PHYSIOLOGICAL & THERAPEUTIC
EFFECTS, ADVANTAGES &
DISADVANTAGES, INDICATIONS &
CONTRAINDICATIONS, MODALITIES
& APPLICATION OF HYDROTHERAPY
Loganathan Chandrasekar
PHT 328 – 1435 -1436H – 1st Semester
Lecture Outline
2

Physiological effects of Hydrotherapy

Therapeutic effects of Hydrotherapy

Advantages & Disadvantages of Hydrotherapy

Modalities used

Application for different conditions
PHT 328 - HYDROTHERAPY - 1435 - 1436H - 1st Semester
7/1/2016
Learning Objectives
3

At the end of this lecture, the students will be able to

Recall the physiological & therapeutic benefits of water
& List down some of it.

Describe the physiological & therapeutic effects,
advantages & hazards, indications & contraindications
& different modalities.

Demonstrate the application for different conditions
PHT 328 - HYDROTHERAPY - 1435 - 1436H - 1st Semester
7/1/2016
Physiological Effects – Circulatory effects

Increase in blood circulation

Hydrostatic Pressure
Heat
Physiological Effects - Wound care

Cleansing

Pressure

Dissolved antimicrobial agents, etc.
(Wounds)
Physiological Effects - Musculoskeletal
Effects

Decreases weight-bearing (Arthritis)
 75%

immersion ↓ WB 75%

Increases blood flow to muscles – Hydrostatic pressure

Strengthening – Resistance / Hydromechanics
Decreased bone density loss

Good for obese secondary to non-weight bearing exercise
Physiological Effects - Musculoskeletal
Effects

OFF-LOADING INCREASES AS THE DEPTH OF
IMMERSION INCREASES

CLINICALLY, LESS JOINT COMPRESSION IS
PRODUCED & IMPACT STRAIN over the joint is
DIMINISHED
Physiological Effects - Cardiovascular
Effects
Water immersion to chest or higher
Increased hydrostatic pressure
Venous compression
Lymphatic compression
Central blood volume increases
Arterial pressure raises
Pulmonary arterial pressure
raises
Stroke volume Increases
Cardiac Output increases
Cardiac volume
Increases
Cardiovascular Effects

Increased cardiac output
 Up

to 30% while upright to neck
Decreases HR and Systolic BP (cool water)
 May
increase in warm or hot water
Physiological Effects - Respiratory Effects

Increases work of breathing


Due to hydrostatic pressure on lungs

up to 60%

May need to be very careful with respiratory and/or cardiac patients
Decreases exercise-induced asthma

High humidity
Physiological Effects - Renal Effects

Increases urine production

Increases sodium and potassium excretion
 May
be used to patient’s advantage with hypertension,
peripheral edema
Physiological Effects - Psychological Effects

Relaxing
 Warm
water
Proposed physiologic & therapeutic
effects of Hydrotherapy
HYDROTEHRAPY
THERMAL ENERGY
CRYO
Vasoconstriction
THERMAO
Vasodilation
↓ Blood flow
↑ Blood flow
↓ Metabolism
↑ Metabolism
Stimulation
MECHANICAL ENERGY
Cleansing &
Debridement
Wound
Management
Hydrostatic
pressure
Limb
Compression
Edema
Management
Buoyancy
force
Body
weightlessness
Body
Unloading
Assisting /
Resisting effect
Aquatic
Exercise
Water
sedation
Drag
force
Indications

Musculoskeletal conditions;
a.
Control of Pain & swelling – Cold whirlpools
b.
Acute Sprains & strains - Cold whirlpools
c.
Facilitate motion & ex’s for Sub acute & chronic stages of sprains &
strains - Warm whirlpools
d.
Facilitation of stretching of contracture (simultaneous or immediate
pre application of Warm whirlpools)
e.
Postsurgical repair of joints (after post surgical wounds are healed
fully – to help soften scar tissue, ↓ pain & promote restoration of
motion )
Indications
f. Healing fractures of bones – after clinical union has been achieved.
g. Assist in ↑ of mobility – thermal & buoyancy of warm whirlpools
h. OA & RA – Buoyancy effects of warm whirlpools – off loading of the
affected joints – leading to decrease in pain & ↑ in mobility.
i. Help to ↓ post operative peripheral oedema – Hydrostatic pressure.
j. Psychological effect – Relaxing & ↓ of anxiety
k. Wound care – Mechanical debriding by removing necrotic material &
cleansing.
Contraindications & its Rationale

Acute inflammatory conditions - ↑ intravascular pressure - ↑ in
oedema.

