Peat mud is more commonly used as a partial bath. For example, a patient with arthritis can immerse his or her hand into a bucket of peat mud. While receiving both local and systemic effects from the peat, the patient is instructed to exercise his or her hand during the procedure as a form of resistive exercise. This is an example of a balneophysical method (peat mud plus physical exercise) frequently used in spas. Due to its greater density, the peat mud offers a resistance against which the patient can exercise.

Peat mud can be used as a poultice as well. Unlike the partial bath discussed above, poultice is merely placed over an area, and offers no form of resistance for the patient to perform resistance exercises. As a result, balneophysical method is more advantageous because its synergistic effect with the outcome is better than the sum of the particular methods applied separately.

Finally, peat mud can be placed over the eyes and used in gynecological and proctological conditions. The procedure can be messy, and the peat mud must be sterile. These two issues present a challenge to clinicians, but the balneotechnical department, which is devoted to research and development of new spa equipment and procedures, is devising methods to overcome these obstacles.

One of the biggest impediments to peat mud has to do with its disposal, since it has to be transported and dumped into a large reservoir, not discarded down pipes. A Polish professor developed an ingenious method of grinding the peat mud into a fine texture and adding the appropriate proportion of water to form a cream. This is known as peat paste.

The processing method in converting mud to paste subsequently alters the chemical composition of mud to have several interesting properties unique to paste. Mud is much denser and has a thickness of about 4 to 5 centimeters when applied on the patient. Paste is finer in texture and has a thickness of 1 centimeter, which makes it feasible to be washed down the drain after a procedure. Furthermore, peat paste is applied at 37¼ C [99¼ F] (temperature similar to body temperature), while peat mud is heated between 42¼ C and 45¼ C [108¼ and 113¼ F], thus having significant clinical significance.

Because of the differences, peat paste can be spread on the patient with simultaneous use of iontophoresis (the use of galvanic current or direct current to deliver chemicals across the skin barrier). The chemical factors present in paste with a thickness of 1 centimeter can be delivered easily by iontophoresis at 10 to 20 mA for 15 to 30 minutes. This is another example of a balneophysical method (peat paste plus iontophoresis).

The second advantage with paste has to do with its similar temperature to the body. Patients with lower extremity ischemia (decreased blood flow to the tissue) worsen their condition when undergoing hyperthermic procedure because heat increases the metabolic demand and would require greater perfusion to the lower extremity. Therefore, the application of peat mud between 42¼ and 45¼ C [108¼ to 113¼ F] to an ischemic leg is contraindicated; peat paste is the proper method of treatment.

Peat paste should not be used in gynecological and proctological conditions because it is too moist. Peat mud is preferred for its denser composition.
Peat mud is indicated for the following conditions: osteoarthritis, ankylosing spondylitis, gout, hemiparesis, discopathy, gynecological diseases, chronic inflammatory disease, infertility, postmenopausal symptoms, gastroenterological diseases, chronic hepatitis with poultice over the hepatic region, bladder inflammation via sitz bath with mud, and paradontosis.

Peat paste can be used for the following conditions: inflammatory component of osteoarthritis (much better result compared to mud), lower extremity ischemia, and laryngotological conditions, such as poultice over the throat, eyes and nose.

Climatotherapy
Climate therapy gives each health resort a natural and unique environment that separates one spa town from another. Since some diseases respond favorably to a particular climate, the spa physician must factor climate into his or her curing profile. In short, there are several complex factors associated with climatotherapy. They are as follows:

• Air temperature (major factor);

• Speed of the wind (major factor);

• Humidity (major factor);

• Sunshine or infrared radiation;

• Ultraviolet radiation associated with the synthesis of vitamin D;

• Chemical factors such as pollution (negative factor);

• Magnetic and electric field; and

• Ionization-pollution is associated with positive ions while negative ions are associated with clean air for breathing. As a result, there are many fountains at spas that produce a lot of negative ions.

The climatic procedures are as follows:

• Solarium or sun bath;

• Natural aerosol; and

• Terrain therapy on a walking terrain or bike route.

Polish therapist Dr. Agnieszka Szczendor is massaging the hand and leg of patient Kasia Bryl, who is recuperating after having a brain tumor operation.  The therapy is being given at the children's rehabilitation facility in Kudowa Spa.

Hydrotherapy
Three major factors-thermal, mechanical and hydrostatic-are encountered in hydrotherapy. When looking at thermal effects, it is important to discuss the temperature of the bath: 20¼ to 27¼ C [68¼ to 81¼ F]-cool; 28¼ to 33¼ C [82¼ to 91¼ F]-tepid; 34¼ to 37¼ C [93¼ to 99¼ F]-warm; and 38¼ to 42¼ C [100¼ to 108¼ F]-hot. Hot application produces dilation of the veins, arteries and capillaries, which is commonly referred to as passive and active hyperemia. In addition, there is an increase in heart rate, increase in diuresis, lowering of blood pressure, sedative effect and muscle relaxation.

