The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

The Science Behind Water, Heat, and Cold Therapies A Collection of Evidence

The Science Behind Water, Heat, and Cold Therapies A Collection of Evidence

The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

Table of contents

Chapter 01: Introduction..............................................................................5 Chapter 02: A History of Thermal Bathing......................................... 11 Chapter 03: Thermal and Mineral Water Bathing............................. 15 3.1 General Information............................................................ 16 3.2 Benefits of Thermal and Mineral Bathing.................... 18 Chapter 04: Sauna...................................................................................... 25 4.1 General Information............................................................ 26 4.2 Benefits of Sauna................................................................ 30 02

Chapter 05: Massage Therapy................................................................ 41 5.1 General information............................................................ 42 Chapter 06: The Benefits of Infrared Therapy................................... 47 6.1 General information............................................................ 48 Chapter 07: Cold Exposure Therapy..................................................... 53 7.1 General information............................................................ 54 Chapter 08: Benefits of Spending Time in Nature............................ 59 Annex 01: Resources................................................................................. 65

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

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CHAPTER 01

Introduction

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

Introduction

Therme Group’s facilities address the vital modern-day need for wellbeing for all by maintaining and restoring the physical and mental health of millions of guests every year.

The Therme Experience The Therme experience is organised into three programme areas, each with its own specific set of activities and moods. Each facility also includes a smaller, higher-priced subarea offering additional treatments and services.

The programme areas vary significantly in terms of the sensory experience they provide:

Using cutting-edge technology, Therme is reviving and reconceptualising global traditions of thermal bathing. Its facilities combine water-based activities, fitness, wellness therapies, arts and culture programming, and nutritious food, offering a unique blended experience for mind, body and spirit that is fundamentally different from anything people may have experienced before.

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More than just a fun and relaxing leisure experience, Therme facilities act as social and cultural centres. They benefit the communities they serve directly through the experience and by

acting as a catalyst for wider activities around biodiversity, cultural inclusion and urban greening. This, combined with the many health benefits they provide, is why Therme projects can be considered vital pieces of social infrastructure.

This document brings together just some of the key benefits of the Therme experience. The peer-reviewed, scientific research collated here is just some of the wealth of evidence that shows the impact Therme can have on its guests’ mental, physical, and social health and wellbeing.

1.

PLAY

Indoor family area for all ages. Activities are centred around shared, enjoyable family experiences and include water slides, a variety of pools, steam rooms for all ages, play areas, therapies, immersive art experiences, and self-service F&B. While the dominant mood is loud, sporty, and active, a “relax” area offers quieter and more restorative environments for children and adults alike.

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2.

RELAX

Adult bathing and relaxation. This area includes pools of various sizes and mineral compositions, steam rooms, swim-up bars, entertainment, fitness classes, self-service F&B, and immersive art experiences. While the mood is predominantly relaxed and laid back, there are focal points of activity and fun around the bars and shared athletic activities.

3.

RESTORE

Adult area focused on bespoke wellbeing rituals. This area offers saunas, hammams, thermal pools, mineral and vitamin pools, cold plunges, sensory showers, therapy areas, immersive art experiences, and table-service F&B. The mood in this area is contemplative, quiet, mature and restorative.

The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

Instructured around a set of ‘contrasts’ that, in combination, produce a sense of balance and wellbeing in guests. These ‘contrasts’ are mutually dependent, each requiring and reinforcing the other.

They include:

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Cold vs. Hot

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Wet vs. Dry

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Light vs. Dark

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Silence vs. Noise

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Nature vs. Human made

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Passive vs. Active

These contrasting atmospheres are distributed throughout Therme facilities, creating a seemingly infinite array of experiences. These are further enhanced by the demographic diversity of our customer base and the temporal transition from day to night and week to weekend.

Therme visitors may not be consciously aware of the complex layering of contrasts that permeates our facilities. Therme designers use contrast as a tool to create a nuanced and multilayered experience. This approach stands in opposition to theme parks, which tend to deliver scripted and standardised experiences that leave visitors depleted.

The Therme experience is also deeply sensorial and carefully designed to engage all five senses: sight, sound, touch, smell and taste. Therme’s environments are visually dynamic, richly scented, accompanied by a constantly shifting soundtrack, and thrilling to the touch. The goal is not to produce sensory overload, however, but to create a stimulating environment that leaves our guests refreshed and reinvigorated.

The Therme experience is also deeply sensorial and carefully designed to engage all five senses: sight, sound, touch, smell and taste.

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

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CHAPTER 02

A History of Thermal Bathing

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

A History of Thermal Bathing

Thermal bathing in varying forms is widely practised by different cultures across the globe.

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Ancient Greece

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Ancient Rome

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Contemporary trends

ANCIENT GREECE

ANCIENT ROME

CONTEMPORARY TRENDS

Some of the most welldocumented historical examples of thermal bathing culture can be found in ancient Greece.

“One of the first observers of the therapeutic properties of thermal water was the historian Herodotus (484-410B.C.). He described various spa therapies and suggested that cures take place in certain seasons and for 21 consecutive days.”

During the Roman and Byzantine eras, hydrotherapy and thermalism were commonly used as health cures. Public baths for bathing and relaxing were a common feature of Roman cities throughout the empire.

Analysis of current trends shows that thermal and mineral water bathing appeals to a growing segment of consumers who are seeking to connect with nature, experience cultural traditions, and pursue alternative modalities for healing, rehabilitation and prevention.

Hippocrates of Kos (460-375 B.C.), who is often acknowledged as one of the founders of western medical science and the father of hydrotherapy, believed that natural waters, such as those found in hot springs, held medicinal properties. These natural sulphurous springs were believed to heal skin diseases and relieve muscular and joint pain.

The often-huge bath complexes included a wide variety of rooms offering different temperatures and facilities, including swimming pools and places to read, relax and socialise. Roman baths, with their need for large open spaces, were also important drivers in the evolution of Roman architecture, offering the first dome structures in the classical world. For more information, please see this indepth article provided by the World History Encyclopaedia.

The industry is heavily concentrated in Asia and Europe, reflecting the centuries-old history of water-based healing and relaxation in these two regions.

According to the ‘Global Wellness Economy Monitor 2018,’ together, Asia and Europe account for 95% of industry revenues and 94% of establishments in the thermal and mineral springs industry.

