HYDROTHERAPY

D R . M . FA I S A L
Objectives
•Understand Hydrotherapy Fundamentals
•Explore Clinical Applications
•Recognize Indications and Contraindications
•Learn Patient Preparation and Safety
•Monitor and Manage Sessions
•Understand Hydrotherapy Equipment
•Analyze Case Studies
•Integrate Techniques into Practice
Definition
• Hydrotherapy, derived from the Greek words hydro,
meaning “water,” and therapeia, meaning “healing,” is
the application of water, internally or externally, for the
treatment of physical or psychological dysfunction.
• Hydrotherapy is the use of water in various forms and
temperatures for health promotion, therapy, and
rehabilitation.

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History of Hydrothrapy:
• Bathing in water has been viewed as a healing method throughout history and across cultures.
• Ancient Uses:
• Hippocrates (4th-5th centuries BCE) used hot and cold water for various treatments.
• Romans established therapeutic baths in the 1st century CE.
• The Japanese have continued ritual bathing practices from ancient times to modern day.
• 19th Century Popularity:
• Hydrotherapy gained popularity in Europe in the late 19th century with health spas near natural springs
(e.g., Baden-Baden, Bad Ragaz).
• The United States saw similar developments in areas with natural hot springs.
• Hydrotherapy was recognized for its effects on both mental and physical health.
• Shift in Focus:
• The transition from preventive and recreational use to a curative and rehabilitative role
occurred during the polio epidemic of the 1940s and 1950s.
• Sister Kenny's Contribution:
• Sister Kenny included water activities in her treatment for polio recovery.
• She
1 0 found
/ 1 9 / 2 0 that
24 water's properties—buoyancy, resistance, and support—enabled weakened patients to perform therapeutic
4
activities more safely and effectively than on dry land
 PHYSICAL
PROPERTIES OF
WATER

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Physical properties of water
• Buoyancy
• Hydrostatic pressure
• Thermodynamics
• Viscosity and resistance
 https://www.youtube.com/watch?
Buoyancy: v=khc2wUBsFU4&t=48s

• Definition: Upward force exerted

by fluid on immersed object
• Archimedes' principle states that
an immersed body experiences
upward thrust equal to the
volume of liquid displaced.
• Effects on body weight in water
(approximate % of weight
bearing at different water levels)
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Clinical Significance of Buoyancy
• Buoyancy creates a sensation of relative
weightlessness for the patient and alleviates joint
stress by lessening the impact of gravity on the body.
As a result, patients can engage in active movements
more easily.
• When a limb is moved against buoyancy, it
encounters resistance, which can be utilized as a
method to enhance muscle strength.
• Body composition also plays a role in buoyancy.
• Patients with obesity experience greater buoyancy due to
the lower specific gravity of fat tissue. Conversely,
individuals with higher bone density have less buoyancy
compared to those with lower bone density.
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Hydrostatic pressure
• Hydrostatic pressure is the pressure
exerted by a fluid on a body immersed in
it.
• Pascal’s law states that the pressure
exerted by fluid on an immersed object is
equal on all surfaces of the object. As the
density of water and depth of immersion
increase, so does hydrostatic pressure.
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Clinical Significance of Hydrostatic Pressure
• he effects of hydrostatic pressure include the following:
• Reduction of Effusion: Increased pressure helps reduce or
limit fluid buildup in tissues.
• Assistance in Venous Return: Hydrostatic pressure facilitates
the return of blood to the heart from the extremities.
• Induction of Bradycardia: It can cause a decrease in heart
rate.
• Centralization of Peripheral Blood Flow: Hydrostatic
pressure promotes blood flow towards the central body areas,
enhancing circulation.
• Exercise Ease with Depth: The relationship between depth
and pressure enables patients to perform exercises more
comfortably when they are closer to the water's surface.
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 Cardiovascular effects of immersion.

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Respirator
y effects
of
immersion
.

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Renal
effects of
immersion
.

