Sauna Bathing as an Alternative Adjunct Therapy in the Prevention and Treatment of Chronic Health Conditions Including Cardiovascular Disease, Neurodegenerative Disease, Metabolic Disease, and Mental Health Disorders
Main Article Content
Abstract
Sauna bathing is a time-efficient, cost-effective health modality that has the potential to mimic the heat thermogenesis and cardiovascular effects of exercise. In recent years, researchers have been able to measure the benefits of sauna on human performance, endurance, and cardiovascular health. While many studies have investigated sauna use and its effect on athletic performance, fewer studies have investigated the use of sauna as a medical treatment for chronic health conditions. This review compiles the proven effects of sauna on human physiology and investigates its applications in the treatment of patients with chronic disease. Sauna use appears to be safe in most patient populations and is shown to be both tolerable and effective in patient populations with cardiovascular disease and late stages of congestive heart failure. Multiple cardiovascular benefits were demonstrated in the review including improved perfusion in peripheral arterial disease, decreased ventricular arrhythmias, 51% reduced annual cardiovascular mortality and 47% reduced annual risk of developing hypertension in men using the sauna 4-7 times per week. Finnish cohort studies have additionally exhibited reductions in lifetime annual risk of dementia by 66% in men using the sauna 4-7 times per week. It is suggested that increased heat shock protein expression through heat exposure may be responsible for the neuroprotective benefits of lifetime sauna use. Sauna has also displayed benefits in metabolic disease by reducing hemoglobin A1C and aiding heat acclimation in diabetics through improved thermoregulation. In mental health research, sauna use has shown potential in the treatment of depression by improving objective depression scores. Another study exhibited that sauna use was able to increase appetite in patients with severe depression and coexisting appetite suppression. Additionally, in cohort studies sauna is shown to be correlated to reduced annual risk of developing psychosis across the lifespan. By compiling and reviewing the current research on sauna bathing, education and guidance are provided to medical providers regarding the potential use of sauna as a treatment adjunct for patients with various conditions including cardiovascular disease, neurodegenerative disease, metabolic disease, and mental health disorders.
Article Details
How to Cite
REEDER, Michael et al.
Sauna Bathing as an Alternative Adjunct Therapy in the Prevention and Treatment of Chronic Health Conditions Including Cardiovascular Disease, Neurodegenerative Disease, Metabolic Disease, and Mental Health Disorders.
Medical Research Archives, [S.l.], v. 11, n. 6, june 2023.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/3965>. Date accessed: 27 dec. 2024.
doi: https://doi.org/10.18103/mra.v11i6.3965.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Roy, R. L. (2004). The Sauna. Chelsea Green Publishing.
2. Covalt, N. K. (1954). Sauna baths-a preliminary report. American Journal of Physical Medicine & Rehabilitation, 33(4), 216-223.
3. Scoon, G. S., Hopkins, W. G., Mayhew, S., & Cotter, J. D. (2007). Effect of post-exercise sauna bathing on the endurance performance of competitive male runners. Journal of Science and Medicine in Sport, 10(4), 259-262.
4. Miyata, M., Kihara, T., Kubozono, T., Ikeda, Y., Shinsato, T., Izumi, T., ... & Tei, C. (2008). Beneficial effects of Waon therapy on patients with chronic heart failure: results of a prospective multicenter study. Journal of cardiology, 52(2), 79-85.
5. Kunutsor, S. K., Khan, H., Laukkanen, T., & Laukkanen, J. A. (2018). Joint associations of sauna bathing and cardiorespiratory fitness on cardiovascular and all-cause mortality risk: a long-term prospective cohort study. Annals of medicine, 50(2), 139-146.
6. Kunutsor, S. K., Khan, H., Zaccardi, F., Laukkanen, T., Willeit, P., & Laukkanen, J. A. (2018). Sauna bathing reduces the risk of stroke in Finnish men and women: a prospective cohort study. Neurology, 90(22), e1937-e1944.
