Radonbalneology

1
Radonbalneology

• Prof. Dr.med. habil. Dr.rer.nat. Helmut G.
  Pratzel
• President of the International Society of Medical
  Hydrology and Climatology (I.S.M.H.)

2
Quality limits for medical bath waters

• Chemical effects can be used in bath tubs if
• no disinfection
• Concentration in tub is
• H2S gt 10 mg/l
• Radon gt 1 kBq/l
• CO2 gt 1 g/l
• Brine 10-150 g/l
• Physical effects can be used in pools if
• water is disinfected
• temperature gt30 C

Which elements in spring waters are effective in
bath therapy?
3
Radon Units
1 Mache Unit 3,64 x 10-10 Ci/l 1 Ci 3,7 x
1010 Bq 1 Mache Unit 13,468 Bq/l
4
Spas using Radonwater
5
Russian Radon Spas
Belochurika (Altai) 4-16 nCi/l Dzchey-Ogus,
Issyk-Kul (Kirgisia) 30- 125 nCi/l Nowosibirsk
(Sibiria) 4-670 nCi/l Pjatigorsk (North Kaukasus)
18-330 nCi/l Chmelnik (Ukraine) 2-97
nCi/l Zhal-Tubo (Georgia) 2,5-33 nCi/l 250
Sanatoria with artificial Radon
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IndicationsRadon-Water in bath tubs and
Radon-Gas-baths or Radon-mines

• Ankylosing spondylitis
• Degenerative joint disease
• Spondylarthrosis
• Myofascial soft tissue syndrome
• Ovarian hypofunction
• Allergic bronchial Asthma

7
Clinical Trial Protocol by the Guidelines for
Good Clinical Practice (GCP) of the European
Community

• Trial objectives and purpose
• Trial design
• Randomisation, Blinding
• Selection and withdrawal of subjects
• inclusion and exclusion criteria
• Treatment of subjects and control medication
• Assessment of efficacy

• Assessment of safety
• Control of side effects and interactions
• Control of Compliance
• Statistics
• Direct Access to Source Data/Documents
• Quality control and Quality Assurance Procedures
• Ethics

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Primary Efficacy Variable

• Only validated parameters should be used.
• Only one efficacy parameter is to defined.
• Endpoints used to determine efficacy should be
  clearly specified.
• Multiple parameters should be assembled to one
  score parameter.
• An efficacy threshold is to defined.

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Controlled Double-Blind Trials on Radon

• Pratzel , Legler, Aurand, Baumann, Franke Phys
  Rehab Kur Med 3 (1993) 76-82
• Lind-Albrecht 1994
• Heisig, Klein, Pratzel 1997
• Reiner, Vulpe, Pratzel 1998
• Skorepa, Klein, Pratzel 1999
• Keil, Klein, Pratzel (not finished)

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Pressure Pain Threshold
Test areas
1. M. levator scapulae 2. M. supraspinatus 3. M.
teres minor 4. M. deltoideus 5. M. glutaeus
maximus 6. M. glutaeus medius 7. M. bizeps
femoris 8. M. semimembranosus
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Double-blind-control equipment

• Electronic control with bar-code-reader

Bar-code-reader
Magnetic valves
Tap-water line
Radon-water line
Bath-tub
Technical room
Bathroom
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The Barcode-Reader
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Pratzel, Legler, Baumann Analgesic Efficacy of
Radon baths in case of spondylosis with cervical
pain
Subject 23 23 patients 45-65 y Verum Radon
baths 3000 Bq/l Control Water baths Treatment 9
baths 36 C during 3 weeks Design ambulant,
massage and gymnastics Follow-up 2 and 4
months Result difference in follow-up period
plt0,001
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Pressure pain thresholdby Radon baths series