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Thermodynamics
• Water Temperature and Its Effects
• Water temperature influences the body and, consequently,
performance in an aquatic environment.
• Temperature Transfer
• Conductivity: Water conducts temperature 25 times faster than air.
• Heat Transfer and Velocity: Heat transfer increases with velocity.
A patient moving through the water loses body temperature more
rapidly than a patient who is simply immersed and at rest.

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Clinical Significance:
• Water retains heat significantly more
effectively than air—approximately
1,000 times more.
• This characteristic allows for prolonged
therapeutic effects during
hydrotherapy, enabling patients to
maintain warmth and benefit from
continuous muscle relaxation without
the rapid loss of heat.
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Viscosity and resistance
• Viscosity is friction occurring
between molecules of liquid
resulting in resistance to flow
• Resistance from viscosity is
proportional to the velocity of
movement through liquid.

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Clinical Significance of Water's Viscosity
Water's viscosity contributes to resistance during active
movements:
• Resistance Creation: Water's viscosity generates
resistance with every active movement.
• Velocity and Resistance: Increasing the speed of
movement enhances the level of resistance experienced.
• Surface Area Impact: A larger surface area moving
through the water also results in increased resistance.
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Physiologic and therapeutic effects of hydrotherapy
•Thermal Energy:
 Cryo-hydrotherapy: Cold water
immersion for vasoconstriction,
reduced blood flow, and
increased alertness.
 Thermo-hydrotherapy: Warm
water immersion for
vasodilation, increased blood
flow, and relaxation.
 Cryo-thermo-hydrotherapy:
Alternating hot and cold water
for improved circulation and
healing.
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Physiologic and therapeutic effects of hydrotherapy
•Physiologic effects:
 Vascular: Vasoconstriction,
vasodilation, improved
circulation.
 Metabolic: Increased or
decreased metabolism.
 Sensory: Invigoration, sedation.
 Pain management: Reduced
pain.
 Healing: Enhanced recovery.
 Body: Unloading, exercise,
wound care.
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Physiologic and therapeutic effects of hydrotherapy
•Mechanical Energy:
 Pressure/suction: For wound cleansing and debridement.
 Hydrostatic pressure: For edema reduction.
 Buoyancy force: For body unloading and rehabilitation.
 Drag force: For resistance training.

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Physiologic and Therapeutic Effects of Hydrotherapy
Effect Physiologic Mechanism Therapeutic Benefits
Reduced muscle tension, improved circulation,
Vasodilation Increased blood flow to tissues decreased pain
Reduced inflammation, decreased swelling, improved
Vasoconstriction Decreased blood flow to tissues muscle tone
Increased
metabolism Increased energy expenditure Increased calorie burn, improved weight management
Decreased
metabolism Decreased energy expenditure Relaxation, reduced stress
Sedation Decreased arousal and alertness Relaxation, improved sleep
Invigorating effects Increased alertness and energy Improved mood, reduced fatigue
Decreased pain Reduced nerve activity Pain relief, improved function
Improved blood flow, reduced
Enhanced healing inflammation Faster tissue repair, reduced scarring
Body unloading Reduced weight-bearing on joints Decreased joint stress, improved mobility
Increased muscle strength and
Resistance training endurance Improved physical fitness, functional capacity

Wound care Cleansing, debridement, edema control Improved wound healing, reduced infection risk

Edema control Reduced fluid accumulation Decreased swelling, improved circulation

Enhanced tissue oxygenation, nutrient delivery, and
Improved circulation Increased blood flow to tissues waste removal
Enhanced 1 0 peripheral
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blood flow Increased blood flow to extremities Improved circulation, reduced cold sensitivity
Physiologic and Therapeutic Effects of Hydrotherapy
System Effect Physiological Mechanism Therapeutic Benefits
Improved cardiac function, increased
Increased central blood volume Increased blood flow to the heart
endurance
Increased heart rate and stroke
Enhanced cardiac output Improved cardiovascular fitness
volume
Cardiovascular
Decreased resistance to blood flow in Improved circulation, reduced blood
Reduced peripheral resistance
peripheral vessels pressure
Blood pressure changes Increased hydrostatic pressure at Improved venous return, reduced
(depth-dependent) greater depths edema
Increased lung function, improved
Increased vital capacity Improved lung expansion
breathing
Improved diaphragmatic Increased diaphragm strength and Improved breathing, increased lung
Respiratory function efficiency capacity
Challenges to respiratory
Increased resistance against breathing Increased respiratory muscle strength
muscles (hydrostatic pressure)