A BILLION-DOLLAR BUSINESS

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A billion-dollars business

In 2020, the global spa market was valued at USD 47.5 billion and is expected to reach USD 52.9 billion by 2028. Currently, about a quarter of thermal bathing establishments are higher-end, targeting tourists and offering value-added spa services. However, in countries with long-established thermal bathing traditions, governments are increasingly promoting thermal bathing facilities as a key wellness offering. As well as investing in the renovation of outdated and closed facilities for local communities, these governments are upgrading service standards and training to meet the expectations of international tourists.

Therme Group is spearheading this movement. Its facilities, which combine ancient traditions with modern health research and technology, are industry-leading in the thermal bathing and wellbeing space.

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

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CHAPTER 03

Thermal and Mineral Water Bathing

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

Thermal and Mineral Water Bathing

3.1 General Information Water is essential for all life on Earth. The human body, for example, is comprised of 70% water and can only survive for about three days without it.

For a long time, people have enjoyed bathing in warm water.

Vladimir Krizek wrote about this in his book “Kulturgeschichte des Heilbades“ (Cultural History of the Healing Bath) that public bathhouses and baths were very important medical treatments in medieval times.

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Evidence of humans using thermal waters as a health treatment can even be found in Greek mythology.

In one myth, the goddess Athena asked Hephaistos to construct a healing sanctuary for Hercules to rest and revitalise after his labours.

To create this, Hephaistos used his hammer on Edipsos, and thus water sprung from the depths of the fiery earth, according to ancient Greek legends.

Roman emperors and noble people travelled from all over the Empire to baths to treat conditions such as rheumatism, arthritis, blood circulation problems, asthma, insomnia, nervous system disorders, circulatory disorders and skin problems.

Currently, water-based health treatments are used across

the globe. Mineral springs vary greatly in terms of their hydrogeologic origin, temperature and chemical makeup. Over the past few decades, researchers have been evaluating the use of mineral water as a treatment for pathological illnesses. This research has found that bathing in mineral water can support relaxation, reduce the production of stress hormones and improve the skin’s ability to feel sensations.

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

3.2 Benefits of Thermal and Mineral Bathing Studies have demonstrated several broad benefits of thermal and mineral water treatments and balneotherapy, including a reduction in the use of chemicals and medicines, the near absence of side effects both during and after treatment and the low risk to the patient’s general health and wellbeing.

In the following section, we will explore some of the direct health benefits of thermal bathing.

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Type of Water

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DIGESTIVE BENEFITS

SKIN BENEFITS

The absorption of thermal water, with its high calcium and magnesium content, has been shown to support digestive and metabolic disorders by stimulating intestinal activity and activating the digestive system.

Due to its high mineral content, thermal water has long been considered a treatment for skin issues such as inflammation, dry skin and rashes.

silicates, iron compounds, sodium and magnesium salts, sulphur compounds and metals, along with traces of elements such as selenium.’

A Well and Good article titled “Thermal Spring Water Is the Secret Ingredient in * So * Many French Skin-Care Products— Here’s What Derms Have To Say About Its Skin-Soothing Benefits,” discusses the benefits of mineral water on skin:

‘Sulphur is abundant in most thermal water and has antimicrobial and antiinflammatory effects,’ states Dr. Maiman, ‘Many of the minerals in thermal water also appear to have antioxidant properties that some studies suggest help neutralize free radicals and reduce inflammation.’”

“According to Rachel Maiman, MD and board-certified dermatologist at Marmur Medical in New York City, as water rises to the surface it passes through rocks and soil, picking up minerals along the way.

She states, ‘the most common soluble minerals found in thermal water are calcium, bicarbonate,

Thermal Water in Dermatology

The benefits of thermal spring water directly correspond to the types of minerals it contains.

These minerals can differ significantly depending on where they have been sourced.

Sulfated waters Sulfurous waters Bicarbonate waters

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Iodo-Bromo-Saline waters

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Saline waters

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Carbonate waters

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Arsenical-ferruginous waters

Most Abundant Chemical Element

Magnesium, Sulfur

Beneficial Effects

Skin regeneration, anti-inflammatory effects, and bactericidal activities

Calcium

Skin protection by improving natural defenses

Magnesium, Iodo, Bromo

Antioxidant effects

Potassium

Skin hydration and enhancement of elastic tissue

Iron and Zinc

Replenishment of oxygen to the cells of the skin

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

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VASCULAR HEALTH

PAIN RELIEF AND MOBILITY

Research suggests that bathing in hot thermal springs can lower blood pressure and improve vascular health. One study into the impact of passive heat therapy found that after 8 weeks of repeated hot water immersion, participants showed increased flow‐mediated dilatation, reduced arterial stiffness, reduced mean arterial and diastolic blood pressure, and reduced carotid intima-media thickness, with changes all on par or greater than what is typically observed in sedentary subjects with exercise training.

Thermal mineral water has been shown to have a significant calming effect on the body through its ability to induce muscle relaxation. A meta-analysis of 16 studies found that thermal mineral water therapy can significantly reduce pain. Additionally, thermal mineral bathing has been shown to improve joint function.

Compared to a control group, patients receiving thermal mineral water therapy scored significantly higher on the European quality of life 5-dimension scale and health assessment questionnaire.

Furthermore, there is no evidence that thermal mineral water is unsafe for treating osteoarthritis.

Mineral water baths have also been shown to help reduce back pain. A study by Tefner, I.K., Bender, T., Kleiber, J. et al. into the effects of immersion in 42°C thermal-mineral water on back pain found that the therapeutic efficacy of thermal bathing on chronic low back pain is significant.

MENTAL HEALTH

EXERCISE IN MINERAL WATER A study from Georgia revealed that bathing in the Tskhaltubo mineral baths is an effective balneotherapeutic treatment for articular pathologies. The study observed 170 osteoarthrosis patients with an age range of 40-70 with experience bathing at Tskhaltubo. The baths were found to have anti-inflammatory and immunoregulatory effects on the patients, as well as promoting the normalisation of cartilage tissue metabolism, hemodynamics and muscle tone.

Bathing in mineral springs, either in association with exercise or alone, is often prescribed for all forms of arthritis, of which rheumatoid and psoriatic are more frequent.

