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BALNEOTHERAPY MUD AND CLIMATOTHERAPY AT THE DEAD SEA
lecture by Shaul Sukenik - Soroka University Medical Center and
Faculty of Health Sciences,
Ben Gurion University of the Negev
Beer-Sheva, Israel

Dr Sukenik was first to do clinical trials in Dead Sea
event sponsored by Bionativas, John and Susan Shepherd
introduction by Dr Szerancko
Dr Sukenik thanks Dr Schleich and others who helped with his trip

clinical trials at dead sea during the last 15-20 years
his hospital in capital of desert of Israel, over 1000 beds, serves 1 million pop
geography review
along border with Jordan
Palestine not mentioned but Dead Sea is up against it too
Dead Sea lowest place on earth
67 km long, 80 km
120m deep
water from holy Jordan river which starts at Lake of Galilee which is also below sea level
Dead Sea is shrinking
will disappear in 50-100 years dt climate change and use of Jordan River
his city 70 km west and south of Dead Sea, again just outside Palestine not mentioned
showing overhead view of lake
salt sea, sea of sodom, ancient seat, arava valley sea
1936 E Volkani Christian monk discovered halophilic bacteria that survive in 3-15% salt
Halopherax Volcani is bacterium with his name

Bible story of Sodom and Gomora
Queen Cleopatra made factories for cosmetics and pharm from Dead Sea in 69-30BC

Bituman, black asphalt
used for preservation of Egyptian mummies
Gladiators used it for wound healing

Romans Legion hydrotherapy
roman Bath on Masada (Herod's palace) 73-4 BC
Dead Sea Water transported to Rome for private use

story of Mtn called Masada
important symbol for Jewish people
not far from Dead Sea
in 1st century AD Israel was occupied by Romans who destroyed Jewish temple
and killed many israeli soldiers but a few escaped but they went to this mtn
and held this place fighting against the Romans
romans built a ramp up the side of it to get to the soldiers and kill them
it took them 2 years to build the ramp, they invaded with 10,000 soldiers
only 800 defenders on tops with wives and children there
when they realized they would lose they decided to suicide
soldiers killed their wives and children and then each other
two women and five children escaped the murder and told to Joseph .... who was born Jew
and became a Roman, was in Roman army
now Israeli soldiers after finishing training are brought to this mountain
they take an oath that
Masada shall never fall again
Herod's palace is on top
nice baths up there

UNIQUE CLIMATIC CONDITIONS AT DEAD SEA
highest barometric pressure in the world
Sea level is 754+6mmHg
Dead sea level is 791+4mmHg
8% more O2 mols/meter3
higher PO2 blood levels and sat
humidity in air there which blocks much of the UVB radiation from the sun
UVA/UVB ratio is highest there
less harm from UVB there, can lay exposed to sun without burning as easily
UVA 320-500nm
UVB 280-320nm
UVC 100-280 nm
CLIMATE: very hot, HIGHS AROUND 100f, lOW IN jAN IS 68f
POLLEN FREE ATMOSPHERE
also rich in Bromine
20times higher bromine in air
tranquilizing effect
serum bromine levels increase
(does it tranquilize because it lower thyroid function???)

RHEUMATOLOGY
1961 Hollander NY Study, special rooms to control pressure, humidity and temp
arthritis pts prefer high pressure, low humidity, high and constant temperatures
before rain starts there is a drop in atmospheric pressure-->pain with drop in P

image of hotels along south basin of Dead Sea

MINERALS
mineral content of water: Cl, Mg, Na, Ca, K, Br, 10x denser than any other sea
large quantities of trace elements: Ba, Mn, Fe, Zn, Li, Pb
LEAD??? Lithium.... Hmmmmm...
"rocks floating on the water" are formed of the salt
people float easily
a couple dozen natural mineral springs
water temp 38.5-44.5
high concentration of hydrogen sulphide, rotten egg smell
can't do double blind studies with this water because of the smell

MINERAL MUD
pelloid
sediment of the sea
alluvial deposit of organic remains incl algae and salts & minerals
silicates and carbonates, sulfides from bio sources
pelloid: 3 types: peat, moor, mud, they use mud which is more inorganic

anti-inflammatory
human studies
decr: PGE2, LTB4, NO, myeloperoxidase
rat studies
injecting adjuvant to make rats have arthritis
then tx with Dead Sea mud and have decr: paw volume, TNA alpha, IL1beta,
decr synovial inflam, incr collagen

shows image of woman covered in black mud

HYDROTHERAPY
based on water temp, immersion, bouyancy, resistance

BALNEOTHERAPY
mineral and thermal properties of water in addition to physical properties
contains more than 1gm/L minerals
hypothermal = under 20C
thermal 20-30C
hyperthermal over 30C