7. Hanusch, K. U., Janssen, C. H., Billheimer, D., Jenkins, I., Spurgeon, E., Lowry, C. A., & Raison, C. L. (2013). Whole-body hyperthermia for the treatment of major depression: associations with thermoregulatory cooling. American Journal of Psychiatry, 170(7), 802-804.
8. Krause, M., Ludwig, M. S., Heck, T. G., & Takahashi, H. K. (2015). Heat shock proteins and heat therapy for type 2 diabetes: pros and cons. Current Opinion in Clinical Nutrition & Metabolic Care, 18(4), 374-380.
9. Hayden, J. A., van der Windt, D. A., Cartwright, J. L., Côté, P., & Bombardier, C. (2013). Assessing bias in studies of prognostic factors. Annals of internal medicine, 158(4), 280-286.
10. Center for Disease Control and Prevention (2022). Heart Disease Facts. Retrieved from https://www.cdc.gov/heartdisease/facts.html
11. Laukkanen, T., Khan, H., Zaccardi, F., & Laukkanen, J. A. (2015). Association between sauna bathing and fatal cardiovascular and all-cause mortality events. JAMA internal medicine, 175(4), 542-548.
12. Miyata, M., & Tei, C. (2010). Waon therapy for cardiovascular disease: Innovative therapy for the 21 st century. Circulation Journal, 1002100612-1002100612.
13. Sobajima, M., Nozawa, T., Ihori, H., Shida, T., Ohori, T., Suzuki, T., ... & Inoue, H. (2013). Repeated sauna therapy improves myocardial perfusion in patients with chronically occluded coronary artery-related ischemia. International journal of cardiology, 167(1), 237-243.
14. Giannetti, N., Juneau, M., Arsenault, A., Behr, M. A., Grégoire, J., Tessier, M., & Larivée, L. (1999). Sauna-induced myocardial ischemia in patients with coronary artery disease. The American journal of medicine, 107(3), 228-233.
15. Zaccardi, F., Laukkanen, T., Willeit, P., Kunutsor, S. K., Kauhanen, J., & Laukkanen, J. A. (2017). Sauna bathing and incident hypertension: a prospective cohort study. American journal of hypertension, 30(11), 1120-1125.
16. Källström, M., Soveri, I., Oldgren, J., Laukkanen, J., Ichiki, T., Tei, C., ... & Hägglund, H. (2018). Effects of sauna bath on heart failure: A systematic review and meta‐analysis. Clinical cardiology, 41(11), 1491-1501.
17. Ouriel, K. (2001). Peripheral arterial disease. The lancet, 358(9289), 1257-1264.
18. Ohori, T., Nozawa, T., Ihori, H., Shida, T., Sobajima, M., Matsuki, A., ... & Inoue, H. (2012). Effect of repeated sauna treatment on exercise tolerance and endothelial function in patients with chronic heart failure. The American journal of cardiology, 109(1), 100-104.
19. Mori H, Maeda A, Wakabayashi K, et al. The Effect of Cilostazol on Endothelial Function as Assessed by Flow-Mediated Dilation in Patients with Coronary Artery Disease. J Atheroscler Thromb. 2016;23(10):1168-1177. doi:10.5551/jat.32912
20. Tei, C., Shinsato, T., Miyata, M., Kihara, T., & Hamasaki, S. (2007). Waon therapy improves peripheral arterial disease. Journal of the American College of Cardiology, 50(22), 2169-2171.
21. Kihara, T., Biro, S., Ikeda, Y., Fukudome, T., Shinsato, T., Masuda, A., & Tei, C. (2004). Effects of repeated sauna treatment on ventricular arrhythmias in patients with chronic heart failure. Circulation Journal, 68(12), 1146-1151.
22. (Ahn, M. S. (2013). Current concepts of premature ventricular contractions. Journal of lifestyle medicine, 3(1), 26.).
23. Fujita, S., Ikeda, Y., Miyata, M., Shinsato, T., Kubozono, T., Kuwahata, S., ... & Tei, C. (2011). Effect of Waon therapy on oxidative stress in chronic heart failure. Circulation Journal, 75(2), 348-356.
