Scientific Evidence-B.sed Effects of Hydrother.

py on
V.rious Systems of the Body
A Mooventh*n *nd L Nivethith*1
Author inform*tion ▶ Copyright *nd License inform*tion ▶ Discl*imer

This *rticle h*s been cited by other *rticles in PMC.

Abstr.ct
The use of w*ter for v*rious tre*tments (hydrother*py) is prob*bly *s old *s
m*nkind. Hydrother*py is one of the b*sic methods of tre*tment widely used in
the system of n*tur*l medicine, which is *lso c*lled *s w*ter ther*py, *qu*tic
ther*py, pool ther*py, *nd b*lneother*py. Use of w*ter in v*rious forms *nd in
v*rious temper*tures c*n produce different effects on different system of the
body. M*ny studies/reviews reported the effects of hydrother*py only on very few
systems *nd there is l*ck of studies/reviews in reporting the evidence-b*sed
effects of hydrother*py on v*rious systems. We performed PubMed *nd PubMed
centr*l se*rch to review relev*nt *rticles in English liter*ture b*sed on “effects of
hydrother*py/b*lneother*py” on v*rious systems of the body. B*sed on the
*v*il*ble liter*ture this review suggests th*t the hydrother*py h*s * scientific
evidence-b*sed effect on v*rious systems of the body.
Keywords: Evidence-b*sed effects, Hydrother*py, V*rious systems

Introduction
Hydrother*py is the extern*l or intern*l use of w*ter in *ny of its forms (w*ter,
ice, ste*m) for he*lth promotion or tre*tment of v*rious dise*ses with v*rious
temper*tures, pressure, dur*tion, *nd site. It is one of the n*turop*thic tre*tment
mod*lity used widely in *ncient cultures including Indi*, Egypt, Chin*, etc.[1]
Though m*ny countries used w*ter to produce different physiologic*l/ther*peutic
effects on different p*rt of the system for m*int*ining he*lth, preventing, *nd
tre*ting the dise*ses, the scientific evidence-b*sed effects *re not well
documented. There *re m*ny studies/reviews th*t reported either physiologic*l or
ther*peutic or combin*tion of both the effects of hydrother*py on p*rticul*r
system but did not report in *ll the m*jor systems of the body, which m*de us to
do this review with the *im *nd objective to report scientific evidenced-b*sed
effects of hydrother*py on v*rious systems of the body. In order to provide *
gener*l overview, we performed PubMed *nd PubMed centr*l se*rch to review
relev*nt *rticles in English liter*ture b*sed on “effects of hydrother*py/
b*lneother*py” on v*rious systems of the body. Articles published from 1986 to
2012 were included in this review.
Hydrother.phy in gener.l
Superfici*l cold *pplic*tion m*y c*use physiologic re*ctions such *s decre*se in
loc*l met*bolic function, loc*l edem*, nerve conduction velocity (NCV), muscle
sp*sm, *nd incre*se in loc*l *nesthetic effects.[2]
One hour he*d-out w*ter immersions (WI) in v*rious temper*tures (32°C, 20°C,
*nd 14°C) produced v*rious effects. Immersion *t 32°C did not ch*nge met*bolic
r*te (MR) *nd rect*l temper*ture (Tre), but it lowered the he*rt r*te (HR) by 15%,
systolic blood pressure (SBP) *nd di*stolic blood pressure (DBP) by 11% *nd 12%,
respectively, comp*red, with controls *t *mbient *ir temper*ture. Along with HR
*nd blood pressure (BP), the pl*sm* renin *ctivity, pl*sm* cortisol, *nd
*ldosterone concentr*tions were *lso lowered by 46%, 34%, *nd 17%,
respectively, while diuresis w*s incre*sed by 107%.[3]
Immersion *t 20°C produced simil*r decre*se in pl*sm* renin *ctivity, HR, SBP,
*nd DBP, in spite of lowered Tre *nd incre*sed MR by 93%. Pl*sm* cortisol
concentr*tions tended to decre*se, while pl*sm* *ldosterone concentr*tion w*s
unch*nged. Diuresis w*s incre*sed by 89%. No signific*nt differences in ch*nges
in pl*sm* renin *ctivity, *ldosterone concentr*tion, *nd diuresis comp*red with
subjects immersed in 32°C.[3]
Immersion *t 14°C lowered Tre *nd incre*sed MR by 350%, HR, SBP, *nd DBP by
5%, 7%, *nd 8%, respectively. Pl*sm* nor*dren*line *nd dop*mine
concentr*tions were incre*sed by 530% *nd by 250%, respectively, while diuresis
incre*sed by 163%, which w*s more th*n *t 32°C. Pl*sm* *ldosterone
concentr*tions incre*sed by 23%. Pl*sm* renin *ctivity w*s reduced. Cortisol
concentr*tions tended to decre*se. Pl*sm* *dren*line concentr*tions rem*ined
unch*nged. Ch*nges in pl*sm* renin *ctivity were not rel*ted to ch*nges in
*ldosterone concentr*tions.[3]
WI in different temper*tures did not incre*se blood concentr*tions of cortisol.
There w*s no correl*tion between ch*nges in Tre *nd ch*nges in hormone
production. The physiologic*l ch*nges induced by WI *re medi*ted by humor*l
control mech*nisms, while responses induced by cold *re m*inly due to incre*sed
*ctivity of the symp*thetic nervous system (SNS).[3]
Regul*r winter swimming signific*ntly decre*sed tension, f*tigue, memory, *nd
mood neg*tive st*te points with the dur*tion of swimming period; signific*ntly
incre*sed vigor-*ctivity scores; relieved p*in who suffered from rheum*tism,
fibromy*lgi*, or *sthm*; *nd improved gener*l well-being in swimmers.[4]

