Effectiveness of Hydrotherapy

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International Journal of Caring Sciences September-December 2023 Volume 16| Issue 3| Page 1237

Original Article

Effectiveness of Hydrotherapy to Lower Blood Pressure in


Hypertensive Patients: A Systematic Review

Rini Angraini, RN, MN


Student of Postgraduate Nursing Program, Department of Medical Surgical Nursing, Faculty of
Nursing. Hasanuddin University, Makassar, Indonesia
Andi Masyitha Irwan, RN, MAN, PhD
Lecturer, Department of Gerontological Nursing, Faculty of Nursing, Hasanuddin University,
Makassar, Indonesia

Rosyidah Arafat, MN
Lecturer Dr., Faculty of Nursing, Hasanuddin University, Makassar, Indonesia
Correspondence: Andi Masyitha Irwan, RN, MAN, PhD Lecturer, Department of Gerontological
Nursing, Faculty of Nursing, Hasanuddin University, Makassar, Indonesia
Email: [email protected]

Abstract
Background: Hypertension is a chronic cardiovascular disease and the leading cause of morbidity and
mortality worldwide. Around 53% of patients with hypertension cannot control their blood pressure and
are at risk for complications. Currently, the treatment of hypertension consists of lifestyle modification
and pharmacological treatment. However, most people need two or more antihypertensive drugs to lower
blood pressure. Lifestyle modification can also increase the effect of antihypertensive treatment, one of
which is a complementary therapy, such as hydrotherapy. Hydrotherapy is very easy for everyone,
inexpensive, has no harmful side effects, and a method of treatment, healing by using a water medium to
obtain a therapeutic effect, especially for older people and someone with physical limitations that are
mainly related to orthopedic dysfunction due to water floatation that can reduce the force of gravity.
Purpose: This systematic review aimed to explore the effectiveness of hydrotherapy in lowering blood
pressure on hypertensive patients, with a variety of relevant studies.
Methods: The study was a systematic review using PubMed, Science Direct, Proquest, EBSCO Host,
Wiley, Garuda, and gray literature databases. We included hydrotherapy studies focused on reducing
blood pressure in hypertension patients, published in the last ten years (2010 - 2020), had full text
available, used randomized controlled trial study design, and published in English and Indonesian.
Results: Eight studies were identified and reviewed. Seven studies revealed the type of water-based
exercise hydrotherapy. Only one study revealed the immersion of feet with warm water. All studies
showed that hydrotherapy significantly reduced blood pressure in hypertensive patients with varying
degrees of decline.
Conclusion: Hydrotherapy effectively lowers blood pressure in patients with hypertension. It can be
used as an addition to other therapies. However, further research is needed with follow-up to further
ensure the effectiveness of hydrotherapy interventions for the long term in lowering blood pressure.
Keywords: Hypertension, Hydrotherapy, Blood pressure, Systematic review.

Introduction with a prevalence of 25% of the total world


population (Kemenkes RI, 2019), while in
It is estimated that one billion of the world's Indonesia, it increased from 25.8% to 34.11%
population suffer from hypertension, and this in 2018 (Kementerian Kesehatan RI, 2018).
prevalence increases every year (WHO, Seeing that the incidence of hypertension is
2013). It is predicted to increase to 1.56 increasing, it is necessary to handle it more
billion by 2025 (Forouzanfar et al., 2017). appropriately in reducing the incidence of
Southeast Asia is in the third highest position, hypertension.

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Hypertension is one of the cardiovascular based therapies, such as hydrotherapy,


