Hydrotherapy

PTA 200PTA 200Modalities and Procedures in Physical TherapyModalities and Procedures in Physical Therapy

HydrotherapyHydrotherapy

Definition of HydrotherapyDefinition of Hydrotherapy

Application of water, internally or externally, for Application of water, internally or externally, for the treatment of physical or psychological the treatment of physical or psychological dysfunction.dysfunction.

Types of HydrotherapyTypes of Hydrotherapy

ImmersionImmersion Non-ImmersionNon-Immersion

Primary Use of HydrotherapyPrimary Use of Hydrotherapy

Treatment of WoundsTreatment of Wounds Enhanced Environment for exerciseEnhanced Environment for exercise PainPain EdemaEdema Health maintenance /disease preventionHealth maintenance /disease prevention

Physical Properties of WaterPhysical Properties of Water

High Specific Heat & Thermal ConductivityHigh Specific Heat & Thermal Conductivity Transfers heat by Conduction and ConvectionTransfers heat by Conduction and Convection

Can be used as superficial heating and cooling agentCan be used as superficial heating and cooling agent


Specific Heat 4 times that of airSpecific Heat 4 times that of air Water retains 4x as much thermal energy as an Water retains 4x as much thermal energy as an

equivalent mass of airequivalent mass of air

Thermal Conductivity 25 x airThermal Conductivity 25 x air Water transfers thermal energy 25 x more rapidly Water transfers thermal energy 25 x more rapidly

than air (than air (at the same temperatureat the same temperature))


Transfers heat rapidly, efficientlyTransfers heat rapidly, efficiently Advantage of exercising patient in pool Advantage of exercising patient in pool coldercolder

than patient’s body temperature.than patient’s body temperature. Immersion dissipates heat generated by exertionImmersion dissipates heat generated by exertion


Water that is stationary transfers heat by Water that is stationary transfers heat by ConductionConduction..

Moving water transfers heat by Moving water transfers heat by Conduction Conduction andand ConvectionConvection.. Heating (WP) Heating (WP) acceleratedaccelerated with increased agitation of with increased agitation of

water.water. Cooling (swimming) Cooling (swimming) acceleratedaccelerated as patient moves more as patient moves more

quickly through water.quickly through water.


BuoyancyBuoyancy A force experienced as an upward thrust on the body A force experienced as an upward thrust on the body

in the opposite direction to the force of gravityin the opposite direction to the force of gravity

Archimedes PrincipleArchimedes Principle When a body is entirely or partially immersed in a fluid When a body is entirely or partially immersed in a fluid

at rest.. at rest.. • it experiences an upward thrust equal to weight of fluid it it experiences an upward thrust equal to weight of fluid it

displaces.displaces. Principle used for volumetric measurementsPrinciple used for volumetric measurements

Archimedes PrincipleArchimedes Principle

Amount of fluid depends on density of body Amount of fluid depends on density of body relative to density of fluid.relative to density of fluid. If density of body less than density of fluid, it will If density of body less than density of fluid, it will

displace a smaller volume of fluiddisplace a smaller volume of fluid (Floats) (Floats) • Opposite also trueOpposite also true

If density of body further decreased (If density of body further decreased (adding salt to adding salt to water or air-filled objects at restwater or air-filled objects at rest),),

• Body will float higherBody will float higher

Clinical Uses of BuoyancyClinical Uses of Buoyancy

Decrease stress and compression to body Decrease stress and compression to body tissues (tissues (weight-bearing surfacesweight-bearing surfaces))

Assist weak musclesAssist weak muscles


ResistanceResistance Viscosity of water provides resistance to motionViscosity of water provides resistance to motion Resistance occurs against direction of motion Resistance occurs against direction of motion

Resistance increases proportional to…Resistance increases proportional to… SpeedSpeed Frontal area of body part in contact with waterFrontal area of body part in contact with water

Varying resistance (Varying resistance (and pressureand pressure) can be ) can be beneficial in debriding and cleansing woundsbeneficial in debriding and cleansing wounds


Hydrostatic PressureHydrostatic Pressure Pressure exerted by fluid on body immersed in fluid.Pressure exerted by fluid on body immersed in fluid.

