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A proposal for a worldwide definition of health

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Int J Biometeorol (2010) 54:495507
DOI 10.1007/s00484-010-0321-5
REVIEW
A proposal for a worldwide definition of health resort
medicine, balneology, medical hydrology and climatology
Christoph Gutenbrunner & Tamas Bender &
Pedro Cantista & Zeki Karaglle
Received: 2 December 2009 / Revised: 30 March 2010 / Accepted: 9 April 2010 / Published online: 9 June 2010
# ISB 2010
Abstract Health Resort Medicine, Balneology, Medical
Hydrology and Climatology are not fully recognised as
independent medical specialties at a global international
level. Analysing the reasons, we can identify both external
(from outside the field) and internal (from inside the field)
factors. External arguments include, e.g. the lack of
scientific evidence, the fact that Balneotherapy and Clima-
totherapy is not used in all countries, and the fact that
Health Resort Medicine, Balneology, Medical Hydrology
and Climatology focus only on single methods and do not
have a comprehensive concept. Implicit barriers are the lack
of international accepted terms in the field, the restriction of
being allowed to practice the activities only in specific
settings, and the trend to use Balneotherapy mainly for
wellness concepts. Especially the implicit barriers should be
subject to intense discussions among scientists and special-
ists. This paper suggests one option to tackle the problem of
implicit barriers by making a proposal for a structure and
description of the medical field, and to provide some
commonly acceptable descriptions of content and terminol-
ogy. The medical area can be defined as medicine in health
resorts (or health resort medicine). Health resort medi-
cine includes all medical activities originated and derived
in health resorts based on scientific evidence aiming at
health promotion, prevention, therapy and rehabilitation.
Core elements of health resort interventions in health
resorts are balneotherapy, hydrotherapy, and climato-
therapy. Health resort medicine can be used for health
C. Gutenbrunner (*) : T. Bender : P. Cantista : Z. Karaglle
Department for Rehabilitation Medicine, Institute for Balneology
and Medical Climatology, Hanover Medical School,
Carl-Neuberg-Str. 1,
30625 Hannover, Germany
e-mail: gutenbrunner.christoph@mh-hannover.de
promotion, prevention, treatment, and rehabilitation. The
use of natural mineral waters, gases and peloids in many
countries is called balneotherapy, but other (equivalent)
terms exist. Substances used for balneotherapy are medical
mineral waters, medical peloids, and natural gases (bathing,
drinking, inhalation, etc.). The use of plain water (tap
water) for therapy is called hydrotherapy, and the use of
climatic factors for therapy is called climatotherapy.
Reflecting the effects of health resort medicine, it is
important to take other environmental factors into account.
These can be classified within the framework of the ICF
(International Classification of Functioning, Disability and
Health). Examples include receiving health care by
specialised doctors, being well educated (ICF-domain:
e355), having an environment supporting social contacts
(family, peer groups) (cf. ICF-domains: d740, d760),
facilities for recreation, cultural activities, leisure and sports
(cf. ICF-domain: d920), access to a health-promoting
atmosphere and an environment close to nature (cf. ICF-
domain: e210). The scientific field dealing with health
resort medicine is called health resort sciences. It includes
the medical sciences, psychology, social sciences, technical
sciences, chemistry, physics, geography, jurisprudence, etc.
Finally, this paper proposes a systematic international
discussion of descriptions in the field of Health Resort
Medicine, Balneology, Medical Hydrology and Climatolo-
gy, and discusses short descriptive terms with the goal of
achieving internationally accepted distinct terms. This task
should be done via a structured consensus process and is of
major importance for the publication of scientific results as
well as for systematic reviews and meta-analyses.
Keywords Health resort medicine . Balneology .
Medical hydrology . Climatology . Definitions .
Curriculum . Specialist training
496
Introduction
What is the problem?
Health Resort Medicine, Balneology, Medical Hydrology and
Climatology are not fully recognised as independent medical
specialties at a global international level. Thus this field is not
represented in the European Union of Medical Specialists
(UEMS). However, within the Section for Physical and
Rehabilitation Medicine, a task force on Balneology has been
established. The foundation of a subsection has been refused
recently by the executive committee of UEMS. On the other
hand, in many European and non-European countries,
independent specialties (e.g. Turkey, Spain, and Italy) or
competencies (e.g. Germany, Austria, Serbia, Czech
Republic, Hungary, Portugal, and France) exist. In some
European countries (e.g. Poland, Slovakia, and Romania),
Balneology is included within the specialty of Physical and
Rehabilitation Medicine. Other countries (e.g. UK, The
Netherlands, Sweden, and Denmark) do not recognise any
similar medical specialisation or qualification. On the other
hand, Health Resort Medicine, Balneology, Medical Hydrol-
ogy and Climatology are relevant parts of the health systems
in many countries within and outside Europe (Germany,
Austria, Poland, Hungary, France, Japan, and others), and
health insurances refund health resort treatments, at least
partly. Additionally, it should be noted that a great deal of
scientific work on the physiological mechanisms of these
therapies (Gutenbrunner et al. 1999a, b, 2001a; Fink et al.