The major therapeutic effects of moving in thermal water heated at 36°C can be: • I mprovement of joint mobility joints and range of motion • R eduction of muscle spasms and contractions • C onsiderable soothing of pain and inflammation • Stimulation of blood circulation • M uscular tone, joint mobility and pain intensity are influenced by the physiological changes (diuresis, natriuresis, vasodilatation and elevation in cardiac output) that are induced by thermal and hydrological stimuli • Water-based training programmes are beneficial in the prevention and treatment of osteoporosis • W ater exercises reduce stress on joints as buoyancy reduces the stressful effect of gravity on the body

• T he resistance of water aids in gentle muscle strengthening and so improves muscle strength and tone • I ncrease the range of motion and flexibility, the support of the water allows effective stretching • I mproved balance and coordination since balance can be challenged in a safe environment. The instability and security created by chestdeep water immersion is the ideal training environment for older adults who need to improve balance, which ultimately leads to greater independence, physical function and reduced risk for falls • D ecrease oedema – the hydrostatic pressure of water decreases swelling • I mproving posture and trunk stability.

As well as the many physical benefits of thermal and mineral water, it is thought that the relaxing experience of bathing itself can have significant mental health benefits.

Bathing in thermal water has been shown to help with anxiety, depression and improved sleep.

Some studies have found that it can also reduce stress-related symptoms, including general physical and mental fatigue. Dr. Jyoti Kapoor, Senior Psychiatrist and Founder at Manasthali, argues that “being immersed in water can calm the nervous system, improve our mood, and reduce anxiety and stress levels in the body”.

Moreover, attending a thermal bath and detoxing from digital media can help you focus on the present and be more relaxed.

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

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WEIGHT CONTROL

EXPERIENCING THE BENEFITS OF MINERAL WATER

Steve Faulkner of Loughborough University found that a bath reduces blood sugar levels and increases energy expenditure by up to 80%. During the study, glucose monitors indicated that at a temperature of 40°C participants started burning more energy.

Faulkner’s findings may be useful to support individuals who are unable to exercise to manage their weight.

When bathing in thermal water, the minerals make contact with the skin. These minerals have been shown to improve health. It is not fully understood how this happens, but researchers believe that it is due to the absorption of minerals through the skin.

Additionally, a 2022 cohort study shows that habitual hot-tub bathing was associated with slight improvements in glycemia, obesity and diastolic blood pressure, and therefore could be a possible lifestyle intervention in patients with type 2 diabetes.

There are many kinds of minerals in hot springs, and some have been shown to have healing properties. For example, sulphur in hot springs can help treat skin conditions, improve hair health, and help reduce stress and fatigue. Though many studies have shown promise in the application of mineral water treatments, further research is needed to fully understand this process.

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

ARSENIC

BICARBONATE

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BORON CHLORIDES

While arsenic in larger doses is toxic in the human body, minute amounts may assist the body with plasma and tissue growth. Foot bathing in mineral waters with a high content of arsenic is used to address fungal conditions to the feet.

Balneotherapists utilize bicarbonate waters for bathing to address hypertension and mild atherosclerosis.

Boron builds muscle mass, increases brain activity and strengthens bones.

Saline hot springs are rich in sodium chloride. Mineral springs naturally rich in chlorides, in amounts between 5 to 3%, are considered by some researchers to be beneficial for rheumatic conditions, arthritis, central nervous system conditions, posttraumatic and postoperative disorders, as well as orthopaedic and gynaecological disease.

MAGNESIUM

Magensium converts blood sugar to energy and promotes healthy skin.

POTASSIUM

otassium assists in the normalization of heart rhythms, assists in P reducing high blood pressure, helps to eliminate body toxins and promotes healthy skin.

SODIUM

SULPHUR AND SULPHATES

Sodium and natural salts assist with the alleviation of arthritic symptoms, and may stimulate the body’s lymphatic system when used in baths.

Hot Springs rich in Sulphur are used to address a wide variety of conditions, including skin infections, respiratory problems, and skin inflammations.

MAIN ELEMENTS IN SPRING WATERS

OTHER SUBSTANCES PRESENT AS TRACE ELEMENTS

MAIN GASES IN SOLUTION

Calcium (Ca)

Aluminium (Al)

Carbon Dioxide (CO2)

Chloride (Cl)

Arsenic (As)

Hydrogen sulphide (H2S)

Fluorine (F)

Boron (B)

Nitrogen (N)

Iron (Fe)

Bromide (Br)

Oxygen (O)

Magnesium (Mg)

Caesium (Cs)

Radon (Rn)

Potassium (K)

Cobalt (Co)

Argon (Ar) and Helium

Silica (SiO2)

Copper (Cu)

(He) can occur in some

Sodium (Na)

Iodine (I)

sulphur springs

Sulphate (SO4)

Lithium (Li) Zinc (Zn)

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

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CHAPTER 04

Sauna

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

Sauna

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4.1 General Information Heat bathing (or sauna) has been practised across the globe by many different cultures for thousands of years. Recently, studies have shown that heat exposure can have multiple benefits for health and wellbeing.

TEMAZCAL

FINNISH SAUNA

HEATING A FINNISH SAUNA

For thousands of years, temazcals (a form of sweat lodge) have been an important place of ritual and healing for indigenous communities in Mexico, Guatemala and throughout Central America, and are widely practised today.

Temazcals are usually permanent structures built of volcanic rock and cement, shaped like a dome.

In Finland, the first saunas featured fireplaces and stones that were heated to extreme temperatures before having water thrown over them to generate steam. When Finnish communities began to migrate to other parts of the globe, they brought their sauna traditions with them.

Savusauna (Smoke Sauna): In this type of sauna, wood is burned in a large stove to fill the room with smoke. When the sauna becomes hot enough, the fire is slowly left to die and the smoke is ventilated.

To produce the dry heat, stones are warmed by a fire and placed in a pit either in the centre of the room or near the walls.

Medicinal and aromatic herbs are then diffused through steam.

Historically, temazcal was used after a battle or physically intense games as part of a curative ceremony to cleanse and heal the body following the physical rigours. Temazcal ceremonies continue to be widely practised today as part of rituals or as health-giving experiences.

The traditional Finnish sauna is a heated wooden room with a stone stove in the middle. Inside, the humidity is around 10%, and the temperature is between 85° and 90°C. The benefits can be felt after just 5 minutes, when the body reacts with profuse sweating. It is recommended to take a cold shower or massage the body with ice every 7-10 minutes.