Pascal’s LawPascal’s Law A fluid exerts equal pressure on all surfaces of a body A fluid exerts equal pressure on all surfaces of a body

at rest, at a given depth…at rest, at a given depth… This pressure increases in proportion to depth of fluidThis pressure increases in proportion to depth of fluid

Hydrostatic PressureHydrostatic Pressure

Water = 0.73 mmHg/cm of depth (22.4 mmHg/ft)Water = 0.73 mmHg/cm of depth (22.4 mmHg/ft) Patient uprightPatient upright

Pressure on distal extremities Pressure on distal extremities > > proximal extremitiesproximal extremities Hydrostatic pressure at patient’s feet… Hydrostatic pressure at patient’s feet…

• 4 ft of water = 89.6 mmHg4 ft of water = 89.6 mmHg

Hydrostatic Pressure Hydrostatic Pressure

Water can have similar effect as compression Water can have similar effect as compression devices/ bandagesdevices/ bandages Helpful in decreasing edemaHelpful in decreasing edema If limb in dependent position, counteracts this effectIf limb in dependent position, counteracts this effect

Greatest effects of hydrostatic pressure occur in Greatest effects of hydrostatic pressure occur in vertical positionvertical position NO hydrostatic pressure effects with non-immersion NO hydrostatic pressure effects with non-immersion

hydrotherapyhydrotherapy

Physiological Effects of HydrotherapyPhysiological Effects of Hydrotherapy

Physiological Effects Physiological Effects

CleansingCleansing Pressure (Force = Rate of Flow)Pressure (Force = Rate of Flow) Dissolved antimicrobial agents, etc. (Dissolved antimicrobial agents, etc. (WoundsWounds))

Musculoskeletal EffectsMusculoskeletal Effects Decreases weight-bearing (Decreases weight-bearing (ArthritisArthritis))

• 75% immersion WB 75%75% immersion WB 75% Increases blood flow to musclesIncreases blood flow to muscles Strengthening Strengthening

Physiological Effects Physiological Effects

Decreased bone density lossDecreased bone density loss Decreased fat lossDecreased fat loss

• Compared to other forms of exerciseCompared to other forms of exercise Good for obese secondary to non-weight bearing Good for obese secondary to non-weight bearing

exercise exercise • Not good for general weight lossNot good for general weight loss

Cardiovascular EffectsCardiovascular Effects

Increased venous circulationIncreased venous circulation Secondary to hydrostatic pressure, increased venous Secondary to hydrostatic pressure, increased venous

pressurepressure

Increased cardiac volumeIncreased cardiac volume Increased cardiac outputIncreased cardiac output

Up to 30% while upright to neckUp to 30% while upright to neck

Decreases HR and Systolic BP (Decreases HR and Systolic BP (cool watercool water)) May increase in warm or hot waterMay increase in warm or hot water

Respiratory EffectsRespiratory Effects

Increases work of breathing Increases work of breathing Due to hydrostatic pressure on lungsDue to hydrostatic pressure on lungs

• up to 60%up to 60%• May need to be very careful with respiratory and/or cardiac May need to be very careful with respiratory and/or cardiac

patientspatients

Decreases exercise-induced asthmaDecreases exercise-induced asthma High humidityHigh humidity

Renal EffectsRenal Effects

Increases urine productionIncreases urine production Increases sodium and potassium excretionIncreases sodium and potassium excretion

May be used to patient’s advantage with hypertension, May be used to patient’s advantage with hypertension, peripheral edemaperipheral edema

Psychological EffectsPsychological Effects

RelaxingRelaxing Warm waterWarm water

InvigoratingInvigorating Cold waterCold water

Clinical Uses of HydrotherapyClinical Uses of Hydrotherapy

Superficial Heating and CoolingSuperficial Heating and Cooling

AdvantagesAdvantages Even contact with skinEven contact with skin Does not need to be fastenedDoes not need to be fastened Allows movement of heat/coldAllows movement of heat/cold

DisadvantagesDisadvantages Extremity often in dependent positionExtremity often in dependent position

Wound CareWound Care

Cleansing properties facilitate Cleansing properties facilitate Rehydration Rehydration Softening and debridement of necrotic tissue Softening and debridement of necrotic tissue Removal of wound debrisRemoval of wound debris

Hydrostatic pressure and heat increase Hydrostatic pressure and heat increase circulationcirculation

Provides moist environment to optimize Provides moist environment to optimize healinghealing

