Hydrotherapy for physical therapy (lecture)

This Lecture is Specially designed for Physical therapy students and as well as for general public.
In which general properties of water, temperature and specific exercises are presented.

1. HYDROTHERAPY DR. SHAHABUDDIN BS.PT(JPMC), PP.DPT(IIRS), MPPTA LECTURER COLLEGE OF PHYSIOTHERAPY JINNAH POSTGRADUATE MEDICAL CENTRE KARACHI

2. HYDROTHERAPY

3. INTRODUCTION: Hydrotherapy is a method of treating disease by using water at different temperatures and in different ways. Any activity performed in water to assist in rehabilitation and recovery from hard training or serious injury. It is a part of medicine, Specially in physiotherapy, that involves the use of water for pain relief and treatment. HYDROTHERAPY

4. The term (Hydrotherapy)encompasses a broad range of approaches and therapeutic methods that take advantage of the physical properties of water, such as temperature and pressure , for therapeutic purposes, to stimulate blood circulation and treat the symptoms of certain diseases. HYDROTHERAPY

5. Hydrotherapy is the union between water and physical therapy. It is being used widely throughout the world as a form of physical therapy. By working in a hydrotherapy department of a physical therapy clinic, one may see how patients use hydrotherapy for treating their conditions. HYDROTHERAPY

6. Patients are instructed through a specific program designed to help their physical conditions. H ydrotherapy is a great way to exercise the body. HYDROTHERAPY

7. Facilitate range of motion (ROM) exercise Initiate resistance training Facilitate weight-bearing activities Enhance delivery of manual techniques Provide three-dimensional access to the patient Facilitate cardiovascular exercise Initiate functional activity replication Minimize risk of injury or re-injury during rehabilitation Enhance patient relaxation GOALS AND INDICATIONS

8. The four most important properties of water from a treatment point are: 1 . Water is non-irritating, non-allergic, and totally compatible with human physiology both inside and outside of the body. 2 . Water is a good heat conductor and at the same time greatly heat storing in capacity so that it is the ideal agent for manipulating body temperature . PHYSIOLOGICAL PRINCIPLES OF HYDROTHERAPY

9. 3.Water is totally conformable to the body surfaces. This means that it makes an intimate interface with whatever it comes in contact, which greatly facilitates its ability to affect the temperature the object it contacts. 4.Water is inexpensive in spite of all its marvelous properties. PHYSIOLOGICAL PRINCIPLES OF HYDROTHERAPY

10. In common with other forms of matter, water has certain physical properties which include weight, density, buoyancy, Hydrostatic pressure, and surface tension . The most important physical laws of water that physiotherapist should understand and apply when giving hydrotherapy, are buoyancy and hydrostatic pressure . PHYSIOLOGICAL PRINCIPLES OF HYDROTHERAPY

11. Buoyancy is the force experienced as an up thrust which acts in the opposite direction to the force of gravity. A body in water is therefore subjected to two opposing forces. BUOYANCY

12. BUOYANCY

13. When the weight of the floating body equals the weight of the liquid displaced, and the centers of buoyancy and gravity are in the same vertical line, the body is kept in stable equilibrium. If the centers are not in the same vertical line the two forces acting on the body will cause it to roll over until it reaches a position of stable equilibrium. BUOYANCY

14. BUOYANCY

15. Decrease stress and compression to body tissues (weight-bearing surfaces) Assist weak muscles. Clinical Uses of Buoyancy

16. Pressure exerted by fluid on body immersed in fluid. Pascal’s Law A fluid exerts equal pressure on all surfaces of a body at rest, at a given depth… This pressure increases in proportion to depth of fluid. HYDROSTATIC PRESSURE

17. HYDROSTATIC PRESSURE

18. Water can have similar effect as compression bandages. Helpful in decreasing edema Greatest effects of hydrostatic pressure occur in vertical position. NO hydrostatic pressure effects with non-immersion hydrotherapy. Clinical Uses of Hydrostatic Pressure

19. CLEANSING EFFECTS: Water can be used as a cleanser. Water is most commonly used as cleansing agent for skin. Hydrating effects and friction of water used to soften and remove the Debris. Water is used clinically both as wound exudate or necrotic tissue, and as a cleanser to remove exogenous waste. PHYSIOLOGICAL EFFECTS OF HYDROTHERAPY