Wood Stove Sauna: This is the most common type of Finnish sauna. It uses a metal stove with stones on top (kiuas) that are heated by a wood fire.

Electric Sauna: The electric sauna follows the same process as the more traditional wood stove sauna, however, the stones are heated using electricity.

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

RUSSIAN BANYA

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In Russian, ‘banya’ literally means ‘bathhouse,’ though over time the term has been adapted to refer to the sauna-like room found in a Russian bathhouse. It is almost identical to a Finnish sauna in design and purpose; however, it can have higher levels of humidity.

Similar to Finnish sauna, bathers are encouraged to hit themselves or another person with ‘veniks’ or bunches of dried branches and leaves from birch, oak or eucalyptus trees to help improve circulation.

According to HotRock Spa, the word banya is of Greek origin and means “cleansing of a body

HAMMAM with the help of steam.” Some linguists believe the word takes its root from the Latin ‘balneum,’ “something that makes pain and sadness go away.” The notion of a steam bath has long been part of Slavic culture. In Russia, banyas were often associated with a healthy way of life. In 1733, authorities gave a special order for cities to build “a healing banya.”

They warned the owners to keep prices low so that it could be made available to as many people as possible. This differentiated Russia from many other European countries; in France, for example, going to the bath was a privilege of the rich.

Hammam is probably the oldest surviving bathing tradition in the world. When the Ottomans took Constantinople (now Istanbul) from the Romans in 1450, they brought with them their bathing traditions. The Ottoman Turks encountered Roman bathing habits and merged them with their own. Thus, a whole new cleansing ritual was born, conforming to the requirements and rules of Islam.

It was named hammam, which means “the spreader of warmth.”

The Romans believed in centralisation, building one massive bath complex where thousands of people could visit for their daily bathing routines and to catch up on the latest news. The Ottomans, however, were inspired by their religion and followed their own cleanliness rules. They considered bathing to be a purification ritual completed before prayer. Instead of one big Roman bath, they preferred smaller bathhouses scattered

INFRARED SAUNA around the city. For this reason, many modern-day hammams can be found next to mosques.

While Roman bathhouses contained a cold-water pool where people could fully submerge themselves, the Ottomans perceived this tradition as bathing in filth and preferred to clean themselves with bowls of running water. Another significant difference between the Roman and Turkish baths was the cold room: the Turkish tradition required that the cleansing ritual be finished there as a means of recovery, whereas the Romans used it before bathing as a means of preparation.

Originally just for men, once hammams were available to everyone, they became an important social centre for people of all classes and evolved over the years, incorporating numerous relaxation techniques.

Due to their heat source (natural electromagnetic radiation), infrared saunas are generally cooler than typical saunas and heat the bather’s body directly without warming the air. Infrared radiation is on the longer end of the electromagnetic spectrum.

Because of this, it is considered gentler and more comfortable and can penetrate the body’s tissues more deeply.

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

4.2 Benefits of Sauna Sauna is one of those rare health practises that is both, strongly rooted in the history of multiple cultures and has long-term scientific research to back it up.

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PROMOTE BRAIN HEALTH

FIGHT DEPRESSION

HELP BOOST BRAIN FUNCTION AND HEALTH

REDUCE INSOMNIA AND PROMOTE GOOD REST

HEART HEALTH

Research from Finland published in 2017 found that men who used a sauna four to seven times a week for an average length of 15 minutes had a 66% lower risk of developing dementia and a 65% lower risk of developing Alzheimer’s compared to men who used the sauna only once a week.

In one study of the relationship between sauna use and depression, 28 patients with mild depression, general fatigue and appetite loss were divided into treatment and control groups.

Fourteen subjects participated in 20 sauna sessions over four weeks. Each session lasted fifteen minutes in a 60°C unit, followed by 30 minutes of bed rest with a blanket. When compared with the control group, sauna treatment produced statistically significant improvements in somatic complaints, hunger and the ability to relax.

Research has shown that regular sauna use increases levels of norepinephrine, a stress hormone that improves focus and attention, as well as prolactin, which may promote myelin growth, helping the brain function faster and repair nerve cell damage. There are many reasons why sauna use may boost brain health, including lowering inflammation and blood pressure, improving vascular function, and enhancing relaxation and wellbeing.

In a study into the impact of sauna use on rest, 84% of respondents reported improved sleep lasting for one to two nights after sauna use. Given the importance of sleep for general health, sauna seems to hold promise as an enjoyable and non-pharmacological tool to promote better rest.

The “Kuopio Ischemic Heart Disease Risk Factor Study” tracked the health of 2,300 middle-aged men from eastern Finland for an average of 20 years.

Researchers found a reduced risk of sudden cardiac death, fatal coronary heart disease, fatal cardiovascular disease (CVD) and all-cause mortality in sauna users.

Moreover, the risk reduction was dose-dependent. For example, for men who reported using the sauna 4-7 times per week, the risk of fatal coronary heart disease was significantly lower when compared to men who used the sauna once per week and, most

Researchers have also found a link between heat exposure and brain-derived neurotrophic factor (BDNF), which activates brain stem cells to convert into new neurons. BDNF also triggers numerous other chemicals that promote neural health. Heat therapy through sauna use also prevents the aggregation of proteins in the arteries and the brain.

importantly, the risk of all-cause mortality was 40% lower among frequent sauna users.

Several German studies have examined the effect of radiantheat sauna therapy on individuals with hypertension. For example, a group of 46 hypertensive males who had fortnightly saunas for three months demonstrated a decrease in blood pressure from an average of 166/101 mmHg to 143/92 mmHg. This decrease is equivalent to what some people get with anti-hypertensive medication.

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

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SKIN HEALTH AND ANTI-AGEING

SAUNA AND EXERCISE

Steam baths have a highly beneficial effect on the skin.

The moist heat stimulates the subcutaneous blood flow and cleanses the skin, opening pores, removing dead skin and impurities, and leaving the skin feeling soft, clean and silky smooth. Steam bathing also supports the body’s natural process of detoxification.

Sweat generally exceeds plasma or urine in concentrations of toxins. For example, sweating can help excrete metals such as cadmium, arsenic, lead and mercury, all of which can have very serious health effects if they remain in the body.

