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 Abstract

Spas are being reconsidered. Instead of unhealthy way of life and aggressive therapies, crenotherapy  take sure place. The new demand for spas is a response to new values. We offer thecnics information above suitable indications and balneotherapy kinds.

Introduction

Baths are fashionable again. They are not as splendorous as they used to in the XIX century, but in the modern life style of the XXI century, the people have become victims of the rhythms of life and competition. Thus they suffer of physical and psychological disorders that force these individuals to undergo health treatments to restore their physical condition and state of mind. Since the 80´s there has been a change on thermal spas. This transformation has to do with the stressful life of big cities, the search for alternative holidays, the consolidation of ecological movement, a new leisure culture, the cult of body and new trends, the encounter with a nature that seemed to be lost.all this gathers in a conspiracy for the recovery of spas.

It has become fashionable to recover the natural ideal of older times, avoiding medicines and recovering health by other means. The search for quietness and self personality leads to the reunion with nature. Thus, in this going back to old ideals, the recovery of spas acquires a new meaning as places where to overcome stress and the psychological tension imposed by modern life (Latiessa-Álvarez Soussa, 2000). All this contributes to the development of a new type of tourism: health tourism. Therefore, resorts that offer thalasotherapy spas or similar body treatments are the new main destination for this kind of tourist (Vila, 1995; Cockerell, 1996).

The concept "kur" (to take the baths) has a long tradition in some developed countries (mainly in northern Europe) but it's also becoming popular in others (e.g. USA, where doctors still doubt their benefits for health) (Baudbovy, 1998). Sevilla (1997) informs that 81.1% of clients repeat after having improved. Thus Sevilla classifies the types of pathologies treated at a spa as: 76.3% locomotive system, 22% respiratory system, 16.9% digestive system, 6.8% circulatory system, 5.1% nervous system, 1.7% endocrine system, 1.7% dermatologic problems (non exclusive categories). Sevilla's works (1997) concludes stating that during the stay in the spa, 22% of the users have reduced their medicaments consumption, and 5.1% did not take any more medicaments.

San Pedro (1998) has the opinion that there is a lack of social trust on the curative properties of minero-medicinal water because of the influence of the aggressive and flourishing pharmacologic industry. Even among professional, there is a low credibility on techniques such a crenoteraphy, mainly due to the lack of specific subject that cover this topic in medicine schools. San Pedro (1998) also criticizes the conditions in which many spas are, and defends the need for investments oriented to the renovation of the spa resorts in order to adapt them to the needs of the new type of young clients who demand new techniques, qualified staff, quality and professionalism of the medical services, etc. Most of the thermal stations of Spain are missing all the previous amenities.

The thermal treatment aims to: recovery of illness, prevention of illness, physical maintenance, physical and psychical well being. The recent phenomenon of the day spa is now expanding in Europe: spa services (mostly bath and massage) during just a few hours. It is also possible to find now spas that offer full programs to elite sportsmen (Vázquez, 1997). Spain is considered to be the most important thermal station in Europe due to the quality of its water and the amount of springs it has. There are 128 spas in the country, 50% of them are open all year round and the rest only during summer holidays (Vila, 1995).

Definition of Spa

There are a few criteria that define the special characteristics of a spa (Díez, 1998):

1) In comparison to hygienic thermal baths where water has been heated up, in the spa the water does not need to be heated and neither does it have to be manipulated.

2) The water of the spa cures, while the water of thermal baths has a hygienic function.

The spa water provides two types of therapeutic benefits:

1) The "scientific" cure, based on the characteristics of the water and its therapeutic power. This cure requires medical prescription.

2) The "miraculous" cure bases its effects on the divine presence that exist in the water and that transfer some of divinity to the water. The water thus acquires a purifying value that relieves the soul and the body of psychic suffering (González, 1995; Píñar, 1999).