24. Kihara, T., Biro, S., Imamura, M., Yoshifuku, S., Takasaki, K., Ikeda, Y., ... & Tei, C. (2002). Repeated sauna treatment improves vascular endothelial and cardiac function in patients with chronic heart failure. Journal of the American College of Cardiology, 39(5), 754-759.
25. Tsutamoto, T., Wada, A., Maeda, K., Hisanaga, T., Maeda, Y., Fukai, D., ... & Kinoshita, M. (1997). Attenuation of compensation of endogenous cardiac natriuretic peptide system in chronic heart failure: prognostic role of plasma brain natriuretic peptide concentration in patients with chronic symptomatic left ventricular dysfunction. Circulation, 96(2), 509-516.
26. Puwanant, S., Priester, T. C., Mookadam, F., Bruce, C. J., Redfield, M. M., & Chandrasekaran, K. (2009). Right ventricular function in patients with preserved and reduced ejection fraction heart failure. European Journal of Echocardiography, 10(6), 733-737.
27. van Campen, L. C., Visser, F. C., & Visser, C. A. (1998). Ejection fraction improvement by beta-blocker treatment in patients with heart failure: an analysis of studies published in the literature. Journal of cardiovascular pharmacology, 32 Suppl 1, S31–S35.
28. Zhongyou Li, Wentao Jiang, Yu Chen, Guanshi Wang, Fei Yan, Tao Zeng, Haidong Fan. (2021). Acute and short-term efficacy of sauna treatment on cardiovascular function: A meta-analysis. European Journal of Cardiovascular Nursing, 20(2), 96–105.
29. Newman, A. B., Fitzpatrick, A. L., Lopez, O., Jackson, S., Lyketsos, C., Jagust, W., ... & Kuller, L. H. (2005). Dementia and Alzheimer's disease incidence in relationship to cardiovascular disease in the Cardiovascular Health Study cohort. Journal of the American Geriatrics Society, 53(7), 1101-1107.
30. Hyman, B. T., Phelps, C. H., Beach, T. G., Bigio, E. H., Cairns, N. J., Carrillo, M. C., ... & Montine, T. J. (2012). National Institute on Aging–Alzheimer's Association guidelines for the neuropathologic assessment of Alzheimer's disease. Alzheimer's & dementia, 8(1), 1-13.
31. Adachi, H., Katsuno, M., Waza, M., Minamiyama, M., Tanaka, F., & Sobue, G. (2009). Heat shock proteins in neurodegenerative diseases: pathogenic roles and therapeutic implications. International Journal of Hyperthermia, 25(8), 647-654.
32. Hafen, P. S., Preece, C. N., Sorensen, J. R., Hancock, C. R., & Hyldahl, R. D. (2018). Repeated exposure to heat stress induces mitochondrial adaptation in human skeletal muscle. Journal of applied physiology, 125(5), 1447-1455.
33. Asahina, M., Vichayanrat, E., Low, D. A., Iodice, V., and Mathias, C. J. (2013). Autonomic dysfunction in parkinsonian disorders: assessment and pathophysiology. Journal of Neurology, Neurosurgery, and Psychiatry. 84:674.
34. Lang, A. E., & Espay, A. J. (2018). Disease modification in Parkinson's disease: current approaches, challenges, and future considerations. Movement Disorders, 33(5), 660-677.
35. Danzer, K. M., Ruf, W. P., Putcha, P., Joyner, D., Hashimoto, T., Glabe, C., et al. (2011). Heat-shock protein 70 modulates toxic extracellular alpha-synuclein oligomers and rescues trans-synaptic toxicity. FASEB J. 25, 326–336.
36. Gao, X., Carroni, M., Nussbaum-Krammer, C., Mogk, A., Nillegoda, N. B., Szlachcic, A., et al. (2015). Human Hsp70 disaggregase reverses parkinson’s-linked alpha-synuclein Amyloid fibrils. Mol. Cell 59, 781–793.
37. Stetler, R. A., Gan, Y., Zhang, W., Liou, A. K., Gao, Y., Cao, G., et al. (2010). Heat shock proteins: cellular and molecular mechanisms in the central nervous system. Prog. Neurobiol. 92, 184–211.
