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NAmJMedSci.2014May6(5):199209.

PMCID:PMC4049052

doi:10.4103/19472714.132935

ScientificEvidenceBasedEffectsofHydrotherapyonVariousSystemsoftheBody
AMooventhanandLNivethitha1
NaturopathyClinical,SDMCollegeofNaturopathyandYogicSciences,Ujire,India
1
DepartmentofResearchandDevelopment,SVYASAUniversity,Bangalore,Karnataka,India
AddressforCorrespondence:Dr.MooventhanA.,DepartmentofNaturopathyclinical,SDMCollegeofNaturopathyandYogicSciences,Ujire,Karnataka,India.E
mail:dr.mooventhan@gmail.com
Copyright:NorthAmericanJournalofMedicalSciences
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract
Theuseofwaterforvarioustreatments(hydrotherapy)isprobablyasoldasmankind.Hydrotherapyisoneofthebasic
methodsoftreatmentwidelyusedinthesystemofnaturalmedicine,whichisalsocalledaswatertherapy,aquatictherapy,pool
therapy,andbalneotherapy.Useofwaterinvariousformsandinvarioustemperaturescanproducedifferenteffectsondifferent
systemofthebody.Manystudies/reviewsreportedtheeffectsofhydrotherapyonlyonveryfewsystemsandthereislackof
studies/reviewsinreportingtheevidencebasedeffectsofhydrotherapyonvarioussystems.WeperformedPubMedand
PubMedcentralsearchtoreviewrelevantarticlesinEnglishliteraturebasedoneffectsofhydrotherapy/balneotherapyon
varioussystemsofthebody.Basedontheavailableliteraturethisreviewsuggeststhatthehydrotherapyhasascientific
evidencebasedeffectonvarioussystemsofthebody.
Keywords:Evidencebasedeffects,Hydrotherapy,Varioussystems
Introduction
Hydrotherapyistheexternalorinternaluseofwaterinanyofitsforms(water,ice,steam)forhealthpromotionortreatmentof

variousdiseaseswithvarioustemperatures,pressure,duration,andsite.Itisoneofthenaturopathictreatmentmodalityused
widelyinancientculturesincludingIndia,Egypt,China,etc.[1]Thoughmanycountriesusedwatertoproducedifferent
physiological/therapeuticeffectsondifferentpartofthesystemformaintaininghealth,preventing,andtreatingthediseases,the
scientificevidencebasedeffectsarenotwelldocumented.Therearemanystudies/reviewsthatreportedeitherphysiologicalor
therapeuticorcombinationofboththeeffectsofhydrotherapyonparticularsystembutdidnotreportinallthemajorsystemsof
thebody,whichmadeustodothisreviewwiththeaimandobjectivetoreportscientificevidencedbasedeffectsof
hydrotherapyonvarioussystemsofthebody.Inordertoprovideageneraloverview,weperformedPubMedandPubMed
centralsearchtoreviewrelevantarticlesinEnglishliteraturebasedoneffectsofhydrotherapy/balneotherapyonvarious
systemsofthebody.Articlespublishedfrom1986to2012wereincludedinthisreview.
Hydrotheraphyingeneral

Superficialcoldapplicationmaycausephysiologicreactionssuchasdecreaseinlocalmetabolicfunction,localedema,nerve
conductionvelocity(NCV),musclespasm,andincreaseinlocalanestheticeffects.[2]
Onehourheadoutwaterimmersions(WI)invarioustemperatures(32C,20C,and14C)producedvariouseffects.
Immersionat32Cdidnotchangemetabolicrate(MR)andrectaltemperature(Tre),butitloweredtheheartrate(HR)by15%,
systolicbloodpressure(SBP)anddiastolicbloodpressure(DBP)by11%and12%,respectively,compared,withcontrolsat
ambientairtemperature.AlongwithHRandbloodpressure(BP),theplasmareninactivity,plasmacortisol,andaldosterone
concentrationswerealsoloweredby46%,34%,and17%,respectively,whilediuresiswasincreasedby107%.[3]
Immersionat20Cproducedsimilardecreaseinplasmareninactivity,HR,SBP,andDBP,inspiteofloweredTreand
increasedMRby93%.Plasmacortisolconcentrationstendedtodecrease,whileplasmaaldosteroneconcentrationwas
unchanged.Diuresiswasincreasedby89%.Nosignificantdifferencesinchangesinplasmareninactivity,aldosterone
concentration,anddiuresiscomparedwithsubjectsimmersedin32C.[3]
Immersionat14CloweredTreandincreasedMRby350%,HR,SBP,andDBPby5%,7%,and8%,respectively.Plasma
noradrenalineanddopamineconcentrationswereincreasedby530%andby250%,respectively,whilediuresisincreasedby
163%,whichwasmorethanat32C.Plasmaaldosteroneconcentrationsincreasedby23%.Plasmareninactivitywasreduced.
Cortisolconcentrationstendedtodecrease.Plasmaadrenalineconcentrationsremainedunchanged.Changesinplasmarenin
activitywerenotrelatedtochangesinaldosteroneconcentrations.[3]
WIindifferenttemperaturesdidnotincreasebloodconcentrationsofcortisol.TherewasnocorrelationbetweenchangesinTre
andchangesinhormoneproduction.ThephysiologicalchangesinducedbyWIaremediatedbyhumoralcontrolmechanisms,