Traditional old medicine explained the curative power of thermal waters without this supernatural nuance. However, many still believed on the divine character of some water. According to this sort of thinking, healing water is magic water: the spa thus becomes the space where the deity shows its most favourable side, its capacity to cure (Díez de Velasco, 1998)

From a modern point of view and according to the criteria established by the National Association of Thermal Stations, spas and thermal stations have to meet the following criteria:

- Have minero-medicinal water declared of public utility,  

- Have medical and auxiliary staff supervising the use of the means in each patient.

- Have the appropriate techno-sanitary facilities for the correct application of the prescribed thermal treatments

A basic element in the spa is the source that provides minero-medicinal water. There are more than 2000 springs in our country that supply this kind of water. In Andalusia there are more than a dozen of these spas with a high reputation because of the quality of their water and because of the diversity of the services provided.

The WHO on its resolution EB 77.R 16 of January 1987, recognizes the importance of thermalism, thus considering this sort of thermal centres as health centres. Hydrotherapy is the use of water in the treatment of disease. Crenoterapy is the use of mineral-medicinal water. The therapeutic complex that has the water as main element also takes into account the effects of climate, the geologic characteristics of the place, ionization, humidity of the air, sport and rest habits of the patient, the diet, as well as the psychic influence of the atmosphere

Minero-medicinal waters

The origin and definition of minero-medicinal waters has never been a unilateral one.  The WHO defines in 1969 the Natural Mineral Water as any non bacteriological polluted water that, coming from a underground source, contains a certain amount of mineralization, and thus can have positive effects when applied to humans. Minero-medicinal water can be found at special places like where there are faults in the terrain. Spas with very hot waters are usually located at areas with a compact rocky substrate with many faults that permits semi superficial waters to get to the surface relatively quickly, thus keeping the water of the temperature they had while being underground (Bel and Marinez, 1995).

Many experts have tried to explain the high temperatures of certain thermal fountains since old times. The first one who tries to find the reason is Aristotle, who believes that the warmth of the water is related to the heat that penetrates the globe. This heat accumulates in the centre and is absorbed by the water storage in subterranean fountains. Some of this temperature is lost by the time water reaches the surface (Oró, 1996). A high percentage of this warm water has it origin in fountains more than two thousand mitres deep. Is the depth of these sources of water what explains two of the main characteristics of mineral-water: the stability of its chemic properties, and the constant volume of the water that reaches the surface (Bel and Martínez, 1995). This stability of its chemic properties is related to the continuous soaking of the mineral substances found in every rocky stratus the water crosses. The volume of the water is explained if we take into account that the water caudal is not affected by the changes of the season that occur on the surface of the planet. They are therefore fossil waters of many years of age (Bel and Martínez, 1995)

The benefits of Crenoterapy are related to its positive effects on the endocrine and metabolic homeostasis. Thus, it contributes to enhance the natural mechanisms of defence, balance and organic adaptation. Water becomes the universal physiologic regulator and that is why thermal cures are authentic natural therapies (San José, 1996). The ability to cure depends on the chemic composition of the water. Water can then be classified in the following categories:

-Sulphate water: Most sulphate (SO4) compounds originate from the oxidation of sulphite ores. The absorption of sulphur by the skin results on the following benefits for the body: improvement of the articulations and the vascular structure by taking part in oxidation-reduction processes, and forcing tissue tropism. Its mineralization is high and its taste is bitter. Its use as a laxative, diuretic, intestinal alterations and gastritis.  

- Chloride water: Its main salty component is chlorides (C1). This type of water is usually found on deep salty stratum that date back to old geologic periods. Chloride waters increase the natural defenses of the skin and are used as a treatment for the following cases: gynaecologic pathologies, muscular injuries, bone traumatisms, and to stimulate the gastric, hepatic and biliary functions.

- Bicarbonate water. This water contains calcic and sodic bicarbonates. Bicarbonate calcic waters have a mild taste and they are used for digestive treatments. Most bottled waters are calcic bicarbonate waters and they have their origin in the interaction of water with aquifer sediments, principally limestone. Sodic bicarbonate waters have a different origin. That origin is related to recent volcanic phenomena and contains high levels of carbonic gas on their composition. They are also used as table water and when having hepatic, gastric and renal problems.

