Balneology, a field of the therapeutic use of baths and physical medicine, employs natural therapeutic methods and physical phenomena for diagnosis, rehabilitation, healing and prevention of physical ailments. This method is applied most often in the health-resort setting, and includes the following factors for healing:

• Natural healing factors derived from mineral waters, gases and vegetable peloids/peat;

• Natural environmental factors, such as climate, landscape and flora;

• Various forms of muscle effort; and

• Physical energy, such as sound, light and the electromagnetic field.

There are 40 health resorts or spa towns in Poland that provide the full range of service. The resorts operate under the guidelines of their own statutes. Every health resort has a specific profile, natural resources, a medical balneological department, professional medical staff, a unique therapeutic climate for a range of illnesses, and technical background.

In order to obtain the status of a health resort, each town has to meet rigorous standards on the basis of climate, the type of mineral water and the natural resources that can be utilized for therapeutic purposes. Towns that meet these strict criteria obtain their status as a health resort under the law, and qualify as a spa town where patients are sent for spa treatments. Additionally, these health resorts will be required by law to keep their population (the town's population) more or less constant to minimize the impact that an expanding population has on the environment in terms of overcrowding and sanitation.

Spa medicine is an integral part of the Polish health-care system, particularly for patients with chronic illnesses, or those who just recently recovered from an acute illness and afterward were referred to the health resort for restoration. Each health resort in Poland has several spa hospitals and sanatoriums, all of which are registered with the head spa physician after meeting specific medical and hotel standards.
 

Medical Spa Prescription
Poland has a long tradition of spa therapy. Historical records show that spas were used as far back as 800 years, although the methods were quite primitive. Spa treatments were quite empirical until a concerted effort was made to investigate this form of therapy on a scientific basis. Today, spa therapy in Poland is administered by a qualified spa physician who has undergone extensive training in balneology. Common questions asked by those health practitioners who are unfamiliar with spa medicine is the indication for referring patients to the spa and the diverse levels of spa care.

Spa therapy in Poland is utilized as a cost-effective measure to deliver quality care for two major indications: 1) rehabilitation after an acute event; and 2) remedying chronic illnesses. Depending on the condition of the patient's illness, he or she can be sent to a spa hospital, sanatorium or polyclinic.

A spa hospital is reserved for patients requiring intensive care and rehabilitation after an acute event. For example, a patient who sustains a heart attack is often sent to a spa hospital two weeks after initial hospitalization. The rehabilitation at a spa hospital can be more intensive, and the patient's progress is monitored on a daily basis by a spa physician. Not surprisingly, therapy administered at a spa hospital is half the cost of therapy at a hospital. The Polish government insurance, known as Kasa Chorych, pays 100 percent without restriction on the length of time for rehabilitation.

A sanatorium, on the other hand, is reserved for patients with nonthreatening chronic illnesses that can be debilitating on quality of life and functional capacity. Due to the chronic nature of the illness, patients are often seen by a spa physician one to two times per week at a sanatorium. Similar to a spa hospital, the sanatorium has accommodations, and is staffed with physicians and nurses who provide spa treatments in the medical balneological department. Patients spend 24 days for spa therapy, and are responsible for 10 to 15 percent of the total cost. Prices at each sanatorium fluctuate according to the level of accommodation that the patient chooses.

Typically, a patient with a chronic condition would be advised by his or her family physician to utilize spa therapy. A case history with pertinent diagnostic studies is submitted to Kasa Chorych for review by a staff balneologist. The balneologist from the insurance company determines whether the patient qualifies for spa therapy based on indications and contraindications. If the request is accepted, the patient is referred to one of the 40 spas best suited for the patient's illness, with special attention to climate as a therapeutic consideration at a particular spa.

Patients who do not fit into the above categories can still partake in spa therapy at a polyclinic. A patient with lower back pain not relating to an intervertebral disc problem can ask his or her family physician to send a request to Kasa Chorych, and if approved, the patient receives a voucher to the spa chosen by the balneologist employed by the insurance company. The patient arranges his or her own room and board out of pocket, and makes an appointment with a balneologist at a polyclinic. Prescriptions are taken to an assigned medical balneological department at the spa. The voucher is valid for two weeks at no cost to the patient.

The Mechanism Of Therapeutic Stimuli In Balneology
All modalities of spa therapy have a stimulating effect on the patient. Such therapies include climate, mineral water and peloids, all of which have chemical and physical effects. Physical medicine is included because of its utilization of natural energy in the form of light, magnetic fields and artificial energy found in ultrasound and electrotherapy.