C.rdiov.scul.r system
Cold exposure (CE) to sm*ll surf*ce *re* produced compens*tory v*sodil*t*tion
in deeper v*scul*r system resulting incre*sed blood flow to the tissues underlying
the site of exposure. This v*scul*r re*ction occurs m*inly to m*int*in const*nt
deep tissue temper*ture.[2]
In p*tient with chronic he*rt f*ilure (CHF), therm*l v*sodil*t*tion following w*rm-
w*ter b*thing *nd low-temper*ture s*un* b*thing (LTSB) *t 60°C for 15 min
improves c*rdi*c function;[5] repe*ted s*un*-ther*py (ST) incre*sed left
ventricul*r ejection fr*ction; incre*sed 6-min w*lk dist*nce in *ssoci*tion with
improvement in flow-medi*ted dil*tion *nd incre*se in number of circul*ting
CD34 (+) cells; reduced pl*sm* levels of norepinephrine *nd br*in n*triuretic
peptide. These indic*tes th*t ST improves exercise toler*nce in *ssoci*tion with
improvement in endotheli*l function.[6] LTSB improves peripher*l circul*tion in
cerebr*l p*lsy (CP).[5]
After ST reduced level of tot*l *nd low density lipoprotein (LDL)-cholesterol
concentr*tion, while incre*sed level of high density lipoprotein (HDL)-cholesterol
w*s observed. These ch*nges *re good prognoses for the prevention of ischemic
he*rt dise*se.[7] ST incre*ses endotheli*l nitric oxide synth*se (eNOS) *ctivity
*nd improves c*rdi*c function in he*rt f*ilure *nd improve peripher*l blood flow
in ischemic limbs. In myoc*rdi*l inf*rction (MI)-induced Wist*r r*ts ST incre*ses
myoc*rdi*l eNOS, v*scul*r endotheli*l growth f*ctor mRNA levels. It *ttenu*tes
c*rdi*c remodeling *fter MI through improving coron*ry v*scul*rity in the
noninf*rcted myoc*rdium *nd thus ST might serve *s * novel noninv*sive ther*py
for p*tients with MI.[8] Acute MI w*s thought to result from thrombosis or pl*que
rupture bec*use of coron*ry *rtery sp*sm. The v*sosp*sm might be induced by
stimul*tion of the *lph*-*drenergic receptors during *ltern*ting he*t exposure
during s*un* b*th followed by r*pid cooling during cold w*ter b*th. This effect
showed the d*ngers of r*pid cooling *fter s*un* b*thing in p*tients with coron*ry
risk f*ctors.[9] Regul*r ST (either r*di*nt he*t or f*r-infr*red units) *ppe*rs to be
s*fe *nd produce multiple he*lth benefits but use of ST in e*rly pregn*ncy is *
potenti*l concern bec*use evidence suggesting th*t hyperthermi* might be
ter*togenic.[10]
Cold w*ter immersion (CWI) induces signific*nt physiologic*l *nd biochemic*l
ch*nges in the body such *s incre*se in HR, BP, met*bolism, *nd peripher*l
c*techol*mine concentr*tion; *nd decre*se in cerebr*l blood flow.[11]
Reduction in HR, *nd incre*ses in systolic *nd di*stolic biventricul*r functions,
were observed during *cute w*rm-WI.[12] In contr*st, incre*se in HR *nd *
decre*se in SBP *nd DBP were observed in 30 min of he*d-out WI (38.41 ±
0.04°C).[13]
Hyperthermic immersion (HI) produced shortening of *ctiv*ted p*rti*l
thrombopl*stin time. During HI pl*sminogen *ctiv*tor inhibitor (PAI) *ctivity w*s
decre*sed; thrombocyte count w*s incre*sed; incre*ses in tissue-type
pl*sminogen *ctiv*tor concentr*tion *nd leukocytes count were *ttributed to
hemoconcentr*tion. Immedi*tely *fter HI, fibrinogen concentr*tion decre*sed but
incre*sed during recovery. During thermo-neutr*l immersion prothrombin time,
PAI *ctivity *nd gr*nulocyte count ecre*sed. W*rm w*ter b*thing le*ds to
hemoconcentr*tion *nd minim*l *ctiv*tion of co*gul*tion; decre*se in PAI-1
*ctivity. During w*rm w*ter b*thing, m*rked risk for thrombotic or bleeding
complic*tions in he*lthy m*les could not be *scert*ined.[14] During contr*st
b*ths, longer dur*tion in the second he*ting ph*se w*s required to produce
sufficient fluctu*tion in blood flow.[15]
WI up-to shoulder levels *t different temper*tures (25°C, 34°C, *nd 40°C)
showed no signific*nt effect on c*rdi*c output in 25°C comp*red with 34°C, but
in 40°C * consider*ble incre*se in c*rdi*c output w*s observed.[16]
C*rbon dioxide (CO2) enriched WI reduced free r*dic*l pl*sm* levels, r*ised
*ntioxid*nts levels, *nd induce peripher*l v*sodil*t*tion suggests improvement in
microcircul*tion.[17,18] Decre*se in tymp*nic temper*ture; incre*se in cut*neous
blood flow *t immersed site w*s signific*ntly gre*ter in CO2-WI comp*red with
fresh WI.[18] The three m*in effects of CO2 enriched WI *re decline in core
temper*ture, incre*se in cut*neous blood flow, *nd elev*tion of score on therm*l
sens*tion, which were *n*lyzed.[19]

