studies on the effects of spa therapy on endocrine functions

studies on the effects of spa studies on the effects of spa therapy on endocrine functionstherapy on endocrine functions

Prof Dr Hatice GürdalProf Dr Hatice Gürdal

İstanbul University, İstanbul Faculty of Medicineİstanbul University, İstanbul Faculty of Medicine

Medical Ecology and Hydroclimatology departmentMedical Ecology and Hydroclimatology department

spatherapyspatherapy

spatherapy can be regarded as a kind of stimulus spatherapy can be regarded as a kind of stimulus - adaptation therapy because patients are - adaptation therapy because patients are repeatedly exposed therapeutic stimulations repeatedly exposed therapeutic stimulations including thermomineral and peloid baths, including thermomineral and peloid baths, exercises and other complementer therapies.exercises and other complementer therapies.

The direct effects of thermomineral baths on the body are The direct effects of thermomineral baths on the body are mainly consist of physical , thermal and chemical effects.mainly consist of physical , thermal and chemical effects.

spatherapyspatherapy

spatherapy can be regarded as a kind of stimulus spatherapy can be regarded as a kind of stimulus - adaptation therapy because patients are - adaptation therapy because patients are repeatedly exposed therapeutic stimulations repeatedly exposed therapeutic stimulations including thermomineral and peloid baths, including thermomineral and peloid baths, exercises and other complementer therapies.exercises and other complementer therapies.

The direct effects of thermomineral baths on the body The direct effects of thermomineral baths on the body are mainly consist of physical , thermal and chemical are mainly consist of physical , thermal and chemical effects.effects.

The complex therapeutical factors work to alter the The complex therapeutical factors work to alter the physiological functions comprehensively and non-physiological functions comprehensively and non-specifically.specifically.

The process of alteration is considered to be mediated by the The process of alteration is considered to be mediated by the autonomic nervous system, autonomic nervous system, endocrine systemendocrine system and immun and immun system system

Most physiological functions exhibit a circaseptan (about 7 Most physiological functions exhibit a circaseptan (about 7 days ) or a circadecan (about 10 days ) rhythm during the days ) or a circadecan (about 10 days ) rhythm during the course of adaptation to the therapeutic normalizationscourse of adaptation to the therapeutic normalizations

It generally takes three to four weeks to achive these changesIt generally takes three to four weeks to achive these changes

( ( Agishi& Hildebrandt, 1989 Agishi& Ohtsuka ,1995 )Agishi& Hildebrandt, 1989 Agishi& Ohtsuka ,1995 )

Such effects of long- term balneotherapy have Such effects of long- term balneotherapy have been examined using various indicators such been examined using various indicators such as as catecholamine ,cortisolcatecholamine ,cortisol, blood pressure , blood pressure and pulse rate and other parameters. and pulse rate and other parameters.

During the course of treatment , a variety During the course of treatment , a variety of physiological functions have been of physiological functions have been found to be normalizedfound to be normalized

( Agishi& Ohtsuka , 1995 )( Agishi& Ohtsuka , 1995 )

Figure Figure 44 shows shows

weekly change in circadian rhytm of plasma weekly change in circadian rhytm of plasma cortisol during 4 weeks balneotherapy in cortisol during 4 weeks balneotherapy in hospitalized patients .it clearly demonstrateshospitalized patients .it clearly demonstrates

the lowering of acrophase and the decrease of the lowering of acrophase and the decrease of the amplitude during the curethe amplitude during the cure

Bursa Military Hospital in TurkeyBursa Military Hospital in Turkey

The studies, which we performed in The studies, which we performed in Bursa Military Hospital using the Bursa Military Hospital using the acratothermal water of this place to acratothermal water of this place to investigate the endocrinological investigate the endocrinological nonspecific effects of balneotherapynonspecific effects of balneotherapy

URINARY CORTISOL LEVELS DURING URINARY CORTISOL LEVELS DURING BALNEOTHERAPY WITH ACRATOTHERMAL BALNEOTHERAPY WITH ACRATOTHERMAL WATERWATERHatice GÜRDAL, Bora GÜVENER, Selahattin SÜRGİT , Elif ÖZKÖK, Hatice GÜRDAL, Bora GÜVENER, Selahattin SÜRGİT , Elif ÖZKÖK,