Regular exercise and sauna use have both been shown to improve cardiovascular functions in clinical populations. However, one 2022 study has shown that when combined with exercise, sauna bathing demonstrated a substantially supplementary effect on CRF (cardiorespiratory fitness), systolic BP, and total cholesterol levels in sedentary adults. The study concluded that sauna bathing is a valuable lifestyle tool that complements exercise for improving CRF and decreasing systolic BP. It was recommended

SUPPORT THE RESPIRATORY SYSTEM that future research focus on the duration and frequency of exposure to ascertain the doseresponse relationship.

Saunas are popular after an intense workout because the increased circulation from the intense heat reduces muscle soreness, improves joint range of motion and eases pain. A small study also demonstrated that regular use can preserve muscle mass.

A 2022 study published in the Journal of Cardiopulmonary Rehabilitation and Prevention revealed that, in a middle-aged to older male Caucasian population, frequent sauna baths attenuated the increased risk of pneumonia due to inflammation.

Finnish saunas were found to decrease pulmonary congestion and increase forced vital capacity (FVC), peak expiratory flow rate (PEF) and forces expiratory volume in one second (FEV1).

Research also indicates sauna

IMPROVE THE IMMUNE SYSTEM therapy can help respiration in patients with asthma and bronchitis; however, saunas should not be used during the acute phase of a respiratory infection. Regular Finnish sauna therapy improved lung function in a group of 12 men from the Netherlands with chronic obstructive pulmonary disease (COPD). These men did not experience adverse effects from the sauna, had significant improvements in FEV1 and FVC, and reported not having to expend as much effort to breathe.

According to a 2023 study, sauna bathing can be a way to improve the immune response, but only when it is undertaken as a series of treatments. It was found that having a Finnish sauna session twice weekly for six months reduced the incidence of common colds by 50% during months 4-6 of the research.

A 2016 study by Brun et al. demonstrated that passive heat improves the microcirculation of skin vessels through increased nitric oxide (NO)-dependent vasodilation. Improved blood circulation is particularly noticeable in the hands and feet because, here, blood flow at the service of thermoregulation is much more variable than, for example, in the torso. Improved circulation to the extremities means better defences to fight infections.

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

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SUPPORT BONE AND JOINT HEALTH

DECREASE BMI AND INCREASE MUSCLE MASS

Patients with rheumatoid arthritis and ankylosing spondylitis reported positive effects on their symptoms following infrared sauna therapy. After four weeks and eight treatments, pain and stiffness were significantly reduced, and improvements were also seen in fatigue.

Sauna has been found to prompt several beneficial changes and adaptations to BMI and muscle mass.

One study has shown that saunas increase blood flow to the heart and muscles, resulting in increased athletic endurance and muscle mass due to greater levels of heatshock proteins and the human growth hormone (HGH).

A further study found that body weight and body fat in obese patients significantly decreased after 2 weeks of sauna therapy.

The acceleration of appetite and abnormal feeding behaviours, such as eating a snack between meals and overeating, did not appear. These results suggest that repeated sauna therapy decreases body weight and body fat in obese patients without increasing plasma ghrelin concentrations

or decreasing serum leptin concentrations.

Furthermore, according to a study titled “Physiological Response to Thermal Stress in Obese vs.

Non-Obese Physically Inactive Men,” exposure to extreme thermal stress during a 10-minute sauna session (temperature: 90 °C, humidity: 15%) induced significantly more pronounced physiological changes in young males with class 1 obesity than in subjects with normal body mass.

A Spanish team of researchers exploring the impact of heat on the human body showed that exposure to high heat provokes stress on the human body. This stress increases heart rate and so, could substitute physical exercise as an alternative stressor to produce similar beneficial effects.

REDUCE CHRONIC PAIN SYNDROME

SAUNA USE IN SUPPORTING KIDNEY FUNCTION

HELP WEIGHT LOSS

Two randomised control trials investigated the subjective effects of repeated sauna sessions on chronic pain disorders. One New Zealand study of 37 patients diagnosed with chronic tension headaches reported a 44% reduction in headache intensity within 6 weeks of the sauna treatment. The other, a Japanese randomised controlled trial of 46 patients with chronic pain disorders, found an increased likelihood of return to work within 2 years and decreases in anger scoring (on the CMI, Cornell Medical Index) in the 4-week sauna-treated group compared to the control group, which received the same courses of behavioural, rehabilitation and exercise therapy without the additional sauna therapy.

A pilot study published in 2022 found that stimulated diaphoresis with a portable sauna bath could be a novel, safe and effective alternative to reduce fluid overload in continuous ambulatory peritoneal dialysis patients.

However, larger studies are needed to confirm these results.

A 2021 study that explored the short-term thermal and cardiovascular responses in women using an infrared sauna as compared to moderateintensity exercise found that the physiological effects of infrared sauna bathing are underpinned by thermoregulatory-induced responses, more so than exercisemimetic cardiorespiratory or cardiovascular activations.

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

IMPROVE THYROID FUNCTION AND HORMONE BALANCE

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Sauna helps the body excrete nonbiological halides such as bromine and fluoride that displace iodine. This is particularly important for people at risk of developing thyroid-related issues.

A lack of sweating or an inability to sweat is often a sign of hypothyroidism (underactive thyroid). Hypothyroidism may be exacerbated by halides found in baked goods, soft drinks, pesticides, fire retardants and other products. The more the body excretes the halides (and reduces exposure), the more iodine is free to produce thyroid hormones.

Steam sauna activates many biological systems in the body

including the endocrine system.

Research on the influence of steam bathing on volunteers using steam saunas showed that hyperthermia causes a shift of metabolism toward carbohydrate changes. Steam sauna is an important modality in biological regeneration and is used by both athletes and people who do not practice any exercise.

A 2018 study into the impact of steam saunas on fasting blood glucose levels found that glucose levels dropped significantly after seven sessions compared to pre-sauna levels. This suggests that steam saunas may help prevent hyperglycemia and, hence, diabetes mellitus.

IMPROVE SYMPTOMS OF FIBROMYALGIA

IMPROVE STAMINA

THERAPEUTIC BENEFITS OF AROMATHERAPY IN SAUNA

Individuals suffering from fibromyalgia have experienced great results from using saunas to reduce discomfort and pain.

In one small study, 44 patients with fibromyalgia found a reduction in pain between 33 and 77%. Six months after the study ended, the participants continued to report a reduction in pain between 28 and 68%.