diseases that cause significant morbidity and diathermy, light and color, heat, and alternate
mortality worldwide. It is considered a nostril breathing (Lindquist & Synder, 2002).
primary risk factor for stroke, heart disease, In providing nursing care, nurses are
and kidney failure (Olsen et al, 2016). This authorized to conduct complementary and
disease can continue to get worse unnoticed alternative nursing management in individual
until it can threaten the life of patients (Casey, health efforts (Presiden RI, 2014). The role of
2012). Due to the high-risk factors that can be nurses in complementary therapy, following
caused, it is necessary to use more appropriate the limits of ability and competence obtained
strategies to reduce the incidence of through nursing education and training
hypertension and improve the quality of life (Regulation of the Minister of Health of the
of hypertension patients. Republic of Indonesia, 2019).
Hydrotherapy has a relaxing effect on the
Because hypertension is a chronic disease,
body, stimulating the production of the
patients need to manage themselves to reduce
hormone endorphin, suppressing adrenaline,
symptoms and reduce the risk of
and reducing BP (Madyastuti, 2012).
complications (Muliaty et al., 2013 ;
Hydrotherapy is very easy for everyone, not
Sitoresmi et al., 2020 ;Irwan, 2016). Most
expensive, and has no harmful side effects
guidelines emphasize lifestyle modification
(Sudoyo, 2014), where warm foot soaking
as the first step in treating hypertension
therapy can be performed at home (Batjun,
(Whelton et al., 2012).
2015). Several reviews have been conducted
Lifestyle modification can also increase the
about the effects of hydrotherapy, including
effect of antihypertensive treatment, one of
hydrotherapy in stroke patients but only to
which is complementary, alternative, or
improve post-stroke life activities (Mehrholz
traditional medicines (Unger et al., 2020).
et al., 2011), hydrotherapy for people with
One of the complementary therapies to
type 2 Diabetes Mellitus and Heart Failure but
decrease BP is hydrotherapy, which is a
limited to reducing blood sugar (Åsa et al.,
therapeutic application of water in all its
2012), hydrotherapy for older people with
forms, for example, liquid, vapor, and solid to
chronic heart failure (Caminiti et al., 2011),
maintain or restore health (Williams, L. &
and hydrotherapy for rheumatoid arthritis
Wilkins, 2008), treatment, and healing
(Verhagen et al., 2015). However, a
methods using water media to obtain a
systematic review has not been conducted on
therapeutic effect (Chaiton, 2002). According
the effectiveness of hydrotherapy in reducing
to recommendations by the American College
BP in people with hypertension. Therefore, it
of Sports Medicine/America Hearth
is necessary to conduct a systematic review by
Association, water-based exercise is a safe
synthesizing and summarizing existing
alternative for older people and someone with
studies and collecting all relevant evidence,
physical limitations that are mainly related to
following the study eligibility criteria to
orthopedic dysfunction due to water floatation
provide the best evidence so that nurses can
that can reduce the force of gravity (Nelson et
be more familiar with complementary
al., 2007).
therapies, especially hydrotherapy, in order to
The increasing needs of the community and
be used in various health facilities and
the development of research on
communities for hypertensive patients.
complementary therapies are opportunities
Therefore, this review was conducted to
for nurses to contribute following the
explore other effects of hydrotherapy, to
community's needs (Smith et al., 2004).
reduce blood pressure in hypertensive patients
Nurses also handle healing professionally,
with various relevant studies. This systematic
including physical, mental, emotional, social,
review will be reviewed based on patient
and spiritual dimensions, and actively engage
characteristics, type of hydrotherapy, duration
with other healthcare professionals to provide
of hydrotherapy, frequency of hydrotherapy,
optimal care and healing (Lindquist et al.,
time of doing hydrotherapy, the therapist
2014 ;Irwan et al., 2016 ; Sitoresmi et al.,
doing hydrotherapy, and the effect of
2020). With this review, nurses can use
hydrotherapy on decreasing BP.
several complementary/alternative medicine
therapies involving manipulative and body-

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Methods Indonesian, namely P: Hypertension, I: Soak