Kamil YAZICIOĞLU, Yağız ÜRESİN, Nurten ÖZERKamil YAZICIOĞLU, Yağız ÜRESİN, Nurten ÖZER

Proceedings of The 33rd Conference of SITH in Hakone, Proceedings of The 33rd Conference of SITH in Hakone,

Kanagawa, Japan December 1-6 1997Kanagawa, Japan December 1-6 1997

This work was supported by Istanbul This work was supported by Istanbul University Research Fund. Project University Research Fund. Project

Number 485-230791Number 485-230791

Bursa Military HospitalBursa Military Hospital

The acratothermal water in Bursa Military The acratothermal water in Bursa Military Hospital is mostly used in Hospital is mostly used in rrheumatological heumatological diseases as balneotherapy.diseases as balneotherapy.

The total mineral content of the water is The total mineral content of the water is 606.33 mg / lt ( Na , Ca , Mg , HCO3 , SO4 , 606.33 mg / lt ( Na , Ca , Mg , HCO3 , SO4 , H2SiO3 ) and the Radon ( Rn222 ) content is H2SiO3 ) and the Radon ( Rn222 ) content is 3329 pci / lt.. 3329 pci / lt..

PATİENTS and METHODPATİENTS and METHOD

I- The I- The balneotherapy groupbalneotherapy group :had :had twenty-twenty-four patientsfour patients ( 5 males, 19 females ; mean ( 5 males, 19 females ; mean age 59.3 years )age 59.3 years )

II- The II- The control groupcontrol group eleven patients (4 eleven patients (4 males , 7 females ; mean age 61.4 years )males , 7 females ; mean age 61.4 years )

patients which in both groups were patients which in both groups were primary primary osteoarthritis osteoarthritis

All subjects were All subjects were hospitalized in Bursa hospitalized in Bursa Military HospitalMilitary Hospital and had not any medical and had not any medical treatments excluding analgesic. treatments excluding analgesic.

General datas of two groups (patient who suffering from General datas of two groups (patient who suffering from primary osteoarthritis) primary osteoarthritis) in Bursa Military Hospitalin Bursa Military Hospital

balneotherapy group

( n= 24 )

control group ( n= 11)

Female 19 7

Male 5 4

Age ( year ) 59.3 61.4

The The balneotherapy balneotherapy group patients have had a group patients have had a whole body immersion bath, once at morning for whole body immersion bath, once at morning for 15 minutes in 3615 minutes in 360 0 C ± 2C ± 200 C C with with acratothermal water acratothermal water and and appliedapplied physiotherapyphysiotherapy and physical and physical exercisesexercises for 3 weeks balneotherapy cure period. for 3 weeks balneotherapy cure period.

The control group patients have had only The control group patients have had only physiotherapyphysiotherapy as with infrared, ultrasound and as with infrared, ultrasound and short-short-wavewave diathermy and physical diathermy and physical exercises exercises along the cure period.along the cure period.

Balneotherapygroup(n=24 )

at morning head outimmersion bath, for 15minutes in 360 C ± 20 Cacratothermal water andphysiotherapy / regularexercise

Control group(n=11) physiotherapy ( Infra Red,

Ultrasound, Short WaveDiathermie) and regularexercise

Cure duration for 21 days at Bursa MilitaryHospital

urine samplesurine samples

The 24 hrs. urine samples were collected The 24 hrs. urine samples were collected on the 1on the 1stst, 4, 4thth, 7, 7thth, 11, 11thth and 19 and 19thth days of study days of study periodperiod ( (in the course of the in the course of the the three weeks the three weeks of of cure ). cure ).

All samples acidified immediately and All samples acidified immediately and transported in ice-boxes to the analytical transported in ice-boxes to the analytical department and stored in deep-freezer (-20department and stored in deep-freezer (-200 0 C) until analysis.C) until analysis.

Methods for Methods for analysesanalyses

Diethyleter was used for the extraction of cortisol from Diethyleter was used for the extraction of cortisol from urine samples and the levels were urine samples and the levels were determined by determined by high-performance liquid chromatographyhigh-performance liquid chromatography (HPLC ) (HPLC ) method method byby using Waters HPLC equipment ( Millipore using Waters HPLC equipment ( Millipore Corp.U.S.A.).Corp.U.S.A.).

