DR.

SHAHABUDDIN
BS.PT(JPMC), PP.DPT(IIRS), MPPTA
LECTURER
COLLEGE OF PHYSIOTHERAPY
JINNAH POSTGRADUATE MEDICAL CENTRE KARACHI
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.
 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 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.
 Patients are instructed through a specific
program designed to help their physical
conditions.
 Hydrotherapy is a great way to exercise the
body.
 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
 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.
 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.
 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.
 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.
 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.
 Decrease stress and compression to body
tissues (weight-bearing surfaces)
 Assist weak muscles.
 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.
 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.
 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.
 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.
 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.
 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.
 RENAL EFFECTS:
 Increase Sodium and Potassium excretion
 Increase Urine Production
 May be used to treat the patient with
hypertension and peripheral edema.
PSYCHOLOGICAL EFFECTS:
Water immersion can be invigorating and/or
Relaxing.
The Variation in the Psychological effects
depends primarily on the temperature of water
 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
 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
 PAIN CONTROL:
 Increased sensory stimulation to peripheral
mechanoreceptors
 Cold water decreases inflammation
 Decreases weight-bearing, increases “ease of
movement”.
 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
  Miscellaneous 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 )
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.
 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 (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
 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
 ↓ 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)
 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 (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
 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
 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
 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
 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
 Whirlpool bath

 Hubbard tank

 Pool/Aquatic Therapy
 Low Boy Whirlpool
High Boy Whirlpool
Extremity Whirlpool

Chair for Whirlpool

 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.
 Agitator/ Turbine ejector/ Aerator
 Hot and cold water mixing valve
 Temperature gauge
 Gravity drain
 Seat / Chair
 On / Off switch
Motor Pump/Turbine Motor

Thermometer

Steel Tank

Wheels
 stimulation of circulation
 promotion of muscle relaxation
and pain relief
 debridement

 facilitation of exercise
 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.
 Dimensions
width: 24 inches
length: 52 – 66 inches
depth: 18 inches
 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.
 Dimensions
width: 20 -24 inches
length: 36 -48 inches
depth: 28 inches
 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.
 Dimensions
width: 15 inches
length: 28 – 32 inches
depth: 18 – 25 inches
 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.
 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
 Walk trough

 Adjustable seat

 Motorized chair lift

 Hydro stretcher with hydraulic lift

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.
 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.

 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.
 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

 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

 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
 Base decision on

◦ Desired effects

◦ Size of area to be treated

◦ Allowance for safety, control of infection

◦ Cost-effectiveness
 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
 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 !!
 Prevention of falls

 Precautions for prevention of

drowning

 Electrical safety
 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.
 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.
 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.
 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.
 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