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A Prospective “Study by Correspondence”
on the Effects of Kneipp Hydrotherapy in Patients
with Complaints due to Peripheral Neuropathy
Bernhard Uehleke1, Heike Wöhling2, Rainer Stange1
1Charité Universitätsmedizin Berlin, Immanuel-Krankenhaus, Dep. for Natural Healing, Berlin, Germany
2DABIO Gesellschaft für Auftragsforschung mbH, Höhenkirchen, Germany
Paresthesia and other malfunction
of sense are typical complaints of
peripheral neuropathy (PNP) which
are most often located symmetrically
in the lower limbs. In more severe
forms, there are also paresis, muscu-
lar atrophy and trophical changes of
the skin. The prevalence of PNP is esti-
mated at 1:2500 inhabitants in Ger-
many. Etiologic relations include meta-
bolic diseases, intoxications, infections
and immunological diseases, yet in
many patients their etiology remains
unclear. The diagnosis is based on
anamnesis, neurological examinations,
particularly on nerve conduction ve-
locity [1].
The therapy focusses on the under-
lying disease, provided there is one,
and consists of supplementation of
neurotrophic vitamins and α-liponic
acid, the latter mainly for patients with
diabetes mellitus [2]. Other sympto-
matic treatments with drugs include
calcium channel blockers in patients
with muscle cramps, antiphlogistics,
analgetics and antidepressants as well
as topically applied capsicum extract
standardized to capsaicin [3].
Various methods of physiotherapy
are also used for the treatment of the
symptoms of polyneuropathy, also hy-
drotherapy is recommended. There
are no systematic investigations about
hydrotherapy. Hydrotherapeutic appli-
cations in the tradition of Sebastian
Kneipp (1821–97) are administered lo-
cally as cold stimulus with short dura-
tion, thereby inducing a local reactive
hyperemia, involving neuronal, vege-
tative, endocrinal and immunological
systems [4]. Long-term treatment with
a series of hydrotherapeutic measures
Background: Kneipp hydrotherapy is often recommended to reduce symptoms of peripheral neu-
ropathy on the basis that the cold stimulus could influence neuronal networking and that improve-
ment of circulation and metabolism could improve local neuronal function. However, no data on clin-
ical effectiveness are available. Aim of the Study: To evaluate the effectiveness of and compliance
with hydrotherapeutic self-treatment in patients with peripheral neuropathy (PNP). Design of the
Study: Preliminary open prospective observational “study by correspondence”: Patients received
written information, instructions and questionnaires without direct contact with the study physician.
Methods: Patients with interest in participation were enrolled from self-help groups and by TV and
internet and were given instructions.They were asked to self treat at home daily using at least two
out of four Kneipp hydrotherapeutic applications (knee affusion, cold foot-bath, alternating foot-bath,
wet socks). After 8 weeks of treatment, patients returned their diaries with self-ratings of com-
plaints before and after each application as well as their judgments before the cure and at its end.
Results: We received completed forms from 27 patients (15 females, 12 males; mean age 68.2
years). Patients reported a significant decrease in dysesthesia from a mean of 3.4 (baseline) to 2.9
(t-test, 2p<0.04) after the cure. Hypesthesia (numbness) improved from 3.5 to 3.1 (2p<0.12). There
were no significant changes for total pain (2.6 to 2.5) and paresis (0.8 to 0.8). Acute relief of symp-
toms was reported after 30–62% of applications with an increasing trend during the cure versus
acute impairments only after 5 to 9% of applications. Conclusions: Our results give hints for effec-
tiveness of self-treatment with hydrotherapy in patients with PNP – at least in a subgroup of them.
Yet, there are limitations of the interpretation of the results of this uncontrolled study. Efficacy might
be better after detailed and personal instruction on the hydrotherapeutic procedures. Conducting a
prospective “study by correspondence” seems to be appropriate at least for generating preliminary
data for natural healing self-treatments under realistic everyday conditions.