Eligibility Criteria: It uses a systematic the feet, Hydrotherapy, C: Ordinary care and
review design with Preferred Reporting Items O: Reducing Blood Pressure.
for Systematic Review and Meta-Analysis Study Selection: The selection of studies was
checklist-guideline 2009 (Moher et al., 2014). carried out following PRISMA guidelines
Inclusion criteria: hydrotherapy study that (Moher et al., 2009). Two reviewers of RA
focuses on reducing BP in hypertensive and AMI screened titles and abstracts to
patients, hypertensive disease with or without obtain relevant studies following inclusion
accompanying disease, full-text article, with and exclusion criteria. If not approved, it will
randomized controlled trial (RCT) research be discussed with the RA until an agreement
design, published in the last ten years (2010 - is reached. In total, 1,088 titles and abstracts.
2020), conducted in humans, both English Furthermore, RA thoroughly assessed the full
and Indonesia articles. While other text to assess the feasibility of the article.
interventions accompanied the exclusion Then after the screening, 104 articles
criteria, studies with hydrotherapy remained and filtered again into 21 articles;
interventions, the article was only in titles and 13 articles were not following the study's
abstracts, adult population with hypertension results, so eight studies that met the
but pregnant. predetermined criteria were evaluated by RA
The clinical question was based on PICO and AMI
(patients, interventions, comparisons, and Evaluation Quality assessment: Assessment
results) (Brandt Eriksen & Faber Frandsen, of the feasibility of studies was conducted
2018)(Polit, Denise F., Beck, 2018) as with the Critical Appraisal Skill Program
follows P P: Hypertension I: Hydrotherapy (CASP) RCT (Critical Appraisal Skills
with standard care, C: Standard care O: Programme (CASP), 2020) and the Center for
lowering blood pressure. Evidence-Based Medicine (CEBM) (Centre
for Evidence-Based Medicine (CEBM),
Data Sources and Search Methods: Using
2011) (Table 1). Assessment of the risk of
five databases: PubMed, Sciencedirect,
bias was conducted based on the Cochrane
Proquest, EBSCO Host, Wiley, with
Risk of Bias Tool: + (Low risk of bias), -
keywords based on free terms, BOOLEAN
(High risk of bias), ± (Risk of bias is unclear)
OPERATORS AND or OR, The keywords
(J. P. T. Higgins et al., 2011). The bias quality
use PICO, P: Hypertension, I: Hydrotherapy
of each study is determined independently by
with Standard care, C: Standard care, O:
RA, then evaluated to AMI and RA so that
Lowering blood pressure, and Garuda Portal
consensus occurs (Table 2).
(Digital Referral Garba) with keywords using

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Table 1. Critical Appraisal


No Critical Appraisal (Arca et (Bocalini (de (Guimãr (Ngomane (Ruangtha (Mali (Cunha
Intervensi (Critical al., 2014) et al., Barro aes et al., et al., i et al., bel et et al.,
Appraisal Skills 2017) s Cruz 2018) 2019) 2020) al., 2012)
Programme et al., 2020)
(CASP), 2020) 2017)
1 Is the research Yes Yes Yes Yes Yes Yes Yes Yes
focused on the
problem?
2 Is patient selection Yes Yes Yes Yes Yes Yes Yes Yes
for intervention
randomized?
3 Are all patients Yes Yes Yes Yes Yes Yes Yes Yes
involved in the study
taken into account to
this end?
4 Is the patient, Yes Yes Yes Yes Yes Yes Can’t Can’t
officer, or researcher tell tell
blind?
5 Are the patient's Yes Yes Yes Yes Yes Yes Yes Yes
characteristics the
same from the
beginning of the
study?
6 In addition to the Yes Yes Yes Yes Yes Yes Yes Yes
interventions
provided, are both

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groups treated
equally?
7 Are the effects of the Yes Yes Yes Yes Yes Yes Yes Yes
intervention reported
comprehensively?
8 Is the unanimity of Yes Yes Yes Yes Yes Yes Yes Yes
the estimated effects
of the intervention
reported?
9 Are the benefits of Yes Yes Yes Yes Yes Yes Yes Yes
the study
comparable to the
disadvantages and
costs used?
10 Can all clinical Yes Yes Yes Yes Yes Yes Yes Yes
outcomes be applied
to your local
population?
11 Are benefits worth Yes Yes Yes Yes Yes Yes Yes Yes
the cost?
Note. CASP = Critical Appraisal Skills Programme

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Table 2. Risk of Bias


No Cochrane risk-of-bias (Arca (Bocalini et (de (Guimãr (Ngomane (Ruangtha (Malibel (Cunh
domain et al., al., 2017) Barros aes et et al., i et al., et al., a et al.,
(J P T Higgins et al., 2014) Cruz et al., 2018) 2019) 2020) 2020) 2012)
2011) al., 2017)