24-hour urine total catecholamines were measured by 24-hour urine total catecholamines were measured by HPLCHPLC for separation for separation with electrochemical detection with electrochemical detection and quantification, in a methodand quantification, in a method modified from Holmes modified from Holmes et al.et al. (measured(measured using liquid chromatography) and using liquid chromatography) and creatinine.creatinine.

statistical evaluation statistical evaluation

The results of both groups and the mentioned The results of both groups and the mentioned days were analyzed statidays were analyzed statististically with One-Way cally with One-Way ANOVA test method among each other ANOVA test method among each other separately.separately.

According to the ANOVA test the mean values According to the ANOVA test the mean values were not significantly different ( P > 0.05 ) . were not significantly different ( P > 0.05 ) .

Statistical dataStatistical data

ANOVA test and post hoc test were ANOVA test and post hoc test were used to compare the changes and to used to compare the changes and to determine the differences in level determine the differences in level cortisol and catecholamine among two cortisol and catecholamine among two groups for the three weeksgroups for the three weeks

resultsresults

The urinary cortisol levels of patients of The urinary cortisol levels of patients of balneotherapy and control groups are shown balneotherapy and control groups are shown in figuresin figures

As seen from figureAs seen from figuress, the levels varied , the levels varied between large distance ( 0.041 and 108.87 between large distance ( 0.041 and 108.87 mcg / 24-hrs. )mcg / 24-hrs. )

The very high cortisol levels of some The very high cortisol levels of some patients in the first week of the curepatients in the first week of the cure

0

20

40

60

80

100

the

leve

l of

uri

nar

y co

rtis

ol (

m

cg /

24 h

rs )

Before 4th day 7th day 11th day 19th day

3 weeks cure period

The UrinaryDaily Cortisol Levels During Balneotherapy (groupI n=24 )

1 2 3 4 5 6 7 8 9 10 11 12 13 1415 16 17 18 19 20 21 22 23 24

the urinary daily cortisol levels during physiotherapy in Bursa (control group n=11 )

0

5

10

15

20

25

30

35

40

Before 4th day 7th day 11th day 19th day

3 weeks therapy period

The

uri

nary

cor

tiso

l le

vel

(mcg

/ 2

4 h

rs )

1 2 3 4 5 6 7 8 9 10 11

mean urinary cortisol levels at balneotherapy and mean urinary cortisol levels at balneotherapy and control groups during 3 weeks cure in Bursa Military control groups during 3 weeks cure in Bursa Military

HospitalHospital

0

2

4

6

8

10

12

14

the

uri

nar

y co

rtis

ol le

vel

(mcg

/ 24

hrs

)

Before Day 4 Day 7 Day 11 Day 19

control Balneotherapy

female patients in control groupfemale patients in control group

0

5

10

15

20

25

30

Uri

nary

cor

tiso

l lev

els

before 4th day 7th day 11th day 19th day

1 2 3 4 5 6 7

-10

10

30

50

70

90

110

Th

e u

rin

ary

cort

isol

lev

els

( m

cg /

24h

rs )

before Day 4 Day 7 Day 11 Day 19

the female patients in Balneotherapy group (n:17)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

5

Tot

al U

rin

ary

Cat

ech

olam

ine

leve

l (m

g/d

ay )


the urinary total catecholamine excretion in balneotherapy group( n:17 )

1 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18

0

0,5

1

1,5

2

2,5

3

the

urin

ary

tota

l cat

echo

lam

ine

mg/

day


the urinary daily total catecholamine excretion in control group during 3 weeks period

1 2 3 4 5 6 7

0

0,5

1

1,5

2

2,5

The

uri

nary

tot

al c

atec

hola

min

e (m

g/da

y)


The Mean Urinary Daily Total Catecholamine Excretion During 3 Weeks

Balneothr control

DISCUSSION andDISCUSSION and C CONCLUSIONONCLUSION

there was an increase at mean urinary cortisol there was an increase at mean urinary cortisol level on fourth day of level on fourth day of Spa therapy Spa therapy

there was an increase at mean urinary cortisol there was an increase at mean urinary cortisol level on seventh day of level on seventh day of physiotherapyphysiotherapy group group

the catecholamine levels were slightly increased the catecholamine levels were slightly increased at seventh day of cure but not statistically at seventh day of cure but not statistically significantsignificant . .