2001; Shehata et al. 2006; Bender et al. 2007; Braga et al.
2008; Vaile et al. 2008) and their clinical outcomes
(Gutenbrunner et al. 1997, 2001b; Gundermann et al. 1998;
Gutenbrunner and Gundermann 1998; Fioravanti et al. 2000;
Franke et al. 2000; van Tubergen et al. 2001; Costantino and
Lampa 2005; Costantino et al. 2006; Cutovic et al. 2006;
Gusi et al. 2006; Balint et al. 2007; Bellometti et al. 2007;
Brockow et al. 2007a; b; Eversden et al. 2007; Evcik et al.
2007; Fransen et al. 2007; Franke et al. 2007a; Karaglle et
al. 2007a; Lund et al. 2008; Odabasi et al. 2008; Silva et al.
2008; Tomas-Carus et al. 2008) has been published within
the last decades (for an overview see Gutenbrunner and
Hildebrandt 1998; Bender et al. 2005; Gutenbrunner 2006);
in particular, the number of randomised prospective con-
trolled studies has grown recently (Forestier 2000; Strauss-
Blasche et al. 2000a; Guillemin et al. 2001; Leaute-Labreze
et al. 2001; Gutenbruner et al. 2002; Codish et al. 2005;
Dnmez et al. 2005; Ardic et al. 2007; Cantarini et al. 2007;
Franke et al. 2007b; Karaglle et al. 2007b; Gaal et al.
2008). Nowadays even some systematic reviews and meta-
analyses are available, most of them on the effects on
osteoarthritis (Karaglle and Karaglle 2004; Devereux et al.
2005; Pittler et al. 2006; Bartels et al. 2007; Verhagen et al.
Int J Biometeorol (2010) 54:495507
2007; Tomas-Carus et al. 2007; Forestier and Francon 2008;
Hall et al. 2008). The conclusions are mostly in favour of
spa treatments; however, due to the large variety of
interventions, the results are still mostly inconclusive. The
same applies to studies on cost-effectiveness (Van Tubergen
et al. 2002; Brefel-Courbon et al. 2003; Fioravanti et al.
2003; Epps et al. 2005; Zijlstra et al. 2007; Klick and
Stratmann 2008).
At this point, it is appropriate to reflect on the arguments
that are raised against the recognition of Health Resort
Medicine, Balneology, Medical Hydrology and Climatology
regarding medical specialty or sub-specialty or competence.
As expected in such discussions, there are both external
arguments and implicit barriers contributing to the current
situation1. External arguments include:
& A lack of scientific evidence.
This argument is widely used, and Health Resort Medicine,
Balneology, Medical Hydrology and Climatology are widely
claimed to be paramedical. As there is a clear definition on the
methods used in the field, the mechanisms involved, and
growing evidence on the outcomes (at least in some
conditions), the argument of lack of evidence does not appear
to be very strong, and in fact is no weaker than with other well
recognised medical interventions (e.g. physiotherapy, occu-
pational therapy, some methods used in psychotherapy).
& The fact that Balneotherapy and Climatotherapy are
not used in all countries.
As Balneotherapy and Climatotherapy are dependent on
specific geological, geographic and meteorological precon-
ditions, regional aspects have a major influence on the use
of these treatments. Taking this into account, this argument
seems to be justified. However, other factors have effects
on the use of mineral waters and climatic factors for
therapy, e.g. regional traditions, and national health sys-
tems, especially reimbursement by health insurances. The
latter point in particular may change in future and is in
some respects related to the first argument described above.
If the idea of a definition as proposed below is accepted
internationally, the practice of Health Resort Medicine and
Balneology will be more independent of regional factors
and will encourage the use of natural resources like mineral
waters and peloids outside health resorts, the use of plain
water (hydrotherapy) and the use of the contextual factors
of a health resort (even without balneotherapy). Addition-
ally, the planning and prescription of health resort inter-
ventions may be part of the specialisation of Health Resort
Medicine.
1
This paper does not claim to cover all possible arguments or implicit
barriers but aims to highlight the core arguments and to promote
further discussion
Int J Biometeorol (2010) 54:495507
& The fact that Health Resort Medicine, Balneology,
Medical Hydrology and Climatology focus only on
single methods and do not have a single underlying
comprehensive concept.