Reduced joint loading Decreased weight-bearing on joints Decreased joint pain, improved mobility
Reduced muscle tension and joint
Increased range of motion Improved flexibility, reduced pain
stiffness
Musculoskeletal Muscle relaxation in warm Increased blood flow, decreased Reduced muscle spasms, improved
water muscle tension recovery
Increased resistance provided by Improved muscle strength and
Potential for strength gains
water endurance
Changes in sensory information from Improved proprioception, balance,
Sensory input alteration
the body coordination
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Pain modulation (gate control 22
Interference with pain signals Reduced pain perception
Water Temperature Classification
Water
Temperatur
e Fahrenheit Celsius Expected Physiological Effects
Classificatio
n
33°F to 1°C to
Very cold Vasoconstriction, decreased blood flow, increased alertness
55°F 13°C
56°F to 14°C to
Cold Vasoconstriction, decreased metabolism, reduced inflammation
65°F 18°C
66°F to 19°C to
Cool Mild vasoconstriction, increased circulation
80°F 26°C
81°F to 27°C to
Tepid Neutral temperature, comfortable for most individuals
92°F 32°C
93°F to 33°C to
Neutral Slightly warming, promotes relaxation
96°F 35°C
97°F to 36°C to
Warm Increased blood flow, decreased muscle tension
99°F 37°C
100°F to 38°C to
Hot Significant vasodilation, increased metabolism, pain relief
1 0 / 1 9 104°F
/2024 40°C 23
Immersion Technique
• Explanation: Immersion therapy involves submerging part or all of the
body in water, leveraging water’s properties (buoyancy, hydrostatic
pressure) to reduce joint strain, improve circulation, and enhance mobility.
• Full Body Immersion: Submersion of the entire body for total support
and therapeutic benefits such as pain relief, muscle relaxation, and
improved circulation.
• Partial Immersion: Only a specific part of the body (e.g., limb) is
submerged.
• Contrast Baths: Alternating immersion in hot and cold water to stimulate
circulation and reduce swelling.
• Whirlpool Treatments: Localized immersion with water agitation for muscle
relaxation or wound care.
• Temperature Considerations:
• Cold: Ideal for reducing inflammation and treating acute injuries.
• Neutral: Used for relaxation or in patients sensitive to temperature extremes.
• Warm/Hot: Relieves muscle tension, improves circulation, and reduces joint
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stiffness, particularly in chronic conditions.
Contrast Therapy
• Explanation: Contrast therapy involves alternating hot and cold
treatments, primarily used to enhance circulation and reduce
inflammation. This method is effective for acute injuries and chronic
pain management.
• Alternating Hot and Cold Treatments: Involves immersing limbs
or the body in hot and cold water at specific intervals.
• Physiological Effects:
• Vasodilation: Hot water dilates blood vessels, improving circulation.
• Vasoconstriction: Cold water constricts blood vessels, reducing swelling
and inflammation.
• Applications:
• Acute Injuries: Controls swelling, pain, and inflammation following injury,
particularly in sports injuries.
• Chronic Conditions: Reduces long-term pain and
stiffness
1 0 / 1 9 /in
2 0 2conditions
4 such as arthritis by promoting 25
Aquatic Exercises
• Explanation: Aquatic exercises use water as a medium to perform a
variety of physical activities, harnessing water’s resistance and support
for muscle strengthening, cardiovascular improvement, and
rehabilitation.
• Range of Motion Exercises: Increases joint flexibility and mobility
using water’s buoyancy, which reduces strain on the body.
• Strengthening Exercises: Water provides resistance to movement,
making it ideal for building muscle strength without joint stress.
• Aerobic Conditioning: Cardiovascular exercises such as water walking
or jogging improve heart health and endurance with minimal impact on
the joints.
• Balance and Proprioception Training: Water’s unstable environment
challenges balance and coordination, beneficial for patients recovering
from strokes or neurological conditions.
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Aquatic Temperature and Therapeutic Exercise
• Water temperature selection is determined by the
patient’s condition and therapeutic goals.
• Cooler temperatures: For higher intensity exercises
(Aerobic Exercises).
• Warmer temperatures: For mobility, flexibility, and
muscle relaxation.