Keywords: Kneipp, hydrotherapy, peripheral neuropathy, study by correspondence
Eine prospektive „Fernstudie“
(Study by Correspondence)
über die Wirkung der Kneipp Hydrotherapie bei Patienten
mit Beschwerden infolge einer Polyneuropathie
Hintergrund: Kneippsche Hydrotherapie wird zur Symptomlinderung im Rahmen von Polyneuro-
pathie empfohlen. Der Kältestimulus könnte die Funktion der neuronalen Netze beeinflussen und
die Anregung der Durchblutung könnte die neuronale Funktion lokal verbessern. Allerdings sind
keine Daten über die klinische Wirksamkeit bekannt. Studienziel: Untersuchung von Wirksamkeit
und Compliance einer hydrotherapeutischen Selbstbehandlung bei Patienten mit Polyneuropathie
(PNP). Studiendesign: Preliminäre offene prospektive Beobachtungsstudie („Fernstudie“, “Study
by correspondence“): Die Patienten erhielten schriftlich Informationen, Anleitungen und Fragebö-
gen ohne direkten Kontakt mit einem Prüfarzt. Methoden: Patienten mit Interesse an der Teilnahme
wurden über Selbsthilfegruppen sowie über TV und Internet angesprochen und erhielten die Unter-
lagen. Sie sollten mindestens zwei von vier Kneippanwendungen täglich zu Hause durchführen (Knie-
guss, kaltes Fussbad, Wechselfussbad und nasse Socken). Nach 8-wöchiger Behandlung schickten
die Patienten ihre ausgefüllten Fragebögen und Tagebücher mit Bewertungen der Beschwerden
vor und nach jeder einzelnen Anwendung ein sowie ihre Gesamtbeurteilung ihrer Beschwerden vor
und nach der Kur. Ergebnisse: Wir erhielten ausgefüllte Fragebögen von 27 Patienten (15 Frauen
und 12 Männer, durchschnittliches Alter 68,2 Jahre). Nach Abschluss der kurmässigen Anwen-
dungen berichteten die Patienten eine signifikante mittlere Abnahme der Dysaesthesie von 3,4 (Ba-
seline) auf 2,9 (t-test, 2p<0,04). Hypaesthesie (Taubheit) verbesserte sich von 3,5 auf 3,1 (2p<0,12).
Es gab keine signifikanten Änderungen für Gesamtschmerz (2,6 auf 2,5) und für Parese (0,8 auf
0,8). Eine akute Symptomlinderung wurde nach 30–62% der Anwendungen berichtet mit einer Zu-
nahme während der Kur, während akute Verschlimmerungen nur nach 5–9 % der Anwendungen
berichtet wurden. Schlussfolgerungen: Unsere Ergebnisse geben Hinweise auf eine Wirksamkeit
von Selbstbehandlung mit Hydrotherapie bei Patienten mit PNP – mindestens in einer Untergruppe.
Es gibt Limitierungen für die Interpretation der Ergebnisse in dieser speziellen unkontrollierten Stu-
die. Die Wirksamkeit könnte jedoch besser ausfallen nach einer detaillierten persönlichen Schulung
über die Wasseranwendungen. Die Methode einer „Fernstudie“ erscheint wenigstens zur Erhe-
bung preliminärer Daten über naturheilkundliche Selbstbehandlungen angemessen und zeigt ein
realistisches Bild unter Alltagsbedingungen.
Schlüsselwörter: Kneipp, Hydrotherapie, Wassertherapie, Polyneuropathie, Fernstudie
Schweiz. Zschr. GanzheitsMedizin 20 (5), September 2008 287
Schweiz. Zschr. GanzheitsMedizin 2008;20(5):287–291. © Verlag für GanzheitsMedizin, Basel. www.ganzheitsmedizin.ch
Originalarbeit R
Original Article
is expected to train sensory feeling,
circulation and metabolism in skin and
the peripheral muscle. In addition, a
series of hydrotherapy induces an
adaptation to stressor stimuli [5] and
influences local and systemic immuno-
logical functions (“hardening”).
There is a marked hyperemia for
about 1 hour after a short cold stimu-
lus in the affected skin region [6]. A
general improvement of peripheral
circulation after serial application of
Kneipp hydrotherapeutic measures
has been shown in several studies [7].