SPA THERAPY
health resort
spa is name of a village in Belgium
farmer who suffered from joint dz and was healed
espa = fountain
heliotherapy = sun rays
grottotherapy = caves with Radon which help pts with arthritis
Peloma = water and mus
Thalassotherapy = seawater
physiotherapy
health farms

PHYSIOLOGY OF IMMERSION
density and specific gravity
hydrostatic pressure
bouyancy

CV EFFECTS
displace approx 700cm3 blood from extremities and abdominal vessels
into great veins of thorax and heart-=>incr R atrial pressure-->
-->incr atrial natriuretic peptide-->incr urination
also incr cardiac output muscle circulation, lymphatic return
decr: systemic vascular resistance, pulse rate, plasma norepi

RENAL EFFECTS
diuresis
natriuresis, kaliuresis
suppression of ADH
suppression of renin-aldosterone axis

MOA for improved arthritis sx

mechanical: improve muscle relax->circ, mobility incr, decr joint swelling

thermal: heat incr secretion of ACTH, cortisol, GH, prolactin, Beta endorphins
decr serum level of RF and immunoglobulinsm decr PGE2 and LTB4
decr T lymphocytes, decr EOS, no chance in CD4's, incr CD8's and B cells
increased mobility and phagocytic activities of granulocytes
incr extensibility of collagen rich tissues: tendons, fascia, articular capsules

chemical:
abn of trace elements and metab
zinc/copper balance, Mn, Se imbalanced in inflammatory arthridites
no evidence of absorption of trace elements through skin into blood while bathing
one study (Shani 1985) shows incr absorption of Bromine, rubidium, calcium and zinc in psoriatic pts bathing in Dead Sea water
(Halevi is his only sister, study: 1997) incr absorption of manganese when bathing in reg water with Dead Sea salts

other:
climate, rest, vacation, stress reduction

spa therapy at Dead Sea effective to treat:
skin dz: psoriasis, vitiligo, atopic derm, mycosis fungoides
lung dz: COPD, CF,
CV dz: CAD, CHF
eye dz: uveitis
IB dz: Crohn's

ADVERSE EFFECTS
near drowning (don't drink the stuff, it's dangerous, must have dialysis to save pt)
resp failure
hypercalcemia, hypermagnesemia
sunburn
skin rashes, itching
thermal rxn, after first wk of tx:
feel more tired and more pain dt drop in blood level of ACTH and cortisol
pts who have this rxn feel better later than those who don't
no evidence of infx of skin CA

CI
absolute:
LOC, epilepsy, severe arrhythmias, acute mental disorders
severe nfx, sepsise
relative:
photosensitivity (lupus)
varicosities
**malignancies, HTN, preg are NOT CI

survey of studies on inflammatory arthridites

RA
chronic systemic AI dz
female/male: 2.5-3/1
1-2% of pop peaking in 4-5th decade of life
dx is inflam of synovium which gets much infiltrated with inflam cells
if dx must treat aggressively to prevent irreversible damage
when he was in school he was told to start slow with anti-inflam, then DMARDS, then steroids
now he knows start treating it immediately with combination therapy to prevent damage
erosions into bone happen more quickly than known in the past
pannus invades cartilage and bone-->erosion
he studied rheumatology in Toronto and told his docs to sent pt to Dead Sea
they said prove it

SCIENCE ABOUT DEAD SEA
so did two studies during his fellowship
mud packs, sulphur bath, mud and sulphur, bath in Dead Sea, or no tx
looked at duration of morning stiffness, hand grip strength, time walking 15 meters,
number of active joints, effusive joints, pain scale
ESR, CRP, serum amyloid A, WBC, electrolytes, RF
sig improvement in most clinical parameters lasting 1-3mo
discordance between clinical and laboratory parameters
clinically they felt better even when labs didn't say so

a teacher told him not to sent pt in active dz to baths
he now disagrees, sent pt when aggravated
balneotherapy recommended as adjunctive therapy, not sub for reg drug therapy

ANOTHER STUDY
done outside Dead Sea area, above sea level
double blind
group 1: Dead Sea salt dissolved in tub, heated to 35C, 20 minutes
group 2: NcCl dissolved in tub, same temp and time
group 1 improved
most therapeutic effect at end of tx (2 wks)
improvement lasts only 1 month
(is he going to sell us some salt?)
(what about epsom salt?)