Immersion vs. Non-ImmersionImmersion vs. Non-Immersion

Non-immersion therapy becoming more popularNon-immersion therapy becoming more popular Concern for increased pressure on regenerating Concern for increased pressure on regenerating

tissues by water and turbinetissues by water and turbine Potential for infection in contaminated tankPotential for infection in contaminated tank

WP recommended forWP recommended for Extensive thick exudateExtensive thick exudate Slough or necrotic tissueSlough or necrotic tissue Gross purulenceGross purulence Dry escharDry eschar

Immersion versus Non-ImmersionImmersion versus Non-Immersion

Discharge all forms of hydrotherapy when Discharge all forms of hydrotherapy when wound is cleanwound is clean Many antimicrobial products are cytoxic to normal Many antimicrobial products are cytoxic to normal

tissue (tissue (unless very dilutedunless very diluted))

Tank and turbine must be thoroughly cleaned Tank and turbine must be thoroughly cleaned and disinfectedand disinfected

Non-Immersion TechniquesNon-Immersion Techniques

Fluid delivered at pressure of 4-15 psiFluid delivered at pressure of 4-15 psi Below this bacteria not removedBelow this bacteria not removed Above this, wound trauma may occur, or bacteria Above this, wound trauma may occur, or bacteria

driven into wounddriven into wound Saline squeeze bottle, Water PikSaline squeeze bottle, Water Pik

Non-Immersion TechniquesNon-Immersion Techniques

Recommended forRecommended for NNecrotic, nonviable tissue or debrisecrotic, nonviable tissue or debris

• Continue until all removed and full granulation bed Continue until all removed and full granulation bed presentpresent

• Often use bothOften use both

With both types, must thoroughly dry intact skin With both types, must thoroughly dry intact skin in surrounding area in surrounding area prevents macerationprevents maceration

Treatment of BurnsTreatment of Burns

Similar, but burns particularly painful when Similar, but burns particularly painful when debrideddebrided Wounds sometimes less deep, sensory nerves intactWounds sometimes less deep, sensory nerves intact

Monitor patient closely Monitor patient closely often high-dose analgesicsoften high-dose analgesics

Hubbard Tank for large body surface areaHubbard Tank for large body surface area Chance of contaminationChance of contamination Greater loss of sodium (Greater loss of sodium (add saltadd salt))

Shower (non-immersion) in early stagesShower (non-immersion) in early stages After re-epithelialization, water for exerciseAfter re-epithelialization, water for exercise

Pain ControlPain Control

Increased sensory stimulation to peripheral Increased sensory stimulation to peripheral mechanoreceptorsmechanoreceptors Gait TheoryGait Theory

Cold water decreases inflammationCold water decreases inflammation Decreases weight-bearing, increases “ease Decreases weight-bearing, increases “ease

of movement”.of movement”.

Edema ControlEdema Control

Hydrostatic pressureHydrostatic pressure Cool waterCool water

VasoconstrictionVasoconstriction Decreased vascular permeabilityDecreased vascular permeability Hot waterHot water increases edemaincreases edema

• Increased arterial blood flow, increased vasodilation.Increased arterial blood flow, increased vasodilation.

Edema Control Edema Control

Contrast BathsContrast Baths ““Trains” smooth muscles of blood vessel; Trains” smooth muscles of blood vessel;

vasoconstriction/vasodilation.vasoconstriction/vasodilation. No research to solidly supportNo research to solidly support

Contraindications, PrecautionsContraindications, Precautionsand Adverse Effectsand Adverse Effects

Contraindications,Contraindications, Local ImmersionLocal Immersion

MacerationMaceration Increased maceration, increased size of woundIncreased maceration, increased size of wound

BleedingBleeding In or near the areaIn or near the area

Precautions,Precautions, Local ImmersionLocal Immersion

Impaired thermal sensationImpaired thermal sensation Check temperature of water with thermometer firstCheck temperature of water with thermometer first

InfectionInfection Universal PrecautionsUniversal Precautions Clean WPClean WP

Confusion, impaired cognitionConfusion, impaired cognition Use constant, direct supervisionUse constant, direct supervision Temperature of water near body temperatureTemperature of water near body temperature

Recent Skin GraftsRecent Skin Grafts Direct agitator away from graft.Direct agitator away from graft. Neutral or mild warmth (96 - 98Neutral or mild warmth (96 - 9800 F) F)