• Ende der Behandlung

kg/cm2
End of Treatment
3,0
2,8
After 4 month
2,6
After 2 month
After 1 week
2,4
2,2
After 2 weeks
After 3 weeks
2,0
Period of inspection
15
Pressure Pain Threshold 3000 Bq/L Rn Schlema 1993
Follow up after 4 months
0.9
kg/qcm
Follow upafter 2 months
0.8
0.7
after 3rd week
0.6
p0,0007
p0,028
after 2nd week
0.5
0.4
0.3
after 1st week
0.2
0.1
0
-0.1
Period of evaluation
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Pressure Pain Threshold and subjective feeling of
pain
Follow-up period
2
0
3 baths
10
VAS
3 baths
VAS
20
VAS
3 baths
1.5
30
VAS
40
VAS
50
Control
1
60
VAS
70
80
after 1 week
after 2 weeks
after 3 weeks
after 4 months
after 2 months
before
0.5
90
PPT general pressure pain threshold
VAS subjective pain
feeling
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Subjective feeling of pain
Water
Radon
18
Pain on movement
Water
Radon
19
Pain at rest
Water
Radon
20
Heisig Analgetic effect of Radon baths in
degenerative joint disease and spondylarthrosis
Subject 25 27 patients 28-74 y Verum Radon
baths 800 Bq/l Control Water baths Treatment 8
baths 36 C during 3 weeks Design ambulant,
mono-therapy Follow-up 2 and 4 months Result
difference in follow-up period plt0,05
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Change of Pressure Pain Threshold Bad Steben 1995
Follow up after 4 months
0.9
kg/qcm
Follow upafter 2 months
0.8
after 3rd week
0.7
0.6
after 2nd week
p0,0141
0.5
0.4
after 1st week
0.3
0.2
0.1
0
-0.1
Period of evaluation
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Pressure Pain Threshold (mean and max)
Follow-up period
2.5
2
3 baths
3 baths
3 baths
PPT
MAX
MAX
PPT
2
MAX
1.5
Control
MAX
1.5
MAX
MAX
after 4 months
before
after 1 week
after 2 weeks
after 3 weeks
after 2 months
1
1
PPT general pressure pain threshold
MAX maximum pressure pain threshold
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Pressure Pain Threshold and Subjective feeling of
pain
Follow-up period
2.5
0
3 baths
3 baths
10
3 baths
VAS
PPT
PPT
VAS
20
VAS
VAS
PPT
VAS
2
30
PPT
PPT
Control
40
1.5
VAS
PPT
50
60
after 1 week
after 2 weeks
after 3 weeks
after 2 months
after 4 months
before
1
70
PPT general pressure pain threshold
VAS subjective pain
feeling
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Skorepa Effect of CO2 in Radon baths treatment
in degenerative joint disease and spondylarthrosis
Subject 35 33 patients 22-73 y Verum Radon
400 Bq/l and CO2 1 kg/l Control Radon baths 800
Bq/l Treatment 8 baths 36 C during 3
weeks Design ambulant, mono-therapy Result no
difference CO2 increase radon effect
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Pressure Pain ThresholdBad Steben 1997
Follow-up period
after 4 months
after 2 months
after 3 weeks
after 2 weeks
after 1 week
before
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Subjective Feeling of Pain Bad Steben 1997
before
Follow-up period
after 1 week
after 4 months
after 2 months
after 2 weeks
after 3 weeks
27
Maximum Pressure Pain Threshold Bad Steben 1997
Follow-up period
after 4 months
after 2 months
after 3 weeks
after 2 weeks
after 1 week
before
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Franke, Reiner, Pratzel, Franke, Resch Long-term
efficacy of radon spa therapy in rheumatoid
arthritis a randomized, sham-controlled study
and follow-up. Rheumatology 200039894-902
Subject 30 30 RA patients lt75 y Verum
natural radon 1,3 kBq/l and CO2 1,6 kg/l Control
artificial CO2 1,6 kg/l Application 15 baths 35
C during 4 weeks Follow up 3 and 6 month after
end of treatment Result relevant difference in
follow-up period
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Subjective pain feelingRheumatoide Arthritis
(Radon trial Bad Brambach 1997)
mm VAS
Differences to 1st value and 95-Confidence
interval
CO2
1st value
Improvement
Radon CO2
N 30
N 30/27
N 28/30
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Moving test by Keitel
Standing on toes and heel Knee-crooking Standing
on one foot Outside Rotation of the hit
join Mobility of legs and feet Walking
Climbing stairs

• To bend the fingers
• Motility of hand joins and arms
• Stand up from lying
• Active straddle of legs from lying
• Stand up from a stool

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Moving Test by KeitelRheumatoide Arthritis
(Radon trial Bad Brambach 1997)
Skt
Differenzen zum Ausgangswert und
95-Konfidenzintervall
RadonCO2
1st value
CO2
N 30
N 28/30
N 30/29
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Measurement of Patient Outcome MOPO (AIMS
questionaire)Physical handicap and psychosocial
Consequences by Rheumatoid Arthritis
Assessment included

• Mobility
• Physical activity
• Skill
• Activities at home
• Activities in daily life
• Social activities
• Pain
• Depression
• Anxiety

