Pr CF ROQUES LATRILLE MDPr CF ROQUES LATRILLE MDISMH General SecretaryAFRETH Scientific Committee President (Paris)Institute of Thermalism President (Dax)

Cares to the touristsCares to the tourists First aid +++ Primary cares GP

Care to the migrant returning home for Care to the migrant returning home for holidaysholidays Secondary cares (recourse advices +++)

Cares using natural therapeutic resourcesCares using natural therapeutic resources Climatotherapy Thalassotherapy Medical Balneotherapy (medical cares Medical Balneotherapy (medical cares

delivered in thermo-mineral resorts)delivered in thermo-mineral resorts) High technology cares delivered to better costsHigh technology cares delivered to better costs

Dental cares Medical Assessment Cardiac surgery Grafts, …

104 resorts, 1200 mineral springs, 500 doctors

2009 : 493 153 persons 9 073 807 days for medical treatment(Social Security pays)

490 889 days for wellnessFemale : 64 % ; male : 36 %Age : above 60 : 65 % - under 16 : 7 %Aetiology : Rheumatic conditions = 72 %Gross product of spa resorts : 1 Billion €Social security involvement (thermal

cares + doctors fees) : 290 Millions €Employed persons : 110 000

Made of Hydrothermal cares Complementary cares (medical,

paramedical, patient education, …) Resort stay▪ Climate ▪ Rest ▪ Social interactions▪ Adapted physical activities, …

With Consequences on Care delivery Scientific investigation, …

Medical benefit assessment ++++ Preclinic investigation ++ Safety studies + Specificity of thermo-mineral products +

+ Medico-economics + Other topics +

Data from papers published in Data from papers published in english speaking journals with english speaking journals with impact factorimpact factor

Rheumatic conditionsENT conditionsMetabolic diseasesHeart & vesselsSkin diseasesGynaecological disordersStress related disordersAgeing Other topics

A very prevalent condition : in France about 160 000 patients in SPA resorts are treated for KOA

Balneotherapy reduces pain and improves functional abilities (RCT) Balint Clin. Rheumatol., 2007, 26, 890; Evcik Joint Bone Spine, 2007, 74, 60; Cantarini, Rheumatol. Int., 2007, 27, 523 ; Karagülle M, Clin. Rheumatol., 2007, 26, 2063; Vaht, Compl. Ther. Clin. Pract., 2008, 14, 60 ; Odabasi, J Alt Compl Med, 2008;14:559 ; Sherman, Isr Med Asoc J, 2009;11:88 ; Fioravanti, Am J Phys Med Rehabil. 2010;89:125; Fraioli, Rheumatol Int. 2010 Epub Kiliçoglu, Rheumatol Int. 2010;30:739; Forestier, Ann Rheum Dis. 2010;69:660 ; Cecarelli, Clin Exp Rheumatol, 2010;28:250

Balneotherapy acts on cellular mechanisms Action on pro-inflammatory cytokines damaging

cartilage Ceccarelli, Clin Exp Rheumatol. 2010;28:250 :

Action on leptine and adiponectin, Fioravanti, Rheumatol Int. 2010; epub

Antioxidative, anti-inflammatory, cartilage protection of SULFUR: Benedetti, Clin Biochem, 2010, epub)

Potentializes chondroprotective drugs : Caraglia, Exp. Mol. Med., 2005, 37, 476

Action on inflammation markers and anti-oxidative status: Olah, Int J Biometeorol. 2010;54:249

Topics made with thermal muds are efficient Mahboob, J Alt Compl Med.2009;11:1239

Reviews : Balneotherapy : useful in OA of lower limb Forestier, Joint Bone Spine, 2008; Falagas ,Int J Clin Pract, 2009; 63:1068 Harzy, Clin Rheumatol. 2009;28:501

Meta-analysis : Silver evidence concerning the beneficial effects of mineral baths compared to no treatment; methodological quality of the trials was poor. Verhagen , J. Rheumatol., 2008, 35, 1118-1123

Beneficial on painful chronic spinal conditions Balogh. Forsch. Komplementarmed. Klass.

Naturheilkd., 2005, 12, 196-201 (Low back pain) Olah, Rheumatol Int., 2008, 28, 749-7562008)

(low back and neck pain) Kulisch , J Rehab Med.2009;41:73 (low back

pain)Beneficial effect on intensity of

chronic back pain of balneotherapy and spa therapy .