Treatment methods normally prescribe the (traditional)
definitions of professional practice, and indeed, similar to
Physical and Rehabilitation Medicine, Health Resort
Medicine, Balneology, Medical Hydrology and Climatol-
ogy can be functionally defined in terms of treatment
goals (improvement of functioning in terms of ICF,
especially improved regulatory capacities of the autono-
mous nervous system, use of plasticity in many organ
systems) andas Health Resort Medicineinclude many
other treatments (see below). A special characteristic
possibly the most innovativeis the systematic use of
environmental factors for health promotion, prevention,
therapy and rehabilitation. Lastly, specific diagnostic
tools for functional tests and assessment as well as
prognosis should be further developed by specialist
organisations.
Implicit barriers include:
& The lack of international accepted terms in the field.
The use of terms in this field in the international
scientific literature is very inconsistent. This results from
the fact that English has become the dominant scientific
language whereas Balneology has been developed mainly
in Roman (France, Italy, Spain, Portugal), German-
speaking (Germany, Austria, Switzerland, South Tyrolia)
and eastern European (Poland, Czech Republic, Romania,
Russia and others) countries. Only two examples can be
given here: the term hydrotherapy in the UK is used
mainly to describe underwater (pool) exercise, and other
methods involving the external use of plain water are not
used. On the contrary, in Germany the external use of water
(e.g. water jets) according to Kneipp aiming at thermal
stimulation is called hydrotherapy, and pool exercise is
seen as part of physiotherapy. The term balneotherapy in
Germany is used for the use of natural mineral waters for
bathing, drinking and inhalation whereas in France and
other Latin-speaking countries this term is used for bathing
outside medical concepts only, and the equivalent scientific
term to balneotherapy is crenotherapy. This causes a initiated by scientific organisations and professional
significant barrier to research and especially limits the
performance of meta-analyses. It also constructs barriers to
the recognition and development of the field. Hence, an
international consensus process aiming at an internationally
recognised terminology should be completed as soon as
possible. Such a project should allow translation into
different languages (recognising cultural differences in the
use of terms).
497
& The restriction of practice of activities to specific
settings only2.
The traditional definition of Balneology claims that it
covers only the use of natural remedies at their place of
origin. Such a definition excludes the use of these factors as
therapy outside health resorts, and limits the medical
specialty to given settings (see above). Additionally, it has
to be stated that there is no scientific proof that Balneo-
therapy is only effective within the setting of a health
resort. On the contrary, for some methods, efficacy outside
health resorts has been proven already (e.g. drinking
mineral water for renal stone metaphylaxis, CO2-bathing
for the improvement of skin microcirculation and improve-
ment of pO2). The restriction to regional settings may
support the development of health resorts but hinders the
international recognition of the medical specialty. However,
if the specialty is described by the competence to use all
factors of a health resort in all possible settings and is to
include the management of patients in need of Health
Resort Medicine, Balneotherapy and Climatotherapy, inter-
national recognition could be attained much more easily as
the definition is much more universal (and additionally is in
accordance with scientific criteria).
& The trend to use Balneotherapy mainly for wellness
concepts.
In many countries there is increasing use of advertising
to promote the use of Balneotherapy interventions for
wellness concepts. Most of these concepts lack a
systematic medical approach and are aimed simply at
short-term well-being (and of course economic profit).
Despite attempts to focus wellness methods on health-
promoting and prevention programs (so-called medical
wellness), the promotion of wellness programs in health
resorts in the public view draws attention away from the
medical use of treatments and sets health resorts on an
equal level with other services providing wellness pro-
grams (e.g. hotels, health clubs, spas, etc.). Although this
is a political rather than a scientific argument, it should be
considered carefully in this context.
These implicit barriers should be subject to intense
discussions among scientists and specialists within the
field, and systematic problem-solving processes should be
bodies.
2
The often used argument that the use of Balneotherapy outside
health resorts weakens the position of health resorts in the health care
system is an economic and political argument and cannot be accepted
as basis for the definition of a medical specialty or health strategy,
respectively. Here, scientific definitions and facts have to be the
leading arguments.
498
Approach and concept
This paper will give one option to tackle the problem of
implicit barriers by making a proposal for a structure and
description of the medical field, and to give some
commonly acceptable descriptions of content and terminol-
ogy. However, the descriptions should be discussed further
and a systematic international consensus process is still
needed. Such a process has already been started within
the framework of the International Society for Medical
Hydrology (ISMH) but is not yet finalised. Regarding
terminology, it is particulary important to explore the
possibility of translating words used in national languages
into internationally accepted scientific terms. Such a
dictionary may be based on recently published glossaries
(Hernansanz 2001; Kirschner 2005).
This paper intends to:
& make proposals for a description for the medical field of
Health Resort Medicine, Balneology, Medical Hydrology
and Climatology that is more independent of local or
national conditions; and
& propose short descriptions of terms within the field that
could be used as a basis for an international consensus
and a dictionary to translate these terms into different
languages.
Of course, this paper cannot replace a systematic
international consensus process on terms, descriptions and
definitions. It also does not claim to be comprehensive or
complete, especially with respect to terms and methods
used in specific languages or regions. Additions, comments
and discussion are very welcome.