Hyperpyrexia - ↑ tissue temperature

Malignancies – Spreading - ↑ blood flow

Active bleeding – Prolonging arterial blood flow

Cardiac dysfunction – Not able to adapt to thermal homeostasis

Respiratory dysfunction – Not able to resist hydrostatic
pressure, tolerate heat or both
Contraindications & its Rationale

↓ thermal sensation – Inability to sense too much heat / cold

PVD – Not able to meet ↑ metabolic demand

X-ray therapy – Not able to meet ↑ metabolic demand

Venous ulcers – May promote venous congestion

Acute RA – Heat C.I.

Surface infections – Cross contamination

Uncontrolled bowels – Contaminate water

Dermatological conditions(Atopic eczema) – Exacerbate

Severe epilepsy – Risk of drowning (Full body immersion)
Precautions & its Rationale

Impaired thermal sensation in area to be immersed – Burns

Infection in area to be treated – Need additional infection control
measures

Impaired cognition – Not able to report problems or discomfort

Recent skin grafts – May not able to tolerate agitation or not able to
compensate for extremes of heat or cold

After ingestion of alcohol– Impaired judgment – risk of drowning.

Limited strength, endurance, balance or ROM (full body immersion)
– Safety hazard – risk of drowning

Medications – May alter CVS
Precautions & its Rationale

Urinary incontinence (full body immersion) – Risk of UTI

Fear of water (full body immersion) – May refuse to participate

Respiratory problems – ↑ respiratory distress

Pregnancy (1st trimester - full body immersion) – CNS abnormalities
in child

Multiple sclerosis (full body immersion) – ↑ fatigue & weakness

Poor thermal regulation (full body immersion) – Risk of thermal
shock

Previously existing oedema (full body immersion) – ↑ oedema

Seasickness – Cause anxiety
Modalities
WATER IMMERSION
MODALITIES

Whirlpool bath

Hubbard tank

Pool/Aquatic Therapy
Low Boy Whirlpool
High Boy Whirlpool
Extremity Whirlpool
Chair for Whirlpool
Whirlpools

These are stainless steel or acrylic tanks of various sizes.

It has an attached motor called – TURBINE.

The turbine – AGITATES the water in the tank to create
the whirlpool effect.

These WP are intended to used as single-patient
treatments & must be drained & cleaned after each use.
WP Parts in general


Agitator/ Turbine ejector/ Aerator
Hot and cold water mixing valve

Temperature gauge

Gravity drain

Seat / Chair
TURBINE

It is the electrical motor pump that creates agitation in a WP.

A switch on the top of the turbine turns the motor on/off.

The turbines are attached with 2 or 3 tubular metal shafts.

One of these tubes is the drive shaft, which contains an
impeller housed in a casing at the bottom of the tube.

The amount of water ejected at the base of the drive shaft
will determine the force of the ejected water.
Components of the Turbine
TURBINE

Adjusting the throttle near the top of the shaft can control the
amount of water ejected.

The other tube is called the breather tube.

The amount of air mixing with the ejected water (Aeration) at the
base of the breather tube can be adjusted by turning the butterfly
valve near the top of the shaft.

Agitation of water in WP tank can be controlled by;

1. Adjusting the force of the ejected water.

2. Amount of aeration of the water.
Care of the turbine

Near the bottom of one of the shafts of the turbine is a
small hole on the side of the shaft. This hole must under
the surface of the water whenever the turbine motor is
turned on.

Make sure the turbine ejector is not blocked by
bandages, wound packing or patient fingers or toes.
Parts of a Whirlpool Bath
On / Off switch
Motor Pump/Turbine Motor
Thermometer
Steel Tank
Wheels
Objectives for use

stimulation of circulation

promotion of muscle relaxation
and pain relief

debridement

facilitation of exercise
Additives

wounds: (Anti microbial agent help to reduce
infection)
- Povidone-iodine solution
- sodium hypochlorite or Chloramine-T
- saline solution

dry skin:
- bath oil

burn patients:
- 4% solution Lidocaine
TYPES OF WHIRLPOOL BATH
According to shape:

Low boy tank

High boy tank

Extremity tank
According to mobility:

Movable

Fixed
LOW BOY WP tank

It is designed for ease of transfer in & out of the
tank by virtue of low walls & length.