1 Random process + + + + + + + +

2 Concealing allocation - + - - - + + +

3 Blind participants and + + + + + +


researchers
4 blind research results + + + + + + + +
5 Incomplete result data + + + + + + + +

6 Reporting bias + + + + + + + +
7 Other biases + + + + + +
+ = Low risk of bias, - = High risk of bias,? = Unambiguous risk of bias

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Results and 13 articles were not following research


results. So that the eight articles that meet our
Study Selection
review criteria, thus the eight articles that
From the screening results of five databases meet our inclusion criteria (Figure 1)
and one gray literature used, 1,088 articles
were identified. We excluded 578 articles Study Characteristics
from publications over the last ten years (2010 The eight articles analyzed were RCTs
to 2020). As many as 196 articles did not use describing the effects of hydrotherapy
English, 210 articles with titles and abstracts interventions on Hypertensive patients, with
were not following research questions, 58 the level of bias risk assessment was found to
articles were not full text, five articles were be moderate bias risk two studies and six
not researched in humans, two articles with studies low bias risk assessment.
combined interventions, 18 duplicate articles,

Figure 1. Flowcharts for study selection and inclusion

PubMed Science Direct ProQuest EBSCOHost Wiley Gray Literature


(n=546) (n= 80) (n=131) (n=91) (n=238) (n=2)
Identification

Articles identified
Exclusion:
(n =1088)
> 10 years (n =578)
Not in English (n =196)
Not relevant to the research
question (n =210)

Results are filtered


Screening

(n =104)
Exclusion:
No full text (n = 58)
Not in humans (n = 5)
Other combination interventions
(n = 2) Duplicate (n =18)
Articles
Eligibility

corresponding to
research questions

Exclusion:
Not consistent with the results of
the study (n =13)
Included

Articles containing
inclusions

Note. PubMed= Public/publisher Medline; EBSCO=Elton B. Stephens Company.

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Table 3. Study Characteristics

Author, year, Design Age Number Blood pressure Hypertensi Length of Healthcare
(years) of on suffering professionals
Country (mmHg) initial
Samples Categories from who perform
hypertension
Stage 2
(Arca et al., Between 140/90
RCT >64 52 Hypertensi Not specified Physiotherapist
2014); Brazil and 179/109
on
Stage 2
(Bocalini et al., Systole 155±4 and
RCT > 60 45 Hypertensi Not specified Not specified
2017); Brazil diastole 92 ± 3
on
Stage 2
(de Barros Cruz et Systole >140
RCT >50 44 Hypertensi Five years Not specified
al., 2017); Brazil Diastole >90
on
Stage 2
(Guimãraes et al., Systole >140
RCT 40-65 32 Hypertensi Five years Not specified
2018); Brazil Diastole >90
on
Stage 1
(Ngomane et al., Systole 131 ± 9
RCT >60 45 Hypertensi Five years Not specified
2019); Brazil Diastole 81 ± 9
on
Systole ≥ 130 Stage 1
(Ruangthai et al.,
RCT >60 53 Diastole ≥ 80 Hypertensi 6,5 years Not specified
2020); Thailand
on
Stage 2
(Malibel et al. Systole 144
RCT 50-59 60 Hypertensi Not specified Nurses
2020); Indonesia Diastole 91
on
Stage 2
(Cunha et al., Systole ≥ 160
RCT 60-70 32 Hypertensi Not specified Physiotherapist
2012); Brazil Diastole ≥100
on
Note. RCT = Randomized controlled trials; mmHg = Milimeter merkuri hydrargyrum.

