Sleep and spa therapies: What is the role of balneotherapy associated with exercise? A systematic review.

Balneotherapy and exercise are potential factors influencing sleep through several physiological pathways and relaxing effects. This review aims to assess whether balneotherapy can improve sleep quality in concomitance or not with exercise. The research was conducted on Medline, Scopus, PubMed, Web of Science, and Cochrane Library databases. The current review followed PRISMA reporting guidelines and involves twenty-one articles grouped into four sections based on the characteristics of the balneotherapy protocol: 1.a Balneotherapy-thermal water immersion alone (five studies); 1.b Balneotherapy-thermal water immersion with other spa treatments (six studies); 2.a Balneotherapy and physical exercise-balneotherapy and out-of-the-pool physical exercise (eight studies); 2.b Balneotherapy and physical exercise-balneotherapy and in-pool physical exercise (three studies). Apart from healthy or sub-healthy subjects, patients recruited in the studies were affected by fibromyalgia, ankylosing spondylitis, osteoarthritis, musculoskeletal pain, subacute supraspinatus tendinopathy, and mental disorders. Duration, number of sessions, and study protocols are very different from each other. Only one study objectively evaluated sleep, whereas the others used subjective sleep assessment methods. Eight studies considered sleep as a primary outcome and ten as secondary. Sixteen out of twenty-one studies described improvements in self-perceived sleep quality. Thus, balneotherapy associated with other spa treatments and physical exercise seems to be effective in improving self-perceived sleep quality. However, the miscellany of treatments makes it difficult to discern the isolated effects of balneotherapy and physical exercise. Future studies should consider using an objective sleep assessment method and describing the pathways and physiological mechanisms that could provoke sleep changes during balneotherapy treatments.

Acute adrenal failure as the heralding symptom of primary antiphospholipid syndrome: report of a case and review of the literature.

Acute adrenal failure is a potentially fatal condition if overlooked. Occasionally, acute adrenal insufficiency may ensue from bilateral adrenal haemorrhage in patients with known antiphospholipid syndrome (APS). APS is characterized by recurrent arterial and venous thrombosis, pregnancy complications and detection of autoantibodies to phospholipids. This syndrome may be associated with non-organ specific diseases (e.g. connective tissue disorders) or with malignancies, but it may also appear in isolated form (primary APS). In a very few cases the heralding manifestation is given by adrenal failure. We report here a 63-year-old man presenting with acute adrenal insufficiency as the opening clinical manifestation of an APS. We also carried out a computer-aided search of the literature to identify all cases of primary adrenal failure as the first-recognized expression of a primary APS, a condition that not so infrequently may be tackled by endocrinologists. 20 patients fulfilled the inclusion criteria. The great majority of them were males (75%) with a mean age of 42 years. Abdominal pain was present in 14 patients, followed by fever (13 patients) and hypotension (12 patients). The main morphological findings by computed tomography or magnetic resonance were consistent with bilateral adrenal haemorrhage in 11 patients. Lupus anticoagulant was present in all of the 19 tested patients. Our observations emphasize the importance in the assessment of clotting times, and possibly of antiphospholipid antibodies, in all patients with diagnosis of rapidly progressive adrenal failure and concurrent abdominal pain.