History

Therapeutic bathing is an ancient art and probably the oldest of medical procedures. Hippocrates wrote on the application of therapeutic bath in 400 BC and how it soothed pain in the side, improved respiration, soothed the joints and skin, was diuretic, and removed heaviness of the head. It was suited for those who benefited, but could be unsuitable if applied in the wrong way. It enjoyed tremendous popularity until about 75 years ago when, along with other natural techniques, it fell out of favor as conventional medicine produced its modern successes. Since then, the large corpus of empirical wisdom has been expanded on and much scientific evidence has contributed to the advancement of balneology as a science. Many institutions are teaching hydrotherapy and balneologic techniques, and many spas have wonderful programs for people to utilize. It is not hard to imagine that the reason this art survived and improved is because it can better people’s health.

Balneotherapy’s modern day roots lie predominantly in European spas, which have some of the longest continuously running histories of any medical institution. Millions of patients flock to clinics throughout Europe and the world each year for treatment in hydrology departments under the supervision of physicians and their staffs. Such clinics provide a variety of balneotherapeutic techniques. Spa therapy is a term used for the combination of balneotherapy and other techniques usually delivered at a resort setting. The effects of spa therapy are influenced positively by the pleasure of being in a beautiful setting with the stresses of home and work removed. Medical spas are often in an area where earth’s elements are present. The pristine air, the ambient temperature, the humidity or amount of light, nourishing food, and exercise can effect a change in the spirit, mind, and body.¹⁹

Balneotherapy in Combination with Other Therapies

Many therapies work well together, such as phototherapy and mud therapy in the treatment of psoriasis. Mud pack therapy, peloidotherapy, massage, soft and osseous tissue manipulation, iontophoresis, phonophoresis, and exercise work together.²⁷ The combination of buoyancy and heat in the water make sense, for example, in underwater traction bath and massage, which have been shown to reduce the levels of analgesic consumption in patients.¹⁸ In my own experiences with patients, hydrotherapy, with and without mud in combination with other treatments, such as naturopathic manipulation, can work like nothing else to help people heal and stay healthy. A multitude of conditions can be treated with balneotherapeutic methods—pain, injury, and dermatologic and rheumatic conditions rank high.^2,19,28,29 Under the right conditions and with the right application, balneotherapy stimulates healing and speeds recovery.³⁰

Physiologic Effects

Balneotherapeutics induce direct and indirect actions on the body. The direct actions of balneotherapy take into consideration the physical actions of water on the body, such as hydrostatic pressure, buoyancy, viscosity, and frictional resistance, as well as thermal effects and the chemical and pharmacologic effects of the percutaneous absorption of the substance being used.⁴⁴ Such substances are found in hot spring waters of various types, such as carbon dioxide, hydrogen sulfide, chloride, sulfate, iron, acid, and radon. Mineral waters contain cations such as sodium, potassium, calcium, and magnesium, and anions SO₄^–, Cl^–, and HCO₃^–. The concentrations of these ions are usually significantly high (1 g/L). In spring water, levels of nitrogen compounds, such as nitrate, nitrogen dioxide,_, and nitrogen oxide, are very low and the water is free of or low in bacteria.¹⁷ Peat muds, plant preparations, and mineral-containing muds are also used. In Europe, peat bath and peloids are traditional. These applications are used in combination with exercise, aquatics, steam bath, sauna therapy, climatotherapy, physical therapy, and pharmacotherapy, among others, with important consideration being given during treatment to the chronobiologic and circadian rhythmic phases of the body.^{1,14,23,25–28}

The indirect actions of balneotherapy arise from the repeated application of therapeutic stimulation, such as climatic exposure to the elements, training effects of exercises, and social and psychological effects arising from changes in environment. These elements act as a complex stimulation in a nonspecific manner of the physiologic function of the organism’s central nervous system, autonomic nervous system, endocrine system, immune system, and so on. The result of these stimulations is a reactive response by the body, leading to activation and improvement of capacity, adaptation, and self-healing potential. In other words, balneotherapy has a normalizing effect on the body’s systems and rhythms.^*