According to the ANOVA test the mean values were not significantly different ( P > 0.05 ) .According to the ANOVA test the mean values were not significantly different ( P > 0.05 ) .

the mean values of urine cortisol

0

2

4

6

8

10

12

14

Before Day 4 Day 7 Day 11 Day 19

mea

n co

rtis

ol le

vels

mcg

/day

control Balneotherapy

As seen from the figure, mean cortisol levels As seen from the figure, mean cortisol levels increased on the 4th day of the cure at increased on the 4th day of the cure at balneotherapy group and increased on the balneotherapy group and increased on the 7th day of the cure at control group7th day of the cure at control group

The very high cortisol levels of some The very high cortisol levels of some patients in the first week of the cure left us patients in the first week of the cure left us think about the possibility of the outcome of a think about the possibility of the outcome of a cure crisis . cure crisis .

These finding left us think about the possibility These finding left us think about the possibility of the outcome of a cure crisis during of the outcome of a cure crisis during the the course of course of adaptation to the therapeutic adaptation to the therapeutic normalizations.normalizations.

conclusionconclusion

at the end of the cure , Increasing of cortisol levels in at the end of the cure , Increasing of cortisol levels in patients with low beginning levels at patients with low beginning levels at balneotherapybalneotherapy groupgroup

Decrease in cortisol level at the end of Decrease in cortisol level at the end of physiotherapyphysiotherapy ( control group ) was less manifest ( control group ) was less manifest

These finding left us think about the possibility of the These finding left us think about the possibility of the Regulatory effect of balneotherapy??!!Regulatory effect of balneotherapy??!!

On the other hand the effects of single or cure On the other hand the effects of single or cure therapy in hyperthermic bath or sauna were therapy in hyperthermic bath or sauna were studied and the change of stress hormon studied and the change of stress hormon levels were investigated (8 , 9 ,10 ,11 ). levels were investigated (8 , 9 ,10 ,11 ). Bühring et alBühring et al. have shown that plasma . have shown that plasma cortisol levels increased two fold after single cortisol levels increased two fold after single hyperthermic bath therapy ( 12 ). hyperthermic bath therapy ( 12 ).

But But Epstein et alEpstein et al . have demonstrated . have demonstrated that there was no difference in the urinary that there was no difference in the urinary or plasma 17- OHCS levels between or plasma 17- OHCS levels between health subjects of therapy and control health subjects of therapy and control groups after an immersion in hot water groups after an immersion in hot water ( 34 ( 34 00C ) ( 13 ) .C ) ( 13 ) .

Ayats et al.Ayats et al. have showed the increase of have showed the increase of ACTH levels but there was no change of ACTH levels but there was no change of urinary cortisol levels after hydrotherapy urinary cortisol levels after hydrotherapy cure in patients with chronic rheumatic cure in patients with chronic rheumatic pain ( 14 ) . pain ( 14 ) .

It seems that our results are It seems that our results are similar with the results of Ayats et similar with the results of Ayats et al.,but in conclusion , we think that al.,but in conclusion , we think that more detailed investigations more detailed investigations should be carriedshould be carried on the effect of on the effect of balneotherapy with acratothermal water ,balneotherapy with acratothermal water ,

for example bath application in different for example bath application in different temperature, with healthy subjects , with temperature, with healthy subjects , with subjects in different age groups and subjects in different age groups and cure periods .cure periods .

Recent studies of urinary catecholamines Recent studies of urinary catecholamines have shown that the excretion of these have shown that the excretion of these hormones is detectably related to life-styles, hormones is detectably related to life-styles, habits and subjective feelings on ahabits and subjective feelings on a

population basis (Jenner, Reynolds, Harrison population basis (Jenner, Reynolds, Harrison and Palmer )and Palmer )

Urinary catecholamine excretion rates, previously Urinary catecholamine excretion rates, previously shown to be related to lifestyles and shown to be related to lifestyles and environmental influences, Significant inter-environmental influences, Significant inter-population differences in excretion rates and in population differences in excretion rates and in creatinine-related excretion were observed. creatinine-related excretion were observed. most most of the studies were carried out of the studies were carried out retrospectively retrospectively output was expressed output was expressed relative to creatininerelative to creatinine

Recent studies showed that Recent studies showed that internal and external effective internal and external effective factors on endocrin responses to factors on endocrin responses to spa therapyspa therapy

primary promoting factors on hormone levels primary promoting factors on hormone levels during spa therapyduring spa therapy

Water compositionWater compositionRadon gas contentRadon gas contentBath temperatureBath temperatureBath duration Bath duration

Time of bath Time of bath applicationapplication

Number of BathNumber of Bath

Additional therapies Additional therapies

Cure durationCure duration

AgeAgeSexSexHealthy or morbid Healthy or morbid kind of diseasekind of disease

disease disease characteristicscharacteristics

Schnizer Schnizer w.w.