Description of the medical field
As illustrated in Fig. 1, the medical field of Health Resort
Medicine can be described by a general definition that
includes core elements, modalities (methods) and agents
(substances, factors).
& The field can be defined as medicine originating in and
derived from health resorts (or Health Resort Medicine).
The term medicine includes both diagnostics and
treatment and can refer to health promotion, prevention,
therapy, and rehabilitation.
& Core elements are:
the use of (natural) mineral waters, gases and peliods
(Balneotherapy or Crenotherapy)
the use of plain water (tap water; Hydrotherapy)
the use of climatic factors (Climatotherapy)
the use of other therapies in health resorts, e.g. physical
modalities (physical therapy, physiotherapy), diet
Int J Biometeorol (2010) 54:495507
(nutrition therapy), exercise, massage therapy, psycho-
therapy, health education, complementary and alterna-
tive therapies, etc.3
the use of environmental factors (as classified by the
International Classification of Functioning, Disability
and Health
& Modalities such as bathing, drinking, inhalation, etc.
& Agents, e.g. mineral waters, plain water, gases, peloids
(fango), etc. This level includes therapeutic factors as
exercise, thermotherapy, massage, galvanisation, etc.
Such a definition of the medical field iscompared to
the classical approach (see below)much more compre-
hensive and more appropriate to be used as a basis for an
international use. Compared to the classical approach there
are many advantages, namely
& the definition is more open for the use of all aspects of a
health resort including treatments complementary to
balneotherapy and environmental factors according to
the ICF-model (holistic approach)
& the definition is open for the use of similar and/or
identical substances outside health resorts (e.g. artificial
CO2 baths and injections in hospitals, drinking mineral
water at home to supplement mineral intake or prevent
renal stone formation, mud packs for use in medical
practice)
& it focusses on the general skills and aptitudes of a
specialist in the field (including advising patients when
and how to use Health Resort Medicine, Balneotherapy
and Climatotherapy)
& it is more similar to the definitions of other specialties
(as it includes diagnostic skills and a variety of
treatments)
& it enables research on comprehensive concepts as well
as on modalities and agents (including meta-analyses)
& it focusses on an international terminology
However, some limitations have to be mentioned too:
& the definition is open to methods in other settings, e.g.
outside traditional health resorts
& it has some overlap with other specialties (e.g. Physical
and Rehabilitation Medicine)
& it is somewhat different from some well-established
national descriptions of the specialty or competence
On the other hand, the traditional approach defines this
medical field as the use of regional remedies at the place of
their origin, which has to be a health resort (as described
elsewhere). In terms of Fig. 1, this approach goes from right
to left and includes the elements outside the use of mineral
3
May be summarised as treatments complementary to balneotherapy)
Int J Biometeorol (2010) 54:495507 499

Use of (natural) Bathing CO2, H2S, Brine, and others

mineral waters,
gases and peloids Drinking HCO3, SO4, and others

Inhalation NaHCO3, NaCl, and others

Medicine Use of (plain)
(diagnostic water
and others
and
treatment) in Head-out
health Under water Exercise
Use of climatic immersion
resorts
factors Application to
(health Thermotherapy
promotion, body parts
prevention,
therapy, Use of other and others Hydrogalvanic baths
rehabilitation) therapeutic
factors
others

Use of
environmental
factors

Fig. 1 Scheme of the structure of the medical field

waters, gases and peloids (Balneology) or climatic factors
(Climatotherapy) only in a secondary way. Advantages of
this approach are
& a clear definition of substances used
& supporting health resorts as exclusive centres for the use
of these substances
& the standardisation of the use of the terminology in
many countries
The main disadvantages and limitations are
& the restriction to local application of therapeutic
remedies (not holistic)
& the above-described barriers to international recognition
& focussing on specific properties (setting barriers on
generalising research and meta-analyses)
& and a dominance of national terms
Additionally, definition of remedies, which in most
countries is not medically but chemically driven, is much
more decisive in the classical approach.
Summarizing the above arguments, the holistic approach
to describing Health Resort Medicine has to be given
priority over the classical approach defining the specialty in
terms of the locally restricted use of regional natural
remedies.
Medicine in health resorts
Health resort therapy includes all medical activities based
on scientific evidence that are employed in health resorts
and are aimed at health promotion, prevention, therapy and
rehabilitation (Gutenbrunner and Schuh 2002). Core ele-
ments of health resort therapy interventions in health resorts
are balneotherapy, hydrotherapy, and climatotherapy. Other
interventions frequently used are massage, exercise, sauna,
Turkish bath, other physical therapies, e.g. kinesiotherapy,
thermotherapy, electrotherapy, occupational therapy, medi-
cation (pharmacotherapy), psychotherapy, nutrition (diet),
health education and cognitive behavioural therapies,
relaxation therapies, complementary therapies (e.g. integra-
tive medicine). Additionally a health-promoting environ-
ment, recreational activities, cultural and social activities as
well as sports form part of health resort medicine.
