass index (OR 0.907；95%CI 0.856-0.960) and smoking% (OR 0.222; 95%CI 0.134-0.367). In autumn, women presented significantly higher values in age (OR 1.033；95%CI 1.012-1.053) and total cholesterol (OR 1.009；95%CI 1.004-1.013), significantly lower in smoking% (OR 0.168；95%CI 0.098-0.289). In winter, women presented significantly higher values in diabetes% (OR 1.845；95%CI 1.250-2.725), hypertension% (OR1.550；95%CI 1.001-2.402), and total cholesterol (OR 1.008；95%CI 1.004-1.012), significantly lower in smoking% (OR 0.188；95%CI 0.119-0.297).
Conclusion: The differences between women and men in risk factors for AMI did present seasonal variation in eastern Taiwan. This finding would provide further insight into medical climatology in preventing serious cardiovascular events.

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  Rheumatoid arthritis (RA) is a bone destructive autoimmune disease. Many patients with RA recognize fluctuations of their joint synovitis according to changes of air pressure, but the correlations between them have never been addressed in large-scale association studies. To address this point we recruited large-scale assessments of RA activity in a Japanese population, and performed an association analysis. Here, a total of 23,064 assessments of RA activity from 2,131 patients were obtained from the KURAMA (Kyoto University Rheumatoid Arthritis Management Alliance) database. Detailed correlations between air pressure and joint swelling or tenderness were analyzed separately for each of the 326 patients with more than 20 assessments to regulate intra-patient correlations. Association studies were also performed for seven consecutive days to identify the strongest correlations. Standardized multiple linear regression analysis was performed to evaluate independent influences from other meteorological factors. As a result, components of composite measures for RA disease activity revealed suggestive negative associations with air pressure. The 326 patients displayed significant negative mean correlations between air pressure and swellings or the sum of swellings and tenderness (p=0.00068 and 0.00011, respectively). Among the seven consecutive days, the most significant mean negative correlations were observed for air pressure three days before evaluations of RA synovitis (p=1.7x10^-7, 0.00027, and 8.3x10^-8, for swellings, tenderness and the sum of them, respectively). Standardized multiple linear regression analysis revealed these associations were independent from humidity and temperature. Our findings suggest that air pressure is inversely associated with synovitis in patients with RA.

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Objective: To review the related articles and consider the potential of Japanese climate and geographical features to health promotion and disease prevention in the context of health resort medicine.
Method: To summarise the studies concerning climatotherapy in the world, PubMed database was searched from 1965 to 2014. Additional references were identified from bibliographical searches of included studies.
Results: One hundred thirty-five articles were included. These articles were sorted according to the place of health resort and the objective: 1) At the Dead Sea, of maritime climate with natural sunlight and salt water, climatotherapy for psoriasis, atopic dermatitis, rheumatic diseases, vitiligo, uveitis, mycosis fungoides and hypertension; 2) At the Canary Islands, of subtropical maritime climate, climatotherapy for psoriasis, cerebral palsy and atopic dermatitis; 3) At the Alpine mountain area, of moderate- and high-altitude mountain climate, bronchial asthma, atopic eczema, chronic obstructive pulmonary disease (COPD), circulatory diseases, osteoporosis and metabolic syndrome; 4) At the North Sea, climatotherapy for bronchial asthma and atopic dermatitis; 5) At the Baltic Sea, climatotherapy for bronchial asthma, chronic bronchitis, psoriasis, pulmonary silicosis and children after rheumatic disease; 6) At the Island of Jerba in Tunisia, of the Mediterranean maritime climate, climatotherapy for fibromyalgia; 7) At the Adriatic Sea shore in Croatia, climatotherapy for bronchial asthma; 8) At the Black Sea shore, including Evpatoria health resort (Crimea), Azov Sea zone, Black Sea health resort and Sochi health resort, climatotherapy for chronic dermatoses, atherosclerosis, coronary heart disease, rheumatic heart disease, after lung resection in children and non-organized vacationers; 9) At the west coast of Caspian Sea shore, climatotherapy for cerebrovascular disorder; 10) At the mountain hospital in Kyrgyz, of high-altitude mountain climate, aplastic anaemia and idiopathic thrombocytopenic purpura; 11) At the north shore of Sea of Japan, climatotherapy for the children with oncological disease.
  In Japan, the total length of coastline is 35,558 km, and the total number of islands is 6,852. The percentage of forest area is 66.4%, moderate-altitude mountain area (250-1,000m above sea level) is 45.0% and high-altitude mountain area (1,000-3,000m) is 6.4%. Climatic region distributes from the subtropical zone to the subarctic zone. Most of the coastal area is close to the mountain area. There are many health resorts for the forest therapy, balneotherapy and thalassotherapy.
Conclusions: There would be a high potential of Japanese climate and geographical features as a health resort of climatotherapy and terrain kur to health promotion and disease prevention.