38. Roglic, G. (2016). WHO Global report on diabetes: A summary. International Journal of Noncommunicable Diseases, 1(1), 3.
39. Center for Disease Control and Prevention (2017). Long-term Trends in Diabetes. Retrieved from https://www.cdc.gov/diabetes/statistics/slides/long_term_trends.pdf
40. American Diabetes Association. (2021). 2. Classification and diagnosis of diabetes: Standards of Medical Care in Diabetes—2021. Diabetes care, 44(Supplement 1), S15-S33.
41. Hooper, P. L. (1999). Hot-tub therapy for type 2 diabetes mellitus. New England Journal of Medicine, 341(12), 924-925.
42. Beever, R. (2010). The effects of repeated thermal therapy on quality of life in patients with type II diabetes mellitus. The Journal of alternative and complementary medicine, 16(6), 677-681.
43. Petrofsky JS, Lee S, Patterson C, Cole M, Stewart B. Sweat production during global heating and during isometric exercise in people with diabetes. Med Sci Monit 2005; 11:CR515–21; PMID:16258395.
44. Wick, D. E., Roberts, S. K., Basu, A., Sandroni, P., Fealey, R. D., Sletten, D., & Charkoudian, N. (2006). Delayed threshold for active cutaneous vasodilation in patients with Type 2 diabetes mellitus. Journal of applied physiology, 100(2), 637-641.
45. Semenza JC, McCullough JE, Flanders WD, McGeehin MA, Lumpkin JR. Excess hospital admissions during the July 1995 heat wave in Chicago. Am J Prev Med 1999; 16: 269–77.
46. Kenny GP, Sigal RJ, McGinn R. Body temperature regulation in diabetes. Temperature (Austin). 2016;3(1):119-145. doi:10.1080/23328940.2015.1131506.
47. Notley, S. R., Poirier, M. P., Sigal, R. J., D’Souza, A., Flouris, A. D., Fujii, N., & Kenny, G. P. (2019). Exercise heat stress in patients with and without type 2 diabetes. JAMA, 322(14), 1409-1411.
48. Ketelhut, S., & Ketelhut, R. G. (2019). The blood pressure and heart rate during sauna bath correspond to cardiac responses during submaximal dynamic exercise. Complementary Therapies in Medicine. https://doi.org/10.1016/j.ctim.2019.05.002.
49. Santo L, Okeyode T. National Ambulatory Medical Care Survey: 2018 National Summary Tables. Available from: https://www.cdc.gov/nchs/data/ahcd/namcs_summary/ 2018-namcs-web-tables-508.pdf.
50. Masuda, A., Nakazato, M., Kihara, T., Minagoe, S., & Tei, C. (2005). Repeated thermal therapy diminishes appetite loss and subjective complaints in mildly depressed patients. Psychosomatic Medicine, 67(4), 643-647.
51. Laukkanen, T., Laukkanen, J. A., & Kunutsor, S. K. (2018). Sauna bathing and risk of psychotic disorders: a prospective cohort study. Medical Principles and Practice, 27(6), 562-569.
52. Kukkonen-Harjula, K., & Kauppinen, K. (2006). Health effects and risks of sauna bathing. International journal of circumpolar health, 65(3), 195-205.
53. Hannuksela, M. L., & Ellahham, S. (2001). Benefits and risks of sauna bathing. The American journal of medicine, 110(2), 118–126.
54. Roine, R., Luurila, O. J., Suokas, A., Heikkonen, E., Koskinen, P., Ylikahri, R., ... & Salaspuro, M. (1992). Alcohol and sauna bathing: effects on cardiac rhythm, blood pressure, and serum electrolyte and cortisol concentrations. Journal of Internal medicine, 231(4), 333-338.
55. Harper CD, Bermudez R. Anhidrosis. [Updated 2021 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555988/.
56. Hao, J., Ghosh, P., Li, S. K., Newman, B., Kasting, G. B., & Raney, S. G. (2016). Heat effects on drug delivery across human skin. Expert opinion on drug delivery, 13(5), 755–768. https://doi.org/10.1517/17425247.2016.1136286.