Pittler Rheumatology, 2008, 45, 880 (meta-analysis)

Efficiency in Rheumatoid Arthritis Codish, Rheumatol. Int., 2005, 25, 49 Franke, Rheumatol. Int., 2007, 27, 703

Ankylosing Spondylitis Codish, Isr. Med. Assoc. J., 2005, 7, 443 Yurkturan, Rheumatol. Int., 2007, 27, 703 Cozzi, Joint Bone Spine, 2007, 74, 436 and people accept to pay: Boonen, Ann.

Rheum. Dis., 2005, 64, 1650 Biological actions

H2S reduces IL6 in Fibroblats Like Synoviocytes in RA. Kloesch, Cell Biol Int. 2010;34:477

Increase in TGF beta in AS: Shehata, Wien Klin. Wochenschr., 2006, 118,266)

Clinical effects : improvement of pain and function Dönmez, Rheumatol. Int., 2005, 26, 168 Zijlstra, Rheumatology, 2005, 44, 539-546 Fioravanti, Rheumatol. Int., 2007, 27, 1157 for an acceptable cost (Zijlstra, Rheumatology, 2007, 46,

1454 De Andrade, Rheumatol. Int, 2008;29:147 Tomas-Carus, J Rehabil Med, 2008;40:248 Tomas-Carus, Rheumatology, 2009;48:1147 Improvement of respiratory symptoms :

Kesiktas, J Back Musculoskelet Rehabil. 2011;24:57 Biological actions : decrease in IL1, LTB4, PGE2 :

Ardiç, Rheumatol. Int., 2007, 27, 441EVIDENCEEVIDENCE

* strong Mc Veigh (review), Rheumatol Int, 2008;29:119* moderate Langhorst (meta-analysis) (SMD pain : -1.27 et QOL : -1.16), Rheumatology, 2009;48:1155

Recommendations : EULAR BRecommendations : EULAR B

Improvement of sinusal mucoses after surgery (SH, Fe, As water): reduction of mucoses infiltration by eosinophilic cells (Staffieri, Am J Otolaryngol, 2008;29:223)

Recovery of epithelial cells (junction sites recovery)(NaCl, Br, I water)Fenu, Journal of Alternative and Complementary Medicine,2010: 341

Sulphurous water inhalation is helpful in Upper Air Tract Chronic Infections.Salami, Int J Pediatr Otorhinolaryngol, 2008;72:1717

Overweight and obesity reeduction Reduction of 5% of body weight (4kg)

(Hanh, 2011, under press) Intestine motility speed increased

Gasbarrini, World J. Gastroenterol., 2006, 12, 2556

Reduction of post-prandial lipaemia, serum and chylomicrons triacylglycerols Schoppen, Br. J. Nutr., 2005, 94, 582

Augmentation of insulin sensitivity of post-menopausal women Schoppen, . Nutr. Hosp., 2007, 22, 538

Improvement of cutaneous trophic lesions of venous insufficiency . Carpentier, J Vasc Surg, 2009;49:163).

Improvement of gait perimeter in patients with chronic peripheric arterial disease . Fabry, Vasa. 2009;38:213)

CO2 therapy needs better quality assessment. Pagourelias, Int J Biometeorol. 2010; epub

Increase in VEGF (NO dependant capillary neo-formation in animal ischemic limb)Irie, Circulation, 2005, 111, 1523

Mineral Hydrocolloid gel as efficient and better tolerated than Trolamine in post-radic dermatitis: Ribet, Ann. Dermatol. Venereol., 2008, s1, 5)

Improvement of psoriasis by spa therapy alone Cohen, J. Dermatol. Treat., 2005, 16, 308 Or SPA therapy combined with phototherapy Schiener, Arch. Dermatol., 2007, 143, 647-649; Brockow, J. Altern. Complement. Med., 2007, 13, 725; Tabolli, Yonsei Med J.2009;50:215)

Silica muds and microalgae (blue Lagoon) improve skin barrier function (expression gene Collagene 1A1 and 1A2) (skin ageing+++). Grether Beck, Experimental Dermatology.2008;17:771)

Efficient in children atopic dermatitis. Farina, J Dermatolog Treat. 2011 Jan 22. Epub

Drinking mineral water improves the skin hydratation: Mac Marry, Skin Res. Technol., 2006, 12, 199

H2S anti-inflammatory action (psoriasis, skin cultures): Polynuclears (Rinaldi, Lab Invest,

2006;86:391), Pymphocytes (Mirandola, J Cell Physiol,

2007;213:826) Action on TNF alpha, IL6, IL8, CK16

expression in psoriasis Chiarini, . Int. J. Mol. Med., 2006, 18, 1073 Dal Pra. Int. J. Mol. Med., 2007, 19, 373