whileresponsesinducedbycoldaremainlyduetoincreasedactivityofthesympatheticnervoussystem(SNS).[3]
Regularwinterswimmingsignificantlydecreasedtension,fatigue,memory,andmoodnegativestatepointswiththedurationof
swimmingperiodsignificantlyincreasedvigoractivityscoresrelievedpainwhosufferedfromrheumatism,fibromyalgia,or
asthmaandimprovedgeneralwellbeinginswimmers.[4]
Cardiovascularsystem

Coldexposure(CE)tosmallsurfaceareaproducedcompensatoryvasodilatationindeepervascularsystemresultingincreased
bloodflowtothetissuesunderlyingthesiteofexposure.Thisvascularreactionoccursmainlytomaintainconstantdeeptissue
temperature.[2]
Inpatientwithchronicheartfailure(CHF),thermalvasodilatationfollowingwarmwaterbathingandlowtemperaturesauna
bathing(LTSB)at60Cfor15minimprovescardiacfunction[5]repeatedsaunatherapy(ST)increasedleftventricular
ejectionfractionincreased6minwalkdistanceinassociationwithimprovementinflowmediateddilationandincreasein
numberofcirculatingCD34(+)cellsreducedplasmalevelsofnorepinephrineandbrainnatriureticpeptide.Theseindicates
thatSTimprovesexercisetoleranceinassociationwithimprovementinendothelialfunction.[6]LTSBimprovesperipheral
circulationincerebralpalsy(CP).[5]
AfterSTreducedleveloftotalandlowdensitylipoprotein(LDL)cholesterolconcentration,whileincreasedlevelofhigh
densitylipoprotein(HDL)cholesterolwasobserved.Thesechangesaregoodprognosesforthepreventionofischemicheart
disease.[7]STincreasesendothelialnitricoxidesynthase(eNOS)activityandimprovescardiacfunctioninheartfailureand
improveperipheralbloodflowinischemiclimbs.Inmyocardialinfarction(MI)inducedWistarratsSTincreasesmyocardial
eNOS,vascularendothelialgrowthfactormRNAlevels.ItattenuatescardiacremodelingafterMIthroughimprovingcoronary
vascularityinthenoninfarctedmyocardiumandthusSTmightserveasanovelnoninvasivetherapyforpatientswithMI.[8]
AcuteMIwasthoughttoresultfromthrombosisorplaquerupturebecauseofcoronaryarteryspasm.Thevasospasmmightbe
inducedbystimulationofthealphaadrenergicreceptorsduringalternatingheatexposureduringsaunabathfollowedbyrapid
coolingduringcoldwaterbath.Thiseffectshowedthedangersofrapidcoolingaftersaunabathinginpatientswithcoronary
riskfactors.[9]RegularST(eitherradiantheatorfarinfraredunits)appearstobesafeandproducemultiplehealthbenefitsbut
useofSTinearlypregnancyisapotentialconcernbecauseevidencesuggestingthathyperthermiamightbeteratogenic.[10]
Coldwaterimmersion(CWI)inducessignificantphysiologicalandbiochemicalchangesinthebodysuchasincreaseinHR,
BP,metabolism,andperipheralcatecholamineconcentrationanddecreaseincerebralbloodflow.[11]

ReductioninHR,andincreasesinsystolicanddiastolicbiventricularfunctions,wereobservedduringacutewarmWI.[12]In
contrast,increaseinHRandadecreaseinSBPandDBPwereobservedin30minofheadoutWI(38.410.04C).[13]
Hyperthermicimmersion(HI)producedshorteningofactivatedpartialthromboplastintime.DuringHIplasminogenactivator
inhibitor(PAI)activitywasdecreasedthrombocytecountwasincreasedincreasesintissuetypeplasminogenactivator
concentrationandleukocytescountwereattributedtohemoconcentration.ImmediatelyafterHI,fibrinogenconcentration
decreasedbutincreasedduringrecovery.Duringthermoneutralimmersionprothrombintime,PAIactivityandgranulocyte
countecreased.WarmwaterbathingleadstohemoconcentrationandminimalactivationofcoagulationdecreaseinPAI1
activity.Duringwarmwaterbathing,markedriskforthromboticorbleedingcomplicationsinhealthymalescouldnotbe
ascertained.[14]Duringcontrastbaths,longerdurationinthesecondheatingphasewasrequiredtoproducesufficient
fluctuationinbloodflow.[15]
WIuptoshoulderlevelsatdifferenttemperatures(25C,34C,and40C)showednosignificanteffectoncardiacoutputin
25Ccomparedwith34C,butin40Caconsiderableincreaseincardiacoutputwasobserved.[16]
Carbondioxide(CO2)enrichedWIreducedfreeradicalplasmalevels,raisedantioxidantslevels,andinduceperipheral
vasodilatationsuggestsimprovementinmicrocirculation.[17,18]Decreaseintympanictemperatureincreaseincutaneousblood
flowatimmersedsitewassignificantlygreaterinCO2WIcomparedwithfreshWI.[18]ThethreemaineffectsofCO2
enrichedWIaredeclineincoretemperature,increaseincutaneousbloodflow,andelevationofscoreonthermalsensation,
whichwereanalyzed.[19]
Respiratorysystem