- Ferric water. Ferric water contains high level of iron as a result of having been absorbed by soil with a high level of this mineral. This type of water is highly indicated in case of anaemia, growth disorders, obesity, and diet treatments.

- Radio active water. Very uncommon water. This sort of water can be found at not very deep underground levels and it's in contact with very old geologic materials usually intrusive. The components of this water (lithium, cobalt, nickel, radius, etc.) in very small quantities are prescribed in treatments against stress, anxiety, depression and nerve alterations. Also in case of atrophic rheumatism, muscular or gynaecologic (no related with tuberculosis or tumors) problems, dermathosis (eczema, psoriasis).

Minero-medicinal waters are usually a mixture of the different types of water there are. This explains its polyvalency when applied to different health treatments.  Another factor that contributes to the beneficial effects of mineral water is related to climatology and the surroundings of the spa. Those located at mountain areas, have a tonic and stimulating climate, indicated for people with heart pathologies.  Those at a medium low high (less than 400 metres over sea level) offer milder temperatures, suitable for all people and treatments.

It is evident that spa therapy has a positive effect in case of osteoarticular pain and it improves the articular function. They also contribute to improve the quality of physic and psychic life, flexibility, reduces anxiety and depression as well as increase the self esteem of the patient (Cherkin, D, 1998; Constant, F, 1998).

Ancient authors were also aware of the contraindications of thermal baths in certain cases. Modern hydrologists are aware that in case of incurable illness or the way those illnesses have evolved, mineral waters can accelerate the process of deterioration of the patient's health. At a different stage of the illness, this water would have had a complete different outcome as it would have helped to slow down or even stop the worsening of the patient's disease. In any case, mineral waters are only contraindicated for apparently incurable illnesses in some specific circumstances (Oró, 1996).

Generally, mineral waters should not be indicated in case of severe illnesses or worsening of the evolution of the pathology. Many times, the negative outcome of the treatment with mineral water is related to the excessive amount of water drunk.  Long immersions or high water temperatures can also be contra productive.

In some European countries where "taking the waters" is a national tradition (as Cockerell (1996) tells us when referring to Germany, France and Italy) the thermal treatment is part of the Social Security provisions package. In other   countries such as Spain, this possibility does not exist, even though the IMSERSO finances the stay of older people at thermal stations but with a social purpose rather than with the idea of improving the health of these people (IMSERSO, 1996). In the United States these type of treatments are consider to be a luxury (Cherkin, D, 1998).

Water application techniques

The oral Ingestion of mineral-medical water (HIDROPINIC CURES) helps the organism to absorb the mineral components of the water. It is more convenient to do it in the mornings, before eating, and then going for a calm walk. This treatment is recommended in case of digestive or kidney problems. Almost all types of water can be drunk and almost all thermal stations offer treatments that combine external and internal water cures (Bel and Martínez, 1995). The baths are a very important hydrotherapeutic complement.

Baths have been long used for helping to relax, heal wounds, and improve dermatologic treatments, bone traumatism and rheumatic processes (Rus, 1994). Its mechanic and thermic action improves the affections of the locomotor system while the absorption of the minerals by the skin is also beneficial. In this case, the assimilation of these mineral elements by the skin will depend of the thickness of the skin, temperature, vascularization, pH, and potential redox of the environment (Rus, 1994). The thermal and mechanical action of the water does not only dilate the tissular irrigation and paralyzes vasoconstrictive responses (Rus, 1994). What is more, the hidropinic cure triggers psychotropic actions that can act as a placebo. This stimulus is a reaction to (Rus, 1994):

- Corticomotor reaction. The experiments of Euler and Söderberg in 1957 showed the application of certain temperatures that produced electroencephalographic reactions and also demonstrated the synchronization with the archicortex as well as a decrease of the skeletal muscular tone. The responses to these stimuli are mood changes, and irritation with an effect on the heart, vascular, respiratory and metabolic activity. When cold water is applied, the responses are the opposite of the ones previously described. When the temperature is medium (33-35ºC) the response corresponds to the hydrostatic pressure. The perimeter of the thorax reduces, the intra thoracic pressure goes higher, and intraabdominal pressure increases the. The muscular tone increases as well as the circulatory/minute volume.