19951995 N=24N=24 32-36oC32-36oC

30-60 30-60 minuteminute

İmmersionİmmersion

3weeks3weeks

Blood Blood cortisolcortisol

-0.6 -0.6 Adrenaline Adrenaline +3.4+3.4

Jezova D.Jezova D. 19941994 N=16N=16 80oC-90oC80oC-90oC


HypertermiHypertermia in saunaa in sauna

Blood Blood cortisolcortisol

ACTH ACTH AdrenalineAdrenaline

increaseincrease

KukonenKukonen 19891989 N= 8N= 8 80-100oC80-100oC


in saunain sauna Plasma Plasma cortisolcortisol

decreased decreased Acth and Acth and Adrenaline Adrenaline

increasedincreased

KurabayKurabayashi ashi

20012001 N=7N=7 37oC- 42oC37oC- 42oC

10 minute10 minute

Headout Headout water water immersionimmersion

CatecholaCatecholamine mine decreased decreased ( 37oC)( 37oC)

increasedincreased

( 42oC)( 42oC)

YamaokaYamaoka 20042004 N= 15N= 15

Male Male

36oC36oC

Radon hot Radon hot springspring

42oC 42oC saunasauna

Plasma Plasma ACTH ACTH

İncreased İncreased ( 40 fold ( 40 fold higher ) in higher ) in Radon Radon groupgroup

Yamaoka Yamaoka 20042004 N=20N=20 42oC room 42oC room temp.temp.

after radon after radon therapy therapy 2hrs, 2 2hrs, 2 weeks , 4 weeks , 4 weeks, 6 weeks, 6 weeksweeks

Plasma Plasma ACTH ACTH

İncreased İncreased at weeks 2 at weeks 2 and 4 and 4

K. Yamaoka, F.Mitsunobu, et all , K. Yamaoka, F.Mitsunobu, et all , Study on Biologic Effects Study on Biologic Effects of Radon and Thermal Therapy on Osteoarthritis, of Radon and Thermal Therapy on Osteoarthritis, The Journal of The Journal of

Pain, Vol 5, No 1, :( pp 20-25) 2004 Pain, Vol 5, No 1, :( pp 20-25) 2004

the effect of the radioactivity of radon and the the effect of the radioactivity of radon and the thermal effect were compared at room thermal effect were compared at room temperature or a hot spring condition with the temperature or a hot spring condition with the same chemical component by usingsame chemical component by using

The results were about 2-fold larger in the radon The results were about 2-fold larger in the radon effects than in the thermal effects.effects than in the thermal effects.This suggests that the antioxidation function was more This suggests that the antioxidation function was more enhanced by radon therapy than by thermal therapy,enhanced by radon therapy than by thermal therapy,

Radon therapy increases the ANP level and Radon therapy increases the ANP level and decreases the level of vasopressin, an antidiuretic decreases the level of vasopressin, an antidiuretic hormone, in the hormone, in the blood of patients with osteoarthritis.blood of patients with osteoarthritis.

In addition, -endorphin and ACTH significantly In addition, -endorphin and ACTH significantly increased, suggesting a part of the mechanism of increased, suggesting a part of the mechanism of alleviation of pain by radon. These findings suggest that alleviation of pain by radon. These findings suggest that an appropriate amount of active oxygen is produced in an appropriate amount of active oxygen is produced in the body after radon inhalationthe body after radon inhalation..

•K. Yamaoka, F.Mitsunobu, et all , Study on Biologic EffectsK. Yamaoka, F.Mitsunobu, et all , Study on Biologic Effects• of Radon and Thermal Therapy on Osteoarthritis,of Radon and Thermal Therapy on Osteoarthritis,• The Journal of Pain, Vol 5, No 1, :( pp 20-25) 2004The Journal of Pain, Vol 5, No 1, :( pp 20-25) 2004

There were statistically significant differences between the control and the aquatic exercise groups for the 6 months percent of changes in IGF-1insulin like growth fact.( p<0.001), GH growth hormone (p<0.001), PTH parathormone (p<0.001) and CT calcitonin (p<0.01). Conclusions. Aquatic exercise was determined to be effective to make an anabolic effect on the bone of the postmenopausal sedentary subjects.