WIuptoshoulderlevelsatdifferenttemperatures(25C,34C,and40C)showedincreasedMR,oxygen(O2)consumption
(VO2)onlyat25C.TwomainfactorsaffectingO2transportduringimmersionaretemperatureandhydrostaticpressure.O2
transportwasimprovedaboveneutraltemperature,becauseofincreaseincardiacoutputresultingfromthecombinedactionsof
hydrostaticcounterpressureandbodyheating.Belowneutraltemperature,O2transportisaltered.Atanyofthetemperatures
tested,thepulmonarytissuevolumeandarterialbloodgaseswerenotsignificantlyaffected.[16]
Significantdecreaseinvitalcapacity(VC)withbathtemperaturewasobserved(i.e.,VCat40C>34C>25C).Significant
increaseintidalvolume(VT)incoldorhotwatercomparedwiththermoneutralwater(i.e.,VT40C>34C<25C).
Alterationsinrespiratorymusclesfunctioningmightproducevariationsofthepulmonaryvolumesasafunctionofwater
temperature.[20]

CWIwasassociatedwithincreaseinrespiratoryminutevolumeanddecreaseinendtidalCO2partialpressure.[11]Repeated
coldwaterstimulationsreducedfrequencyofinfectionsincreasedpeakexpiratoryflow,lymphocytecounts,andexpressionof
gammainterferonmodulatedinterleukinexpressionandimprovedqualityoflife(QOL)inpatientswithchronicobstructive
pulmonarydisease.[21]
Inchildrensufferingfromrecurrentandasthmaticbronchitisinremission,asingletotalairbath,ordoucheandlocal(coolingof
thefeetwithwater)exposuretomildcolddidnotraisenoticeabledisordersoftherespiratoryfunction.Localcoldprocedures
improvebronchialpatencybutheatexposureresultedinitsworsening.[22]
Inhalinghotairwhileinasaunaproducednosignificantimpactonoverallsymptomseverityofcommoncold.[23]Amale
trackandfieldathlete,acaseofbreathingdifficultiesatrestandduringexercise,wasexacerbatedinthesupinepositionand
duringWI.[24]
Nervoussystem

Threecoldmodalitiessuchasicemassage,icepack,andCWIappliedtorightcalfregionfor15minreducedskintemperature
(Tsk)(mean18.2C)reducedamplitudeandincreasedlatencyanddurationofcompoundactionpotential.Italsoreduced
sensoryNCVby20.4,16.7,and22.6m/sandmotorNCVby2.5,2.1,and8.3m/s,respectively.Eventhoughallthree
modalitieseffectivelyreducedTskandsensoryconductionataphysiologicallevel,CWIisthemostindicated,effective
modalityforinducingtherapeuticeffectsassociatedwiththereductionofmotornerveconduction.[25]
Temperatureandpressureofwaterinaquaticorhydrotherapycanblocknociceptorsbyactingonthermalreceptorsand
mechanoreceptorsandexertpositiveeffectonspinalsegmentalmechanisms,whichisusefulforpainfulcondition.[26]Forty
sessionsofAiChiaquaticexercise(AE)programimprovespain,spasms,disability,fatigue,depression,andautonomyin
patientwithmultiplesclerosis.[27]
InastudyonphysiotherapyonlandorwaterinpatientwithParkinson'sdisease(PD),functionalreachtestwasimprovedin
boththerapies,butBergBalanceScale(BBS)andUnifiedParkinson'sDiseaseRatingScale(UPDRS)wereimprovedonlyin
aquatictherapygroup.ItindicatesimprovementinposturalstabilityinPDwassignificantlylargerafteraquatictherapy.[28]
Saunabathonparaplegic(P)groupandtetraplegic(T)group,HRincreasedsignificantlyduringsaunabutdecreased
significantlyduringpostsaunaphaseinPgroup.DBPsignificantlyreducedinTgroupduringpostsaunaphasebutno
significantchangesinSBPinboththegroups.[29]
InastudyonCP,LTSBproducedincreaseinHRandcardiacoutputdecreaseinBPandtotalperipheralresistancesignificant