57. Kowatzki, D., Macholdt, C., Krull, K., Schmidt, D., Deufel, T., Elsner, P., & Fluhr, J. W. (2008). Effect of regular sauna on epidermal barrier function and stratum corneum water-holding capacity in vivo in humans: a controlled study. Dermatology, 217(2), 173-180.
58. Ravanelli, N., Casasola, W., English, T., Edwards, K. M., & Jay, O. (2019). Heat stress and fetal risk. Environmental limits for exercise and passive heat stress during pregnancy: a systematic review with best evidence synthesis. British journal of sports medicine, 53(13), 799-805.
59. Graham Jr, J. M., & Edwards, M. J. (1998). Teratogen update: gestational effects of maternal hyperthermia due to febrile illnesses and resultant patterns of defects in humans. Teratology, 58(5), 209-221.
60. Artal, R., & O'Toole, M. (2003). Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. British journal of sports medicine, 37(1), 6-12.
61. Laukkanen, J. A., Laukkanen, T., & Kunutsor, S. K. Cardiovascular and other health benefits of sauna bathing: a review of the evidence. Mayo clinic proceedings. 2018; Vol. 93, No. 8, pp. 1111-1121. Elsevier.
2. Covalt, N. K. (1954). Sauna baths-a preliminary report. American Journal of Physical Medicine & Rehabilitation, 33(4), 216-223.
3. Scoon, G. S., Hopkins, W. G., Mayhew, S., & Cotter, J. D. (2007). Effect of post-exercise sauna bathing on the endurance performance of competitive male runners. Journal of Science and Medicine in Sport, 10(4), 259-262.
4. Miyata, M., Kihara, T., Kubozono, T., Ikeda, Y., Shinsato, T., Izumi, T., ... & Tei, C. (2008). Beneficial effects of Waon therapy on patients with chronic heart failure: results of a prospective multicenter study. Journal of cardiology, 52(2), 79-85.
5. Kunutsor, S. K., Khan, H., Laukkanen, T., & Laukkanen, J. A. (2018). Joint associations of sauna bathing and cardiorespiratory fitness on cardiovascular and all-cause mortality risk: a long-term prospective cohort study. Annals of medicine, 50(2), 139-146.
6. Kunutsor, S. K., Khan, H., Zaccardi, F., Laukkanen, T., Willeit, P., & Laukkanen, J. A. (2018). Sauna bathing reduces the risk of stroke in Finnish men and women: a prospective cohort study. Neurology, 90(22), e1937-e1944.
7. Hanusch, K. U., Janssen, C. H., Billheimer, D., Jenkins, I., Spurgeon, E., Lowry, C. A., & Raison, C. L. (2013). Whole-body hyperthermia for the treatment of major depression: associations with thermoregulatory cooling. American Journal of Psychiatry, 170(7), 802-804.
8. Krause, M., Ludwig, M. S., Heck, T. G., & Takahashi, H. K. (2015). Heat shock proteins and heat therapy for type 2 diabetes: pros and cons. Current Opinion in Clinical Nutrition & Metabolic Care, 18(4), 374-380.
9. Hayden, J. A., van der Windt, D. A., Cartwright, J. L., Côté, P., & Bombardier, C. (2013). Assessing bias in studies of prognostic factors. Annals of internal medicine, 158(4), 280-286.
10. Center for Disease Control and Prevention (2022). Heart Disease Facts. Retrieved from https://www.cdc.gov/heartdisease/facts.html
11. Laukkanen, T., Khan, H., Zaccardi, F., & Laukkanen, J. A. (2015). Association between sauna bathing and fatal cardiovascular and all-cause mortality events. JAMA internal medicine, 175(4), 542-548.
12. Miyata, M., & Tei, C. (2010). Waon therapy for cardiovascular disease: Innovative therapy for the 21 st century. Circulation Journal, 1002100612-1002100612.