Ay A., Yurtkuran M.: Anabolic effect of aquatic exercise on bone. Am J Phys Med Rehabil 2003;82:942-9

to compare the effects of peat and water to compare the effects of peat and water bathsbaths

• Beer A.M., Fey S . ; Clin. Lab. 2001;47:161-7. The effect of peatcomponents on endocrine and immunological parameters andon trace elements

have shown that peat components -independent from their thermal effects -are the reason for the occurrence of specialeffects on endocrine and immunologicalparameters

Circadian differences of the secretory Circadian differences of the secretory responses to thermal stimulation are responses to thermal stimulation are shown by cortisol( Agishi,Ohtsuka& shown by cortisol( Agishi,Ohtsuka& Watanabe,1996,Watanabe,1996,

( Agishi Ohtsuka, 1996 ).( Agishi Ohtsuka, 1996 ).

Daily changes in cortisol,noradrenaline and Daily changes in cortisol,noradrenaline and adrenaline during 4 weeks balneotherapy in adrenaline during 4 weeks balneotherapy in a patient with Non-insulin-dependant a patient with Non-insulin-dependant diabetes a circaseptan (about 7 days ) or a diabetes a circaseptan (about 7 days ) or a circadecan (about 10 days ) rhythmical circadecan (about 10 days ) rhythmical changechangeThe typical charcteristics of these The typical charcteristics of these periodicities during the course of adaptationperiodicities during the course of adaptation

Endocrin responses to thermal stimuli Endocrin responses to thermal stimuli by head-out water immersionby head-out water immersion

In general, hormone secretion tends to In general, hormone secretion tends to increase when the water temperature reaches increase when the water temperature reaches 40oC or higher.40oC or higher.When the water temperature reaches 25oC or When the water temperature reaches 25oC or lower,secretıon of some hormones is lower,secretıon of some hormones is enhanced (noradrenaline, cortisol,Atrial enhanced (noradrenaline, cortisol,Atrial natriuretic peptide,etc ) while that of other natriuretic peptide,etc ) while that of other hormones is suppressed( ADH, renin,etc.)hormones is suppressed( ADH, renin,etc.)

Plasma cortisolPlasma cortisol

Plasma cortisol declined gradually by a hot water Plasma cortisol declined gradually by a hot water bathing at 42oC in the morning, but a significant bathing at 42oC in the morning, but a significant increase was found in the evening.increase was found in the evening.Cold water bathing at 25oC caused significant Cold water bathing at 25oC caused significant increments of plasma cortisol in the morning but increments of plasma cortisol in the morning but no change was observed in the evening as no change was observed in the evening as shown in figure shown in figure ((Agishi & Hildebrandt, 1989 )Agishi & Hildebrandt, 1989 )

These results suggest that there is a circadian These results suggest that there is a circadian difference of responsiveness of plasma cortisol to difference of responsiveness of plasma cortisol to 42oC and 25oC water bathing (Agishi & 42oC and 25oC water bathing (Agishi & Hildebrandt, 1989 )Hildebrandt, 1989 )

Circadian difference of responsiveness of plasma Circadian difference of responsiveness of plasma cortisol to 42oC and 25oC water bathing (cortisol to 42oC and 25oC water bathing (Agishi & Agishi &

Hildebrandt, 1989 )Hildebrandt, 1989 )

1 - AGİSHİ,Y., OHTSUKA,Y, WATANABE,I.,YABUNAKA,N.,NORO, 1 - AGİSHİ,Y., OHTSUKA,Y, WATANABE,I.,YABUNAKA,N.,NORO, H.,"Effects of Therapeutic Elements on Functions in Man in H.,"Effects of Therapeutic Elements on Functions in Man in Balneotherapy ": in by Agishi, Y . ;Ohtsuka , Y. ;Recent Progress in Balneotherapy ": in by Agishi, Y . ;Ohtsuka , Y. ;Recent Progress in Medical Balneology and Climatology ,Kokoku Printig Co. Ltd. ,Sapporo Medical Balneology and Climatology ,Kokoku Printig Co. Ltd. ,Sapporo , (1995 ), (1995 )