MUDPACKS IN RA STUDY
double blind randomized
also done in Beer Sheva
group 1: mud packs 40C
group 2: washed out mud same temp, no salt left in mud
only those who got the true mud improved

PSORIASIC ARTHRITIS
1-2% 1:1 genderwise
1/3 of pts with skin dz get arthritis
85% of cases skin dz happens first
distal interphalangeal 5-12%
arthritis mutilans (destructive) 5-16% shortening of digits dt jt disappears, dips
symmetric 15-40%
assymmetric oligoarthritis 16-70%
spinal predominant 2-5%
image of toenails and sausage toe, if see sausage finger know it is psoriasis
pockmarked nails-->indicator of future arthritis

1994 study
166 German pts
group 1: sun and Dead Sea water
group 2: sun, Dead Sea water, mud packs and sulphur pool
duration: 3 weeks
PASI score: psoriasis area skin index
durat morning stiff, grip, ADL, pt self assess, no of active juts, Ritchie score, spine pain
both groups experienced sig improvement
spinal group improved much more, less pain better ROM

ANKYLOSING SPONDYLITIS
young adults
males:females 2:1
doc thought Stalin was paranoid and Stalin killed this doc
90% HLA-B27 positive on xsome 6
bilateral sacroileiitis (diagnostic: x-ray joint)
bamboo spine
.1-1% of pop
group 1: mud, sulphur, Dead Sea water
group 2: sweet water pool
BASDAI bath AS dz activity index
VAS for pain and mobility
PE
SF-36 about quality of life
neither group improved much
he thinks the disease was too advanced to be strongly improved

OSTEOARTHRITIS
most common
uncommon before 40
after 70 most people have it
risk: age, race, genetic, obesi, trauma, occup
dz of cartilage not synovium
cartilage doesn't repair well and dmg accumulates over time
osteophytes grow in
reduction in joint space
pips and dips
heberden's nodes
fingers, knees, hips, big toe base

STUDY 1999
compared four groups with diff modalities
Lequesne index assessment and others
the pts who got the sulphr pool or Dead Sea water or both improved most
control group no improvement

INTERMITTENT VS TRADITION SPA THERAPY
does intermittent work? in Eur they say pt must stay 10-14 days at spa
but 1-2x at spa still helps
a study comparing mineral spring water vs Jacuzzi tap water both at 35C, 2x weekly x 6wks
sig improvement lasting up to 6 mo only in tx group
"unbelievable"
is intermittent as effective as traditional (staying) therapy?
still can't answer this

FIBROMYALGIA
big problem in Israel
esp when pt develop it after trauma
mc cause of widespread pain in US
4% of pop in US
DX:chronic widespread pain in all 4 quadrants of body and axial skel
11/18 tender pts with 4 kg pressure
"overlap with CFS yuppie disease and so on"
study 48 pts with sulphur vs no tx, 10 days
used dolometer, measures at what point when tenderness turns to real pain, see what pressure
physical fx improved in both but better in tx gruop
longer duration of effect in tx group, better quality of life in tx group

ARTHRITIS SUMMARY
results less impressive with non-inflammatory than with inflam arthritis

WHY NOT MORE STUDIES ABOUT THIS?
in Israel spa therapy is not incl in national health
not covered by insurance
not many gvt grants so not much science
long distance travel to get there
pharm co's not interested
expensive stay in hotel

PSORIASIS
dz known long time
present in 2-3%
male:female 1:1
appears at any age
immune mediated: T cells activaetd-->migrate to dermis-->inflam cytokines-->too many skin cells
tx: sunlight up to 6 hrs/day, bathing up to 1 hr/day, use of topicals
x4wks
complete remission in 58%, marked improvement in 30%
better than with any med
why does it work?
high UVA/UVB
magnesium salts in sea water has anti-proliferative effect
STUDY
comparing climatotherapy vs bathing vs combo
combo best 87% remission, climato only 79%, bathing only 22%
types: guttat, chronic plaque, flexural, palmoplantar, scalp, erythrodermic, pustular
CI with pusturlar
guttate works best, then chronic, flx and palm best

ATOPIC DERMATITIS
asthma of the skin, eczema
chronic inflam skin dz, allergic and familial dz
10-15% in kids before 5 yrs
1-3% in adults
red, flacky, itchy thickening, bacterial
dx is clinical
clearance of 95% observed in pts who stay over 4 wks with sun up to 5 hours/day
very cost effective

HEALTHY VOLUNTEERS
compared one forearm in Dead Sea water, other forearm in tapwater
after 6 wks of tx 15 min/day
arm txd with Dead Sea water showed:
improved skin barrier function, enhanced stratum corneum, reduced skin roughness and inflam