In contrast, cold therapy produces an initial arterial vasoconstriction followed by arterial and capillary vasodilatation, otherwise known as active hyperemia. Cold therapy also produces a decrease in heart rate, increased blood pressure, increased muscle tone and increased appetite. Hydrotherapeutic procedures used during the biological phase can produce greater stimulation. The biological phase is divided into a warm phase from 3 a.m. to 3 p.m. and a cold phase from 3 p.m. to 3 a.m. Cold therapy used during the cold phase will cause less stimulation than used during the warm phase. Likewise, warm therapy used during the warm phase will cause less stimulation than during the cold phase. This specialized study of balneology exploring the use of balneological procedures with the biological phase is known as chronobiological study in balneotherapy.

Hydrostatic factors deal mostly with immersion. With full immersion, there is a decrease in the circumference of the chest and abdomen with increase venous return and systemic vascular resistance. The heart must work harder and will encounter problems if there is underlying systolic dysfunction (weak pumping chamber of the heart).

Another principle that accompanies hydrostatic forces is Archimedes' principle, which states that the weight of the object in water is equal to the weight of the water displaced. This becomes useful with regard to patients rehabilitating in hydrotherapeutic pools. The patient in water weighs less than on land, and the patient can undergo rehabilitation with the assistance of the upward force of buoyancy.

Finally, mechanical effects intensify both the thermal and hydrostatic effects. Examples of this are showers and water jets commonly used at spas. By applying pressure, one can achieve greater stimulation, but when combined with contrast therapy of hot and cold water, a powerful, invigorating effect (tonic) can be achieved. For an in-depth discussion of hydrotherapy, refer to Dr. John Harvey Kellogg's book Rational Hydrotherapy under the chapter "Techniques of Hydrotherapy."

Massage
Therapeutic massage is used throughout Polish spas and has been recognized for its medicinal value. The mechanical stimulus from massage has two effects: 1) directly on the tissues treated and generally through the skin touch receptors, as well as proprioceptive and interceptive receptors; and 2) increases perfusion and blood outflow of the tissue, thereby improving the venous and lymphatic vessels function. Muscle relaxation and analgesic effects are additional benefits of massage.

Massage is indicated widely, especially in diseases of muscles, joints and microcirculation at Polish spas. It is often prescribed with other techniques, such as bath and massage, peat therapy and massage, thermotherapy and massage, and kinesitherapy and massage.

Kinesitherapy
Various forms of physical activity are prescribed with careful adjustment. The most popular techniques employed at a health resort are passive, resistant, free individual exercise, coordination exercises and walk-learning, individual and group exercises in the pool. Besides that, physical exercises in the open air play a supporting role, but these activities still need to be monitored and prescribed accordingly. Kinesitherapy is useful not only in locomotor diseases, but also in cardiologic and angiologic conditions, diabetes, obesity and osteoporosis.

Physical Therapy
This therapy employs various forms of energy present in the environment and has more of a supporting role in balneology. These procedures can be used alone, but when combined with balneological procedures, the outcome is a synergistic effect as discussed earlier with balneophysical methods.

The different methods are as follows: 1) electrotherapy is the stimulation achieved by the use of a direct current; 2) magnetotherapy employs impulses of alternating magnetic fields to achieve analgesic, antiswelling and anti-inflammatory, and also increases tissue perfusion; 3) ultrasound utilizes imperceptible acoustic waves to influence the thermal, chemical and mechanical properties of tissues; and 4) light therapy, such as infrared and ultraviolet.

Psychotherapy
A health resort is a place of rest, relaxation and rehabilitation. The proper psychological, social and natural surroundings are of great importance and value, and can influence the outcome of therapy. Some patients need typical sessions of psychotherapy (i.e., after a heart attack, deep injuries and neurosis). Most patients require only regular, short-term psychotherapy, or as an alternative, participation in relaxation exercises. A daily stroll in an attractive landscape may be of great importance for the whole result of spa therapy.

Health Education
No spa therapy is complete without health education. While patients are receiving treatments at the spa, they are instructed on proper diet and exercise. All patients are simultaneously treated and educated on the premise that when they return to their original environment, they would no longer adopt their unhealthy ways of living. Of course, this goal is rather optimistic, given the fact that the health resort is conducive to healing and relaxation and takes the patient away from his or her everyday worries and stress. Nevertheless, health education still plays a significant role and is included in the spa program.
 

Polish therapist Patrycja Syc is applying BOA massage to Polish patient Justyna at the Centrum Kongresowe hotel in Kudowa Zdroj Spa Resort (both photos).