A 2022 study on both strengthtraining athletes and nonexperienced athletes showed that a passive, extreme-heat sauna lasting 12 minutes and taken immediately before a relative maximum repetition test provokes positive responses for the development of strength.

Since ancient times, essential oils derived from plants have been used for their medicinal value.

For thousands of years, they have been used as perfumes, flavourings for foods and beverages or to heal both body and mind (Baris et al., 2006; Margaris et al., 1982; Tisserand, 1997; Wei & Shibamoto, 2010).

Additionally, a further study shows that an acute passive increase in muscle temperature through activities such as saunas enhances the voluntary and involuntary rate of muscle contraction.

These responses to passive heating may help people with low muscle contractile activity, including older adults, physically inactive individuals, injured athletes and clinical populations, improve contractile function.

Findings in Mesopotamia, China, India, Persia and ancient Egypt show essential oils were used for many treatments. Due to their volatility, they can be inhaled easily through the respiratory tract and lungs, meaning they can be easily distributed into the bloodstream (Margaris et al., 1982; Moss et al, 2003).

Depending on the essential oil blend, the benefits that can be added to a sauna session can be: • Antimicrobial, pesticidal, antiseptic, antiparasitic, antifungal • B rain and circulatory benefits, stimulate the digestive system, emmenagogue (relating to the menstrual cycle, lymphatic, diuretic, hepatoprotective (relating to the liver) • Healing, astringent, decongestant, expectorant, mucolytic, anaesthetic and analgesic (reducing pain), antiinflammatory Relaxing and comforting, a general tonic and stimulant, aphrodisiac, support scalp health and refreshing.

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SAUNAS AND SOCIAL-ECONOMIC STATUS

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Various studies have been undertaken to understand the interplay between sauna bathing and social-economic status. One study, which explored sauna bathing and all-cause mortality risk in a general Finnish male population, found that frequent sauna baths may offset the increased overall mortality risk due to low social-economic status.

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CHAPTER 05

Massage Therapy

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

Massage Therapy

5.1 General information Massage can be used to treat a wide range of medical conditions and often forms part of integrative medicine programmes, with medical centres offering it alongside standard treatments.

Studies of massage benefits have found massage can: • Help reduce stress • L essen pain and muscle tightness • Increase relaxation • I mprove the work of the immune system.

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At the Mayo Clinic, medical providers routinely recommend massage therapy to help people cope with the pain and stress of conditions such as cancer, heart disease, stomach problems or fibromyalgia.

The word ‘massage’ itself encompasses many different types, from general massage,

commonly referred to as Swedish massage, to more specialised ones, such as sports massage aimed at athlete recovery.

According to Tiffany Field, PhD, director of the Touch Research Institute at the University of Miami School of Medicine, massage produces benefits for the body as the pressure from the movements on the skin calms the nervous system. This slowing of the nervous system leads to other physiological effects such as a decrease in heart rate, lowered blood pressure and changes in EEG patterns (electrical activity in your brain).

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5.2 Benefits of Massage Therapy

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HOT STONE THERAPY

COLD STONE MASSAGE

Hot stone therapy helps relax muscles more than a standard massage, allowing practitioners to work more effectively on areas of concern. This form of massage increases blood and lymph circulation to the area and relaxes muscles, relieving minor aches and pains. It has also been shown to soothe the nervous system, reduce stress, and ease tension headaches and menstrual pain.

Cold stone massage has been shown to decrease inflammation and swelling, stimulate the nervous system, and ease sinus congestion, arthritis and pain caused by strains and soft tissue injuries. This technique is effective as it encourages blood to flow away from the affected area and into surrounding tissues.

HOT-COLD CONTRAST MASSAGE (THERME’S SIGNATURE TREATMENT) The benefits of contrast therapy are underpinned by the increase, followed by the decrease, in blood circulation to a specific area, creating what is called a ‘blood pump’.

The circulation of blood and lymph is increased in one area by massaging with heat. This warmed blood and lymph are then forced into the adjacent tissues by the application of the cold massage. This type of massage therapy increases blood flow in areas that have poor circulation, removes blood from areas that are hyperaemic and strengthens circulation more generally.

CUPPING THERAPY

THERAPEUTIC MASSAGE

Cupping therapy is a promising method for the treatment and control of chronic back pain in adults. Studies have shown that it significantly decreases pain intensity scores when compared to control groups.

Numerous studies across several fields, including psychology, medicine, nursing and kinesiology, support massage therapy’s therapeutic value.

Therapeutic massage has proven to be effective in the treatment of symptoms associated with a variety of clinical conditions, including pregnancy, labour, burn treatment, postoperative pain, juvenile rheumatoid arthritis, fibromyalgia, back pain, migraine headache, multiple sclerosis, spinal cord injury, autism, attentiondeficit/hyperactivity disorder, posttraumatic stress disorder, eating disorders, chronic fatigue, depression, diabetes and asthma.

Therapeutic massage also produced benefits such as improved circulation, relaxation, feelings of wellbeing, and reductions in anxiety and pain, all of which are endorsed as benefits of massage therapy by the American Massage Therapy Association (AMTA, 1999b).

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CHAPTER 06

The Benefits of Infrared Therapy

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The Benefits of Infrared Therapy

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6.1 General information Infrared therapy (RLT) is an emerging treatment that is showing promise in the treatment of wrinkles, redness, acne, scars and other signs of ageing. Though studies published so far show potential for certain conditions, more clinical trials are needed to confirm its effectiveness as a treatment.

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6.2 Benefits

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CARDIOVASCULAR HEALTH

HEALING AND PAIN RELIEF

ALLEVIATING MITOCHONDRIAL DYSFUNCTION

One of the key health benefits of infrared therapy is an improvement in cardiovascular health. Infrared light increases the production of nitric oxide, a vital signalling molecule important for the health of blood vessels. This molecule helps relax the arteries and prevents blood from clotting and clumping in the vessels.

Moreover, infrared therapy has been shown to combat free radicals, prevent oxidative stress and regulate blood pressure.

Studies have shown that infrared therapy could be used as an effective and safe remedy for pain and inflammation.

The action of infrared light on water dynamics in membranes, mitochondria and/or cells could modulate signalling pathways and the production of reactive oxygen species (ROS), ATP (adenosine triphosphate), Ca2+, NO, and inositol phosphates.