VITILIGO
acquired dz
1-2%
male:female 1:1
melanocytes can't make melanin
usu appears in 3-4th decade
mb in combo with other AI dz: thyroid, adrenal, inflam a, etc
usu tx with steroid ointment or systemic, UV therapy, puva/uvb, ointment with somekindacatalase
complete remission in 11%, partial repigmentation in 82% from climatotherapy
pseudocatalase cream removes H2O2 from epidermis and is toxic in melanocytes
combo of both climato and catalase was best and faster

COPD
5th cause of mortality
irreversible obstruction fo airflow
emphysema or chornic bronchitis
mc over 50
main cause: smoking 20%
survival better in pts living at sea level compared with high altitude (Denver)
FEV1 = forced expiratory volume in 1 sec (normal is 4 liters),
DX: FEV1/FVC<0.7
Sir Richard Barton in 19th century figured out to use Dea Sea location for Pulmonary Dz (TB)
1300 feet below sea level
a study: comparing pts in Jerusalem and Dea Sea, all dependent on O2 therapy
104mmHg difference = 21.8 mmHg more inspired PaO2
10 days later all but one pt had drastically improved PaO2
improved exercise capacity lasting 2-3 weeks after leaving, sleep O2 sat, quality of life

CYSTIC FIBROSIS
hereditary, on xsome 7
1:2000-3000 births
life expectancy about 30
defect in chlorine transport-->mucus accumulation-->recurrent infx
visiting Dead Sea increased O2 sat and weight gain!!

CAD
took pts from Haira 130m above sea level
exercised them, they got better

UVEITIS
50% idiopathic
mb AI
3-4 wks at Dead Sea
imrpove visual acuity, anterio chamber flare, anterior chamber cells, vitreous cells
64% required less meds nad had fewer and milder attacks

he wrote the book
The World's Ultimate Natural Healing Resort for dz of skin, jts, lungs...etc

QUESTIONS
(I recognize voices...)

Mindy asks if you can go and get to the Dead Sea without staying in fancy hotels:
yes there are public beaches, 1 and 2 star hotels

Karen asks cost for a week
he doesn't know

he doesn't know of any comparisons of one spa vs another
nobody knows ideal composition of mineral water for best results

Dead Sea products in stores here: sustainable?
must use 4-5kg of salt in bathtub to get same concentration at home
any info on quality of products? how do we validate any claims?
he can't answer, many products not checked
hesitate to buy from company that doesn't tell exactly
Ahava is company he likes, is good quality

home txs recommended are 5x/wk for 2-3 wks
no comparison studies on less/wk

incidence of dz among locals in area less?
only 4-5,000 people living there
too small a group to really compare
now comparing kibbutz residents there with others above sea level

ACTH, cortisol mentioned
studies on adrenal fx?
he knows of Italian study that shows that staying 1 wk in health resort
-->incr production of both hormones, ATCH first and that leads to more cortisol
(really? I don't know this)

diabetic glucose levels drop while in mineral water?
studying that next

Comments

( 6 comments — Leave a comment )
wildrrrumpus
Apr. 26th, 2010 11:40 pm (UTC)
i have floated there. :)
liveonearth
Apr. 26th, 2010 11:45 pm (UTC)
Really! How exciting. Did you float so high you thought you'd pop out of the water??
wildrrrumpus
May. 2nd, 2010 10:48 pm (UTC)
pretty much - it was nearly impossible to go underwater at all... !
liveonearth
May. 2nd, 2010 11:44 pm (UTC)
Cool. Were you there for vacation or therapy or ??? Do they have conferences at those 5star hotels? Any recommendations for a person who might someday go there?
wildrrrumpus
May. 2nd, 2010 11:52 pm (UTC)
Well, I was in Palestine for the summer, half to do an exchange at a hospital there, and half to explore & when possible, participate in peace/justice/solidarity work.

And I just went to the Dead Sea on a weekend day trip actually, so I guess that part of it was vacation. :)

Recommendations would include thinking about the political and environmental implications of particular therapy choices. Like it was rad to be there, but I wouldn't suggest someone go without knowing some about the history of the region, what is going on with dropping dead sea levels and why and who has access to the river jordan water anyway, etc etc etc. :)
liveonearth
May. 3rd, 2010 12:01 am (UTC)
Good point. I suppose many Americans might go there obliviously as we do to other parts of the world.

Hope you are successful in building some bridges in your peace efforts!
( 6 comments — Leave a comment )

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