Prescription of comprehensive treatment programs and
dispensing of the treatments must be done by a specialist in
health resort medicine (see below) according to the medical
diagnosis and functional needs of the patient.
Diagnostic tools, such as evaluation of pathology,
functional assessments, psychosocial assessments, predic-
tion parameters, etc., are also included in health resort
medicine.
At least for some indications, studies have shown that
health resort medicine is effective (Forestier 2000; Strauss-
Blasche et al. 2000a; Guillemin et al. 2001; Leaute-Labreze
et al. 2001; Gutenbruner et al. 2002; Codish et al. 2005;
Dnmez et al. 2005; Ardic et al. 2007; Cantarini et al. 2007;
Franke et al. 2007b; Karaglle et al. 2007b; Gaal et al.
2008; Karaglle and Karaglle 2004; Devereux et al. 2005;
Pittler et al. 2006; Bartels et al. 2007; Verhagen et al. 2007;
Tomas-Carus et al. 2007; Forestier and Francon 2008; Hall
500
et al. 2008). Most of the latter studies deal with disorders of
the locomotor system; however, there is evidence of
beneficial effect in cardiovascular disorders (Gutenbrunner
and Schuh 2002; Carpentier and Satger 2009; Ippolito et al.
2008; Mancini et al. 2003); skin disease (Coccheri et al.
2002; Matz et al. 2003; Kazandjieva et al. 2008a; Brockow
et al. 2007c; Gambichler 2007); ear, nose and throat as well
as lung disease (Tabolli et al. 2009; Petraccia et al. 2005;
Vu and Mitsunobu 2004; Tanizaki et al. 1997); and
metabolic syndromes, gastrointestinal conditions and psy-
chosomatic disorders (Vu and Mitsunobu 2005; Salamon et
al. 2008; see also Gutenbrunner and Hildebrandt 1998).
A uniform and internationally used name for the medical
field dealing with Health Resort Medicine, Balneotherapy,
Hydrotherapy, and Climatotherapy does not exist. Two
approaches are used:
& using the interventions as the basis for the umbrella term
(Balneology and Medical Climatology or Medical
Balneology and Climatology (Central and Eastern
European Countries), Medical Hydrology and Climatol-
ogy (UK), Medical Hydrology (Spain, France,
Portugal, Italy4), Hydroclimatology (Turkey), Balne-
ology (United States, East Asia)
& using the setting of health resorts as basis for umbrella term,
resulting in Health resort medicine (Kurortmedizin)
Health strategies and purposes of treatment
The treatments in health resorts can be applied to different
groups of people, e.g. healthy subjects, persons with non-
specific disorders and patients with defined health conditions.
The main goals of these interventions are:
& Health promotion related to health resort medicine
aimed at improving general health, well being and
regulatory capacity as well as reducing and/or eliminat-
ing risk factors.
& Prevention related to health resort medicine aimed at
risk reduction for specific health conditions, e.g.
cardiovascular diseases, metabolic diseases, etc.
& Primary prevention aimed at reduction of incidence
of symptomatic disease, including measures like
behavioural changes (e.g. increasing physical activi-
ty), reduction of nutritional risk factors and improve-
ment of regulatory capacity of various body functions
(e.g. circulatory function, muscle function, metabolic
function).
& Secondary prevention aimed at early diagnosis and
early treatment of disease.
4
In these countries the term Crenotherapy is used for the use of
natural remedies for therapy and is equivalent with the term
Balneology
Int J Biometeorol (2010) 54:495507
& Tertiary prevention aimed at preventing relapse of
disease, improving functioning, reducing complication
and education to enable living with the damage
& Treatment aimed at the elimination or reduction of
symptoms of a disease (e.g. pain reduction, increase of
range of motion, blood pressure reduction, improve-
ment of lung function, and many others). The specific
action of treatments in health resort medicine are
beyond the scope of this paper (see textbooks on
balneology, climatology and health resort medicine)
& Rehabilitation aimed at improvement of functioning
according to the WHO definition, and improvement of
health-related quality of life. This includes enabling
strategies for people with disabilities and chronic
disabling conditions as well as compensatory strategies
and the adaptation of the environment to the specific
needs of these persons. Improvements of quality of life
and participation have been shown in recent studies
(Gusi et al. 2006; Eversden et al. 2007; Gaal et al. 2008;
Tomas-Carus et al. 2007).
Health resort medicine contributes to all the above health
strategies.