improvementinskinbloodflow,bloodflowvelocity,pulsatileindex,andresistiveindexdecreaseinnumbnessandchronic
myalgiaoftheextremitieswithnoadverseeffects.[5]
Tenminutesofimmersionsinwhirlpoolsproducedincreasesinpulseandfingertemperaturewithincreasedfeelingsofwell
beinganddecreasedstateanxiety.[30]CO2WIactivatesparasympatheticnerveactivityinhumans.[18]
Adaptedcoldshowermighthaveantipsychoticeffectsimilartothatofelectroconvulsivetherapybecauseitcouldworkasmild
electroshockappliedtosensorycortex.Additionally,coldshowerisexampleofstressinducedanalgesiaandwouldalsobe
expectedtocrowdoutorsuppresspsychosisrelatedneurotransmissionwithinmesolimbicsystem.[31]
CEcanactivatecomponentsofreticularactivatingsystemsuchaslocusceruleusandraphenuclei,whichcanresultin
activationofbehaviorandincreasedcapacityofcentralnervoussystem(CNS)torecruitmotoneurons.[32]CEactivatesSNS
increasebloodlevelofbetaendorphinandnoradrenalineandincreasesynapticreleaseofnoradrenalineinbrain.
Antidepressiveeffectofcoldshowerattributedtopresenceofhighdensityofcoldreceptorsinskinexpectedtosendan
overwhelmingamountofelectricalimpulsesfromperipheralnerveendingstothebrain.Ithassignificantanalgesiceffectandit
doesnotcausedependenceornoticeablesideeffects.[33]Mostnarcoticsadministeredrectallycancauseintoxication.Thereisa
significantcomorbidityofschizophreniawithintestinalillnessesandthuscoloncleansingcansignificantlyimprovemental
state.[31]
Musculoskeletalsystem

Walkinginwateratumbilicallevelincreasestheactivityoferectorspinaeandactivatesrectusfemoristolevelsneartoorhigher
thanwalkingondryground.[34]CWI<15Cisoneofthemostpopularinterventionusedafterexercise,[11,35]which
significantlyloweredratingsoffatigueandpotentiallyimprovedratingsofphysicalrecoveryimmediatelyafterimmersionwith
reductionindelayedonsetmusclesorenessat24,48,72,and96hfollowupsafterexercisecomparedwithpassive
interventionsinvolvingrestornointervention.[35]
Rateofdecreaseinplasmalactateconcentrationover30minrecoveryperiodafterintenseanaerobicexercisewassignificantly
higherincontrastWI[hot(36C)andcold(12C)]comparedwithpassiverecoveryonbedforbothgenders.[36]
Legimmersioninwarmwater(441C)for45minbeforestretchshorteningexercisereducedmostoftheindirectmarkersof
exerciseinducedmuscledamage,includingmusclesoreness,creatinekinaseactivityintheblood,maximalvoluntary
contractionforce,andjumpheight.Decreasingmuscledamagedidnotimprovevoluntaryperformance,thereforeclinical
applicationofmuscleprewarmingmaybelimited.[37]

Contrastwatertherapy(CWT)[alternating1minhot(38C)and1mincold(15C)]for6/12/18minloweredsubjective
measuresofthermalsensationandmusclesorenesscomparedwithcontrol(seatedrest)butnoconsistentdifferenceswere
observedinwholebodyfatigue.ItindicatesCWTfor6minassistedacuterecoveryfromhighintensityrunningandCWT
durationdidnothavedoseresponseeffectonrunningperformancerecovery.[38]Contrastbathshavebeensuggestedfor
reducingpainhandvolumeandstiffnessinaffectedextremitiesbutithadnosignificanteffectonpreand/orpostoperative
handvolumeincarpaltunnelsyndrome.[39]
Coldwaterorcold/thermoneutralwaterdidnotinducemodificationsofinflammatoryandhematologicalmarkers.The
performancesofathleteswerenotnegativelyinfluencedbyCWIorCWT.Reducedperceptionoffatigueaftertrainingsession
wastheprincipaleffectofCWI[45]becauseCEincreasesopioidtoneandhighMR,whichcoulddiminishfatiguebyreducing
musclepainandacceleratingrecoveryoffatiguedmuscle,respectively,[32]whichcanimprovetrainingandcompetitionsin
youngsoccerplayers.[40]
Asystematicreviewonmanagementoffibromyalgiasyndrome(FMS)throughhydrotherapydescribedasthereisstrong
evidencefortheuseofhydrotherapyinthemanagementofFMSanditshowedpositiveoutcomesforpaintenderpointcount
andhealthstatus.[41]CombinationofST(oncedailyfor3days/week)andunderwaterexercise(oncedailyfor2days/week)
for12weekssignificantlyreducedpainandsymptoms(bothshortandlongterm)andimprovedQOLinpatientswithFMS.
[42]Poolbasedexerciseusingdeepwaterrunningthreetimes/weekfor8weeksissafeandeffectiveinterventionforFMS
becauseitshowedsignificantimprovementingeneralhealthandQOLcomparedwithcontrolandsignificantimprovementin
fibromyalgiaimpactquestionnairescore,incorporatingpainfatiguephysicalfunctionstiffnessandpsychologicalvariables.
[43]
Hydrotherapymayhavesomeshorttermbenefittopassiverangeofmovementinrehabilitationafterrotatorcuffrepair.[44]Spa
water(37C)andtapwaterheatedto37Cforthedurationof20min/dayfor5days/weekfortheperiodof2weekswith
homebasedexerciseprogramimprovedtheclinicalsymptomsandQOLinpatientwithosteoarthritisofknee(OAK).
However,painandtendernessstatisticallyimprovedinspawater.[45]Itmaybeduetothatspawatersarenotonlynaturally
warm,buttheirmineralcontentisalsosignificant.Spawaterhasmechanical,thermal,andchemicaleffects.
Inankylosingspondilitis(AS)patients,balneotherapystatisticallyimprovedpainphysicalactivitytirednessandsleepscore
BathAnkylosingSpondilitisDiseaseActivityIndex(BASDAI)NottinghamHealthProfile(NHP)patient'sglobalevaluation
andphysician'sglobalevaluationat3weeks,butonlyonmodifiedShobertestandpatient'sglobalevaluationparametersat24
weeks.ItindicatestheeffectofbalneotherapyinimprovingdiseaseactivityandfunctionalparametersinASpatients.[46]
Infraredsauna,aformoftotalbodyhyperthermiawaswelltoleratednoadverseeffectsandnoexacerbationofdiseasewere