13. Sobajima, M., Nozawa, T., Ihori, H., Shida, T., Ohori, T., Suzuki, T., ... & Inoue, H. (2013). Repeated sauna therapy improves myocardial perfusion in patients with chronically occluded coronary artery-related ischemia. International journal of cardiology, 167(1), 237-243.
14. Giannetti, N., Juneau, M., Arsenault, A., Behr, M. A., Grégoire, J., Tessier, M., & Larivée, L. (1999). Sauna-induced myocardial ischemia in patients with coronary artery disease. The American journal of medicine, 107(3), 228-233.
15. Zaccardi, F., Laukkanen, T., Willeit, P., Kunutsor, S. K., Kauhanen, J., & Laukkanen, J. A. (2017). Sauna bathing and incident hypertension: a prospective cohort study. American journal of hypertension, 30(11), 1120-1125.
16. Källström, M., Soveri, I., Oldgren, J., Laukkanen, J., Ichiki, T., Tei, C., ... & Hägglund, H. (2018). Effects of sauna bath on heart failure: A systematic review and meta‐analysis. Clinical cardiology, 41(11), 1491-1501.
17. Ouriel, K. (2001). Peripheral arterial disease. The lancet, 358(9289), 1257-1264.
18. Ohori, T., Nozawa, T., Ihori, H., Shida, T., Sobajima, M., Matsuki, A., ... & Inoue, H. (2012). Effect of repeated sauna treatment on exercise tolerance and endothelial function in patients with chronic heart failure. The American journal of cardiology, 109(1), 100-104.
19. Mori H, Maeda A, Wakabayashi K, et al. The Effect of Cilostazol on Endothelial Function as Assessed by Flow-Mediated Dilation in Patients with Coronary Artery Disease. J Atheroscler Thromb. 2016;23(10):1168-1177. doi:10.5551/jat.32912
20. Tei, C., Shinsato, T., Miyata, M., Kihara, T., & Hamasaki, S. (2007). Waon therapy improves peripheral arterial disease. Journal of the American College of Cardiology, 50(22), 2169-2171.
21. Kihara, T., Biro, S., Ikeda, Y., Fukudome, T., Shinsato, T., Masuda, A., & Tei, C. (2004). Effects of repeated sauna treatment on ventricular arrhythmias in patients with chronic heart failure. Circulation Journal, 68(12), 1146-1151.
22. (Ahn, M. S. (2013). Current concepts of premature ventricular contractions. Journal of lifestyle medicine, 3(1), 26.).
23. Fujita, S., Ikeda, Y., Miyata, M., Shinsato, T., Kubozono, T., Kuwahata, S., ... & Tei, C. (2011). Effect of Waon therapy on oxidative stress in chronic heart failure. Circulation Journal, 75(2), 348-356.
24. Kihara, T., Biro, S., Imamura, M., Yoshifuku, S., Takasaki, K., Ikeda, Y., ... & Tei, C. (2002). Repeated sauna treatment improves vascular endothelial and cardiac function in patients with chronic heart failure. Journal of the American College of Cardiology, 39(5), 754-759.
25. Tsutamoto, T., Wada, A., Maeda, K., Hisanaga, T., Maeda, Y., Fukai, D., ... & Kinoshita, M. (1997). Attenuation of compensation of endogenous cardiac natriuretic peptide system in chronic heart failure: prognostic role of plasma brain natriuretic peptide concentration in patients with chronic symptomatic left ventricular dysfunction. Circulation, 96(2), 509-516.
26. Puwanant, S., Priester, T. C., Mookadam, F., Bruce, C. J., Redfield, M. M., & Chandrasekaran, K. (2009). Right ventricular function in patients with preserved and reduced ejection fraction heart failure. European Journal of Echocardiography, 10(6), 733-737.
27. van Campen, L. C., Visser, F. C., & Visser, C. A. (1998). Ejection fraction improvement by beta-blocker treatment in patients with heart failure: an analysis of studies published in the literature. Journal of cardiovascular pharmacology, 32 Suppl 1, S31–S35.