A better circulation should improve
the impaired neuronal function in PNP.
Furthermore, there are many complex
physiologic and psychologic aspects of
self-treatment with cold water applica-
tions which might be relevant for per-
ception and reporting of neuropathic
symptoms.
In order to investigate the efficacy
of Kneipp hydrotherapy, we performed
a first preliminary study as prospective
intervention study in outpatients with-
out personal contact to the study
physician. The patients were given
written information and instructions,
were asked to complete questionnaires
and to document in a diary symptoms
and applications over a study period of
8 weeks under self-treatment. This
type of study setting is new and was
named ‘study by correspondence’. The
only difference to normal open obser-
vational clinical studies is that there is
no direct contact between patient and
study physician. There is no reason
why a patient could not document his
history and his symptoms in well-ex-
plained questionnaires. Kneipp Hydro-
therapy with several daily applications,
on written or personal instruction, is
normally a self-treatment anyway.
Materials and Methods
Patients
This was an open prospective study on
the effects of Kneipp hydrotherapy in
patients with complaints due to PNP.
Study information material had been
distributed to approximately 100 inter-
ested patients (most of them by pa-
tients’ self-help groups, some patients
had become aware of this study on TV
and internet); only 27 patients, however,
returned completed questionnaires.
There was no inclusion limitation
with regard to severity of complaints,
yet, we did not advise to apply hydro-
therapy in more severe cases of pare-
sis. There were also no limitations re-
garding etiology and status of diagno-
sis but we asked in our questionnaires
for all available respective information.
Intervention
The intervention consisted of a series
of hydrotherapeutic applications ac-
cording Kneipp to be applied by the pa-
tients themselves. They were advised
to continue with any prior therapies.
They were given extensive written in-
structions how to apply the following
four Kneipp applications: cold “knee
affusion”, cold “wet socks”, “footbath”
(= cold bath of lower limbs), alternat-
ing foot bath. These applications have
in common that they provide a short
but intensive cold stimulus by using
water as cold as available (appr.
15° C). Patients were informed that the
applications should induce local physi-
ological reactions (initial vasoconstric-
tion, followed by a longer lasting hyper-
emia) as well as systemic vegetative re-
actions including neurohormonal and
circulatory reactions. As partial appli-
cations on the lower limbs, they should
lead to moderate reactions and should
usually be well tolerated.
A knee affusion is applied by means
of a wide-lumen (3/4”) water hose with
a steady low-pressure flow of cold wa-
ter in order to avoid mechanical stimu-
lation of the skin. It starts at the right
fore-foot, is then directed upwards the
calf to a few inches above the hollow of
the knee, remains there for about 10
seconds and goes down at the inner
side of the calf. Then the procedure is
repeated in similar manner at the front
side and afterwards the other leg is
treated. The affusion is terminated
with a short affusion of the soles. The
whole procedure takes no longer than
one minute.
For the foot-bath, a bucket filled
with cold water – its surface reaching
some inches below the knee – is re-
quired. The foot-bath lasts 10 to 30
seconds and is terminated immediately
as soon as a cold pain is felt.
For the alternating foot bath, two
buckets, one with cold (ca. 15° C) and
one with warm water (ca. 36° C) are
used. After having started with the
warm foot bath for 3 minutes, one
changes to the cold water bath for ap-
prox. 20 seconds. This procedure has
to be repeated immediately and has al-
ways to be finished with the cold bath
in order to induce the reactions after
the cold stimulus as described above.
Wet socks of cotton are moistened
with cold water and then applied. Hav-
ing warmed-up after approximately 30
minutes, they are taken off before on-
set of sweating
Patients were asked to apply two to
four of these Kneipp applications each
day. Patients were free to choose the
time of day and the type of each appli-
cation.
