Hydrotherapy

1. PTA 200PTA 200
Modalities and Procedures in Physical TherapyModalities and Procedures in Physical Therapy
HydrotherapyHydrotherapy

2. 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.

3. Types of HydrotherapyTypes of Hydrotherapy
ImmersionImmersion
Non-ImmersionNon-Immersion

4. 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

5. 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

6. Physical Properties of WaterPhysical Properties of Water
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))

7. Physical Properties of WaterPhysical Properties of Water
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

8. Physical Properties of WaterPhysical Properties of Water
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.

9. Physical Properties of WaterPhysical Properties of 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

10. 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

11. 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

12. Physical Properties of WaterPhysical Properties of Water
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

13. Physical Properties of WaterPhysical Properties of Water
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

14. 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

15. 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

16. Physiological Effects of HydrotherapyPhysiological Effects of Hydrotherapy

17. 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

18. 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

19. 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

20. 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

21. 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

22. Psychological EffectsPsychological Effects
RelaxingRelaxing

Warm waterWarm water
InvigoratingInvigorating

Cold waterCold water

23. Clinical Uses of HydrotherapyClinical Uses of Hydrotherapy

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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”.

32. 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.

33. 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

34. Contraindications, PrecautionsContraindications, Precautions
and Adverse Effectsand Adverse Effects

35. 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

36. 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 - 98
00
F) F)

37. 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

38. 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

39. Precautions,Precautions, Full Body ImmersionFull Body Immersion
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

40. Precautions,Precautions, Full Body ImmersionFull Body Immersion
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 >88
00
F may cause increase fatigue, F may cause increase fatigue,
weakness.weakness.
Patients with poor thermal regulationPatients with poor thermal regulation

Elderly, infantsElderly, infants

41. Precautions,Precautions, Non-Immersion HydrotherapyNon-Immersion Hydrotherapy
MacerationMaceration
IneffectivenessIneffectiveness
DrowningDrowning

42. 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

43. Application of HydrotherapyApplication of Hydrotherapy

44. 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

45. 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

46. WhirlpoolWhirlpool
TanksTanks

Low-BoyLow-Boy

High-BoyHigh-Boy

ExtremityExtremity

Hubbard TankHubbard Tank

47. 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.

48. Low-BoyLow-Boy

49. Hubbard TankHubbard Tank

50. Extremity TankExtremity Tank

51. Temperature RangeTemperature Range
ColdCold (32-79(32-79
0 0
F)F)

Acute inflammationAcute inflammation
TepidTepid (79-92 (79-92
0 0
F) F)

Exercise Exercise

Acute inflammation if cold not toleratedAcute inflammation if cold not tolerated
Neutral warmthNeutral warmth (92-96 (92-96
0 0
F)F)

Open wound Open wound

Medically compromised patients Medically compromised patients

Decrease toneDecrease tone

52. Temperature RangeTemperature Range
Mild warmthMild warmth (96-98(96-98
00
))

Increase mobilityIncrease mobility

BurnBurn
HotHot (99-104(99-104
00
) )

Pain, Pain,

Increase ROMIncrease ROM

Increase soft tissue extensibilityIncrease soft tissue extensibility
Very HotVery Hot (104-110(104-110
00
))

Limited body areaLimited body area

Chronic conditionsChronic conditions
DO NOTDO NOT use WP at temperatures use WP at temperatures > 110> 110
00
F F !! !!

53. 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

54. 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)

55. Application, Non-Immersion Irrigation Application, Non-Immersion Irrigation
PulsaVac: Lab PulsaVac: Lab

56. Application, PoolApplication, Pool
Temperature 79 - 97Temperature 79 - 97
00

Never below 65Never below 65
00

•Impairs muscles ability to contractImpairs muscles ability to contract

57. 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

58. 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

59. 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

60. 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

61. Aquatic ExerciseAquatic Exercise

62. 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

63. 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.

68. The EndThe End