28. Zhongyou Li, Wentao Jiang, Yu Chen, Guanshi Wang, Fei Yan, Tao Zeng, Haidong Fan. (2021). Acute and short-term efficacy of sauna treatment on cardiovascular function: A meta-analysis. European Journal of Cardiovascular Nursing, 20(2), 96–105.
29. Newman, A. B., Fitzpatrick, A. L., Lopez, O., Jackson, S., Lyketsos, C., Jagust, W., ... & Kuller, L. H. (2005). Dementia and Alzheimer's disease incidence in relationship to cardiovascular disease in the Cardiovascular Health Study cohort. Journal of the American Geriatrics Society, 53(7), 1101-1107.
30. Hyman, B. T., Phelps, C. H., Beach, T. G., Bigio, E. H., Cairns, N. J., Carrillo, M. C., ... & Montine, T. J. (2012). National Institute on Aging–Alzheimer's Association guidelines for the neuropathologic assessment of Alzheimer's disease. Alzheimer's & dementia, 8(1), 1-13.
31. Adachi, H., Katsuno, M., Waza, M., Minamiyama, M., Tanaka, F., & Sobue, G. (2009). Heat shock proteins in neurodegenerative diseases: pathogenic roles and therapeutic implications. International Journal of Hyperthermia, 25(8), 647-654.
32. Hafen, P. S., Preece, C. N., Sorensen, J. R., Hancock, C. R., & Hyldahl, R. D. (2018). Repeated exposure to heat stress induces mitochondrial adaptation in human skeletal muscle. Journal of applied physiology, 125(5), 1447-1455.
33. Asahina, M., Vichayanrat, E., Low, D. A., Iodice, V., and Mathias, C. J. (2013). Autonomic dysfunction in parkinsonian disorders: assessment and pathophysiology. Journal of Neurology, Neurosurgery, and Psychiatry. 84:674.
34. Lang, A. E., & Espay, A. J. (2018). Disease modification in Parkinson's disease: current approaches, challenges, and future considerations. Movement Disorders, 33(5), 660-677.
35. Danzer, K. M., Ruf, W. P., Putcha, P., Joyner, D., Hashimoto, T., Glabe, C., et al. (2011). Heat-shock protein 70 modulates toxic extracellular alpha-synuclein oligomers and rescues trans-synaptic toxicity. FASEB J. 25, 326–336.
36. Gao, X., Carroni, M., Nussbaum-Krammer, C., Mogk, A., Nillegoda, N. B., Szlachcic, A., et al. (2015). Human Hsp70 disaggregase reverses parkinson’s-linked alpha-synuclein Amyloid fibrils. Mol. Cell 59, 781–793.
37. Stetler, R. A., Gan, Y., Zhang, W., Liou, A. K., Gao, Y., Cao, G., et al. (2010). Heat shock proteins: cellular and molecular mechanisms in the central nervous system. Prog. Neurobiol. 92, 184–211.
38. Roglic, G. (2016). WHO Global report on diabetes: A summary. International Journal of Noncommunicable Diseases, 1(1), 3.
39. Center for Disease Control and Prevention (2017). Long-term Trends in Diabetes. Retrieved from https://www.cdc.gov/diabetes/statistics/slides/long_term_trends.pdf
40. American Diabetes Association. (2021). 2. Classification and diagnosis of diabetes: Standards of Medical Care in Diabetes—2021. Diabetes care, 44(Supplement 1), S15-S33.
41. Hooper, P. L. (1999). Hot-tub therapy for type 2 diabetes mellitus. New England Journal of Medicine, 341(12), 924-925.
42. Beever, R. (2010). The effects of repeated thermal therapy on quality of life in patients with type II diabetes mellitus. The Journal of alternative and complementary medicine, 16(6), 677-681.
43. Petrofsky JS, Lee S, Patterson C, Cole M, Stewart B. Sweat production during global heating and during isometric exercise in people with diabetes. Med Sci Monit 2005; 11:CR515–21; PMID:16258395.
44. Wick, D. E., Roberts, S. K., Basu, A., Sandroni, P., Fealey, R. D., Sletten, D., & Charkoudian, N. (2006). Delayed threshold for active cutaneous vasodilation in patients with Type 2 diabetes mellitus. Journal of applied physiology, 100(2), 637-641.