2- AMELUNG , W . ,HİLDEBRANDT , G .;Balneologie und 2- AMELUNG , W . ,HİLDEBRANDT , G .;Balneologie und Mediziniche Klimatologie Band I Therapeutische Physiologie Mediziniche Klimatologie Band I Therapeutische Physiologie Grundlagen der Kurortbehandlung ( 1985 ) Springer Verlag Berlin Grundlagen der Kurortbehandlung ( 1985 ) Springer Verlag Berlin Heidelberg New York Tokyo Heidelberg New York Tokyo

3 - AMELUNG , W . . ,HİLDEBRANDT , G .; Balneologie und 3 - AMELUNG , W . . ,HİLDEBRANDT , G .; Balneologie und Mediziniche Klimatologie Band II Balneologie ( 1985 ) Springer Verlag Mediziniche Klimatologie Band II Balneologie ( 1985 ) Springer Verlag Berlin Heidelberg New York Tokyo Berlin Heidelberg New York Tokyo

4 - AGİSHİ, Y. ; HİLDEBRANDT , G . : Chronobiological Aspects of 4 - AGİSHİ, Y. ; HİLDEBRANDT , G . : Chronobiological Aspects of Physical Therapy and Cure Treatment , Kokoku Printing Co. Ltd. , Physical Therapy and Cure Treatment , Kokoku Printing Co. Ltd. ,

Sapporo ( 1989 ) . 11-23Sapporo ( 1989 ) . 11-23

5 - YAMEN , A . ;GÜRDAL , H. ; CANBAZ , M. ; ÖZER , N. : "The Changes 5 - YAMEN , A . ;GÜRDAL , H. ; CANBAZ , M. ; ÖZER , N. : "The Changes of Urine PGE 2 Levels During Spa Therapy" ; Edit by H. G. Pratzel ; Health of Urine PGE 2 Levels During Spa Therapy" ; Edit by H. G. Pratzel ; Health Resort Medicine ISMH Verlag Gerestried , 1995 , ( 191 - 193 ) Resort Medicine ISMH Verlag Gerestried , 1995 , ( 191 - 193 )

6 - GÜRDAL , H. ; CANBAZ , M. ; YAMEN ,A; GÜLSOY ,S.;YURDAKOŞ, 6 - GÜRDAL , H. ; CANBAZ , M. ; YAMEN ,A; GÜLSOY ,S.;YURDAKOŞ, M.; ÖZER , N.:"Catecolamine Levels in Balneotherapy" X I. Congres of M.; ÖZER , N.:"Catecolamine Levels in Balneotherapy" X I. Congres of OMTh Proceedings , Doyuran Matbaası ,İstanbul,1993 ( 262- 265 )OMTh Proceedings , Doyuran Matbaası ,İstanbul,1993 ( 262- 265 )

7 - YAMEN A, ;GÜLSOY S . ; GÜRDAL H. ; YURDAKOŞ M. ; İŞSEVER 7 - YAMEN A, ;GÜLSOY S . ; GÜRDAL H. ; YURDAKOŞ M. ; İŞSEVER H. CANBAZ M. :"Effect of Balneotherapy on Urine Ascorbic Acid Levels of H. CANBAZ M. :"Effect of Balneotherapy on Urine Ascorbic Acid Levels of Patients with The Same Alimentation" XI. Congres of OMTh Proceedings , Patients with The Same Alimentation" XI. Congres of OMTh Proceedings , Doyuran Matbaası , İstanbul 1993 ( 279 - 284 )Doyuran Matbaası , İstanbul 1993 ( 279 - 284 )

14 - AYATS , R . , ORSETTİ , A . , KERDELHUE ,B .“ Crenoterapie externe 14 - AYATS , R . , ORSETTİ , A . , KERDELHUE ,B .“ Crenoterapie externe a Balaruc- les -Bains Axe hypothalamo-hypophyso -surrenalien : etude de a Balaruc- les -Bains Axe hypothalamo-hypophyso -surrenalien : etude de la beta- endorphine , de I’ ACTH et du cortisol ” ; Presse thermale et la beta- endorphine , de I’ ACTH et du cortisol ” ; Presse thermale et Climatique , ( 1990 ) ,127, No 4. 173 - 178 .Climatique , ( 1990 ) ,127, No 4. 173 - 178 .

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studies on the effects of spa therapy on endocrine functions