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Background/Purpose: Previous studies have suggested that environmental factors, such as weather, atmospheric temperature, humidity and seasonal change, may affect the disease activity of rheumatoid arthritis (RA). In the present study, we aimed to determine whether RA disease activity, including patient’s global assessment (PtGA), is influenced by seasonal variation, using a nationwide Japanese cohort database, NinJa (National Database of Rheumatic Diseases by iR-net in Japan).
Methods: RA patients, who were registered in NinJa, are evaluated at any point during the indicated year. We analyzed data from RA patients (n=8,726), whose PtGA, pain visual analog scale (VAS) and physician’s global assessment (PhGA) data were available in NinJa 2012. In the present study, spring was defined as from March to May, summer as from June to November, Fall as from September to November and winter as from December to February. Age, sex, disease duration, number of tender joints, swollen joints, pain VAS, PtGA, PhGA, ESR, CRP, stage, class and mHAQ were also included as explanatory variables.
Results: Univariable analysis using NinJa 2012 database revealed that PtGA, pain VAS and disease activity score (DAS)-28 were lowest during the fall months with statistical significance, which was reproducible in NinJa 2011 database analysis. On the other hand, multivariate analysis revealed that pain VAS, mHAQ and the number of swollen joints were the main determinants of PtGA, and seasonal variation was not identified as a statistically significant factor.
Conclusion: We have clearly demonstrated that PtGA was lowest in fall. Seasonal changes can thus affect RA, although to a lesser degree than pain and activity of daily living, which should be taken into account when examining RA patients to better understand their symptoms.

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Objectives: The Bulgarian Black Sea coastline is 378km long and offers many opportunities for prophylactic and rehabilitation treatments in a number of conditions of significant social impact. Of special importance is the favourable temperate continental climate, the calm and safe sea ideal for swimming, with low salinity and endless beaches. Another key factor for the development of Black Sea rehablitation and balenology is the abundance of mineral waters and therapeutic mud, which has excellent physical-chemical indicators.
  Diabetes mellitus and its complications are a source of considerable morbidity and mortality, with important medical and social implications. The aim of our study was to establish the efficacy of combined application of seawater, Pomorie therapeutic mud and lye in the diabetic polyneuropathy prophylaxis and rehabilitation.
Materials and methods: The study was carried out during the 2011 and 2012 summer seasons in 43 patients (18 male and 25 female) with diabetic polyneuropathy from Germany, Russia and Bulgaria. The average age was 62±2.15 years and the average duration of diabetes was 16±3.4 years.
  All patients underwent combined treatment with mud baths (temp 37°C, duration 15-20min, 10 applications) and 10 lye electrophoresis procedures to the lower limbs, and sea water baths.
  The visual analogue scale (VAS) was used before and after the course of treatment to objectively measure the pain and parasthesiae of the lower limbs.
Results: Following a 2 week treatment course there was significant improvement in the clinical symptoms of diabetic polyneuropathy. 90% of patients reported improvement in pain, with VAS decreasing from 4.85±0.31 to 2.75±0.24, p<0.05. There was also a decrease in lower limb parasthesiae in 95% of patients, with VAS decreasing from 5.61±0.65 to 3.26±0.31, p<0.05.
Conclusion: The clnical symptoms and quality of life of patients with diabetic polyneuropathy imroved significantly following combined treatment with Pomorie natural resources as a result of the trophic and pain-reducing properties of therapeutic mud, lye and sea water. We support the combined application of these treatments in the prevention and rehabilitation of patients with diabetic polyneuropathy.

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