20. MUSCULOSKELETAL EFFECTS: The Buoyancy of water unload the weight-bearing of anatomical structures and allow patients to perform exercise with less trauma and pain. Buoyancy effect can help patients with; Decrease weight bearing (Arthritis) Increase blood flow to muscles Muscle Strengthening Ligamentous instability And other degenerative or traumatic conditions. PHYSIOLOGICAL EFFECTS OF HYDROTHERAPY

21. CARDIOVASCULAR EFFECTS: The Cardiovascular benefits of hydrotherapy are primarily due to the effects of hydrostatic Pressure. Increased Venous circulation Increase Cardiac Volume Increase Cardiac Output. PHYSIOLOGICAL EFFECTS OF HYDROTHERAPY

22. RESPIRATORY EFFECTS: Immersion of the whole body in water increases the Work of Breathing. Hydrostatic Pressure on the chest wall increases the resistance to lungs expansion. Water based exercise is also often recommended for patients with EXERCISE-INDUCED ASTHMA because it appears that High Humidity of the air inspired during water exercise, which prevents drying and/or cooling of the Respiratory mucosa. PHYSIOLOGICAL EFFECTS OF HYDROTHERAPY

23. RENAL EFFECTS: Increase Sodium and Potassium excretion Increase Urine Production May be used to treat the patient with hypertension and peripheral edema. PHYSIOLOGICAL EFFECTS OF HYDROTHERAPY

24. PSYCHOLOGICAL EFFECTS: Water immersion can be invigorating and/or Relaxing. The Variation in the Psychological effects depends primarily on the temperature of water PHYSIOLOGICAL EFFECTS OF HYDROTHERAPY

25. SUPERFICIAL HEATING AND COOLING: Warm or cold water can be used clinically to heat or cool the superficial tissues Advantages Even contact with skin Does not need to be fastened Allows movement of heat/cold Disadvantages Extremity often in dependent position CLINICAL USES OF HYDROTHERAPY:

26. WOUND CARE: Cleansing properties facilitate Rehydration Softening and debridement of necrotic tissue Removal of wound debris Hydrostatic pressure and heat increase circulation Provides moist environment to optimize healing CLINICAL USES OF HYDROTHERAPY:

27. PAIN CONTROL: Increased sensory stimulation to peripheral mechanoreceptors Cold water decreases inflammation Decreases weight-bearing, increases “ ease of movement”. CLINICAL USES OF HYDROTHERAPY:

28. EDEMA CONTROL: Water immersion has shown to reduce peripheral edema. This effect is due to Hydrostatic pressure Contrast Baths are frequently used to control edema CLINICAL USES OF HYDROTHERAPY:

29. Miscellaneous conditions ; Control of Pain & swelling – Cold whirlpools Acute Sprains & strains - Cold whirlpools Facilitate motion & ex’s for Sub acute & chronic stages of sprains & strains - Warm whirlpools Facilitation of stretching of contracture (simultaneous or immediate pre application of Warm whirlpools) Postsurgical repair of joints (after post surgical wounds are healed fully – to help soften scar tissue, ↓ pain & promote restoration of motion ) INDICATIONS

30. 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 edema – Hydrostatic pressure. j. Psychological effect – Relaxation & ↓ of anxiety k. Wound care – Mechanical debriding by removing necrotic material & cleansing . INDICATIONS

31. CONTRAINDICATION (LOCAL IMMERSION): Maceration Increased maceration, increased size of wound Bleeding In or near the area ( Maceration is defined as the softening and breaking down of skin resulting from prolonged exposure to moisture). CONTRAINDICATION

32. CONTRAINDICATION (FULL BODY IMMERSION): Cardiac instability Uncontrolled hypertension or heart failure Infectious conditions that spread with water like UTI’s , plantar warts, tinea pedis ( pool ) Severe epilepsy Increased risk of drowning Suicidal patients Increased risk of drowning CONTRAINDICATION

33. 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 CONTRAINDICATION & ITS RATIONALES

34. ↓ 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 Surface infections – Cross contamination Uncontrolled bowels – Contaminate water Dermatological conditions(Atopic eczema) – Exacerbate Severe epilepsy – Risk of drowning (Full body immersion) CONTRAINDICATION & ITS RATIONALES

35. PRECAUTION (LOCAL IMMERSION): Impaired thermal sensation Check temperature of water with thermometer first Infection Universal Precautions Clean WP Confusion , impaired cognition Use constant, direct supervision Temperature of water near body temperature Recent Skin Grafts Neutral or mild warmth (96 - 98 F) PRECAUTION