Questionnaire and diary
The questionnaire sent to the patients
asked for demographic data, general
feeling, physical activities, use of nico-
tine and alcohol, history and etiology
of PNP, former therapies and the
symptoms (pain, paresthesia, numb-
ness, paresis, other complaints, gen-
eral impairment and feeling). These
symptoms were to be rated in Likert
scales from zero (none) to six (most se-
vere complaints) before and after 8
weeks of treatment.
Patients were asked to record in the
diary time and type of each applica-
tion, the complaints before administra-
tion (from 0 to 6) and the immediate
change of pain, hyperaesthesia, and
paresthesia (unchanged, plus or mi-
nus) after each water application. In-
take of analgetics was also recorded.
Statistics
Data were analysed descriptively; t-
test was used, paired if appropriate.
The outcome parameters were symp-
tom scores before and after the treat-
ment period, course of symptoms
recorded in the diary, number of appli-
cations and initial changes of symp-
toms after each hydrotherapeutic
measure. Compliance (frequency of
applications) and questions regarding
tolerability were used as a measure for
practicability.
288 Schweiz. Zschr. GanzheitsMedizin 20 (5), September 2008
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Original Article
Ethic Comitee
There was no need for an approval by
an ethic comittee since it was an ob-
servational study with an intervention
which is usually recommended as self-
treatment in media and advisory books
for patients [8]. Consent for anony-
mous data processing was given by the
participants.
Results
Patients
We received completed questionnaires
from 27 patients (12 male, 15 female).
The patients’ mean age was 68 years,
their mean height 172 cm and mean
weight 75.5 kg. Two patients out of 27
stopped treatment after 3 weeks, four
patients reported intermediate discon-
tinuation of the hydrotherapy within
the first few days due to “worsening of
complaints”.
On the scale for physical activity
(from 0 = bed rest to 6 = practising
sports several times per week), the
mean value was 3.6 before the study.
Five patients reported that they could
walk only with the aid of sticks. Twelve
patients were smokers and 9 patients
ingested moderate amounts of alco-
holic beverages. In 12 patients, the
etiology of PNP was unknown, the oth-
ers reported: diabetes (2), cancer resp.
cancer treatments (2), arteriosclerosis
(2), rheumatic disease (2), neuroborre-
liosis (2), hormonal disease (1), meta-
bolic disorder (1), vitamin deficiency
(1), genetic disease (1), neuronal muscle
atrophy (1), “other etiologies” (10). 23
patients were under observation of a
neurologist, 13 patients of their gen-
eral practitioner; 5 patients saw other
medical specialists and 14 patients re-
ported previous hospital treatments
related to their PNP.
Twenty patients knew test results of
their glucose levels, 15 patients of their
lipids, 14 patients of levels of vitamin
B12 and folic acid. Seven patients re-
ported prior biopsies of muscle and
nerve; 6 patients remembered tests of
cerebral spinal fluid or NMR.
Concomitant therapy was reported:
18 patients took supplementations of
vitamins; 7 patients received infusions
and 11 patients orally applied α-liponic
acid. 13 patients took analgetics and
11 patients received physiotherapy.
23 and 22 patients had symptoms of
their right or left toes respectively. In-
volvement of the right or left lower
limbs was recorded each in 15 pa-
tients. Eleven and 10 patients had also
symptoms at the right or left hand re-
spectively.
Therapy/Compliance
The most-favored Kneipp application
was the knee affusion which was used
about 11 times per patient and per
week within the first week of treat-
ment. Towards the end of the treat-
ment period, this practice was reduced
to 9 times per week and per patient on
average. There was a wide variation in
the number of applications from pa-
tient to patient, e.g. a total of 8 to 179
knee affusions within 8 weeks. Cold
foot-bathes were used between 0 to
152 times per patient, giving a mean of
2 foot-baths per week per patient. Al-
ternating foot-bathes were used about
2 times per week and per patient. Wet
socks were used 14 times in 8 weeks
on average.
289
Schweiz. Zschr. GanzheitsMedizin 20 (5), September 2008
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Original Article
Symptomatiken
0
1
2
3
4
5
6
vorh er nachh er
Schmerzen (p= 0. 73) Empfindungsstörungen ( p=0.12)
Missempfin dun gen (p =0.04) Lähmun g en (p =1.00)
P
ain dysesthesia
paresthesia paresis
pre post
(
Fig. 1. Primary outcome parameters (mean on Likert Scale from 0=none to 6=most severe) be-
fore (pre) and after 8 weeks treatment (post).