Respir.tory system
WI up-to shoulder levels *t different temper*tures (25°C, 34°C, *nd 40°C)
showed incre*sed MR, oxygen (O2) consumption (VO2) only *t 25°C. Two m*in
f*ctors *ffecting O2 tr*nsport during immersion *re temper*ture *nd hydrost*tic
pressure. O2 tr*nsport w*s improved *bove neutr*l temper*ture, bec*use of
incre*se in c*rdi*c output resulting from the combined *ctions of hydrost*tic
counter pressure *nd body he*ting. Below neutr*l temper*ture, O2 tr*nsport is
*ltered. At *ny of the temper*tures tested, the pulmon*ry tissue volume *nd
*rteri*l blood g*ses were not signific*ntly *ffected.[16]
Signific*nt decre*se in vit*l c*p*city (VC) with b*th temper*ture w*s observed
(i.e., VC *t 40°C >34°C >25°C). Signific*nt incre*se in tid*l volume (VT) in cold or
hot w*ter comp*red with thermo neutr*l w*ter (i.e., VT 40°C >34°C< 25°C).
Alter*tions in respir*tory muscles functioning might produce v*ri*tions of the
pulmon*ry volumes *s * function of w*ter temper*ture.[20]
CWI w*s *ssoci*ted with incre*se in respir*tory minute volume *nd decre*se in
end tid*l CO2 p*rti*l pressure.[11] Repe*ted cold w*ter stimul*tions reduced
frequency of infections; incre*sed pe*k expir*tory flow, lymphocyte counts, *nd
expression of g*mm*-interferon; modul*ted interleukin expression; *nd improved
qu*lity of life (QOL) in p*tients with chronic obstructive pulmon*ry dise*se.[21]
In children suffering from recurrent *nd *sthm*tic bronchitis in remission, * single
tot*l *ir b*th, or douche *nd loc*l (cooling of the feet with w*ter) exposure to
mild cold did not r*ise notice*ble disorders of the respir*tory function. Loc*l cold
procedures improve bronchi*l p*tency but he*t exposure resulted in its
worsening.[22]
Inh*ling hot *ir while in * s*un* produced no signific*nt imp*ct on over*ll
symptom severity of common cold.[23] A m*le tr*ck *nd field *thlete, * c*se of
bre*thing difficulties *t rest *nd during exercise, w*s ex*cerb*ted in the supine
position *nd during WI.[24]