Generalized Anxiety Disorder improvement: Dubois, J Alt Compl Med. 2010;18:1

Occupational burnout improved: Blasche, Forsch Komplentmed, 2010;17:132

Positive effect on mood and stress : Toda (salivary cromogranin A . Biomed. Res., 2006, 27,

11-14 Marazziti (increase in platelet serotonin

transportation) . Prog. Neuropsychopharmacol. Biol. Psychiatry, 2007, 31, 1436-1439

Action on NO system (tetrahydrobiopterin BH4 increased) Pall Medical Hypotheses, 2009;73: 610

Corticosteroid secretion reduced Salivary Toda Arch Environ. Occup. Health, 2006, 61, 131-

137 Blood Jandova, Endocrine regulations. 2008;42:17

DHEA reduced by hot spring immersion. Jandova, Endocrine regulations. 2008;42:17. Wang, Steroids. 2009;74:945

Interest in ageing prevention (Secher, J Nutr Health Aging. 2009 ;13:797

Improvement of QOL of elder people with OA : Gaàl, Isr. Med. Assoc. J., 2008, 10, 365

Even in calcium sufficiency Alkaline Mineral Water lowers BONE RESORPTION. Wynn, Bone,2009;44:120

Water exercise program has a positive effect on bone Satus. Rotstein, J Sports Med Phys Fitness, 2008;48:352

Bathing is a potential target for disability reduction in the oldest old. Berlau, Am J Public Health. 2011;101:200

Antioxidative action : BenderArch. Med. Res., 2007, 38, 86

Anti-oxidative properties of SH mineral water drinking Benedetti, Europ J Clin Nutrition. 2009;63:106

Water rich in C02 activates parasympathic nerve . Sato, Int J Biometeorol,2009;53:25

Sulphurous mineral water decreases GADPH activity (Albertini, Food Chem Toxicol, 2008;46:3343)

Immune system maintained. Kamioka, J Epidemiol. 2009;19:2219

Cutaneous ageing prevention (Blue Lagoon)(Grether-Beck, Experimental Dermatology.2008;17:771)

Reduces the risk of recidive of uratic or oxalo-calcic urolithiasis Karagulle O, . Forsch. Komplement. Med., 2006, 13, 9

Reduces dyspeptic and irritable bowel syndrome symptoms, increases gastric output and intestine motility speed Gasbarrini, World J. Gastroenterol., 2006, 12, 2556

Gynaecology Intra-vaginal Dead sea peloid gel increases pelvic

blood output and ovarian estrogens and progesterone productionGel: Artymuk, Int J Gynaecol Obstet. 2010 Jan;108(1):72-3.

Improvement of chronic uterine inflammation (Fe++)(Zambo, Eur J Obstet Gynecol, 2008;140:252)

Basis : Comparing mineral water and/or muds to tap water or neutral muds

Mineral water bathing Improvement remains later in KOA(Balint, Clin

Rheumatol, 2007;26:890) And CLBP (Balogh, Forsch Kompl Med,

2005;12:196), Acts sooner, more and longer in CLBP patients

(Kulisch , J Rehab Med.2009;41:73 ) Mineral water bathing or mud applications

Better in patients with CLBP (Evcik,Joint Bone Spine, 2007;74:60)

Mineral muds application on KOA Better than washed muds (72% vs 33%)(Flusser, J

Clin Rheumatol,2002;8:197) Better without nylon envelopment (Odabasi, , J Alt

Compl Med,2008;14:559)

Combined spa–exercise therapy besides standard treatment with drugs and weekly group physical therapy is more effective and shows favorable cost-effectiveness and cost-utility ratios compared with standard treatment alone in patients with AS. ASTRID VAN TUBERGEN, Arthritis & Rheumatism, 2002;47:459

Spa therapy leads to a statistically significant reduction in both absenteeism and hospitalization, though it is not clear if these health benefits justify the cost of spa therapy. JONATHAN KLICKA AND THOMAS STRATMANN. Eastern Economic Journal, 2008,epub

The military service of the roman republic lasted 30 years

Balneotherapy was an essential mean to maintain the roman soldiers on duty

Cneius Pompeius (1st century BC) used to organize balneotherapy in the mineral springs of South of France and Spain

SPA therapy is a complementary but a scientific medicine

With new fields of action to challenge Based on a lot of clinical evidence

A significant number of papers (RCT +++) published in journals with impact factor

But many RCT have a low statistical power and/or other methodological flaws

And many preclinic investigations But so much is necessary

To demonstrate the medical benefit of the cares

To validate the new fields of action of balneotherapy

An international pragmatic cooperation is needed