0
1
2
3
4
5
6
vorher nachher
Sc hlafstörungen (p =0.65) Einsc hränkung Alltag (p=0.07)
ungüns tiger Einfluß Zukunft (p=0.21)
pre post
Slee p ing d is ord ers (p=0,65)
Everyday restrictions (p= 0,07)
Unforta ble influenc e on fu tur e (p=0,21)
Fig. 2. Further outcome parameters (mean on Likert Scale from 0=none to 6=most severe) be-
fore (pre) and after 8 weeks treatment (post).
Likert Scale
Likert Scale
Symptoms before/after treatment
All patients suffered from pain with a
mean score value of 2.6 at the begin-
ning of the study. Twenty-three pa-
tients gave their rating after 6 weeks’
therapy with a mean of 2.5 score
points. The mean intra-individual
change was 0.07 which means that
there was a minimal alleviation of pain
during the study which showed no sig-
nificance (Fig. 1). An intra-individual
improvement of 0.25 score points on
average (from an average of 3.5 at
baseline to 3.1 at termination) was
analysed for the change of sensibility
(numbness). This change in sensibility
failed significance (t-test: p = 0.12).
Paresthesia improved from a mean of
3.4 to 2.9 score points. The mean in-
tra-individual difference was 0.58
score points (p = 0.04). Paresis was not
very strongly pronounced, with an av-
erage of 0.8 score points and showed
no changes during the study.
The symptoms sleep disorders, dis-
ability in daily activities and anxiety
showed slight improvements. The im-
pairment of daily activities was im-
proved with an average intra-individ-
ual change of 0.38 score points (p =
0.07) (Fig. 2).
Symptoms recorded in diary
A completed diary was obtained from
23 patients. There was a very small in-
crease of pain in the first 2 weeks with
no clear relation to time of application.
Overall, there is no effect to the pain in
the time course (Fig 3). Similarily,
there are no clear effects neither on
sensibility nor on paresthesia.
Immediate effects after
hydrotherapeutic applications
Overall, 49.9% of the Kneipp applica-
tions were reported to have led to
acute improvements of pain; in 42.6%
of the applications no acute changes of
pain were observed. A worsening of
pain was reported after 7.5% of the ap-
plications. The improvement rate rose
during the study, with 40% improve-
ment during the first week, 43.6% in
week 2 compared to 62.4% in week 8.
This change, however, is to be seen in
coincidence with fewer applications
used during the time course. Some pa-
tients did not proceed with ineffective
Kneipp applications and continued
only the beneficial ones during the
treatment period (Fig. 4).
Overall, most applications (61.8%)
did not induce an acute change in sen-
sibility. However, 32.7% of the Kneipp
applications induced acute improve-
ments and only 5.6% impairments. The
improvement rate increased slightly
during the first 5 weeks and then
reached a plateau at about 35%.
In a similar manner, the rate of
acute reductions of paresthesia in-
creased from 30% of applications dur-
ing the first week to 41% at the end of
the treatment period, resulting in a
mean value of 33.7%. Only 9.5% of the
applications caused an acute worsen-
ing, the remaining Kneipp applications
did not lead to acute changes.
Analgetics’ consumption
Eleven patients reported use of oral
analgetics. During the first week, anal-
getics were taken 9.4 times per pa-
tient. This number decreased to 8 dur-
ing week 3 until week 5 and after-
wards to 6.5.
290 Schweiz. Zschr. GanzheitsMedizin 20 (5), September 2008
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Original Article
0
1
2
3
4
5
6
week 1 week 2 week 3 week 4 week 5 week 6 week 7 week 8
early midday afternoon evening total
Fig. 3. Mean values of pain (Likert Scale from 0=none to 6=most severe) over time reported
in patients’ diaries.