Nervous system
Three cold mod*lities such *s ice m*ss*ge, ice p*ck, *nd CWI *pplied to right
c*lf region for 15min reduced skin temper*ture (Tsk) (me*n 18.2°C); reduced
*mplitude *nd incre*sed l*tency *nd dur*tion of compound *ction potenti*l. It
*lso reduced sensory NCV by 20.4, 16.7, *nd 22.6 m/s *nd motor NCV by 2.5, 2.1,
*nd 8.3 m/s, respectively. Even though *ll three mod*lities effectively reduced Tsk
*nd sensory conduction *t * physiologic*l level, CWI is the most indic*ted,
effective mod*lity for inducing ther*peutic effects *ssoci*ted with the reduction
of motor nerve conduction.[25]
Temper*ture *nd pressure of w*ter in *qu*tic or hydrother*py c*n block
nociceptors by *cting on therm*l receptors *nd mech*noreceptors *nd exert
positive effect on spin*l segment*l mech*nisms, which is useful for p*inful
condition.[26] Forty sessions of Ai Chi *qu*tic exercise (AE) progr*m improves
p*in, sp*sms, dis*bility, f*tigue, depression, *nd *utonomy in p*tient with
multiple sclerosis.[27]
In * study on physiother*py on l*nd or w*ter in p*tient with P*rkinson's dise*se
(PD), function*l re*ch test w*s improved in both ther*pies, but Berg B*l*nce
Sc*le (BBS) *nd Unified P*rkinson's Dise*se R*ting Sc*le (UPDRS) were
improved only in *qu*tic ther*py group. It indic*tes improvement in postur*l
st*bility in PD w*s signific*ntly l*rger *fter *qu*tic ther*py.[28]
S*un* b*th on p*r*plegic (P) group *nd tetr*plegic (T) group, HR incre*sed
signific*ntly during s*un* but decre*sed signific*ntly during posts*un* ph*se in
P group. DBP signific*ntly reduced in T group during posts*un* ph*se but no
signific*nt ch*nges in SBP in both the groups.[29]
In * study on CP, LTSB produced incre*se in HR *nd c*rdi*c output; decre*se in
BP *nd tot*l peripher*l resist*nce; signific*nt improvement in skin blood flow,
blood flow velocity, puls*tile index, *nd resistive index; decre*se in numbness *nd
chronic my*lgi* of the extremities with no *dverse effects.[5]
Ten minutes of immersions in whirlpools produced incre*ses in pulse *nd finger
temper*ture with incre*sed feelings of well-being *nd decre*sed st*te *nxiety.
[30] CO2-WI *ctiv*tes p*r*symp*thetic nerve *ctivity in hum*ns.[18]
Ad*pted cold shower might h*ve *ntipsychotic effect simil*r to th*t of
electroconvulsive ther*py bec*use it could work *s mild electroshock *pplied to
sensory cortex. Addition*lly, cold shower is ex*mple of stress-induced *n*lgesi*
*nd would *lso be expected to “crowd out” or suppress psychosis-rel*ted
neurotr*nsmission within mesolimbic system.[31]
CE c*n *ctiv*te components of reticul*r *ctiv*ting system such *s locus ceruleus
*nd r*phe nuclei, which c*n result in *ctiv*tion of beh*vior *nd incre*sed
c*p*city of centr*l nervous system (CNS) to recruit motoneurons.[32] CE
*ctiv*tes SNS; incre*se blood level of bet*-endorphin *nd nor*dren*line; *nd
incre*se syn*ptic rele*se of nor*dren*line in br*in. Antidepressive effect of cold
shower *ttributed to presence of high density of cold receptors in skin expected
to send *n overwhelming *mount of electric*l impulses from peripher*l nerve
endings to the br*in. It h*s signific*nt *n*lgesic effect *nd it does not c*use
dependence or notice*ble side effects.[33] Most n*rcotics *dministered rect*lly
c*n c*use intoxic*tion. There is * signific*nt co-morbidity of schizophreni* with
intestin*l illnesses *nd thus colon cle*nsing c*n signific*ntly improve ment*l
st*te.[31]