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Table 4. Summary of the results of hydrotherapy intervention on BP reduction in hypertensive patients

Author, Methods Objectives Participants Intervention Outcome Results


Year,
Country
(Arca et RCT Compare the 52 female WG: walking with water WG: pretest systole pretest Water
al., 2014); effect of water hypertensive levels to the xiphoid process. 136±6 mmHg, pretest diastole gymnastics
Brazil gymnastics with patients Includes the stretch of lower 86 mmHg, posttest systole: significantly
training on land Water Group (WG, limb muscles (10 minutes), the 124 ± 15 mmHg, posttest reduces
in women with N = 19), Land isotonic movement of lower diastole: 77mmHg. systole and
hypertension. Group (LG, N = limbs, and relaxation for 10 LG: pretest systole 138 ± diastole BP
19) minutes 15mmHg, pretest diastole 87
Control group LG: Hold walking (10 minutes) mmHg, posttest systole 126 ±
(CG, N = 14). CG: do static bicycles. For 12 9 mmHg, posttest diastole
weeks. after 78 mmHg.
CG: pretest systole 140
mmHg, posttest systole 139
mmHg, pretest diastole 89
mmHg, posttest diastole 84
mmHg. (p=0.001)
(Bocalini et RCT To evaluate the 45 older women Ergometer cycling training (on Systole water training 150±2 Water-based
al., 2017); effects of water Normotensive (N) land or water-based) for 45 mmHg and water training cycling
Brazil and soil- (n = 10) minutes in two different systole 88±1 mmHg exercises
ergometric Hypertension sessions (48 hours between Systole land exercises 153±2 significantly
training treated (TH) (n = sessions) mmHg, diastole land exercise lower the
sessions in Post 15) Water-based sports are carried 91±1 mmHg, (p <0.001), in BP in
Exercise Untreated out in ponds with adjustable untreated hypertension hypertension
Hypotension hypertension (UH) temperatures up to 30 ± 1 ° C, that is not
(PEH) of the (n = 20). and the water depth is set at the treated.
subject of xiphoid process level.
healthy
normotensive
with
hypertensive

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patients treated
or untreated
(de Barros RCT To see the heat- 44 resistant The control group maintains Intervention group pretest Water-based
Cruz et al., based effects of hypertensive their habitual activities by systole 162.2 ± 23.2, pretest running
2017) heated exercise patients. practicing calisthenic exercises diastole 83.8 ± 2.5, and exercises
(HEX) in HEX (N = 28) and running in heated pools for posttest systole 135.5 ± 11, significantly
hypertensive Control group (n = 1 hour, three times a week for posttest diastole 76.7 ± 2.1. reduce
patients resistant 16) 12 weeks. The control group pretest systolic and
to the decrease systole 157.6 ± 17.6, pretest diastolic BP
in BP diastole 86.4 ± 2.5, and
posttest systole 157.8 ± 16.6,
posttest diastole 87.1 ± 2.0. (p
<0.05).
(Guimãraes RCT To find out 32 patients Given 36 sessions (60 minutes) Intervention group: systolic Water-based
et al., whether water- Hypertension of warm-up exercises in a hot BP -19.5 ± 4.6 mmHg and warm-up
2018); based heating resistant HEx tub (32o C) diastolic -11.1 ± 2.4 exercises
Brazil exercises (HEX) group (n = 16) The control group was Systolic BP control group have a
can reduce BP in Control group (n = evaluated over the same period 3.0± 0.7 mmHg and diastolic significant
patients with 16) and instructed to maintain their 2.06 ± 0.9 mmHg, (p = 0.001) effect on
resistant habitual activity for 12 weeks lowering
hypertension (training), followed by 12 systolic and
weeks of cessation of training. diastolic BP
(Ngomane RCT To test the 45 older age At controlled room temperature Hex group pretest systole 132 Exercise
et al., hypothesis that systemic (LEx and CON) (21–23 °C) or ± 15 and pretest diastole 81 ± walking in
2019); HEx is superior hypertension controlled swimming pool 10, posttest systole 132 ± 15 the pool has
Brazil to LEx for patients temperature (Hex) (29–32 °C), and posttest diastole 81 ± 9. a significant
acutely reducing Heated water- at the same time Lex group: pretest systole 129 effect on
BP in older age. based (HEx) group Both HEx and LEx consist of a ± 16 and pretest diastole 83 ± lowering
(n=15) 5-minute warm-up, a 30-minute 13, posttest systole 129 ± 16 systolic and
Land-based walk in the pool (HEx), a and posttest diastole 81 ± 13. diastolic BP.
exercise (LEx) motorized treadmill (LEx), and Control group pretest systole
group (n=15) a 5-minute cool-down. 130 ± 11 and pretest diastole
Control The control group (CON) was 81 ± 10, posttest systole 130 ±
intervention given 40 minutes of rest quietly 11 and posttest diastole 86 ±
in a sitting position. 13