Circadian Rhythms

Biorhythms are important in the expression of many conditions.^40,41 Sunlight, mealtimes, and seasonal changes are external cues that, together with internal cues such as blood pressure and respiration, affect the hypothalamus or master clock. This part of the brain then signals hormones, enzymes, and other substances to facilitate healing, produce cells, or cause pain and symptoms. It has been shown that different times of day affect the amount of muscle torque potential, body temperature, and clock-gene messenger RNA (mRNA) expression.⁴² A cold or hot foot bath can induce a rise in temperature of oral mucosa up to 1°C, but the extent of the oral temperature increase depends on the body’s reaction to this stimulus, which is influenced by the body’s own internal clock.¹

Conditions such as arthritis have pain with varying cycles.⁴³ It is thought that some of these cycles are in synchrony with the moon and the sun. Heart attacks, asthma, and rheumatoid arthritis joint pain are early morning diseases, so medication and treatment can be tailored for different times of day when it is significantly more helpful and less wasteful when not needed. Serum adrenocorticotropic hormone, prolactin, luteinizing hormones, and immune parameters such as plasma levels of soluble p75 tumor necrosis factor and tumor necrosis factor-α (TNF-α) vary in 24-hour rhythms in the body.³⁰ These may be affected through balneotherapy, as may melatonin production and expression.⁴⁴ Melatonin affects the organization and expression of biorhythms and is easily susceptible to oxidative stress. Symptom remission in some conditions coincides with a normalization of circadian rhythms promoted by balneotherapeutic treatment.^45–48 In a European study, the combination of carbon dioxide bath and mud bath was shown to downregulate the systolic pressure in hypertension while having a balancing effect on biological clocks.⁴⁹ A study on fibromyalgia patients, in whom altered reactivity of the hypothalamic-pituitary-adrenal axis was observed, supported the theory that mud pack therapy works in synergy with antidepressant treatment to decrease pain and improve depression. Balneotherapy can promote the body’s response systems, such as the stress response system, to achieve homeostasis.⁴⁶

History

The ancients used peat extract baths, and the antiseptic properties of peat mud were recognized in World War I when it was applied directly to wounds to prevent infection.⁵⁰ Natives used mud externally and internally. Peat has been used as a medicinal preparation in baths and peloid packs extensively in Europe for the past 200 years. This unique substance contains many chemical constituents that can interact with organic and inorganic compounds.²⁰ The scientific basis for the physical, chemical, and pharmacologic effects of peat baths has long been known, and such baths have been used extensively in balneotherapeutic applications in Europe and other parts of the world to treat rheumatic diseases, gynecologic disorders, osteoarthritis, lumbago, sciatica, skin diseases, trauma and its sequelae, and many other ailments and afflictions. The many substances in peat offer a vast possibility of medicinal cure applications.^51–61

It is important to consider the region and origin of the peat being used for medicinal purposes. Low moor peat has been shown to contain higher concentrations of nitrous substances, which are thought to contain a higher content of biologically active substances than the high moor peats or peats taken from a shallower depth. It is not just high nitrous content that makes a certain peat more medically useful, but the quality, type, and amount of the biologically active substances it contains that are the determining factors in its medicinal effect. In Germany these types of peats are now a national resource.