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Measurement of Patient Outcome (MOPO)Rheumatoide
Arthritis (Radon trial Bad Brambach 1997)
Skt
Differenzen zum Ausgangswert und
95-Konfidenzintervall
RadonCO2
1st value
CO2
N 29/30
N 29/30
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Lind-Albrecht Treatment of ankylosing
spondylitis in radon mine Bad Kreuznach
Subject 144 118 SA patients,
randomized Verum 10 x 1 hour radon mine Control
no mine Application 4 weeks Follow up 3, 6, 9,
12 month after end of treatment Result relevant
difference in follow-up period
35
Relat. Pain after Radon mine treatment Bad
Kreuznach
Spondylitis Ankylosans (Studie Lind-Albrecht)
36
Relat. NSAIDS-use after Radon mine treatment Bad
Kreuznach
Spondylitis Ankylosans (Studie Lind-Albrecht)
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Meta-AnalyseForest-Plot
treatment
control
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Die Permeabilität der HautResorption für Gase
und Flüssigkeiten durch 2 m2 Haut
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Permeability of skin Skin clearance for
solutions in water
1000
µl Lösung/cm2/h
100
Octanol
Methylsalicylat
Heptanol
Camphen
10
Phenylmercuryborate
Estron
Campher
Water
1
Propanol
Progesteron
Ethanol
Methanol
Water
Testosteron
DMSO
Acetylsalicylic acid
0,1
Ferrum II
Sodium
Strontium
Heparin
Corticosteron
Sulfate
Arsenic
Potassium
Jodide
Bromide
Chloride
Indomethacine
Pertechnetate
Calcium
0,01
Cortison
Salicylic acid
Caesium
Cobalt
Silver
Cadmium
Hydrocortison
Ferrum III
0,001
Chromium III
0,0001
Selenite
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How Dosis can be calculated by Skin-Clearance?
Dosis Skin-Clearance x Area x Concentration x
Time
Dosis limit is the amount on the Skin
Skin-Clearance is realized by optimal Penetration
situation( Bath, wet Skin, Okklusion
Effect of temperature (Q10. 1,1-1,4) but skin
temperature only low variable
41
Blood level and time of bathing
Badedauer
Fließgleichgewichterreichtnicht erreicht
42
Calculation about Radon-kinetic
Skin-Clearance 200 µl/cm2 h-1 Concentration in
bath 3 kBq/l Area of skin 2 m2 Absorption
rate 200 x 3 x 2/100 12 kBq/h
Distribution volum 20 l bei 80 kg
KGElimination constant 20 h-1Blood level in
steady state 12 kBq/h / (20 l x 20 h-1) 0,030
kBq/lBlood level after 10 min-bath 0,030 x
(1-e-20 h-1 x 10 min) 0,029 kBq/l Concentration
in bath water Blood level 100 1
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Radon-222 Dissolution
Polonium Bismutum Plumbum
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The main effect of radon
Radon and the dissolution products penetrate into
the horny layer. Alpha-radiation from the horny
layer is effective in the stratum
spinosum. Dissolution products cannnot penetrate
into the living tissue.
45
Langerhans Cells of the skin
46
Effect of Alpha-Radiation on Langerhans Cells
47
Dosis by use of Radon-baths (Radon concentration
1,5 kBq/L 37 C)
Dosis of skin

• Risk by radon skin-dosis of ca. 1 mSv per cure
  treatment is lesser than risk by long use of
  medicaments..

Dosis of kidneys
Dosis of other organs
natürliche Dosisleistung
Zeit in Stunden
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Trial in radon treatment should be used in future
research by the following disease assessments

• Rheumatoide A. HAQ
• Bechterew BASFI
• Narrow spinal channel LSS-Inst.
• Osteoarthrosis WOMAC

German translation by Sangha O et.al. Rheumatol
56322-333, 1997
49
BASFI for Ankylosing Spondylitis

• Ohne Hilfe und Hilfsmittel Socken und Strümpfe
  anziehen
• Ohne Hilfe von der Hüfte aus nach vorn beugen um
  einen Kugelschreiber vom Boden aufzuheben
• Ohne Hilfe etwas von einem Regal nehmen
• Von einem Wohnzimmerstuhl ohne Armlehne aufstehen
  ohne dabei die Hände oder eine andere Hilfe zu
  benutzen
• Ohne Hilfe vom Boden aufstehen, wenn Sie auf dem
  Rücken liegen

German translation by Sangha O et.al. Rheumatol
56322-333, 1997
50
BASFI for Ankylosing Spondylitis

• Ohne Schmerzen 10 Minuten stehen ohne sich
  anzulehnen
• Ohne Benutzung eines Geländers oder Gehhilfen
  12-15 Treppenstufen steigen. 1 Fuß pro Stufe
• Über die Schulter schauen ohne dabei den Körper
  abzudrehen.
• Körperlich anstrengende Tätigkeiten verrichten
  (z.B. krankengymnastische Übungen, Gartenarbeit
  oder Sport)
• Zu Hause oder bei der Arbeit den ganzen Tag aktiv
  sein.

German translation by Sangha O et.al. Rheumatol
56322-333, 1997
51
Literature of Radonbalneology
Pratzel, Deetjen Radon in der Kurortmedizin,
I.S.M.H. Verlag 1997, ISBN 3-9804437-2-8 Pratzel
Application of Pressure Algometry in Balneology
for Evaluation of Physical Therapeutic Modalities
and Drug Effects. Journal of Musculoskeletal
Pain19986111-137 Deetjen, Falkenbach Radon
und Gesundheit, Peter Lang Verlag 1999, ISBN
3-631-35532-7 Franke, Reiner, Pratzel, Franke,
Resch Long-term efficacy of radon spa therapy in
rheumatoid arthritis a randomized,
sham-controlled study and follow-up. Rheumatology
200039894-902
52
The following power point-files Perkutane
Resorption und Balneologie (German)Kneipp-Therapi
e (German) Radonbalneology (English) Health
Tourism and Medical Treatment - two parts in
Health Resorts (English) Las nuevas
investigaciones en termalismo y los nuevos retos
medicos (Spanish) can be downloaded from the
web side of the International Society of Medical
Hydrology and Climatologyhttp//www.med.uni-mue
nchen.de/ismh
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End of Slides