Use of mineral waters, gases, and peloids
The medical application of natural mineral waters, gases
and peloids (e.g. Fango), being effective for the prevention
or treatment of diseases and the improvement of function-
ing (rehabilitation), is one of the core elements of medicine
in health resorts. Methods of application (modalities) are
bathing (head out water immersion, bathing of body parts),
drinking, inhalation, irrigations, packs (local application of
peloids), dry peloid therapy (e.g. with sand), gas baths,
local application of gases, etc. The effects of the use of
natural mineral waters, gases and peloids are based on both
the chemical and physical properties of the agents.
The use of natural mineral waters, gases and peloids in
many countries is called Balneotherapy.
Substances
The following substances are used in health resorts:
& Medical mineral waters: require minimum concentra-
tions of ions and/or gases for the evocation of relevant
chemical effects. The thresholds of effective concentra-
tion should be defined on scientific evidence, taking
into account the specific methodology of application,
e.g. bathing, drinking, inhalation, etc. These waters are
described in many other documents. The composition
and threshold values may vary from country to country,
or from health resort to health resort. Temperature is an
important factor for therapy. Waters can be described as
Int J Biometeorol (2010) 54:495507
hypothermal (<35C), isothermal (3536C) and hyper-
thermal (>36C).
& Medical peloids: require a high specific heat and heat
keeping capacity, which are related to the composition
of the peloid and the viscosity during application.
Examples are peat, fango (volcanic origin), mud (from
ground of the sea, lakes or rivers), clay, etc.
& Natural gases: CO2, H2S and radon are used for therapy.
Of course, these substances can be used outside health
resorts as well (e.g. mineral water drinking, CO2-baths,
mud packs, etc.
For all these remedies, studies showing some relevant
physiological effects in healthy subjects and patients are
available (Gutenbrunner et al. 1999a, 1999b, 2001a; ; Fink
et al. 2001; Shehata et al. 2006; Bender et al. 2007; Braga
et al. 2008; Vaile et al. 2008). The substances investigated
were mainly mud, CO2, H2S, brine, hydrogen carbonate,
and sulphate. For some of them, controlled trials showed
relevant effects in specific health conditions (Gutenbrunner
et al. 1997, 2001b; Gundermann et al. 1998; Gutenbrunner
and Gundermann 1998; Fioravanti et al. 2000; Franke et al.
2000, 2007a; van Tubergen et al. 2001; Costantino and
Lampa 2005; Costantino et al. 2006; Cutovic et al. 2006;
Gusi et al. 2006; Balint et al. 2007; Bellometti et al. 2007;
Brockow et al. 2007a, 2007b; Eversden et al. 2007; Evcik
et al. 2007; Fransen et al. 2007; Karaglle et al. 2007a;
Lund et al. 2008; Odabasi et al. 2008; Silva et al. 2008;
Tomas-Carus et al. 2008)
Modalities
Mineral waters, gases and peloids can be used in different
ways, e.g. internal and external application. The most
important modalities of use are:
& Bathing: therapy by immersion of the body (head-out
water immersion) or of body parts into water, peloid or
gas. Bathing has chemical and physical effects on the
body. Mineral waters, gases and peloids cause local
effects on the skin, adsorption of ingredients and/or
elution of skin substances as well as subsequent
reaction in the neuro-immuno-endocrine-system.
& Drinking (Hydropenia or mineral water drinking cure):
a treatment method using ingestion of waters (mainly
medical mineral waters) aimed at modification of
gastro-intestinal, metabolic, renal and urodynamic func-
tion. Substitution and supplementation of minerals is
also incuded in drinking mineral waters.
& Inhalation: the application of aerosols via the respirato-
ry tract. For this purpose, medical mineral waters and
some natural gases (mainly radon) are used. Inhalations
have beneficial effects on the mucosa of the respiratory
tract and may improve respiratory function. Some
501
substances will be absorbed after inhalation and may
induce systemic effects.
Other modalities not regularly used in all countries and
all health resorts are mucosal irrigations with mineral
waters (lavage), tampon with peloids, injections (e.g.
CO2-gas), showers and water jets, jacuzzi, facial and body
masks with peloids, etc. This list can be extended due to
other specific methods and new developments in the field.
In scientific studies (as cited above) of the efficacy of the
application of these modalities, it does not make sense to
isolate the results from the effects of the medium used.
However, the physiological effects are well known and
have to be taken into account when prescribing these
modalities.
Use of plain water
The use of plain water (tap water) for therapy is called
hydrotherapy. Hydrotherapy includes the external applica-
tion of water for medical purposes and uses the physical
properties of water, i.e. temperature, hydrostatic pressure,
hydrodynamics, buoyancy, viscosity, and electric conduc-
tivity. Methods of application and modalities in hydrother-
apy are bathing (head-out water immersion, bathing of
body parts), showers, water jets, compresses, body wraps
underwater exercise, hydro-electrical baths, etc.