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Ideal Temperature Ranges for Aquatic Exercises

• Mobility and Functional Control: 26°C to 35°C

• Warm water (33°C) for acute painful musculoskeletal injuries.
• Aerobic Conditioning: 26°C to 28°C
• Intense aerobic training (above 80% max heart rate) between
22°C and 26°C to avoid heat illness.

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Clinical Considerations
• Immersion Time: Start with 10 minutes, increasing to
20 minutes if tolerated.
• Monitor Vital Signs: Always check for patient safety.
• High Temperatures (36°C-37°C): For patients with
rheumatoid arthritis (except in acute stage).
• Lower Temperatures (26°C-35°C): For spasticity or
longer immersion.

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Pools for Aquatic Exercise
• Aquatic therapy pools vary in size, shape, and functionality, tailored to therapy type and
patient needs. Key considerations include:
• Ventilation: Essential to prevent condensation; dressing rooms for changing and showering are needed.
• Traditional Therapeutic Pools:
• Size: Minimum 100 ft long, 25 ft wide; depth 3-4 ft to 9-10 ft.
• Group Therapy: Suitable for sessions with patients and therapists in water.
• Accessibility: Entry via ramps, stairs, ladders, or mechanical lifts for limited mobility.
• Built-in Systems: Equipped with chlorination and filtration for safety.
• Individual Patient Pools:
• Design: Smaller, self-contained for one patient; allows focused sessions.
• Entry: Access via door or steps for independence.
• Therapist Role: Guidance provided from outside, using verbal instructions.
• Features: Often includes filtration, treadmills, adjustable currents, and variable depths for a tailored
experience.

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Patient exercising using
fins on feet for added
resistance
in a therapeutic pool.

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Special Equipment for Aquatic Exercise
A variety of equipment exists to provide buoyant
support, challenge balance, and generate resistance.
• Examples: Resistive paddles, floats, paddle boards,
and weighted stools.
• Equipment choice depends on the patient's functional
level and therapy goals.
• Collars, Rings, Belts, and Vests:
• Cervical Collars: Support the neck for supine patients.
• Flotation Rings: Support extremities in immersed
positions.
• Buoyancy Belts and Vests: Position patients for
shallow and deep water activities.
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Special Equipment for Aquatic Exercise
• Swim Bars:
• Buoyant dumbbells for upper body and trunk support.
• Useful for balance and proprioception in deep water.
• Resistance Tools:
• Webbed Gloves: Increase resistance to arm movements.
• Hydro-tone® Bells: Create significant drag for added
resistance.
• Fins and Hydro-tone® Boots:
• Fins: Enhance resistance during lower extremity exercises.
• Hydro-tone® Boots: Effective for deep water walking and
running.
• Kickboards:
• Versatile tool for buoyancy and resistance; aids in balance
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and strength training
Pool Care and Safety https://www.youtube.com/watch?v=0mEi-rifpiM