45. Semenza JC, McCullough JE, Flanders WD, McGeehin MA, Lumpkin JR. Excess hospital admissions during the July 1995 heat wave in Chicago. Am J Prev Med 1999; 16: 269–77.
46. Kenny GP, Sigal RJ, McGinn R. Body temperature regulation in diabetes. Temperature (Austin). 2016;3(1):119-145. doi:10.1080/23328940.2015.1131506.
47. Notley, S. R., Poirier, M. P., Sigal, R. J., D’Souza, A., Flouris, A. D., Fujii, N., & Kenny, G. P. (2019). Exercise heat stress in patients with and without type 2 diabetes. JAMA, 322(14), 1409-1411.
48. Ketelhut, S., & Ketelhut, R. G. (2019). The blood pressure and heart rate during sauna bath correspond to cardiac responses during submaximal dynamic exercise. Complementary Therapies in Medicine. https://doi.org/10.1016/j.ctim.2019.05.002.
49. Santo L, Okeyode T. National Ambulatory Medical Care Survey: 2018 National Summary Tables. Available from: https://www.cdc.gov/nchs/data/ahcd/namcs_summary/ 2018-namcs-web-tables-508.pdf.
50. Masuda, A., Nakazato, M., Kihara, T., Minagoe, S., & Tei, C. (2005). Repeated thermal therapy diminishes appetite loss and subjective complaints in mildly depressed patients. Psychosomatic Medicine, 67(4), 643-647.
51. Laukkanen, T., Laukkanen, J. A., & Kunutsor, S. K. (2018). Sauna bathing and risk of psychotic disorders: a prospective cohort study. Medical Principles and Practice, 27(6), 562-569.
52. Kukkonen-Harjula, K., & Kauppinen, K. (2006). Health effects and risks of sauna bathing. International journal of circumpolar health, 65(3), 195-205.
53. Hannuksela, M. L., & Ellahham, S. (2001). Benefits and risks of sauna bathing. The American journal of medicine, 110(2), 118–126.
54. Roine, R., Luurila, O. J., Suokas, A., Heikkonen, E., Koskinen, P., Ylikahri, R., ... & Salaspuro, M. (1992). Alcohol and sauna bathing: effects on cardiac rhythm, blood pressure, and serum electrolyte and cortisol concentrations. Journal of Internal medicine, 231(4), 333-338.
55. Harper CD, Bermudez R. Anhidrosis. [Updated 2021 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555988/.
56. Hao, J., Ghosh, P., Li, S. K., Newman, B., Kasting, G. B., & Raney, S. G. (2016). Heat effects on drug delivery across human skin. Expert opinion on drug delivery, 13(5), 755–768. https://doi.org/10.1517/17425247.2016.1136286.
57. Kowatzki, D., Macholdt, C., Krull, K., Schmidt, D., Deufel, T., Elsner, P., & Fluhr, J. W. (2008). Effect of regular sauna on epidermal barrier function and stratum corneum water-holding capacity in vivo in humans: a controlled study. Dermatology, 217(2), 173-180.
58. Ravanelli, N., Casasola, W., English, T., Edwards, K. M., & Jay, O. (2019). Heat stress and fetal risk. Environmental limits for exercise and passive heat stress during pregnancy: a systematic review with best evidence synthesis. British journal of sports medicine, 53(13), 799-805.
59. Graham Jr, J. M., & Edwards, M. J. (1998). Teratogen update: gestational effects of maternal hyperthermia due to febrile illnesses and resultant patterns of defects in humans. Teratology, 58(5), 209-221.
60. Artal, R., & O'Toole, M. (2003). Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. British journal of sports medicine, 37(1), 6-12.
61. Laukkanen, J. A., Laukkanen, T., & Kunutsor, S. K. Cardiovascular and other health benefits of sauna bathing: a review of the evidence. Mayo clinic proceedings. 2018; Vol. 93, No. 8, pp. 1111-1121. Elsevier.