When a patient is subjected to the stimulating effects of spa therapy, it is interesting to note his or her reaction to the spa treatments. A good outcome of spa therapy depends on successive treatments of adequate duration, which is usually three to four weeks of spa therapy.
 

Research in Poland has suggested that there are three stages of a spa response to treatment. The first stage is known as adaptation, whereby the patient is removed from his or her home environment to be acclimated in a new spa residence. This stage typically lasts two to three days, but can be as long as seven days for a patient with comorbidities (i.e., type and total number of coexisting diseases), such as hypertension, diabetes and chronic obstructive pulmonary diseases.

While undergoing spa therapy prescribed by a physician, some patients experience a second stage, known as a spa crisis, approximately two weeks into their treatment. The patient may experience malaise, fever, tachycardia, headache, fatigue, insomnia and pain. A patient may experience an acute flare-up of his or her disease that was initially dormant, such as inflamed joints from rheumatic disease. During this period, the spa procedures and dosage levels are reduced, and sometimes stopped completely or temporarily while the patient is receiving medication to control symptoms. The spa crisis stage is not an indication that the patient is not a future candidate for spa therapy. In fact, spa therapy must continue during a spa crisis with appropriate adjustment for a sufficient amount of time in order for the overall therapy to be effective. In other words, spa crisis is expected to occur in some patients because the physiological system is being stimulated by spa treatments (stimulus-adaptation therapy), and the outcome of a stimulated physiological system in its extreme form is a spa crisis. Patients are scrutinized closely for any deterioration.
 

Polish therapist Katarzyna Kuchta is working at the swimming pool with Jozef Towarnicki and Artur Starosciniak in Polanica Spa in Poland.  Both men are seeking relief from rheumatism at the famous Polish spa.

Even though it is an uncomfortable experience, all the symptoms of a spa crisis typically fade, and the patient enters the final stage, called regeneration. A patient will gradually feel better, and his or her overall condition improves as compared to the initial presentation.

One should note that not all patients will 'feel' the beneficial effect of spa therapy, even at the completion of their 24-day spa program. In fact, some patients will not experience the benefits of spa therapy until many weeks later.

Once the beneficial effects of spa therapy are achieved, the benefits can be extended up to a maximum of 10 to 12 months, depending on the patient's comorbidities after he or she returns home. This has been scientifically proven by follow-up studies in Poland. The finding is not surprising, considering the fact that the body is still undergoing physiological changes from repeated stimuli of spa treatments, and the summation of these reactions may not manifest overall improvement until some time after the completion of spa therapy.

From the three stages of a spa response, the physician can tailor his or her spa prescription accordingly. To adapt, the patient should receive only low-dosage, short-duration treatments. It's important that the patient be gradually acclimated to his or her new environment. As two weeks approach, the spa physician must be cognizant of spa crisis, and make every effort to modify the prescription and address the patient's spa-crisis symptoms. Observation of the patient's response during a spa crisis is important because it provides information about his or her symptoms and the recovering ability (reserve capacity). For this reason, it is important for the patient upon arrival to the spa to have an initial history and physical examination by a spa physician. The physician can assess whether the patient has enough reserve capacity to handle spa therapy, which is a type of stimulus-adaptation therapy. Elderly patients with low-reserve capacities, weak and debilitated patients (low-reserve capacities), and patients who overly respond to spa therapy (physiological system is too sensitive) have relative contraindications to spa therapy.

Polish therapist Adrianna Gembara is making an underwater massage to patient Alfred Joschko in Polanica Zdroj Spa.

Once a spa crisis passes, the physician can prescribe maximum therapy in terms of dosage and duration as tolerated by the patient during regeneration. At the end of his or her spa treatment, in 24 days or upon follow-up, a patient will have an overall improvement because he or she has reached a higher level of homeostasis equated with health.

Based on this research, spa therapy is optimal at four weeks, with a minimum of three weeks. Two weeks of spa therapy is not recommended for treatment because of the possible occurrence of a spa crisis when the patient is discharged too early. Healthy patients who seek spa therapy for the purpose of prevention and wellness can undergo spa therapy in one to two weeks. It is important to make this distinction with regard to the proper use of spa therapy.

Mineral Water
As a natural product, mineral water must meet several requirements in order to be used for spa therapy. It must be: 1) underground and in large reserve to meet the demands at the spa; 2) at a constant mineral concentration; 3) chemically and microbiologically pure, which means that although there are many bacteria in mineral water, there should not be any pathogenic bacteria; 4) proven for its therapeutic effect; and 5) approved by the Minister of Health. Mineral water, similar to any drug, must be prescribed according to dosage, frequency, before or after meals and temperature.