Infrared therapy penetrates deep through the layers of the skin to the muscles and bones, enhancing and improving circulation. Because of this, it can encourage oxygen and nutrients to reach injured tissues, helping to promote healing, ease pain, relieve inflammation, and protect against oxidative stress. Research has also found that infrared therapy can support the relief of arthritic knee pain, increased endorphin levels and the bioactivation of neuromodulators.

Clinical evidence has demonstrated that infrared light can selectively induce cell death by apoptosis, necrosis and anoikis. In parallel, it induces cell differentiation as a physiological response as opposed to proliferation.

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CHAPTER 07

Cold Exposure Therapy

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

Cold Exposure Therapy

7.1 General information Cold water therapy involves immersing the body in cold water (less than 15°C). It can mean taking an ice bath, a cold shower or swimming in open water. Any of these activities should be done for only a few minutes at a time, gradually adapting the body to cold exposure.

Cold water therapy has been reported to have several positive effects on health, however, further research is still needed.

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7.2 The Benefits of Cold Exposure Therapy

THE CARDIOVASCULAR SYSTEM

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One 2000 study involved measuring the physiological impact of cold water immersion on a group of young men. The tests recorded a 5% reduction in heart rate, a 7% reduction in systolic blood pressure, and an 8% reduction in diastolic blood pressure. The cold water immersion also resulted in a 530% increase in adrenaline levels and a 250% increase in dopamine in the participants. Moreover, their basal metabolic rate increased by 350%. Cold water swimming has also been shown to lower triglycerides and homocysteine levels, which could be beneficial for the cardiovascular system.

However, these seem to be gender-dependent.

Although these findings point towards real positive benefits for the cardiovascular system, the long-term impact of cold water immersion has not yet been defined.

INSULIN RESISTANCE

THE IMMUNE SYSTEM

WEIGHT LOSS

REDUCING INFLAMMATION

In a 2016 study, 14 swimmers with an average age of 45 swam outside at least twice a week throughout the winter. The results showed a significant improvement in insulin sensitivity, suggesting that regular cold water swimming may stimulate metabolic changes.

In a 2016 study conducted in the Netherlands, 3018 participants were randomly assigned to either a hot shower followed by a cold shower for 30, 60, or 120 seconds or a control group that did not have a cold shower. They showered daily for 30 days and were then followed up for an additional 60 days.

Researchers from the University of Nottingham have found that people who regularly swim in cold water tend to have higher levels of brown fat cells. Most adult fat is ‘white fat’ used as a solid form of storing energy. However, when people have too much white fat it can lead to excess body fat, which can have a detrimental effect on their health. Brown fat, on the other hand, is used for warmth and to speed up metabolism, and it burns calories at a faster rate.

Research has shown that when athletes immerse themselves in cold water after exercise, they report decreased muscle pain.

Lowering the muscle temperature helps reduce oedema and blood flow to the area, altering the inflammatory response.

Over the 60-day follow-up period, those who took the cold showers had a 29% reduction in absent days from work. At that time of year, the most common reason for time off work in the Netherlands is influenza. The authors suggested that the cold shower group may perhaps have had less influenza.

From previous research, cycling to work has been shown to reduce sickness related absences from work by 35%. The researchers made the comparison that taking cold showers had a similar effect on work attendance to taking regular physical exercise.

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CHAPTER 08

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Benefits of Spending Time in Nature

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Benefits of Spending Time in Nature NATURE AND IMPROVED MENTAL HEALTH The following section has been taken from a detailed article published in Healthline: 62

“Numerous studies have revealed the positive effects that nature and the surrounding environment can have on mental and physical well-being. And now, new research published on August 5 from the University of Tokyo suggests the benefits of spending time in nature extend much further than previously believed.

Researchers conducted a systematic review of 301 academic articles, spanning 62 countries, on ‘cultural ecosystem services’ (CESs) — also known as the non-material or “intangible contributions” to wellbeing that nature provides.

They identified 227 unique “pathways” that “link a single CES to a single constituent of human well-being, [which is]

many more than we initially thought,” explained study coauthor Alexandros Gasparatos, PhD, associate professor of sustainability science at the Institute for Future Initiatives (IFI) at the University of Tokyo.

Gasparatos said that connecting with nature provides opportunities for recreation and leisure, spiritual fulfilment, personal development, social relations and aesthetic experiences.

Previous studies have shown that engaging in such opportunities can provide benefits such as enhanced physical and mental health, social cohesion, and a sense of place.

Alongside the pathways identified by the University of Tokyo researchers, Gasparatos said they also determined 16 “individual mechanisms.” Gasparatos described these mechanisms

as the “overarching types of connection through which more specific pathways are created.”

According to Gasparatos, previous studies had already highlighted some of the mechanisms, but the new research has identified 10 more. These include: • C ohesive: The development of meaningful human relationships through interactions with nature.

It is clear that being outdoors in various environments can provide a host of benefits. But exactly how does nature impact physiological and mental states?

According to environmental psychologist Lee Chambers, “studies have shown we can have a physiological response to being in natural environments, reducing our heart rate, blood pressure, and muscle tension.”

• F ormative: When elements such as mood, attitude, behaviours and values change instantly or over a short duration, following interaction with nature.

“There can also be a level of psychological restoration, with the lowering of cortisol, improved concentration, and feeling a deeper sense of connection,” Chambers added.

• S atisfactive: Feeling that your expectations and needs are satisfied through interactions with nature.

As a result of these effects, participants in previous research

• Transcendent: Obtaining benefits related to religious or spiritual values after interacting with nature.

studies have reported benefits including: • lower stress levels • reduced anxiety and depression • improved self-esteem • a boost in confidence More recently, a 2019 study found that spending 120 minutes outside each week — which can be broken up into smaller blocks of time — was associated with better health and wellbeing. And another study from 2021 revealed that just 30 minutes of outdoor time could lower blood pressure by almost 10%.

“The overall consensus is that 2 hours a week or more make a marked difference to reported well-being and that as little as 20 minutes per day can have a positive impact,” Chambers said.”

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BIOPHILIC DESIGN

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Biophilic design is the practice of reconnecting people and nature in the built environment and is based on the biophilia hypothesis which suggests that humans have an innate need to be around nature.

Biophilic design is claimed to bring many benefits to building occupants and the urban environment.

According to a 2014 study by Catherine Ryan et al., elements such as nature sounds, improved mental health 37% faster than traditional urban noise after stress exposure; surgery patients were exposed to aromatherapy, 45% used less morphine and 56% used fewer painkillers overall.