- Placebo effect. Accompanies any therapeutic act and it is more common on physical acts. When using hydrotherapy they act independently of the effects that the therapeutic staff or the water, the presence of other patients or other stimuli such as the atmosphere, the trip, etc.  The placebo effect is based on the principle of Carpenter that justifies the magic ritual of older therapeutic practices and also the way modern techniques are applied (Armijo, 1968).

Patients must be ready to undergo thermal treatments. Hydrologists agree that when the water is too active, the thermal fibber can be too intense and they recommend to reduce the mineral in the water by mixing it with sweet water (Oró, 1996).

Crenoterapy applications

- Hot baths. Analgesic, anti-inflammatory, relaxing and counterirritant effects beneficial in case of chronic rheumatic, articulation, muscular processes, flat muscular spasms and congestion of inner organs. This type of baths contribute to the interruption of the circle pain-contraction-attitude vicious-pain.

- Cold baths. Applied during seconds or minutes (3-4) have anti-inflammatory, decongestive, analgesic, haemostatic and tonic effects. Indicated in case of neuro-vegetative and neuro-circulatory distonia, stress and endocrine alterations.

- Baths at indifferent temperature. (30 minutes to an hour). This kind of baths have a relaxing effect that reduces the sensibility of the peripheral receptors: excitability and motor activity, relaxing of the muscles, easier peripheral vasodilatation, stimulate the heart activity, town down the metabolism and the respiration insensibility, increase the elimination of urine, and improve the tropism of the skin. Indications: insomnia, alcoholism, hyperesthesia, some dermopathies, some burst, with addiction to CINa in a concentration from 1 to 3%.

- Contrast baths. In two recipients. One with cold water (15-20ºC) and another one with hot water (37-42ºC). Indications: spasmodic peripheral circulation, intermittent claudication, Raynaud disease. Contraindications: heart problems, advanced arteriosclerosis, caquexia, skin sensibility to water, and serious kidney or liver disorders.

The massage, done by moving the water that is inside the containers (moved with turbines, injectors,  bubbles, etc.) is beneficial in case of muscular spasmo, for the activation of the pheripheral circulation, , skin tropism activator, heal of wounds, fractures, inflammatory and edema processes.

- Peloides. They are substances that develop as a result of geological processes. Pulverized and mixed with water, these substances are used as mud and slime with a therapeutic action. (1) Peloides of organic origin: slimes and marshy soils formed over the time by underwater plants. (2) Inorganic Peloides: mud of warm springs and the silt accumulated in rivers. Because of its capability to keep the warmth and because of the amount of minerals they contain, the application of Peloides has an effect much more intense than other hydrotherapies do.

The curative effects of muds are known since old times. In Spain the muds of the spa of Arnedillo (La Rioja) are very well know. There you can fin the spring "Los Barros", a natural source of radioactive mud, with a great amount of seaweeds and organic material on its composition.

- Showers. Tonic, stimulating and relaxing. Some authors argue that for a while showers were not used during ancient times. However, that idea is over now. The Water or steam with a certain pressure can be applied in various ways: forced streams. Pressure of 1,5 or 2  relative atmospheres (it corresponds to a stream of 5-7 meters of lengths) Applied in case of Dysmenorrhea, amenorrea or vegetative alterations. Fan. Rain or fog. Pre-heating (traumatic injuries, circulatory problems, lumbago, mialgias. Alternating or Scottish (Kneipp). A water pump regulates the pressure and the temperature. Inhalations trough aerosols in case of illness related to sinusitis, rhinitis, bronchitis, pharyngitis, etc.

The new concept of spa as a centre for the general recovery of health is related to the introduction of new services such as: stress cures, rest cures, slimming, elimination of toxins, acupuncture, oxigenotherapy, electrotherapy, rehabilitation, etc.

All in all, modern spas offer now a days integral health services that are not always valued or even known by the professionals of the health system. If we would try them, we would repeat.

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