Skin Response

Skin is a reflex, metabolic, immune, and excretory organ. It affects the autonomic, immune, and circulatory systems and participates in the biosynthesis of not only vitamin D but also acetylcholine, histamine, and serotonin.^2,4,10,15 Significantly higher concentrations of minerals and medicaments can be attained in the epidermis with baths than with systemic flooding via the vascular system. There is percutaneous uptake of many substances by the skin but not in large amounts for most natural substances. Permeation into the dermis does occur especially for humic acids, and uptake beyond the stratum corneum is exemplified by measurable urinary excretion rates.^62,63

The primary effects of bath components take place within the skin. For instance, hydrogen sulfide acts as a trap for oxygen radicals, functioning to reduce inflammation. It is thought that the action comes from the effect of sulfur on the Langerhans cells, which play a role in immune presentation and inflammation modulation. In this way, skin responses can act as transmitter-activating helper functions. Sulfur-containing peat baths demonstrate a pain-reducing and healing effect on rheumatic and degenerative diseases. One reason may be the reduction in Langerhans cell activity in producing cytokines that results from the combination of the components within peat and thermal radiation.^*

Physiologic Effects

Peat has a structure containing micropores, which accounts for its sponge-like, water-carrying capacity and its ability to maintain either hot or cold temperatures. When applied, peat produces a gradient rise or fall in temperature, which is especially desirable in a therapeutic bath. A peat formulation bath influences neuromuscular, endocrine, and pulmonary functions, as well as kidney hemodynamics, depending on the consistency and volume of the partial or full bath.^4,10 Peat has well-documented effects, such as tissue dilatation and increases in stroke volume, metabolism, and immunologic stimulation. Peat bath may be preferable to water bath if one considers the gradient rise and fall of temperature, increased buoyancy, and prevention of heat loss during a bath and the possible positive chemical and pharmacologic effects of the constituents of peat.^60,62–65

Those who have experienced a therapeutic bath can appreciate the feelings of exhilaration and deep relaxation induced by a bath that contains an additive such as peat. The response is affected by the constituents in the water, the temperature of the bath, and the time of day the stimulus is given.⁶⁵

The patient’s genetics and physical capacity are also important. A peat bath enhances circulation significantly longer than a water bath.²¹ Microcirculatory vasodilation in the skin has been shown to increase even without hyperthermia. The peripheral and deeper arteries, such as the intrauterine vessels, have shown prolonged increased flow after peat bath. The effects of peat constituents can occur without heat, but heat increases the effect on the body.

The antirheumatic activity of thermal muds has a precise pharmacologic character. Therapy can be prescribed according to the characteristics of the mud for specific conditions.^60,62 For example, specific muds work better with phototherapy for psoriasis and atopic dermatitis. The length of time that the peat mud has undergone humification and maturation lends unique characteristics. Maturation of peat muds increases their thermoinsulating, hydration, and, importantly, biochemical characteristics. The sulfoglycolipid content of mature mud differentiates a natural remedy from a specific application with a precise pharmacologic character. These sulfoglycolipids are absorbed through the skin and stimulate an antirheumatic effect.⁶⁶ Several peat substances are able to permeate the skin.⁶³ Their absorption and action have been documented by the comparisons of placebo, water bath, and peat bath using Doppler ultrasound measurement. One study that measured circulation in the uterine artery after bath therapy showed that only the peat bath achieved the physiologic effect of prolonged vasodilatation and circulation. This effect lasted for several hours after the treatment. It is thought that absorption of peat substances takes place through the hair follicles and apocrine glands via diffusion and partial pinocytosis.^21,38 The fractions of peat components that penetrate the skin include the humic acid fractions, fulvic, ulmic, and volvic. The excitatory effect of humic acid fractions such as fulvic acid impact the reactivity of α2 and D2 receptors of smooth muscle cells.⁶⁴