For underwater exercise, some studies have been
published recently showing good effects in osteoarthritis,
rheumatoid arthritis, and fibromyalgia (Vaile et al. 2008;
Gusi et al. 2006; Eversden et al. 2007; Fransen et al. 2007;
Lund et al. 2008; Silva et al. 2008; Tomas-Carus et al.
2008; Devereux et al. 2005; Bartels et al. 2007; Tomas-
Carus et al. 2007). The use of water in order to apply cold
stimuli was studied very intensively in the 1950s and
1960s. Here again, physiological reactions have been
well studied; however, a few studies show long-term
adaptation to serial applications, with good effects on
autonomous dysregulation and well being (Gutenbrunner
and Hildebrandt 1998; Strauss-Blasche et al. 2000a,
2000b; Armijo Valenzuela 2006). Water exercise is also
used in cardiac rehabilitation programs.
Use of climatic factors
The use of climatic factors for therapy is called climato-
therapy. Climatotherapy includes the planned medical
application of climatic factors, being effective for the
prevention or treatment of diseases and the improvement
of functioning (rehabilitation). Climatotherapy is performed
in specific climates, e.g. high altitude climates, sea coastal
climates, and includes changes of climatic environment.
Climatic factors with relevance for therapy are radiation
502
(ultraviolet, light, infrared), thermal stimuli (temperature,
wind, humidity, etc.) and air composition (pO2, therapeutic
aerosols, absence of pollution and allergens, etc.). Psycho-
logical reactions from the experience of landscapes may be
a factor too. Methods of exposure and modalities in
climatotherapy are open air rest with exposure of the whole
body or body parts to climatic factors [e.g. cold and
radiation (heliotherapy)], walking in conjunction with
exposure to climatic factors (so-called Terrainkur), speleo-
therapy (therapy in caves), etc.
The relevant effects of climatotherapy have been
reviewed, at least for some indications (Jandova et al.
2008; Kazandjieva et al. 2008b; Tsankov 1998; Wolf et al.
2003a). Moreover, randomised controlled studies on
clinical effects (Schuh 1993; de Andrade et al. 2008; Harari
et al. 2007; Hodak et al. 2003; Wolf et al. 2003b; Cohen et
al. 2005; Autio et al. 2002) and relevant factors (Cohen et
al. 2008; Uosif et al. 2008; Kovlen et al. 2007; Nissen et al.
1998) are available within this area. For treatment in
specific climatic regions, scientific studies have shown
beneficial effects in various health conditions (Kragballe et
al. 1996; Gutenbrunner et al. 2007; Sukenik et al. 1990a,
1990b, 1994, 1995; Paran et al. 1998; Sukenik 1998;
Buskila et al. 2001; Neumann et al. 2001)
Use of other therapeutic factors
A description of the use of other therapeutic factors is
beyond the framework of this paper. However, they are well
known and are described in the textbooks of the fields
concerned. Such factors include physical therapies (e.g.
thermotherapy, electrotherapy), physiotherapy, occupational
therapy, medical training and exercise, nutritional therapy,
massage therapy, psychotherapy, and health education.
Pharmacotherapy may also be included here. Of course,
this list can be extended due to particular needs of patients
or specific treatment concepts (e.g. comprehensive or
complementary medicine).
To review the scientific evidence for all these therapies is
also beyond the scope of this paper. Standard databases
(e.g. Medline, Cochrane Collaboration) can be used to
search for scientific reports.
Use of (other) environmental factors
The environmental aspects of health resorts have many
specific components that contribute to their therapeutic
effects. Based on the International Classification of Func-
tioning, Disability and Health, the following environmental
factors are characteristic for health resort settings:
& health care by specialised doctors, qualified therapists
(physiotherapists, occupational therapists, sport thera-
Int J Biometeorol (2010) 54:495507
pists, spa therapists, massage therapists, etc.), cooperat-
ing in teams (ICF-domain: e355)
& appropriate facilities for balneotherapy, hydrotherapy,
climatotherapy, massage therapy, exercise therapy, other
physiotherapy modalities, occupational therapy, nutri-
tional therapy, exercise, massage therapy, health educa-
tion, etc. (ICF-domain: e580, cf. ICF-domain: d839)
& local remedies for treatment (e.g. mineral waters,
peloids, gases, climatic factors; cf. ICF-domain: e110)
& environment supporting social contacts (family, peer
groups; cf. ICF-domain: d740, d760)
& facilities for recreation, cultural activities, leisure and
sports (cf. ICF-domain: d920)
& health-promoting atmosphere and environment close to
nature (cf. ICF-domain: e210)
& and other factors
Within health resorts, both in-patient and out-patient
settings are used.
Other settings in which mineral waters, gases and
peloids may be used are hospitals (departments for
balneology and physical medicine, rehabilitation units and
other wards), medical practice [specialist and general
practitioners (GP)], therapist practices (following GP
prescription), at home (self-application by patients or
relatives). However, the influence of these factors will not
be described or classified in this paper. There is an urgent
need for systematic scientific work on the effects and
efficacy of such factors.