Subterraneotherapy
One interesting method of treatment at Polish health resorts can only be found at Wieliczka Spa. Wieliczka Spa is a salt mine situated 211 meters below the surface, with salt chambers used for subterraneotherapy. Studies on this therapy show that the method is particularly valuable in the treatment of bronchial asthma, chronic bronchitis and chronic inflammatory disorders of the upper respiratory tract. Wieliczka Spa offers its patients:

1. Unique microclimate with air of specific chemical contents, high concentration of free ions, stable temperature and high humidity. Another important factor is air free of pollution, which can be useful for patients with allergies.

2. A modern pulmonary rehabilitation program focuses on the psychosomatic factors responsible for bronchial asthma.

The School for Patients with Bronchial Asthma in Wieliczka employs up-to-date approaches from current studies on the pathogenesis and treatment of bronchial asthma. The program also includes training for the patient and his or her family as essential factors for a successful outcome. The main objectives include the following:

• Gives patients solid knowledge about the disease;

• Instruction in performing respiratory exercises, such as breath control, adjustment of respiratory pattern and respiratory muscle training;

• Instruction of self-management of dyspnea;

• Training in efficient control of the clearance of the respiratory tract, as well as self-evaluation of the respiratory function;

• Demonstration to the patient of peak expiratory flow measurement, and the appropriate use of inhaler devices; and

• Respiratory muscle training with special focus on inspiratory muscles with the use of accessory devices.

Uniqueness Of Subterraneotherapy
The beneficial effects of staying in underground chambers and caves were not discovered earlier than in the 19th century. The real development of subterraneotherapy was observed in the 1950s. The chambers and caves in Poland and throughout the world have variable therapeutic potential, depending on their origin and environment. Some of them came to existence due to natural geological phenomena of dissolving soft rocks, while others were by-products of human exploitation of natural resources. Microclimate and specific environment of these sites depend on the chemical contents of surrounding rocks, as well as depth under the surface level. The underground temperature increases with greater depth.

Dr. Teresa Latour and her colleagues from the Institute of Health Resort Resources in Poznan, Poland, analyzed the microclimate of the chambers at Wieliczka Salt Mine in 1989. The result of their study was published under the title "Microclimate and Environment in Underground Chambers in Wieliczka Salt Mine.'"

The chambers in the Wieliczka Salt Mine were a by-product of human exploitation of the natural resource of salt. The temperature in the chambers is 12¼ to 15¼ C [54¼ to 59¼ F], and the humidity is considerably higher (up to 82 percent) and constant due to underground water streams and their evaporation. This level of humidity diminishes the evaporation that is taking place in the respiratory tract and prevents dryness of the mucosa.

The inhaled air in the chambers has specific chemical parameters, but most noticeable is the considerable amount of sodium chloride and potassium chloride (24 milligrams NaCl, 15.2 milligrams KCl in 1 m3 of air). The air also contains calcium (.5 milligrams/m3), bicarbonate (3.5 milligrams/m3) and iodide anions. All of these chemical parameters have a great impact on the respiratory tract when inhaled.

The final beneficial factor relates to the shifting of pressure when sleeping underground compared to ground level. In the chambers, the partial pressure of oxygen is increased, thus improving the blood oxygen saturation and transport of oxygen to the tissues.

The treatment course is scheduled for 24 days. During this time, patients do morning inhalation therapy and gymnastics, and sleep in the underground chambers overnight. They are accommodated in hospital buildings of the Krakow Health Resort in single or double rooms. Patients spend approximately 100 hours underground during their course of treatment at Wieliczka Spa.

Scientific studies that last for several years confirm the effectiveness of subterraneotherapy as adjunctive and maintenance therapy for patients with respiratory diseases.

Conclusion
As experienced professionals in medicine, balneology and diabetology, we believe that balneology is an effective therapy, particularly for the aging population that is prone to chronic diseases. Although spa medicine does not offer a cure, it allows the patient to cope and be functional with his or her disease. The spa setting encourages the healing of the body and mind. So much emphasis has been placed upon finding a cure that perhaps medicine should equally direct its focus on palliative treatments such as balneology, which can offer healing in a holistic manner. Although spas in Europe have traditionally been used to arrest the disease process, greater effort will be placed on prevention and wellness in the future.

The success of spa treatments depends on numerous factors, but a patient's compliance and enthusiasm to work closely with an interdisciplinary team of spa physicians, physical therapists, massage therapists, nurses and psychotherapists are indispensable to the patient's outcome. Finally, one cannot stress enough the importance of health education to ensure that the patient will not return to unhealthy ways of living.

•••

Irena Ponikowska is president of the Polish Association of Balneology and Physical Medicine. She is a consultant to the Polish Minister of Health on Health Resort Medicine, and is a professor at the Medical University of Bydgoszcz/Clinic of Balneology and Metabolic Diseases in Ciechocinek, Poland.

For more information, contact co-author Khai Vu at: intouch379@wp.pl. Or, check the Web site of the Polish Association of Balneology and Physical Medicine at: http://gray.logonet.com.pl/~balneo/indexa.html.