Contraindications,Contraindications, Full Body ImmersionFull Body Immersion

Cardiac instabilityCardiac instability Uncontrolled hypertension or heart failureUncontrolled hypertension or heart failure

Infectious conditions that spread with waterInfectious conditions that spread with water UTI’s, plantar warts, tinea pedis (UTI’s, plantar warts, tinea pedis (poolpool) )

Bowel or bladder incontinenceBowel or bladder incontinence Use non-immersion techniquesUse non-immersion techniques

Severe epilepsySevere epilepsy Increased risk of drowningIncreased risk of drowning

Suicidal patientsSuicidal patients Increased risk of drowningIncreased risk of drowning

Precautions,Precautions, Full Body ImmersionFull Body Immersion

Confusion, DisorientationConfusion, Disorientation Keep head above waterKeep head above water Constant supervisionConstant supervision Low temperatureLow temperature

After ingestion of alcoholAfter ingestion of alcohol Hypotensive effectsHypotensive effects DrowningDrowning

Patients with limited strength, endurance, Patients with limited strength, endurance, balance, ROMbalance, ROM Hands-on approach requiredHands-on approach required


Patients on medicationsPatients on medications Physician clearance sometimes requiredPhysician clearance sometimes required

Patients with fear of waterPatients with fear of water Patients with respiratory problemsPatients with respiratory problems

Watch for signs of respiratory distress, especially in Watch for signs of respiratory distress, especially in hot or very warm waterhot or very warm water


Patients that are PregnantPatients that are Pregnant 1st trimester (1st trimester (maternal hyperthermiamaternal hyperthermia) ) Use normal water temperatureUse normal water temperature Can be very good therapeutic interventionCan be very good therapeutic intervention

Patients with MSPatients with MS Temperature >88Temperature >8800 F may cause increase fatigue, F may cause increase fatigue,

weakness.weakness.

Patients with poor thermal regulationPatients with poor thermal regulation Elderly, infantsElderly, infants

Precautions,Precautions, Non-Immersion HydrotherapyNon-Immersion Hydrotherapy

MacerationMaceration IneffectivenessIneffectiveness DrowningDrowning

Adverse Effects of HydrotherapyAdverse Effects of Hydrotherapy

Burns, Fainting, BleedingBurns, Fainting, Bleeding Check with thermometer, and gloved handCheck with thermometer, and gloved hand

HypotensionHypotension Immersion in warm/hot water, hypertension Immersion in warm/hot water, hypertension

medicationsmedications

Hyponatremia (Hyponatremia (burnsburns)) Increased edemaIncreased edema

Use of hot waterUse of hot water Dependent positioningDependent positioning

Application of HydrotherapyApplication of Hydrotherapy

Application, General RulesApplication, General Rules

Assess problem and set goals of treatmentAssess problem and set goals of treatment Determine if most appropriate treatmentDetermine if most appropriate treatment Make sure no contraindicationsMake sure no contraindications Select appropriate form of hydrotherapySelect appropriate form of hydrotherapy

WhirlpoolWhirlpool Hubbard TankHubbard Tank Contrast bathContrast bath Non-immersion deviceNon-immersion device PoolPool

Explain the procedure, purpose, sensationsExplain the procedure, purpose, sensations Apply appropriate form of hydrotherapyApply appropriate form of hydrotherapy Assess outcomeAssess outcome DocumentDocument

Selection of HydrotherapySelection of Hydrotherapy

Base decision onBase decision on Desired effectsDesired effects Size of area to be treatedSize of area to be treated Allowance for safety, control of infectionAllowance for safety, control of infection Cost-effectivenessCost-effectiveness

WhirlpoolWhirlpool

TanksTanks Low-BoyLow-Boy High-BoyHigh-Boy ExtremityExtremity Hubbard TankHubbard Tank

WhirlpoolWhirlpool

TurbineTurbine AgitatorAgitator

• Adjustable height, direction, aeration.Adjustable height, direction, aeration.• Should be groundedShould be grounded• Do NOT run without water in tank.Do NOT run without water in tank.