In his article titled ‘Biophilic Design – A Sustainable Path,’ Mustapha Adekoya writes:

“Another study by Kaitlyn Gillis and Birgitta Gatersleben found that the inclusion of plants in interior environments reduces stress and increases pain tolerance; the use of water elements and incorporation of views of nature are also mentally restorative for occupants.

When researching the effects of biophilia on hospital patients, Peter Newman and Jana Soderlund found that by increasing vista quality in hospital rooms depression and pain in patients are reduced, which in turn shortened hospital stays from 3.67 days to 2.6 days.

In biophilic cities, Andrew Dannenberg, et al. indicated that there are higher levels of social connectivity and better capability to handle life crises; this has resulted in lower crime rate levels of violence and aggression.”

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

Annex 1

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Resources

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The Science Behind Water, Heat, and Cold Therapies: A Collection of Evidence

Resources

• https://www.wellandgood.com/thermal-water-skin-care/ • J ournal of clinical medicine, The Role of Thermal Water in Chronic Skin Diseases Management: A Review of the Literature, Received: 21 July 2020; Accepted: 14 September 2020; Published: 22 September 2020 • https://journals.lww.com/md-journal/fulltext/2021/01290/the_effect_ of_thermal_mineral_waters_on_pain.116.aspx • https://journals.lww.com/md-journal/toc/2021/01290 • https://www.bupa.com.au/healthlink/mental-health-wellbeing/ selfcare/the-truth-about-hot-springs • https://www.thezoereport.com/wellness/benefits-of-thermal-baths

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• https://www.healthshots.com/mind/mental-health/know-the-mentalhealth-benefits-of-a-hot-water-bath/ • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8380127/ • h ttps://www.anytimefitness.com/ccc/ask-a-coach/the-burning-truthabout-the-hot-tub-diet/ • h ttps://www.anytimefitness.com/ccc/ask-a-coach/the-burning-truthabout-the-hot-tub-diet/ • https://www.mayoclinic.org/tests-procedures/massage-therapy/ about/pac-20384595 • https://www.mayo.edu/research/clinical-trials/cls-20323062 • https://www.prevention.com/health/g26305736/massage-therapybenefits/ • https://pubmed.ncbi.nlm.nih.gov/2669852/ • https://my.clevelandclinic.org/health/articles/22114-red-light-therapy •

https://www.gov.uk/government/publications/social-prescribingapplying-all-our-health/social-prescribing-applying-all-our-health

• L inking the nonmaterial dimensions of human-nature relations and human well-being through cultural ecosystem services | Science Advances

• https://www.healthline.com/health-news/spending-time-in-nature-isgood-for-you-new-research-explains-why • https://www.england.nhs.uk/personalisedcare/social-prescribing/ • http://www.healthdata.org/Italy • http://www.healthdata.org/france • https://www.researchgate.net/publication/310466609_Arts_on_ prescription_in_Scandinavia_A_review_of_current_practice_and_ future_possibilities • https://www.allianceon.org/Social-Prescribing • https://pubmed.ncbi.nlm.nih.gov/27932366/ • https://www.sciencedirect.com/science/article/pii/ S0531556521002916 • h ttps://figshare.com/articles/journal_contribution/The_effects_ of_a_single_and_a_series_of_Finnish_sauna_sessions_on_the_ immune_response_and_HSP-70_levels_in_trained_and_untrained_ men/22144697 • https://www.mdpi.com/1660-4601/20/3/2082 • https://erepo.uef.fi/handle/123456789/29213 • https://www.sciencedirect.com/science/article/pii/ S0531556522002145?via%3Dihub • https://link.springer.com/article/10.1007/s00484-023-02433-3 • https://www.researchgate.net/publication/326203347_Effect_of_ Steam_Sauna_Bath_on_Fasting_Blood_Glucose_Level_in_Healthy_ Adults • https://pdfs.semanticscholar.org/07ac/ c03ce342698e63ec7b519cf13a39a26be35a.pdf • https://apjai-journal.org/wp-content/ uploads/2016/10/9TheeffectofsixweeksVol31No2June2013P142.pdf • https://journals.4science.ge/index.php/jecm/article/view/571

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• https://journals.4science.ge/index.php/jecm/article/view/571 • https://pubmed.ncbi.nlm.nih.gov/34954348/ • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8945003/ • https://pubmed.ncbi.nlm.nih.gov/36078656/ • https://link.springer.com/article/10.1007/s00421-022-04991-7

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• https://blog.thermasol.com/history-of-the-steam-bath-a-look-at-thehammam/ • https://pubmed.ncbi.nlm.nih.gov/16046381/ • https://www.sciencedirect.com/science/article/abs/pii/ S0306456519305066

• https://pubmed.ncbi.nlm.nih.gov/36203760/

• https://www.clinicwala.com/cure_naturopathy-naturopathysteambath.html

• https://pubmed.ncbi.nlm.nih.gov/35785965/

• https://pubmed.ncbi.nlm.nih.gov/2596966/

• https://pubmed.ncbi.nlm.nih.gov/33797457/

• https://pubmed.ncbi.nlm.nih.gov/18685882/

• https://pubmed.ncbi.nlm.nih.gov/35836731/ • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6195670/

• https://www.enlightenedtherapies.com/2018/09/sauna-therapy-mayreduce-risk-of-dementia-and-boost-brain-health/

• https://www.bupa.co.uk/newsroom/ourviews/cold-water-therapy

• https://pubmed.ncbi.nlm.nih.gov/21742283/

• https://pubmed.ncbi.nlm.nih.gov/10751106/ • https://pubmed.ncbi.nlm.nih.gov/27376416/ • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5025014/ • https://www.businessinsider.com/cold-temperatures-could-lead-toweight-loss-2018-3?r=US&IR=T • https://thermalsprings.wordpress.com/ancient-thermal-baths-andspa/thermalism-medical-considerations-and-aplications/ • G lobal Wellness Economy Monitor: Thermal/Mineral Springs, October 2018.

• https://www.medicalnewstoday.com/articles/323600 • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8065437/ • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045434/ • https://spacarp.ca/nordic_style_spa/history • https://notwaste.ca/sauna/about/ • https://www.kahvecafeslc.com/2021/01/17/the-history-of-thehammam-and-the-pestemal/

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