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(CON) group (p<0.05)


(n=15)

(Ruangthai RCT To compare 53 older people The pond water temperature LET group systolic BP Pool-based
et al., combined water with hypertension with a temperature of 26-29 ° C decreased by 11.6 mmHg exercise has
2020); and land-based Land-based and a depth between the (8.2), p < 0.01) and diastolic a significant
Thailand training exercise (LET) xiphoid process and the 10.6 mmHg (7.5%) (p < 0.05) effect on
programs group (n = 17) shoulder (1.2 meters). WET group systolic BP 6.5 lowering
(aerobic and Water-based The intervention group: the mmHg (4.6%) (p < 0.01) and systolic and
resistance) on exercise (WET) exercise session consisted of 10 diastolic 7.6 mmHg (5.4%) (p diastolic BP
functional group (n = 16) minutes of warm-up with < 0.01)
cardiometabolic Control group stretching, 20 minutes of Control group (CON), there is
parameters. (CON) (n = 20). aerobic exercise, 20 minutes of no change in BP.
Fitness and resistance training, and 10
quality of life minutes of stretching and
(QoL) in older cooling down.
people with Ground exercise group: training
hypertension. sessions including aerobic
exercise, resistance training,
and stretching exercise: 10
minutes
warm-up with stretching
exercises, 20 minutes aerobic
exercise, 20 minutes resistance
training, and 10 minutes
stretching and cool-down
exercises.
The intervention was conducted
three sessions a week for 60
minutes for 12 weeks.
(Malibel et RCT To determine 60 Hypertension Do soaking feet using warm Intervention pretest average Soak the
al. 2020); the effect of BP patients water with a temperature of 38- systole: 144.33 mmHg, foot of
Indonesian before and after Intervention group 40oC for 20-30 minutes, and posttest: 131.00 mmHg warm water
warm water foot (n=30) the length of the intervention is Pretest diastole: 91.00 mmhg, has
soak therapy in not explained. posttest: 83.00 mmhg significant

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hypertensive Control group (n = Pretest systole control group: significantly


patients 30) 144.00 mmHg, posttest: reduced
145.33 mmHg prestest systole and
diastole: 89.33 mmHg, diastole
posttest: 93.33 mmHg (p =
0.000).

(Cunha et RCT To evaluate the 32 women's older A swimming pool as deep as EP group pretest systole: Water
al., 2012); behavior of people with 1.4 m with an average 135.46 (- 7.42), posttest: gymnastics
Brazil subacute BP in hypertension temperature of 28.5 C. 126.93 (- 11.51)
the older woman Experimental A 40-minute water training CP group pretest systole: significantly
with groups (EP) (N = session, mostly aerobics, was 138.25 (- 12.78), posttest: reduces
hypertension 16) done. 137.06 - 16.20 systolic BP
after a water Control Group The EP group starts with 5 (p=0,014)
gymnastics (CP) (n = 16) minutes period. The main part
session. of the session lasts 30 minutes
and a cooling session for 5
minutes.
Hout any physical exercise, for
the same period (40 minutes)
The CP group also occurs
aquatic center pool, a condition
like EP, but without any
physical exercise, for the same
period (40 minutes)