reportedinpatientswithrheumatoidarthritis(RA)andASinwhompain,stiffness,andfatigueshowedclinicalimprovements
duringthe4weekstreatmentperiodbutthesedidnotreachstatisticalsignificance.[47]
Aquajoggingwithoutcaloricrestrictionsinobesepersonsfor6weekswasassociatedwithreductionsinwaistcircumference
andbodyfatimprovementofaerobicfitnessandQOL.[48]
AEmaybeanexcellentalternativetolandexerciseforindividualswholackconfidence,havehighriskoffalling,orhavejoint
pain.[49]Waterbuoyancyreducestheweightthatjoints,bones,andmuscleshavetobear.[50]Warmthandpressureofwater
alsoreduceswellingandreducesloadonpainfuljoints,remotesmusclerelaxation.[51]AEhassignificanteffectsonpainrelief
andrelatedoutcomemeasurementsforlocomotordiseases.PatientsmaybecomemoreactiveandimprovetheirQOLasaresult
ofAE.[52]WaterbasedandlandbasedexercisesreducedpainandimprovedfunctioninpatientswithOAKandthatwater
basedexercisewassuperiortolandbasedexerciseforrelievingpainbeforeandafterwalking.[53]Hydrotherapyishighly
valuedbyRApatientswhoweretreatedwithhydrotherapy(30minsession/week)reportedfeelingmuchbetter/verymuch
betterthanthosetreatedwithlandexercises(similarexercisesonland)immediatelyoncompletionofthetreatmentprogram(6
weeks).Butthisbenefitwasnotreflectedon10mwalktimes,functionalscores,QOLmeasures,andpainscoresby
differencesbetweengroups.[51]Hotcompress(HC)withsurroundingelectroacupunctureneedlingwassignificantlyeffective
onrearthighmusclesstrainanditwassuperiortoconventionalneedlingmethodandcuppinginimprovingsymptomsand
physicalsignsaswellasrecoveryofwalkingfunctionofathletes.[54]
Gastrointestinalsystem

Drinkingwatersignificantlyelevatestherestingenergyexpenditure(REE)inadultsbutinoverweightchildrentransient
decreaseinREEwasobservedimmediatelyafterdrinking10ml/kgcoldwater(4C).ThenasubsequentriseinREEwas
observed,whichwassignificantafter24minandthemaximalmeanREEvalueswereseenafter57min,whichwas25%
higherthanbaseline.Therecommendeddailyamountofwaterconsumptioninchildrencouldresultinenergyexpenditure
equivalenttoadditionalweightlossofabout1.2kg/yearsuggestingthatwaterdrinkingcouldassistoverweightchildrenin
weightlossormaintenance.[55]ExposuretocoldincreasesMR,forexample,headoutimmersionincoldwaterof20Calmost
doublesMR,whileat14Citismorethanquadrupled.[3]
WhenveryHCappliedtolumbarregionofhealthyfemalefor10minbloodflowtothebackincreasedto156%withincreased
bloodflowtoupperarm.ImmediatelyafterHC,bowelsoundsincreased1.7timescomparedwithbeforeapplication,which
suggestthataveryHCcanbeusefultopromoteflatusordefecation.[56]Lowmineralwaterintakenormalizestheintestinal
permeabilityofpatientswithatopicdermatitis.[57]

