1. Institut Balneologie Medizinische Klimatologie für und Medizinische Hochschule Hannover Recent Results in Experimental Balneology Chr. Gutenbrunner Univ.-Prof. Dr. med. Christoph Gutenbrunner, Institut für Balneologie und Medizinische Klimatologie in der Klinik für Physikalische Medizin und Rehabilitation der Medizinischen Hochschule Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, gutenbrunner.christoph@mh-hannover.de

2. Balneologic Science Experimental Balneology  Studies on balneologic agents or methods: - Physiologic effects (healthy subjects)  acute effects  long-term exffects (adaptation) - Clinical effects (patients with defined health conditions; ICD)  acute effects  long-term exffects (efficacy)  Studies on “complex” health resort treatments (patients with defined functional deficits; ICF) : - Short-term effects (before vs. after treatment) - Long-term-effects (e.g. 6, 12, 24 month after the treatment) Controlled trials!

3. Recent Studies Experimental Balneology  Hanover balneological research group (Institute for Balneology and Medical Climatoology, Hanover Medical School; Institute for Rehabilitation Medicine and Balneology, Bad Wildungen, Institute for Balneology and Rehabilitation Research, Bad Nenndorf) : - Effects on the peripheral nervous system  Pain perception (H 2 S)  Thermosensitivity (H 2 S, CO 2 ) - Effects on skeletal muscles (NaCl) - Mineral absorption after drinking of medicinal mineral waters (Mg) - Influence on the renal stone formation risk (HCO 3, Mg)

4. Pain Perception (Sensitivity) Experimental Balneology  Design of the Study: - Controlled study, cross-over-design  Patients: - Healthy subjects (n=17)  Intervention: - head-out water immersion, sulphuric water (20 mg/l, 36°C, 20 min, one arm excluded) - cold-camber expositions (-76°C, 3 min, one arm thermo-isolated) - rest (20 min)  Main Outcome Parameters: - pressure pain threshold (styloideus radii, bilateral) - thermal pain thresholds (forearm, bilateral)

5. Pain Perception (Sensitivity)

6. Pain Perception (Intensity) Experimental Balneology  Design of the Study: - Controlled study, cross-over-design  Patients: - Patients suffering from fibromyalgia (ACR-criteria; n=17)  Intervention: - head-out water immersion, sulphuric water (20 mg/l, 36°C, 20 min, one arm excluded) - cold-camber expositions (-76°C, 3 min, one arm thermo-isolated) - rest (20 min)  Main Outcome Parameters: - pressure pain threshold (styloideus radii, bilateral) - thermal pain thresholds (forearm, bilateral)

7. Pain Perception (Intensity)

8. Experimental Balneology  Design of the Study: - Controlled study, cross-over-design  Patients: - Patients suffering from rheumatoid arthritis (n=17)  Intervention: - head-out water immersion, sulphuric water (20 mg/l, 36°C, 20 min) - head-out water immersion, plain water (36°C, 20 min)  Main Outcome Parameter: - pain (Visual Analogue Scale) - microcirculation (laser-Doppler-flow, forearm)

9. Pain Perception (Intensity)

10. Experimental Balneology  Design of the study: - Randomised controlled study, single blind, prospective  Patients: - Patients suffering from fibromyalgia (ACR-criteria; n=32)  Setting: - serial bathing, 12 bathes within three weeks  Baths: - head-out water immersion, sulphuric water (20 mg/l, 36°C, 20 min) - head-out water immersion, plain water (36°C, 20 min)  Main outcome parameters: - Pain, other complaints, well being - Pain thresholds

11. Pain Perception (Intensity) Experimental Balneology

12. Pain Perception (Intensity) Experimental Balneology Parameter  Anfang-Ende  Anfang- Spätkontrolle Gesamteffektp = 0,003p = 0,472 Schmerzscore n. Lautenschläger p = 0,012p = 0,170 Körperliche Beschwerdenp = 0,011-- Erschöpfungsgefühlp = 0,001-- Thermische Schmerztoleranz p = 0,040p = 0,369 Druckschmerzschwellep = 0,068p = 0,203 Prospektive kontrollierte Studie; Patienten mit Fibromyalgiesyndrom; n= 19 (Studiengruppe), n = 13 (Kontrollgruppe); U1 = vor der Bäderserie, U2 = nach dem Bäderserie, U3 = 4 Monate nach der Bäderserie

13. Muscle Tension Experimental Balneology  Study design: - Controlled study in cross-over design  Patients: - 21 patients with cLBP lasting at least for 6 weeks (10 men, 11 women, age: 47,3 ± 2,9 years)  Intervention: - A single brine (6% NaCl, Solequelle Bad Münder) or tap water plain bath (36 0 C, 16 min) respectively  Outcome parameters: - IEMG activity on defined muscles (M. erector sp. cervicales et lumbales, M. trapezius, M. ext. carpi radialis, M. rect. abd.) - Pain intensity (VAS) - Subjective muscle tension (Chromatic Analogue Scale)