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Sample Characteristics intervention in hot water in patients with


resistant hypertension was significant in the
All participant data (n = 363) with six studies
decrease of systole 135.5 ±11 and diastole
from Brazil, one study from Thailand, and one
76.7 ± 2.1 compared to the control group
study from Indonesia. The majority of the
systole 157.8 ± 16.6 and diastole 87.1 ± 2.0 (p
participants were > 60 years old on average;
<0.05) (de Barros Cruz et al., 2017).
the majority were women, with aged 32
The administration of water-based warm-up
(Guimãraes et al., 2018; Cunha et al., 2012) to
exercise interventions in resistant
60 (Malibel et al., 2020), with a BP of >140
hypertension was significant in decreasing BP
mmHg and a diastole of 90 mmHg, but two
of systole-19.5±4.6 and diastole 11.1±2.4
studies with a BP of 130/80 mmHg are
compared to the control group systole 3.0±0.7
presented in Table 3 (Ngomane et al., 2019;
mmHg and diastole 2.06 ± 0.9 mmHg (p =
Ruangthai et al., 2020) (Table 3).
0.001) (Guimãraes et al., 2018). Exercise
Type, Intervention, and Duration of intervention by walking in the pool of older
Hydrotherapy Intervention hypertensive patients was significant in the
In this review, seven studies reported the type decrease in blood pressure systole 132 ± 15
of hydrotherapy exercises based on water, and and diastole 81 ± 9 compared to the control
only one study revealed the immersion of feet group systole 130 ± 11 and diastole 86 ± 13l
with warm water (Malibel et al., 2020). The (p <0.05) (Ngomane et al., 2019). Water-
majority of studies (four studies) provided a based exercise intervention in hypertensive
12-week intervention (Arca et al., 2014; de older people significantly decreased systole
Barros Cruz et al., 2017; Guimãraes et al., 6.5 mmHg (4.6%) and diastole 7.6 mmHg
2018; Ruangthai et al., 2020), one study (5.4%) compared to the control group with no
conducted a 7-day intervention (Ngomane et change (p < 0.01) (Ruangthai et al., 2020).
al., 2019), then the study explained the Warm water immersion intervention in
duration of the intervention for 90 minutes patients with hypertension significantly
(Bocalini et al., 2017)), two studies with the decreased systole 131.00 mmHg and diastole
shortest duration of intervals of 30 minutes 83.00 mmHg compared to the control group
(Cunha et al., 2012; Malibel et al., 2020). systole 145.33 mmHg and diastole 93.33
Moreover, total immersion was performed mmHg (p = 0.001)(Malibel et al., 2020).
between 20 and 60 minutes, with the most Water gymnastics intervention in older
immersion limit to the xiphoid process. The women with hypertension significantly
water temperature used is between 26oC decreased systole 126.93 (- 11.51) compared
(Ruangthai et al., 2020) to 40 oC (Malibel et to the control group systole 137.06 (- 16.20)
al., 2020) are presented in Table 4. (p =0.014) (Cunha et al., 2012)

Effects of Hydrotherapy intervention on Discussion


decreasing BP in Hypertension Research design, feasibility study, and risk
Hydrotherapy shows a statistically significant of bias
decrease in BP in hypertensive patients of the The effects of hydrotherapy interventions to
eight reviewed studies. The administration of decrease BP in patients with hypertension
water gymnastics interventions in women have been identified and evaluated in this
with hypertension significantly decreased systematic review. All studies used the RCT
blood pressure with systole 124 ± 15 mmHg design in 363 patients with hypertension, and
and diastole 77 mmHg compared to the all hydrotherapy interventions decreased BP
control group systole 139±2 mmHg and in patients with hypertension. RCT is the best
diastole 84 mmHg (p =0.001) (Arca et al., type of study to determine causality between
2014). Water-based ergometer cycling interventions and effects (Kabisch et al.,
exercise interventions in treated or untreated 2011). All studies are valid, reliable, and
hypertension significantly decreased BP with applicable for the study feasibility assessment
systole 150±2 mmHg and diastole 88±1 because statistically, the intervention results
mmHg compared to the control group systole can reduce BP in people with hypertension.
153±2 mmHg and diastole 91±1 mmHg (p Critical assessment evaluates research articles
<0.01) (Bocalini et al., 2017). Exercise carefully and systematically to determine

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reliability, validity, and application (Abdullah Effects of Hydrotherapy intervention on