• Therapeutic pools, due to their warm water and constant

use, are prone to bacterial growth and infections. To
maintain a safe and healthy environment, it's crucial to:
• Clean regularly: This removes debris, dirt, and bacteria that can
accumulate in the water.
• Check chlorine levels: Chlorine is a disinfectant that kills bacteria.
Regular checks ensure it's at the correct level.
• Test pH: The pH level affects the effectiveness of the chlorine and the
comfort of the swimmers. It should be maintained within a specific range.
• Use slip-resistant surfaces: Wet surfaces can be slippery, increasing
the risk of falls. Slip-resistant materials help prevent accidents.
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General Indications for the use of
Hydrotherapy
•Pain relief: Hydrotherapy can help alleviate pain associated with various conditions, including
arthritis, muscle strains, and back pain.
•Improved mobility: The buoyancy of water can help improve flexibility, range of motion, and
overall mobility.
•Enhanced cardiovascular health: Water-based exercises can strengthen the heart, improve
circulation, and increase endurance.
•Stress reduction: The relaxing environment of a pool can help reduce stress and anxiety.
•Weight management: Hydrotherapy can be an effective way to burn calories and maintain a
healthy weight.
•Rehabilitation: Hydrotherapy is often used as part of rehabilitation programs after injuries or
surgeries to aid in recovery.
•Improved balance and coordination: The resistance of water can help improve balance,
coordination, and proprioception.
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Contraindications
• Open wounds or infections
• Severe heart conditions
• Uncontrolled hypertension
• Recent deep vein thrombosis (DVT)
• Fever
• Pregnancy (consult with healthcare provider)
• Severe skin conditions
• Severe kidney disease
• Very old age (consider physical frailty, cognitive impairment, and
underlying health conditions)
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Exercise Interventions
• Stretching Exercises
• Patients may tolerate immersed stretching exercises better than land stretching
because of the effects of relaxation, soft tissue warming, and ease of positioning.
• However, buoyancy creates an inherently less stable environment than land.
Therefore, careful consideration is warranted when recommending aquatic
stretching.
• Manual Stretching Techniques
• Manual stretching is typically performed with the patient supine in waist-depth
water with buoyancy devices at the neck, waist, and feet.
• Alternatively, the patient may be seated on steps. The buoyancy-supported
supine position improves both access to the patient and control by the
practitioner, as well as the position of the patient.
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 Examples of stretching exercises

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Cervical Spine: Lateral Flexion
• Practitioner Position:
Stand at the side facing the patient.
• Patient Position:
Supine without a cervical collar.
• Hand Placement:
Reach the fixed hand dorsally under the patient and grasp the
contralateral arm; support the head with the movement hand.
• Direction of Movement:
Move the patient into lateral flexion and apply stretch force at the desired
intensity. This position prevents patient drift as the fixed hand stabilizes
the patient against the practitioner
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Cervical Spine: Flexion
• Practitioner Position:
Stand at the patient’s head facing caudally.
• Patient Position:
Supine without a cervical collar.
• Hand Placement:
Cup the patient’s head with your hands, the forearms supinated and thumbs placed
laterally. Alternatively, place your hands in a pronated position with the thumbs at
the occiput. This results in a more neutral wrist position at end-range stretch.
• Direction of Movement:
As you flex the cervical spine, the patient has a tendency to drift away from the
practitioner; therefore, it is essential to maintain stabilization throughout the
movement
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Thoracic and Lumbar Spine:
Lateral Flexion/Side Bending
• Practitioner Position:
Stand on the side opposite that to be stretched, facing
cephalad with ipsilateral hips in contact (e.g., if stretching the
left side of the trunk, the therapist’s right hip is against the
patient’s right hip).
• Patient Position:
Supine, if tolerated. The patient’s stretch side arm is abducted to end-range to facilitate the stretch.
• Hand Placement:
Grasp the patient’s abducted arm with the fixed hand; alternatively, grasp at the deltoid if the
patient’s arm is not abducted. The movement hand is at the lateral aspect of the lower extremity of
the side to be stretched (more distal placement improves leverage with stretch).
• Direction of Movement:
With the patient stabilized by your hip, pull the patient into lateral flexion. This technique allows
variability in positioning and hand placement to isolate distinct segments of the spine

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Shoulder Stretching Techniques
• Shoulder Flexion
• Practitioner Position: Stand on the
side to be stretched facing cephalad.
• Patient Position: Supine with the
affected shoulder in slight abduction.
• Hand Placement: Grasp buoyancy belt
with fixed hand; movement hand at the
elbow.
• Direction of Movement: Direct the arm
into flexion and apply stretch force.
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Shoulder Stretching Techniques
• Shoulder Abduction
• Practitioner Position: Stand on affected side facing cephalad.
• Patient Position: Supine.
• Hand Placement: Stabilize scapula; movement hand grasps
medial elbow.
• Direction of Movement: Guide arm into abduction and apply
stretch force.