Patients in a low boy are usually in a long sitting
position.
LOW BOY

Dimensions
width: 24 inches
length: 52 – 66 inches
depth: 18 inches
HIGH BOY WP tank

It’s also referred as “HIP” tanks.

It requires a chair or lift to transfer the patient in & out
of the tank.

Patients in a high boy tank usually sit on a removable
seat attached to rungs on the side of the tank or may sit
on a chair outside the tank with their lower extremity
dangling in the tank.
HIGH BOY

Dimensions
width: 20 –
24 inches
length: 36 –
48 inches
depth: 28
inches
Extremity WP tank

The WP tank is smaller in size, designed especially
to treat distal extremities. (Ankle/foot/hand)

It is often portable with attached wheels for ease
of movement.
EXTREMITY TANK
also called UPPER
EXTREMITY TANK
 Dimensions

width: 15 inches
length: 28 – 32 inches
depth: 18 – 25 inches
Hubbard Tank





These are large whirlpools designed for full body (Head
out) immersion & for pt’s who are unable to stand.
Mainly designed for under water ex’s.
The wide top & bottom & narrow middle allow room for
ex’s for the extremities & PT access to the patient for
assistance with ex’s.
Pt’s are typically lowered into tank on a stretcher by an
over head hydraulic hoist.
It is equipped with 2 turbines, that can be moved around
the perimeter of the tank to direct & control the
agitation pattern.
HUBBARD TANK

Dimensions
length: 7 feet 2
inches
upper wing
width: 6 feet
middle wing
width: 35 inches
lower wing
width: 4 feet 2
inches
depth: 22 inches
ADDITIONAL EQUIPMENT

Walk trough

Adjustable seat

Motorized chair lift

Hydro stretcher with hydraulic lift
Non – Immersion technique – Irrigation
technique
Pressured water
irrigation system: It is mainly used for wounds, where
it is impossible or not required to
immerse the body part treated.
• It should range between 4 & 15
pounds /square inch (psi).
• Used to treat one patient at a time.
• Reusable.
Therapeutic Effects - Wound Care

WP is recommended for
 Delayed
primary wound – Wounds that are surgically
closed after 5 days.
 Secondary
intention – Wounds are allowed to close by
granulation, marginal or budding epithelialization &
wound margin contracture.
Therapeutic Effects - Wound Care

WP application – facilitates;
 Cleansing
 Softening
 Removal
and debridement of necrotic tissue
of wound debris
 Antibacterial
 Circulation
action
enhancement
The WP could be carried out until the wound closes.
Treatment of Burns

Similar, but burns particularly painful when debrided
 Wounds

Monitor patient closely
 often

sometimes less deep, sensory nerves intact
high-dose analgesics
Hubbard Tank for large body surface area
 Chance
of contamination
 Greater loss of sodium (add salt)


Shower (non-immersion) in early stages
After re-epithelialization, water for exercise
Skin grafts & tissue flaps






WP is best recommended by 5th post operative day of
grafting.
If would like to give WP within 3-5 days post grafting,
then agitation is adjusted to minimal levels & only
administered for 5 minutes.
It allows softening of tissues & cleansing with antibacterial
agent in preparation for mechanical debridement.
It also removes superficial wound exudates.
As the graft ages & stability improves, the duration &
aeration may be increased.
In general, the younger the flap, the less turbulence &
shear force it will be able to tolerate.
Pain & muscle spasm Control

Increased sensory stimulation to peripheral
mechanoreceptors

Pain gate Theory

Cold water decreases inflammation

Decreases weight-bearing, increases “ease of movement”.
Edema Control

Hydrostatic pressure

Cool water

Vasoconstriction

Decreased vascular permeability

Hot water increases edema

Increased arterial blood flow, increased vasodilation.
THERAPEUTIC EFFECTS OF EXERCISE IN
WATER: summary