36. PRECAUTION (FULL BODY IMMERSION): Confusion, Disorientation  Keep head above water  Constant supervision  Low temperature Patients with limited strength, endurance, balance , ROM  Hands-on approach required Patients on medications  Physician clearance sometimes required Patients with fear of water Patients with respiratory problems  Watch for signs of respiratory distress, especially in hot or very warm water PRECAUTION

37. 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 extreme 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 PRECAUTION & ITS RATIONALE

38. Urinary incontinence (full body immersion) – Risk of UTI Fear of water (full body immersion) – May refuse to participate Respiratory problems – ↑ respiratory distress Multiple sclerosis (full body immersion) – ↑ fatigue & weakness Poor thermal regulation (full body immersion) – Risk of thermal shock Previously existing edema (full body immersion) – ↑ edema Sea sickness – Cause anxiety PRECAUTION & ITS RATIONALE

39. GENERAL RULES OF APPLICATION: 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 APPLICATION OF HYDROTHERAPY

40. SELECTION OF HYDROTHERAPY MEANS: Select the appropriate form of hydrotherapy according to the condition to be treated desired treatment effects Size of area to be treated Allowance for safety, control of infection Cost-effectiveness APPLICATION OF HYDROTHERAPY

41. Whirlpool bath Hubbard tank Pool/Aquatic Therapy WATER IMMERSION MODALITIES

42. Extremity Whirlpool High Boy Whirlpool Low Boy Whirlpool Chair for Whirlpool

43. These are stainless steel 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. Whirlpools

44. Agitator/ Turbine ejector/ Aerator Hot and cold water mixing valve Temperature gauge Gravity drain Seat / Chair WP Parts in general

45. Parts of a Whirlpool Bath Motor Pump/Turbine Motor Thermometer Steel Tank Wheels On / Off switch

46. stimulation of circulation promotion of muscle relaxation and pain relief debridement facilitation of exercise Objectives for use

47. 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 WP tank

48. Dimensions width: 24 inches length: 52 – 66 inches depth: 18 inches LOW BOY

49. 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 WP tank

50. Dimensions width: 20 - 24 inches length: 36 - 48 inches depth: 28 inches HIGH BOY

51. 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 WP tank

52. Dimensions width: 15 inches length: 28 – 32 inches depth: 18 – 25 inches EXTREMITY TANK

53. These are large whirlpools designed for full body (Head out) immersion & for patients 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

54. 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 HUBBARD TANK

55. Walk trough Adjustable seat Motorized chair lift Hydro stretcher with hydraulic lift ADDITIONAL EQUIPMENT

56. 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 to 15 pounds /square inch (psi). Used to treat one patient at a time. Reusable.

57. 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

58. WP application – facilitates; Cleansing Softening and debridement of necrotic tissue Removal of wound debris Antibacterial action Circulation enhancement The WP could be carried out until the wound closes. Therapeutic Effects - Wound Care

59. 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

60. 6. THE ENCOURAGEMENT OF FUNCTIONAL ACTIVITIES 7. THE MAINTANANCE & IMPROVEMENT OF BALANCE, CO-ORDINATION & POSTURE 8. WOUND HEALING IS ENHANCED 9. SEDATIVE EFFECT & RELAXATION 10. FACILITATES CARDIOVASCULAR EXERCISES 11. FACILITATES THE WEIGHBEARING ACTIVITIES THERAPEUTIC EFFECTS OF EXERCISE IN WATER: summary

61. 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 Application, General Rules

62. Base decision on Desired effects Size of area to be treated Allowance for safety, control of infection Cost-effectiveness Selection of Hydrotherapy

63. Temperature Range Cold (32-79 F) Acute inflammation Tepid (79-92 F) Exercise Acute inflammation if cold not tolerated Neutral warmth (92-96 F) Open wound Medically compromised patients Decrease tone

64. Mild warmth (96-98 ) Increase mobility Burn Hot (99-104 ) Pain, Increase ROM Increase soft tissue extensibility Very Hot (104-110 ) Limited body area Chronic conditions DO NOT use WP at temperatures > 110 F !! Temperature Range

65. Prevention of falls Precautions for prevention of drowning Electrical safety Safety considerations for Hydrotherapy

66. 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. Treatment duration - WP

67. 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. Lower Extremity / mid thorax level immersion Technique

68. The patient 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. Upper Extremity Technique

69. 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 patient with an open wound. Full body immersion – Hubbard tank

70. Pt’s skin thermal sensory discrimination testing Skin status Health & mental status Hydro equipment Accessories Water temperature W ater 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 Key treatment parameters to be documented in patient’s file after hydrotherapy