The functions of peat in medicinal applications are antimicrobial, antiviral, anti-inflammatory, and antineoplastic, to name a few.⁶⁵ Many biochemical effects have been demonstrated in humans and animals. The anti-inflammatory effect of peat mud has been attributed to a sulfoglycolipid associated with a decrease in serum interleukin-1 (IL-1) in patients with arthritis.⁶⁷ The effects of mud applications include elevation of protein synthesis, reduction of arachidonic acid, and inhibition of inflammatory mediators such as leukotrienes (LTB4), prostaglandins (PGE-2), and thromboxane. Biologic activity is ascribed to peat ingredients, such as sulfur compounds, magnesium, manganese, iron, and humic acids.^† Mud pack therapy decreases the proinflammation factors IL-1 and TNF-α and radical-mediated peroxidations, nitric oxide and myeloperoxidase.⁶⁸ It also increases serum levels of insulin-like growth factor 1, which is cartilage protective. Humic substances spread widely in nature, and when found mainly in highly degraded peat, have been shown to have a proliferative effect on certain leukocytes. Water-soluble oxihumate, given orally or dermally, increases the proliferative response in mononuclear leukocytes as well as production and expression of IL-2.^2,50,69

Hyperthermia

The thermal properties of peat mud applications have been shown to be much greater than those of water bath because of the former’s dynamic viscosity, decreased convective cooling, and a protective effect on the skin with hot applications.² Whole-body, extracorporal, and local infrared applications of hyperthermia have uses in cancer therapy. Hyperthermic effects include changes in heat shock proteins (HSPs) and upregulation of heart antioxidant defense proteins such as manganese superoxide dismutase.⁶⁶ Plasma B-endorphins also rise in response to hot water bathing and may be responsible for the euphoric feeling the bath may bring.^44,70 In a study of patients with cancer, hyperthermia was shown to create the same endorphin rise both after sauna bath and in whole-body infrared hyperthermia.

Whole-body hyperthermia (WBH) stimulates an increase in T cells, such as monocytes and absolute numbers of white blood cells.⁷⁰ Heat increases granulocyte mobility, phagocytic and bactericidal properties, and enzymatic activity.¹ There is an increase in homing response to different tissues of lymphocytes, which contributes to antitumor activity. Hyperthermia may increase lymphocyte migration into inflamed tissue or lymphoid tissues such as lymph nodes and Peyer’s patches; this effect may help generate the cellular immune response. TNF-α and IL-6 are regulated by the stimulus of hyperthermia.^71–73 HSPs produced by hyperthermia can provide protection against the muscle damage that occurs through a pathologic increase in intracellular calcium or uncoupling of the mitochondrial respiratory chain. Hyperthermia provides protection against typical damage from reperfusion after ischemia or with excessive exercise damage. Calcium homeostasis, energy loss, increased free radical–mediated reactions, and activation of apoptosis pathways are affected. I use a thermal application of the partial or full peat-additive bath for the treatment of back pain, musculoskeletal disorders, skin problems, viral illnesses, and more. The use of heat in the right amount is crucial to treatment efficacy.^66,73,74

Discopathy

A series of treatments using first peat bath followed by manual traction and then a peat pack over the affected area of the spine has worked marvelously for many of my patients with discopathy. The first thing that is helped is the pain; then there is an improvement in structural integrity and function over time. It is necessary to perform these combination treatments 3 times a week for 3 to 12 weeks if there is significant discopathy.

Myopathy

Muscle pain is easily treated with a thermal peat bath or peat pack. The increase in circulation is very helpful to muscles and can be valuable in assisting with osseous manipulation once the muscles are more relaxed.

Scoliosis

Peat bath followed by traction of the spine can be very helpful in patients with scoliosis who have back pain. Applying a peat pack over the area of spinal pain can also be useful.

Arthritis

Peat treatments have shown efficacy for both osteoarthritis and rheumatoid arthritis. Matrix metalloproteinases (MMP-1 or stromelysin-1) are significantly reduced in mud bath patients with osteoarthritis.⁷⁵ One needs to be careful with acute rheumatoid arthritis because treatment may initially stir up symptoms. Generally, in osteoarthritis, these treatments have been shown in both the literature and my experience to be very beneficial. I have observed significant decreases in swelling and pain with one treatment multiple times in osteoarthritis of the knee and other areas. Generally, a series of either combination bath and pack or single bath or packs is given. Treatments are done every day or two.