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Shoulder Stretching Techniques
• Shoulder External Rotation
• Practitioner Position: Stand lateral to affected extremity
facing cephalad.
• Patient Position: Supine; position arm in desired abduction.
• Hand Placement: Grasp medial side of elbow; movement hand
on midforearm.
• Direction of Movement: Guide forearm dorsally

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Shoulder Stretching Techniques
• Shoulder Internal Rotation
• Practitioner Position: Stand lateral to affected extremity
facing caudally.
• Patient Position: Supine; position arm in desired abduction.
• Hand Placement: Stabilize scapula with fixed hand; movement
hand at distal forearm.
• Direction of Movement: Direct the forearm palmarward

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Knee Stretching Techniques
• Knee Flexion with Patient on Steps
• Practitioner Position: Half-kneel lateral to affected knee.
• Patient Position: Semi-reclined on pool steps.
• Hand Placement: Grasp distal tibia; stabilize lateral aspect of
affected knee.
• Direction of Movement: Apply stretch force into flexion

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Knee Stretching Techniques
• Knee Extension with Patient on Steps
• Practitioner Position: Half-kneel lateral to the affected
knee.
• Patient Position: Semi-reclined on pool steps.
• Hand Placement: One hand proximal and one distal to the
knee joint.
• Direction of Movement: Extend the patient’s knee

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Knee Stretching Techniques
• Knee Flexion with Patient Supine
• Practitioner Position: Half-kneel lateral to affected knee.
• Patient Position: Supine, affected knee flexed.
• Hand Placement: One hand on distal tibia; other on buoyancy
belt.
• Direction of Movement: Pull body over fixed foot to create
stretch

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Knee Stretching Techniques
• Knee Extension with Patient on Steps
• Practitioner Position: Half-kneel lateral to the affected
knee.
• Patient Position: Semi-reclined on pool steps.
• Hand Placement: One hand proximal and one distal to the
knee joint.
• Direction of Movement: Extend the patient’s knee

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Active Exercises and self stretches

https://www.youtube.com/watch?v=5BvDKgVL270

https://www.youtube.com/watch?app=desktop&v=a
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wWmQDA3X3Q
Documentation
• Documentation of hydrotherapy interventions should include the
type of hydrotherapy performed, the parameters of the treatment,
and the patient’s response to the treatment. Water temperature
• Duration of the treatment
• Goals of pool therapy
• Movement or exercise techniques performed during therapy
• Assistive equipment used during therapy
• Means of entry and exit
• The patient’s tolerance to the treatment, including vital signs
• Any adverse reactions
• Post-pool therapy changes in identified impairments or functional
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Precautions for Physiotherapists Conducting Hydrotherapy
•Obtain informed consent
•Assess medical history and physical condition
•Prepare the hydrotherapy environment
•Monitor vital signs and provide support
•Adjust exercises as needed
•Be aware of potential risks
•Communicate effectively
•Monitor for adverse effects
•Document the session
•Provide post-session care
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Reference List
 Kisner, C. (2021). Aquatic Exercise. In Therapeutic Exercises: Foundations and Techniques (6th ed.). Philadelphia: F.A. Davis
Company.
 Kidd, C. (2006). Hydrotherapy: Principles and Practice. Churchill Livingstone.
 Low, J., & Reed, K. (2014). Hydrotherapy: A Guide for Health Professionals. Elsevier Health Sciences.
 O'Sullivan, P. B., & Schmitz, T. J. (2016). Physical Rehabilitation: A Comprehensive Guide. F.A. Davis Company.
 Ardern, C. M., & Croft, P. R. (2005). Hydrotherapy for osteoarthritis of the knee: A systematic review and meta-analysis.
Annals of the Rheumatic Diseases, 64(11), 1515-1521.
 Hillier, S., & Jones, M. (2008). Hydrotherapy for stroke rehabilitation: A systematic review. Clinical Rehabilitation, 22(1), 1-
9.
 McPherson, K. (2011). Hydrotherapy: A review of its use in the treatment of musculoskeletal pain. Physiotherapy, 97(1),
52-58.
 American Physical Therapy Association: https://www.apta.org/
 World Confederation of Physical Therapy:
 https://world.physio

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