Description of the scientific field
The scientific field dealing with health resort medicine is
called health resort sciences. It includes the medical
sciences, psychology, social sciences, technical sciences,
chemistry, physics, geography, jurisprudence, etc. Other
(equivalent) terms of health resort sciences are Kurortwis-
senschaft (Germany), Kurortologia (Russia), Medical hy-
drology, and others.
The scientific field dealing with balneotherapy is called
balneology or medical hydrology. It includes physiology,
medicine, chemistry, (hydro)-geology, physics, balneotech-
niques, etc. Other (equivalent) terms for balneology are
Hydrology, among others.
There is no separate scientific field dealing only with
hydrotherapy; however, the sciences dealing with hydro-
therapy are included under balneology (see above) and
Physical and Rehabilitation Medicine and Rehabilitation
(for definitions, see Gutenbrunner et al. 2007).
The scientific field dealing with climatotherapy and
biotropy is called medical climatology. It includes physiol-
ogy, medicine, meteorology, among others. Other (equiva-
Int J Biometeorol (2010) 54:495507
lent) terms for medical climatology are Biometeorology
(Anglo-Saxon countries), and Bioclimatology (Easter
European Countries, German-speaking countries), among
others.
Corresponding to the scientific field of Physical and
Rehabilitation Medicine (Stucki et al. 2007) science in
Health Resort Medicine, Balneology and Climatology
includes a wide range of research from basic science to
clinical trials (Fig. 2). Research is necessary ranging from
chemical and physical properties to the influences of Health
Resort Medicine on general health and society. The figure
gives some examples of the research fields within this
framework.
Discussion
This paper argues for a more comprehensive description of
the medical field dealing with Health Resort Medicine,
Balneology, Medical Hydrology and Climatology. It aims at
internationally agreed and recognised definitions; however,
the question of whether this field represents an independent
specialty or just a competency remains open and has to be
discussed elsewhere. A more comprehensive definition
requires a holistic approach, which is possible if the
medical work performed in a health resort is taken as the
basis. Definitions arising solely from just the agents or
modalities used in Balneology and Medical Climatology do
not meet these criteria. One of the main reasons for that is
that they differ significantly from region to region or
country to country, respectively. Implicitly, the chosen
approach leads to a more open definition of Balneology
and Medical Climatology, as the use of natural mineral
waters outside health resorts, the use of non-balneologic
therapies as the basis of the treatments and even the use of
Fig. 2 Structure of the scientific
field (following a scheme on the
structure of the scientific field of
Physical and Rehabilitation
Medicine; modified from Stucki
et al. 2007)
503
artificial mineral waters or other remedies may not be
excluded. This may be contested by Health Resort
managers; however, it can be overcome if the definition
of the medical field is not defined in the same way as
the health resort itself.
For the definition of a medical specialty not only the
field but also the competences, skills and aptitudes of the
respective physicians have to be described. This must
include diagnostic methods, assessments and interventions.
This is not the objective of this paper.
The definitions and descriptions given in this paper do
not automatically lead to independence from the traditions
and regional influences surrounding the terminology used.
To use existing words as a basis makes it on the one hand
easier to implement. On the other hand it may provoke
some contradiction because the use of terms in some
languages and/or cultures seems to conflict with others. To
solve this problem, bi-lateral projects may be helpful in
order to translate terms into specific languages. Such
projects should translate not only on the basis of the
meaning of a specific word but should reflect the cultural
background and meaning of a word in its national context.
For example, the English word balneotherapy cannot be
translated into French using balnothrapie but instead
translates as crenothrapie.
As this paper is a position paper it can be seen only as
a proposal or as the basis for future discussion. The
authors propose especially the following process or
actions:
& Discussion of the approach to describe the field of
Health Resort Medicine, Balneology, Medical Hydrol-
ogy and Climatology (i.e. whether to base this on the
comprehensive medical work carried out in a health
resort or solely on treatments and modalities)
504
& Discussion of short descriptions of terms, such as
Balneotherapy and Hydrotherapy, with the goal of
achieving internationally accepted distinct terms. This
task should be done as part of a structured consensus
process and is of major importance for the publication
of scientific results as well as for systematic reviews
and meta-analyses.
& Set up translation of the agreed terms into national
languages, taking into account the traditions of use of
such terms and the underlying culture. This could be
done by linguistically educated experts or small bi-
lingual working groups.
& Create and agree a catalogue or curriculum for the
competence, skills and aptitudes of a specialist in
the field of Health Resort Medicine, Balneology,
Medical Hydrology and Climatology. For this pur-
pose, task forces or working groups within interna-
tional professional and/or scientific organisations
should be set up (if not already existing). It should
be made clear that this would provide only a
framework, as national rules and procedures have
to be taken into consideration for the instigation of
national rules.
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