Mineral water can be classified on several criteria:

• Total mineralization of 1,000 milligrams per liter (mg/l) is considered the lower limit to be classified as mineral water. Anything less than this amount is considered low mineralization.

• Chemical composition that meets the concentration requirement can be used as well. For example, iodide is 1 mg/l, bromide 5 mg/l, sulfur 1 mg/l, fluoride 1 mg/l, CO2 1,000 mg/l, and radon 2 nCi (nanocurie).

• Temperature of thermal water greater than 20¼ C [68¼ F].

• Osmotic pressure influenced by its tonicity, such as hypotonic, isotonic or hypertonic.

• Degree of ionic dissociation-the greater the ionic dissociation, the greater the absorption by the skin and mucous membrane.

• pH of the mineral water (i.e., pH equals 7 [neutral], pH more than 7 [alkaline], pH less than 7 [acidic]).

Mineral Baths
Before discussing the different types of mineral baths, several basic principles should be reviewed. The first has to do with a two-way system of absorption. There is absorption of mineral from the water to the skin, and the excretion of metabolic by-products from the skin to the water. The degree of mineral absorption depends upon the fat/water solubility due to the structure of the skin membrane.

Besides mineral absorption, one should be mindful of the movement of water based on osmolality. In a hypoosmal bath, water moves into the patient while a hyperosmal bath encourages water movement from the patient to the bath. The absorption of water is 1 ug/cm 2/hr (the index of absorption). The osmolality of the bath should be taken into consideration along with the fluid status of the patient. An incorrect prescription may lead to exacerbation of a patient's chronic condition of edema or orthostatic hypotension due to dehydration after the bath.

Minerals, in general, are slowly absorbed by the skin. Such minerals, which are commonly encountered in balneotherapy, are iodine, bromine, potassium and calcium. Although minerals have a slow rate of absorption, this does not necessarily equate to the lack of clinical significance. For example, Dr. Drexler studied the absorption of iodide* from a mineral bath with a concentration of 50 mg/l. He found the absorption of iodide at 100 ug (micrograms) from a single bath. The body turnover for iodine is approximately 100 ug for 24 hours.

Some mineral waters are classified according to the type of gases present, such as carbon dioxide, hydrogen sulfur and radon. These gases are rapidly absorbed by the skin, and when artificial carbon dioxide or hydrogen sulfide is added to mineral water, slowly absorbed iodine, bromine, potassium and calcium are absorbed by the skin at a greater rate. This enhanced action is due to capillary vasodilations of the skin brought about by carbon dioxide and hydrogen sulfide.

Brine Bath
A brine bath can be naturally or artificially prepared. The mineral water can be considered brine water if it has a salt concentration of at least 1.5 percent. For therapeutic purposes, brine bath is administered with a saline concentration of 2 to 3 percent at Polish spas. The bath is administered between 36¼ and 38¼ C [97¼ and 100¼ F] and has the following effects: 1) vasodilation at the skin level; 2) releases hormones at the skin level; 3) relaxation due to its warm, thermal effect; and 4) enhances the absorption of minerals through vasodilation, similar to the effect of carbon dioxide and hydrogen sulfide discussed earlier. The salt from the bath continues to be absorbed after the patient towels off, as long as he or she avoids showering afterward. Patients can receive brine bath every day for a total of 14 to 16 treatments.
Brine bath is indicated for the following: rheumatic arthritis, ankylosing spondylitis, post-trauma conditions and spastic paralysis. The bath is contraindicated in the following conditions: uncontrolled hypertension, congestive heart failure, old patients, leg ulcer, gastric ulcer, hemorrhage and allergy to salt.

Carbon Dioxide Bath
A carbon dioxide bath can be administered as a water bath or a gas bath with the patient enclosed in a cabinet. Naturally carbonated mineral water is preferred, but it can be artificially prepared. A carbon dioxide bath has the following effects: 1) decreases the sensitivity of cold receptors in the skin, thus lowering the indifferent temperature (the temperature at which the patient feels neither hot nor cold) to 34¼ to 35¼ C [93¼ to 95¼ F]; 2) lowers the pulse rate; 3) absorbs quickly in the skin and mucous membrane; and 4) increases peripheral circulation through dilation of skin vessels, thus allowing the heart to work more economically with improved coronary circulation.

The fact that the carbon dioxide bath can be administered at a lower indifferent temperature is beneficial in two ways: 1) it can be given to cardiac patients whose cardiac conditions typically preclude them from baths that are warm or hot; and 2) the free CO2 concentration is greater at cold temperatures as opposed to warm temperatures, thus making the bath more effective.
The bath is given at 32¼ to 35¼ C [90¼ to 95¼ F] for 10 to 15 minutes. The water bath is given every two days for a total of 15 treatments, while the gas bath is given every day for 20 treatments. Physiologically, the gas bath is similar to the water bath, except that patients with conditions that preclude them from being exposed to water can use the gas bath instead due to the lack of hydrostatic pressure exerted by the mineral water.