14. Muscle Tension Experimental Balneology

15. Muscle Tension intervals2-13-14-15-4 M. errect. spin. lumbalis ()()  ()() M. rectus abdominis **  ()()  M. ext. carpi radialis  ** **  M. trapezius pars desc.  **  ***  M. errect. spin. cervicalis  ***   Periods: 1 = Lying before the bath, 2 = During immersion, 3 = Lying after the bath, 4 = Standing before the bath, 5 = standing after the bath, Significance: * = p<0,05; ** = p<0,01; *** = p<0,001 = under water surface

16. Thermal Comfort (H 2 S) Experimental Balneology  Design of the Study: - Controlled study, cross-over-design  Patients: - Patients suffering from fibromyalgia (ACR-criteria; n=17)  Intervention: - head-out water immersion, sulphuric water (20 mg/l, 36°C, 20 min, one arm excluded) - cold-camber expositions (-76°C, 3 min, one arm thermo-isolated) - rest (20 min)  Main Outcome Parameters: - pressure pain threshold (styloideus radii, bilateral) - thermal pain thresholds (forearm, bilateral)

17. Thermal Comfort (H 2 S) Experimental Balneology

18. Thermal Comfort (CO 2 ) Experimental Balneology  Design of the study: - controlled study, cross-over-design  Patients: - healthy subjects (n=17)  Intervention: - forearm baths with CO 2 -water (16 min, 18°C, 3.500 mg CO 2 /l) - forearm bath with tap water (16 min, 18°C)  Main outcome parameters: - Microcirculation of the skin - Pressure- and thermal pain thresholds - temperature perception, local thermal comfort

19. Thermal Comfort (CO 2 ) Experimental Balneology

20. Thermal Comfort (CO 2 ) Experimental Balneology

21. Mineral Absorption Experimental Balneology  Design of the study: - Cross over-study, double blind  Patients: - Healthy subjects (n=22)  Setting: - Over-night-fasting, standardized breakfast  Intervention: - 500 ml Mg-mineral water (281 mg Mg/l) - 500 ml Mg-mineral water (120 mg Mg/l) - 500 ml low-mineralized water (8 mg Mg/l) - magnesium tablet (150 mg Mg)  main outcome parameters: - Magnesium in plasma and urine

22. Mineral Absorption

24. Experimental Balneology  Design of the study: - Cross over-study, single blind  Patients: - Healthy subjects (n=10)  Setting: - Over-night-fasting, standardised breakfast  Intervention: - 600 ml Mg mineral water (252,5 mg Mg/l) - 800 ml Mg mineral water (186,7 mg Mg/l) - magnesium tablet (150 mg Mg)  main outcome parameters: - Magnesium in plasma and urine

25. Mineral Absorption

26. Renal Stone Formation Risk Experimental Balneology  Design of the Study: - Controlled study, cross-over-design  Patients: - Patients with multi-episodic CaOx-urolithiasis (n=32)  Setting: - Everyday activities, nutrition protocol  Intervention: - 1,5 l/d bicarbonated water (2.673 mg HCO 3 /l) - 1,5 l/d low-mineralized water (98 mg HCO 3 /l)  Main Outcome Parameters: - urinary pH, magnesium- and citrate excretion - CaOx supersaturation

27. Renal Stone Formation Risk Experimental Balneology

28. Renal Stone Formation Risk Experimental Balneology

29. Renal Stone Formation Risk Experimental Balneology Super- saturation CaOx Super- saturation Uric acid Super- saturation CaPO 4 Controls Baseline3,41 ± 0,311,22 ± 0,131,33 ± 0,19 Drinking2,44 ± 0,280,70 ± 0,071,01 ± 0,15 Bicarbonate Water Baseline3,39 ± 0,341,03 ± 0,121,44 ± 0,23 Drinking2,42 ± 0,290,24 ± 0,042,01 ± 0,24 p (controls vs. bicarbonate water) 0,9580,0000,001 p (baseline vs. Drinking) Controls0,0010,0000,014 Bi- carbonate Water 0,000

30. Summary Experimental Balneology  In experimental trials relevant physiological effects of medicinal mineral waters can be shown, e.g. - elevation of thermal thresholds (H 2 S)  increase of thermal tolerance (H 2 S, CO 2 ) - good absorbability of relevant electrolytes (Mg)  In experimental trials relevant clinical effects of medicinal mineral waters can be shown, e.g. - analgetic effects (H 2 S) - Muscle relaxation (NaCl) - Reduction of the renal stone formation risk (HCO 3, Mg) Thank you!