Warmwateriseffectiveforcolonicspasminwhichsignificantlylessdiscomfortwasreportedcomparedwithcontrolgroupand
thismaybeusefulasanalternativeforglucagon(expensive)andhyoscyamine(hassideeffects)becauseithasnosideeffects
andcostspracticallynothing.[58]
Inpatientswithacuteanalpainduetohemorrhoidsoranalfissures,neithercoldwater(<15C)norhotwater(>30C)sitzbath
(SB)didcontrolpainstatistically.[59]Similarly,aftersphincterotomyforanalfissure,SBproducednosignificantdifferencein
painbutsignificantreliefinanalburningandbettersatisfactionscorewithnoadverseeffectswereobservedcomparedwith
controlgroup.[60]HealingandpainreliefwasnotsignificantinSBbutitimprovedpatientsatisfactioninacuteanalfissures.
[61]
ThoughtherewasnostrongevidencetosupporttheuseofSBforpainreliefandtoacceleratefissureorwoundhealingamong
adultpatientswithanorectaldisorders(ARDs),patientsweresatisfiedwithusingSBandnoseverecomplicationswere
reported.[62]Incontrast,warmwaterSB(40C,45C,and50Cfor10mineachtime)inARD,painreliefwasmoreevident
andlastedlongerathigherbathtemperatures.PainreliefafterSBmightattributetointernalanalsphincterrelaxation,which
mightbeduetothermosphinctericreflex,resultingindiminutionoftherectalneckpressure.Thehigherthebathtemperature,
thegreaterthedropinrectalneckpressureandinternalsphincterelectromyographicactivity,andlongerthetimeneededto
returntopretestlevels.[63]
Inposthemorrhoidectomycare,waterspraymethodcouldprovideasafeandreliablealternativetoSBasamoreconvenient
andsatisfactoryformoftreatment.[64]
SpatreatmentwithmineralwaterNizhneivkinskaya(sulfatecalcium)inducedclinicalremissionofthedisease,normalizationof
theechoscopicpictureofstomachandgallbladder,theirmotorfunction,tesiocrystalloscopiccharacteristicsofsalivasuggestits
effectivenessinrehabilitationofpatientswithgastricandgallbladdermotorevacuatorydysfunction.[65]Intakeofsulfate
chloridesodiummineralwateractivatesregulationofcarbohydratemetabolismbyinsulinandcortisolduetotheformationof
adaptivereactions.Itpromotedtrophiceffectsofinsulinandgastrininanimalswithsignificantreductioninpepticulcersizeand
enhancedresistancetostressfulfactors.[66]
ImmersioninDeadSeawaterproducedsignificantreductioninbloodglucoseintype2diabetesmellitus(DM)andno
significantdifferencesininsulin,cortisol,andcpeptidelevelswereobservedbetweenDMpatientsandhealthyvolunteers
followingimmersion.[67]
Genitourinarysystem

Meanlaborpainscoresweresignificantlyhigherincontrolgroupthanimmersionbath(IB)groupsuggestthatuseofIBasan
alternativeformofpainreliefduringlabor.[68]WIinprimiparaatanystageoflabor,from2cmexternalopeningoftheuterine
cervix,significantlydecreasedparturitiondurationcomparedwithtraditionaldelivery.Itraisedboththeamplitudeand
frequencyofuterinecontractionsproportionaltouterinecervixgapingwithnodisturbancesincontractionactivityoftheuterus.
A3cmgapingofuterinecervixistheoptimaltimingforWIintheprimiparabecauseearlierWIat2cmuterinecervixgaping
alsoacceleratedthelaborbutrequiredrepetitionsofWIoruseofoxytocinforcorrectingweakeneduterinecontraction.[69]
Incontrast,IBdidnotinfluencethelengthoflaboranduterinecontractionsfrequency.However,contractionslengthwas
statisticallyshorterinIBanditcanbeanalternativeforwoman'scomfortduringlabor,sinceitprovidesrelieftoherwithout
interferingonlaborprogressionorjeopardizingthebaby.[70]
WIduringfirststageoflaborreducestheuseofepidural/spinal/paracervicalanalgesia/anesthesiacomparedwithcontrolsand
thereisnoevidenceofincreasedadverseeffectstofetus/neonateorwomanfromlaboringinwaterorwaterbirth.[71]Neonatal
swimmingcanacceleratebabiesgrowthinearlystage.[72]Inamicrobiologicalstudy,comparingneonatalbacterial
colonizationafterwaterbirthtoconventionalbeddeliverieswithorwithoutrelaxationbathshowednosignificantdifference
betweenthreegroupsinneonataloutcome,infant'sandmaternalinfectionrate.[73]
ColdSBbutnotwarmSB,significantlyreducededemaduringpostepisiotomyperiod[74]andperinealpain,whichwas
greatestimmediatelyafterthebath.[75]Bakera,asteambathpreparedwithvariousplants(commonlytheessentialoilplants)is
traditionallyusedinMinahasa(Indonesia)mainlyforrecuperationafterchildbirth.Itisbasedonthermotherapywith
aromatherapywhichattributeforitstherapeuticeffects.Thermotherapysoothessymptomssuchasheavinessinlimbs,edema,
muscularstrain,lossofappetite,andconstipation.Essentialoilsoftheplantsusedhaveantiseptic,antiphlogistic,and
immunostimulanteffect.Henceitcanbeaneffectiveandsafemethodforrecuperationafterchildbirth.[76]Inpostnatal
mothers,alternate(hotandcold)compressandcoldcabbageleaveswereequallyeffectiveinreducingbreastengorgement,but
inrelievingbreastengorgementpain,alternatecompressesweremoreeffectivethancoldcabbageleaves.[77]
WarmSB(4045C)for10min,foratleast5daysimmediatelyaftertheremovalofFoleyurethralcatheterinpatient
undergonetransurethralresectionofprostate,significantlyreducedurethralstricturecomparedwithnoSBgroupwhohad1.13
foldincreasedriskofrehospitalizationwithin1monthaftersurgeryduetopostoperativecomplicationscomparedwithwarm
SBgroup.[78]Thirtyhealthyvolunteersand21patientswithurinaryretentionafterhemorrhoidectomyunderwentSBat40C,
45C,and50Cwherethenumberofspontaneousmicturitionsincreasedwithhighertemperaturebathsanditseemstobe
initiatedbyreflex(thermosphincterreflex)internalurethralsphincterrelaxation.Theurethralpressurebothinnormaland
retentionsubjectsshowedsignificantreduction,whichincreasedwithhighertemperatureandvesicalpressureorEMGactivity