Low-BoyLow-Boy

Hubbard TankHubbard Tank

Extremity TankExtremity Tank

Temperature RangeTemperature Range

ColdCold (32-79(32-790 0 F)F) Acute inflammationAcute inflammation

TepidTepid (79-92 (79-920 0 F) F) Exercise Exercise Acute inflammation if cold not toleratedAcute inflammation if cold not tolerated

Neutral warmthNeutral warmth (92-96 (92-960 0 F)F) Open wound Open wound Medically compromised patients Medically compromised patients Decrease toneDecrease tone

Temperature RangeTemperature Range

Mild warmthMild warmth (96-98(96-9800)) Increase mobilityIncrease mobility BurnBurn

HotHot (99-104(99-10400) ) Pain, Pain, Increase ROMIncrease ROM Increase soft tissue extensibilityIncrease soft tissue extensibility

Very HotVery Hot (104-110(104-11000)) Limited body areaLimited body area Chronic conditionsChronic conditions

DO NOTDO NOT use WP at temperatures use WP at temperatures > 110> 11000 F F !! !!

Hubbard TankHubbard Tank

8 feet long x 6 feet wide, 4 feet deep8 feet long x 6 feet wide, 4 feet deep 425 gallons water425 gallons water Turbines, stretcher, hoistTurbines, stretcher, hoist Expensive secondary to amount of water, time to Expensive secondary to amount of water, time to

cleanclean

Contrast BathContrast Bath

Alternate immersion (distal)Alternate immersion (distal) First warm/hot water, then cool/cold waterFirst warm/hot water, then cool/cold water

UsesUses Decrease edemaDecrease edema Pain relief Pain relief Decrease sensitivity (desensitize)Decrease sensitivity (desensitize)

Application, Non-Immersion Irrigation Application, Non-Immersion Irrigation

PulsaVac: Lab PulsaVac: Lab

Application, PoolApplication, Pool

Temperature 79 - 97Temperature 79 - 9700

Never below 65Never below 6500 • Impairs muscles ability to contractImpairs muscles ability to contract

Cleaning, WP/Hubbard TankCleaning, WP/Hubbard Tank

Wear gloves, goggles, gownWear gloves, goggles, gown Drain tankDrain tank Rinse with clean waterRinse with clean water Scrub tank with brush and detergent and rinse Scrub tank with brush and detergent and rinse

againagain Disinfect TankDisinfect Tank

Disinfecting the TankDisinfecting the Tank Levels of disinfectionLevels of disinfection

Low levelLow level• Intact skin Intact skin • 70-90% ethyl alcohol, 70-90% ethyl alcohol, • sodium hypochloride bleachsodium hypochloride bleach• germicidal solutiongermicidal solution

Intermediate LevelIntermediate Level • 70-90% ethyl alcohol 70-90% ethyl alcohol • phenolic germicidal detergentphenolic germicidal detergent

High LevelHigh Level • Chlorine-based products Chlorine-based products • Can corrode tankCan corrode tank

Disinfecting the TankDisinfecting the Tank

Change disinfectant periodically to decrease Change disinfectant periodically to decrease risk of resistant strainsrisk of resistant strains

Fill tank Fill tank Add solution (Add solution (hot waterhot water))

expose all inside surfaces x 10 minutesexpose all inside surfaces x 10 minutes

Clean and disinfect turbine, Clean and disinfect turbine, bucket with water/detergent x 5 minutesbucket with water/detergent x 5 minutes bucket with disinfectant x 10 minutesbucket with disinfectant x 10 minutes

Disinfecting the TankDisinfecting the Tank

Drain tankDrain tank Rinse with clean waterRinse with clean water Dry thoroughly with towelsDry thoroughly with towels Culture tank, turbines, drains, and water supply Culture tank, turbines, drains, and water supply

periodicallyperiodically

Aquatic ExerciseAquatic Exercise

Aquatic ExerciseAquatic Exercise

UsesUses Increase circulationIncrease circulation Increase muscle strengthIncrease muscle strength Increase joint ROM, flexibilityIncrease joint ROM, flexibility Improve ambulationImprove ambulation Improve coordinationImprove coordination Increase cardiovascular, respiratory conditioningIncrease cardiovascular, respiratory conditioning Decrease pain, spasmDecrease pain, spasm Decrease weight-bearing on jointsDecrease weight-bearing on joints Relaxation/ psychological well-beingRelaxation/ psychological well-being

Types of Aquatic ExerciseTypes of Aquatic Exercise

SwimmingSwimming Running (Running (with or without vestwith or without vest)) WalkingWalking Cycling Cycling StretchingStretching Underwater treadmill or parallel bars, etc.Underwater treadmill or parallel bars, etc.

The EndThe End