0%
20%
40%
60%
80%
100%
worsening
No cha ng e
Improvement
Fig. 4. Acute change of pain after Kneipp applications.
Likert Scale
week 1
week 2
week 3
week 4
week 5
week 6
week 7
week 7
TOTAL
Discussion
Due to the small number of 27 patients,
the analysis of the study parameters
was limited. There are no apparent
changes in the overall judgements of
pain before and after 8 weeks of self-
treatment using Kneipp hydrotherapy;
which is in line with the mainly un-
changed basic values of complaints be-
fore administrations recorded in the
diaries during the time course. How-
ever, there was a significant decrease
of paresthesia after 8 weeks. This mod-
erate decrease could possibly be ex-
plained by spontaneous course, regres-
sion to mean, reporting bias; one could
argue, however, that other symptoms
should then also have been changed by
this study-immanent factors.
There are relevant percentages (30–
62%) of patients who reported in their
diaries acute improvements of pain,
sensibility and paresthesia after each
single water application versus only
5–9% acute impairments. This per-
centage of Kneipp applications with
acute improvements increased during
the time course. However, it seems
probable that many patients who did
not experience acute improvement
stopped the participation in the study
or reduced the frequency of water ap-
plications during the 8 weeks. There-
fore, the increasing acute response
rate during the course of the study
might be due to the “withdrawals” and
not due to an adaptation process.
On the other hand, acute improve-
ments after more than a third of appli-
cations (in those who had finally par-
ticipated in the study) are reason
enough to consider cold water applica-
tions as probative therapy in patients
with PNP. Acute effects of a cold water
application are plausible and could be
explained by increased local circula-
tion; on the other hand, vasoactive
substances showed no improvement of
symptoms in patients with diabetic
polyneuropathy [9]. Hydrotherapeutic
measures might also stimulate the
same neurophysiologic mechanisms
which are relevant in manipulative
therapies including acupuncture for
pain relief.
A further limitation of the study re-
sults lies in the procedure “study by
correspondence”. The exact diagnosis
and etiology of this complex indication
was only rated by questionnaires and
is less accurate than a diagnosis by a
neurologist. The number of patients is
too small to look into subgroups with
different etiology of their PNP which
might respond in different manner to
Kneipp therapy.
Judging by some of the telephone
calls received during the study, it ap-
pears that many patients were not able
to fully understand the written instruc-
tions and, consequently, some more
patients did not return their question-
aires due to adverse reactions (they
had no reactive hyperemia due to a
prolonged cold application) and side
effects (common colds).
The “study by correspondence” is a
low-cost method to collect preliminary
data about self-treatments and there-
fore a suitable instrument in the field
of natural healing methods and some
of CAM. It would be preferable, how-
ever, to handle inclusion or registra-
tion of patients more restrictively in
order to obtain a more exact descrip-
tion of convenience sample and exact
figures of drop-outs. This could be
achieved by a two-step procedure
where patients would submit their
baseline data before receiving de-
tailled instructions for the intervention
and questionnaires for the course of
the intervention.
On the basis of these results, we
plan to conduct a further clinical study
with personal instruction, anamnesis,
controlled documentation as well as
with a control group (waiting group),
focussing on dysesthesia and paresthe-
sia as primary outcome variables.
Physiologic studies in patients with
PNP versus healthy volunteers about
acute effects on local circulation and
metabolism could clarify the mode of
action of a cold stimulus in PNP.
Acknowledgement
We thank Irmgard-Deutsch-Stiftung, Berlin,
for financial support of data entry and pro-
cessing.
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Disclosure Statement
The authors declare that no financial or
other conflict of interest exists in relation
to the content of this article.
Address for Correspondence:
Dr. med. Dr. rer. nat. Bernhard Uehleke
Charité Universitätsmedizin Berlin
Immanuel-Krankenhaus
Department for Natural Healing
Königstr. 63, DE-14109 Berlin
b.uehleke@immanuel.de
and
University of Zurich, University Hospital
Department of Internal Medicine
Institute of Complementary Medicine
Raemistrasse 100, CH-8091 Zurich
291
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