oftheexternalurethralsphincterdidnotshowsignificantdifferences.[79]
Hematology/immunology

SubsequentCEinducedincreaseofleukocytes,granulocytes,circulatinglevelsofinterleukin(IL)6,andnaturalkiller(NK)
cellsanditsactivity.Leukocytes,granulocyte,andmonocyteresponseswereaugmentedbypretreatmentwithexerciseinwater
(18C)andthusacuteCEhasimmunestimulatingeffects.[80]
DailybriefcoldstresscanincreasebothnumbersandactivityofperipheralcytotoxicTlymphocytesandNKcells,themajor
effectorsofadaptiveandinnatetumorimmunity,respectively.It(for8days)improvedsurvivalofintracellularparasite
Toxoplasmagondiiinfectedmice,withconsistentenhancementincellmediatedimmunity.Thesustained/longertermeffectsof
coldstressrepeateddailyovertheperiodof5daysto6weeksincreasedplasmalevelsoftumornecrosisfactor,IL2,IL6.A
hypothesisdescribes,dailybriefcoldwaterstressovermanymonthscouldenhanceantitumorimmunityandimprove
nonlymphoidcancersurvivalrate.Thepossiblemechanismofnonspecificstimulationofcellularimmunitymightattributeto
transientactivationofSNS,hypothalamicpituitaryadrenal(HPA)andhypothalamicpituitarythyroidaxes.Thoughdaily
moderatecoldhydrotherapydoesnotappeartohavenoticeableadverseeffectsonnormalsubjects,somestudiesshowedthatit
cancausetransientarrhythmiasinpatientswithheartproblemsandcanalsoinhibithumoralimmunity.SuddenicecoldWIcan
producetransientpulmonaryedemaandincreasebloodbrainbarrierpermeability,therebyincreasingmortalityofneurovirulent
infections.Studiesarerequiredtowarrantthishypothesisforimmunotherapydevelopmentforsome(nonlymphoid)cancers,
includingthosecausedbyviralinfections.[81]
Warmwater(28C)treatmentcouldnotonlycurebacterialcoldwaterdiseasebutalsoimmunizeagainstcausativeagent
Flavobacteriumpsychrophilum.[82]
HeadoutWI(38.410.04C)for30mindecreasedbloodviscosityredbloodcellscountandmeanhematocritwithout
significantchangesinleukocytesandplateletscountmeancorpuscularvolumeplasmaviscosityerythrocytefiltrationtimeand
redcelldeformabilityindex.[13]ApplicationofhyperthermicwaterbathproducedsignificantreductionofrelativeB
lymphocyte.WholebodyhyperthermicwaterbathreducedrelativetotalTlymphocytecountsincreasedrelativeCD8+
lymphocyteNKcellcountsanditsactivity,whichwereprobablydependentonincreasedsomatotropichormoneproduction.
[83]
Endocraine/hormonalsystem

DuringCEincreaselevelsofcirculatingnorepinephrinewasobserved[80]andexercisingHPAsystembyrepeatedCEcould

potentiallyrestoreitsnormalfunctioninchronicfatiguesyndrome,oratleastincreasenetHPAactivity(withoutchanging
baselineactivity).[84]Itproducestemporaryincreaseinplasmalevelsofadrenocorticotropichormone(ACTH),beta
endorphin,andcortisol.[32]Thesustained/longertermeffectsofcoldstressrepeateddailyproducedincreaseinACTH,
corticosterone,anddecreasein1antitrypsinandtestosterone.[81]Coldstressreduceslevelofserotonininmostregionsof
brain(exceptbrainstem).[32]Coldstressinducedanalgesiamightbemediatedbyincreasedproductionofopioidpeptidebeta
endorphin(anendogenouspainkiller).[85,86]
ExposuretosaunaandiceWIsignificantlyelevatedepinephrinelevelsinwinterswimmer.[87]Steambathproducedincrease
inbloodserumconcentrationsofgastricandaldosterone,withdecreaseinconcentrationsofcortisolinathletefighters.[88]
WholebodyhyperthermicbathincreasedSTHactivityin8outof10volunteers.[83]
Eye,skin,andhair