& Firmansyah, 2012). In this review, the decreasing BP in Hypertension
majority of studies with low risk of bias. If it
On administering hydrotherapy intervention
can be resolved, the unique strength of
on decreasing BP, all studies show a
randomization and blind will prevent or
significant decrease in systole and diastole
reduce bias (J. Higgins et al., 2016).
compared to the control group. Hydrotherapy
Type, intervention, duration of interventions are given in water gymnastics,
hydrotherapy intervention water-based ergometer cycling exercises, hot
In this review, the majority of types of water exercises, water-based warm-up
hydrotherapy exercises are water-based. The exercises, walking exercises in the pool,
intervention is given 12 weeks, with a total water-based exercises, and warm water foot
immersion carried out between 20 - 60 soak. A previous study reported that when
minutes, the majority immersion to the subjects were confined to those with
xiphoid process using antihypertensive hypertension who performed resistance
therapy, for the water temperature used exercises, the net change in systolic and
between 26oC - 40 oC. Following previous diastolic BP decreased significantly (Igarashi
studies evaluating the effect of water sports & Nogami, 2018). Exercising (e.g., aquatic
regularly on BP, training sessions ranged treadmill, walking, or jogging) in water
from 15 to 60 minutes. The frequency of results in an increase in cardiac output, in
exercises is one to three sessions per week, blood flow to the muscles, and in the diffusion
duration of intervention ranges from 8 to 24 of metabolic waste products from the muscle
weeks (median 12 weeks), water temperature to the blood, as well as a reduction in the time
ranges from 27oC - 36 oC (Igarashi & Nogami, it takes to transport oxygen, nutrients, and
2018). The Aquatic Exercise Association hormones to fatigued muscles. Moreover,
(AEA, 2006) recommends a water heart volume increased by 30-35% with
temperature of 30-31oC. It can use warm immersion into the neck, then more
water at a temperature of 32-35°C is declared significant activity than when doing the same
to have a physiological impact on the body exercise at the same speed on land (Torres-
(Bates A, & Hansen N, 1996). Ronda & Schelling I Del Alcázar, 2014).
Although in this review, we found only one Acute immersion in water causes many
study that reported the administration of this physiological changes related to the
hydrotherapy intervention by nurses, it was hormonal, cardiovascular, and kidney
shown that hydrotherapy intervention is part systems. The primary hemodynamic changes
of complementary/alternative medicine are decreased total peripheral resistance, BP,
therapies involving manipulative and body- HR, increased end-systolic volume, and
based therapies where nurses can use several cardiac output. Hormonal and renal changes
other therapies in this group including are diuresis, natriuresis, potassiuresis, and
hydrotherapy, diathermy, light and color, increased levels of circulating atrial
heat, and alternate nostril breathing natriuretic peptide and inhibition of the renin-
(Lindquist et al., 2014) angiotensin-aldosterone system (Hall et al.,
Nurses have a role as counselors in providing 1990). When renin is produced in the kidneys,
information about the implementation of angiotensin I will be formed, which will turn
hypertension. In this interaction, there will be into angiotensin II, increasing BP and
communication between nurses and patients, indirectly stimulating the release of
a form of collaboration intervention care aldosterone, which results in sodium and
(Lindquist et al., 2014). For this reason, the water retention in the kidneys (Smeltzer &
role of nurses as counselors is obliged to Bare, G, 2001). Later a study revealed that
provide counseling to hypertensive patients in systolic BP decreased in the same way in cold
improving understanding and changing (36°C), neutral (31.1°C), and warm (39°C)
attitudes for better therapy compliance water. However, warm water immersion
(Priyanto, 2010). Nurses can also be a place significantly reduced systolic BP by 11,596
of questioning, consultation, and discussion if mmHg and diastolic BP by 25.826 mmHg
the client needs information before making a (Becker et al., 2009).
decision (Lindquist et al., 2014).

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International Journal of Caring Sciences September-December 2023 Volume 16| Issue 3| Page 1251

Nursing implications needed with better study quality and follow-


up to confirm further the effectiveness of
This finding provides information that
hydrotherapy intervention in lowering BP.
hydrotherapy intervention can reduce the BP
in hypertension with a temperature of 27-40o Acknowledgements: The authors appreciate
C with depth to the xiphoid process. However, the substantial contributions of everyone who
the exercise runs in warm water and water- participated in this study.
based heating exercises, more effective in
reducing BP, carried out three times a week,
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