The bath is indicated for such conditions as hypertension, ischemic lower extremities, macroangiopathy of the lower extremities, and resting tachycardia due to diabetic neurovegetative neuropathy.

Sulfur Bath
To be classified as a sulfur bath, the mineral water must have a hydrogen sulfide concentration of 1 mg/l. Although natural hydrogen sulfide mineral water is the best, it also can be prepared artificially. This bath has the following effects: 1) vascular dilation similar to a carbon dioxide bath; 2) keratolytic, thus becoming useful for psoriasis and other dermatological diseases; and 3) systemic absorption with incorporation of sulfur in the formation of chondroitin sulfuric acid found in cartilage, which can be helpful for osteoarthritis.

The bath is given at 34¼ to 37¼ C [93¼ to 99¼ F] for 10 to 15 minutes, for a total of 15 treatments. There are nine health resorts in Poland that use sulfur baths, but interestingly, only Busko Spa has an unusual mineral water containing both brine and hydrogen sulfide.
A sulfur bath is indicated for osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, post-trauma conditions, hypertension, ischemic lower extremities and dermatological diseases, such as psoriasis.

Radon Bath
To be classified as a radon mineral water, it must have a minimum of 2 nCi/l. As with carbon dioxide and hydrogen sulfide, it is quickly absorbed by the skin and mucous membrane. For this reason, radon is typically used for baths and inhalation to promote systemic absorption. Compared to baths, inhalation of radon is absorbed at a faster rate via mucous membrane.
A radon bath is used for hypertension, rheumatoid arthritis and arteriosclerosis of lower extremities. Inhalation therapy is often administered at speleotherapy centers for conditions such as chronic bronchitis and bronchial asthma.
 

Patient Wladyslawa Strzala is having magnetotherapy to cure her hip disorder in Polanica Zdroj Spa.

Because of the presence of radon in the atmosphere, radon baths and inhalation may cause harm to the patient. Studies to test the safety of radon are problematic because one must examine the effects of several generations. Currently, the consensus of radon therapy in Poland is to preclude a man and woman under the age of 40 due to reproductive concerns. The majority of research on radon has been conducted by radon spas in Austria, Germany and Russia.

Peloidotherapy
Poland is renowed for its peloid (therapeutic mud) because it is 97 to 98 percent organic. To understand the therapeutic effect of peloid, one needs to examine the two types of peloids commonly encountered in practice. Mineral peloid has less than 50 percent organic factors, and is composed predominantly of minerals, otherwise known as an abiolith product. On the other hand, vegetable peloid contains more than 50 percent organic factors, and is otherwise known as a biolith product or peat.
When comparing the two types of peloids, a mineral peloid's benefit is derived only from its hyperthermic effect. Vegetable peloid offers thermal benefit as a local effect, and has several chemical actions on a systemic level. They are as follows: 1) anti-inflammatory; 2) bactericidal-an experiment with bacteria on a petri dish shows that peloid at a temperature of 37¼ C [99¼ F] is able to exert its bactericidal effect within 24 hours, but at a reduced temperature of 25¼ C [77¼ F], the bactericidal effect is observed in 48 hours; 3) estrogenic-a small amount of estrogen is present, which can be used in both gynecological and postmenopausal conditions; and 4) presence of antibiotics in vegetable peloid.

Since organic peloid is more useful, the rest of the discussion will focus on vegetable peloid or peat. With regards to its thermal effect, peat has a high heat retention and low heat conductivity, which makes it quite beneficial as a thermotherapy when compared to baths. Because of its high heat retention, peat can be heated at a higher temperature than baths, but can be applied to the patient without the concern of inflicting burn due to its low heat conductivity and the gradual transfer of heat to the patient.

In the past, peat has been used typically in the form of mud, but later, peat paste was invented thus allowing the physician greater flexibility in choosing mud or paste as dictated by the medical condition. One traditional therapy with peat mud is a full immersion bath. Its therapeutic application is limited because it can be used only in young patients with healthy hearts. It is an expensive procedure because the peat mud can be used only once. After use, the peat mud is transported from the spa and discarded in a large pool for one year before it converts into fertilizer. In the meantime, this large collection of peat mud presents an environmental hazard. As a result, the full immersion bath is seldom used in the form of peat mud.
 

Blind Polish therapist Zbigniew Nowak is giving a massage to patinet Aleksander Ksiazkowski in Polanica Zdroj Spa (above).

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