Warmmoistairdeviceseemstobesafeandproducedimprovementintearstabilityandsymptomaticreliefinocularfatiguein
patientswithmeibomianglanddysfunction.[89]Sauna(80C)producedstableepidermalbarrierfunctionincreaseinstratum
corneumhydrationfasterrecoveryofbothelevatedwaterlossandskinpHdecreaseincasualskinsebumcontentonskin
surfaceofforeheadincreaseinionicconcentrationinsweatandepidermalbloodperfusioninvolunteers.Itsuggestsprotective
effectofSTonskinphysiology.[90]Clinicalremissionofatopicdermatitishasbeenreportedafterintakeoflowsaltwater.[57]
Applicationofheatedmustardcompressproducedseconddegree,partialthicknessburnfollowedbyhyperpigmentationand
hypertrophicscarring.[91]Persistentuseofcoldpillowcompresscouldreducehairfolliclesinhibitionordamagecausedby
chemotherapeuticagents.Soalopeciacanbedecreasedorprevented.[92]
Temperatureregulation

VeryHCappliedtolumbarregionofhealthyfemalefor10minincreasedbackTskto41.143.1CunderHC,followedby
decreasedrapidlybutnochangesobservedinBT.[56]Acaseof20%of2nddegreeburnsandsevereheatstrokefollowedby
temperatureroseupto40.5Candpatientdevelopedseveremultiorganfailureandcriticalpolyneuropathywasreportedafter
exposuretoextremeheatinsaunaforunknownperiodoftime.[93]Themosteffectivemethodofreducingbodycore
temperatureappearstobeimmersioninicedwater,mainpredictorofoutcomeinexertionalheatstrokeisthedurationand
degreeofhyperthermiawherepossiblepatientsshouldbecooledusingicedWI,butifitisnotpossible,combinationofother
techniquesmaybeusedtofacilitaterapidcooling[94]suchasfantherapy,CWI,icedbaths,andevaporativecooling.[95]
Wetice,dryice,andcryogenpacksappliedtoskinoverlyingrighttricepssuraemusclefor15minon10femalesdecreased
meanTsk12C,9.9C,and7.3C,respectively.NoneofthemodalitiesproducedTskcoolingbelow17Candnocoolingwas

demonstrated1cmproximalordistaltoanymodalitiesafter15minofapplication.SignificantmeanTskreductioninbetween
pretreatmentrestinterval(time0)and15minafterremovalofmodality(time30)wasobservedonlyinwetice.Itsuggestswet
icewassignificantlymoreefficientinreducingTskthandryiceandcryogenpacks.[96]
Afterexerciseat65%maximaloxygenconsumptionatambienttemperatureof39CuntilTreincreasedto40Cproducedno
differenceincoolingratebetweenWIat8C,14C,and20Cbutcoolingratewassignificantlygreaterduring2C,whichwas
almosttwiceasmuchasotherconditions.Itsuggeststhat2CWIisthemosteffectivetreatmentforexerciseinduced
hyperthermia.[97]Whenhyperthermicindividualsareimmersedin2Cwaterforapproximately9mintoTrecoolinglimitof
38.6Cnegatedanyriskassociatedwithovercooling.[98]
WholebodyimmersioninmoderatelycoldwateriseffectivecoolingmaneuverforloweringBTandbodyheatcontentof
approximately545kJattheendofimmersioninabsenceofseverephysiologicalresponsesgenerallyassociatedwithsudden
coldstress.[99]SignificantlessBTvariabilityandanoverallhigherBTwereobservedinlatepreterminfantsfollowingtub
bathingprocedure.[100]
Conclusion
Basedonavailableliterature,thisreviewsuggeststhathydrotherapywaswidelyusedtoimproveimmunityandforthe
managementofpain,CHF,MI,chronicobstructivepulmonarydiseases,asthma,PD,AS,RA,OAK,FMS,anorectal
disorders,fatigue,anxiety,obesity,hypercholesterolemia,hyperthermia,labor,etc.Itproducesdifferenteffectsonvarious
systemsofthebodydependingonthetemperatureofwaterandthoughtheseeffectsarescientificallyevidencebased,thereis
lackofevidencesforthemechanismonhowhydrotherapyimprovesthesediseases,whichisoneofthelimitationsof
hydrotherapy,andfurtherstudiesarerequiredtofindthemechanismofhydrotherapyonvariousdiseases.
Footnotes
SourceofSupport:Nil
ConflictofInterest:Nonedeclared.

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