1. THE RELIEF OF PAIN & MUSCLE SPASM
2. MAINTANANCE OR INCREASE IN RANGE OF MOTION OF
JOINTS
3. THE STRENGTHENING OF WEAK MUSCLES & AN INCREASE
IN THEIR TOLERANCE TO EXERCISE

4. THE RE-EDUCATION PARALYSED MUSCLES

5. THE IMPROVEMENT OF CIRCULATION
THERAPEUTIC EFFECTS OF EXERCISE IN
WATER: summary


6. THE ENCOURAGEMENT OF FUNCTIONAL ACTIVITIES
7. THE MAINTANANCE & IMPROVEMENT OF BALANCE, COORDINATION & POSTURE

8. WOUND HEALING IS ENHANCED

9. SEDATIVE EFFECT & RELAXATION

10. FACILITATES CARDIOVASCULAR EXERCISES

11. FACILITATES THE WEIGHBEARING ACTIVITIES
AGITATION (Mechanical) therapeutic effects of WP

debridement

analgesia

facilitation of exercise

muscle relaxation
DEMERITS / HAZARDS

Burns, Fainting, Bleeding

INFECTIONS – UNCLEANLINESS

Increased edema

Use of hot water

Dependent positioning

FATIGUEBILITY

IMBALANCE

SUDDEN CHANGE IN B.P. MAY OCCUR

ANY ALLERGY
Practical point of view
Application of Hydrotherapy
Application, General Rules




Assess problem and set goals of treatment
Determine if most appropriate treatment
Make sure no contraindications
Select appropriate form of hydrotherapy









Whirlpool
Hubbard Tank
Contrast bath
Non-immersion device
Pool
Explain the procedure, purpose, sensations
Apply appropriate form of hydrotherapy
Assess outcome
Document
Selection of Hydrotherapy

Base decision on
 Desired
 Size
effects
of area to be treated
 Allowance
for safety, control of infection
 Cost-effectiveness
Whirlpool

Tanks
 Low-Boy
 High-Boy
 Extremity
 Hubbard
Tank
Temperature Range

Cold (32-790 F)



Acute inflammation
Tepid (79-920 F)

Exercise

Acute inflammation if cold not tolerated
Neutral warmth (92-960 F)

Open wound

Medically compromised patients

Decrease tone
Temperature Range

Mild warmth (96-980)
 Increase
mobility
 Burn

Hot (99-1040)
 Pain,
 Increase
ROM
 Increase soft tissue extensibility

Very Hot (104-1100)
 Limited
body area
 Chronic conditions

DO NOT use WP at temperatures > 1100 F !!
Safety considerations for Hydrotherapy

Prevention of falls

Precautions for prevention of drowning

Electrical safety
Treatment duration - WP

20 min when strictly used as a heating modality – skin
muscle & joint temperature.

5 – 20 min when used for debridement – depending on
amount of necrotic tissue.

10 – 20 min for ex’s – depending on pt’s medical status.
Lower Extremity / mid thorax level
immersion Technique

High boy tank:- it requires the pt’s to flex their hip & knee & limits
the amount of ROM ex’s. But its depth allows a greater body
surface area to be submerged safely & comfortably to as high as
the mid thorax region.

Low boy tank:- Not deep but allows the pt’s to fully extend their
lower extremity & perform full ROM ex’s.

Extremity tank:- When only distal portion of the lower extremity has
to be immersed, then extremity tank with use of chair will be
appropriate.
Upper Extremity Technique

The pt’s should be seated comfortably next to the
extremity tank, with a towel or other form of padding on
the tank edge to avoid compression of axillary area.

Special consideration – Oedema can form.
Full body immersion – Hubbard tank

E.g.

1. Pt’s with arthritis & is unable to negotiate transfers.

2. Pt’s with neurologically involved – paralysis, who can
actively move the limbs in water with the help of water
& unable to do the same in air.

3. A burn pt,

4. An elderly or debilitated pt’s with an open wound.
Key treatment parameters to be
documented in pt’s file after hydrotherapy











Pt’s skin thermal sensory discrimination testing
Skin status
Health & mental status
Hydro equipment
Accessories
Water temperature
Water Additives (When applicable) – Name & concentration
of solution.
Body part treated
Treating method – non immersion or immersion
If immersion – level – partial or full
If immersion - Duration