Musculo skelet.l system

W*lking in w*ter *t umbilic*l level incre*ses the *ctivity of erector spin*e *nd
*ctiv*tes rectus femoris to levels ne*r to or higher th*n w*lking on dry ground.
[34] CWI <15°C is one of the most popul*r intervention used *fter exercise,[11,35]
which signific*ntly lowered r*tings of f*tigue *nd potenti*lly improved r*tings of
physic*l recovery immedi*tely *fter immersion with reduction in del*yed onset
muscle soreness *t 24, 48, 72, *nd 96 h follow-ups *fter exercise comp*red with
p*ssive interventions involving rest or no intervention.[35]
R*te of decre*se in pl*sm* l*ct*te concentr*tion over 30 min recovery period
*fter intense *n*erobic exercise w*s signific*ntly higher in contr*st-WI [hot
(36°C) *nd cold (12°C)] comp*red with p*ssive recovery on bed for both genders.
[36]
Leg immersion in w*rm w*ter (44 ± 1°C) for 45 min before stretch-shortening
exercise reduced most of the indirect m*rkers of exercise-induced muscle
d*m*ge, including muscle soreness, cre*tine kin*se *ctivity in the blood, m*xim*l
volunt*ry contr*ction force, *nd jump height. Decre*sing muscle d*m*ge did not
improve volunt*ry perform*nce, therefore clinic*l *pplic*tion of muscle
prew*rming m*y be limited.[37]
Contr*st w*ter ther*py (CWT) [*ltern*ting 1-min hot (38°C) *nd 1-min cold
(15°C)] for 6/12/18 min lowered subjective me*sures of therm*l sens*tion *nd
muscle soreness comp*red with control (se*ted rest) but no consistent
differences were observed in whole body f*tigue. It indic*tes CWT for 6 min
*ssisted *cute recovery from high-intensity running *nd CWT dur*tion did not
h*ve dose-response effect on running perform*nce recovery.[38] Contr*st b*ths
h*ve been suggested for reducing p*in; h*nd volume; *nd stiffness in *ffected
extremities but it h*d no signific*nt effect on pre- *nd/or postoper*tive h*nd
volume in c*rp*l tunnel syndrome.[39]
Cold w*ter or cold/thermoneutr*l w*ter did not induce modific*tions of
infl*mm*tory *nd hem*tologic*l m*rkers. The perform*nces of *thletes were not
neg*tively influenced by CWI or CWT. Reduced perception of f*tigue *fter tr*ining
session w*s the princip*l effect of CWI[45] bec*use CE incre*ses opioid tone *nd
high MR, which could diminish f*tigue by reducing muscle p*in *nd *cceler*ting
recovery of f*tigued muscle, respectively,[32] which c*n improve tr*ining *nd
competitions in young soccer pl*yers.[40]
A system*tic review on m*n*gement of fibromy*lgi* syndrome (FMS) through
hydrother*py described *s “there is strong evidence for the use of hydrother*py
in the m*n*gement of FMS” *nd it showed positive outcomes for p*in; tender
point count; *nd he*lth-st*tus.[41] Combin*tion of ST (once d*ily for 3 d*ys/
week) *nd underw*ter exercise (once d*ily for 2 d*ys/week) for 12 weeks
signific*ntly reduced p*in *nd symptoms (both short- *nd long-term); *nd
improved QOL in p*tients with FMS.[42] Pool-b*sed exercise using deep w*ter
running three times/week for 8 weeks is s*fe *nd effective intervention for FMS
bec*use it showed signific*nt improvement in gener*l he*lth *nd QOL comp*red
with control; *nd signific*nt improvement in fibromy*lgi* imp*ct questionn*ire
score, incorpor*ting p*in; f*tigue; physic*l function; stiffness; *nd psychologic*l
v*ri*bles.[43]
Hydrother*py m*y h*ve some short-term benefit to p*ssive r*nge of movement in
reh*bilit*tion *fter rot*tor cuff rep*ir.[44] Sp* w*ter (37°C) *nd t*p w*ter he*ted
to 37°C for the dur*tion of 20 min/d*y for 5 d*ys/week for the period of 2 weeks
with home-b*sed exercise progr*m improved the clinic*l symptoms *nd QOL in
p*tient with osteo*rthritis of knee (OAK). However, p*in *nd tenderness
st*tistic*lly improved in sp* w*ter.[45] It m*y be due to th*t sp* w*ters *re not
only n*tur*lly w*rm, but their miner*l content is *lso signific*nt. Sp* w*ter h*s
mech*nic*l, therm*l, *nd chemic*l effects.
In *nkylosing spondilitis (AS) p*tients, b*lneother*py st*tistic*lly improved p*in;
physic*l *ctivity; tiredness *nd sleep score; B*th Ankylosing Spondilitis Dise*se
Activity Index (BASDAI); Nottingh*m He*lth Profile (NHP); p*tient's glob*l
ev*lu*tion *nd physici*n's glob*l ev*lu*tion *t 3 weeks, but only on modified
Shober test *nd p*tient's glob*l ev*lu*tion p*r*meters *t 24 weeks. It indic*tes
the effect of b*lneother*py in improving dise*se *ctivity *nd function*l
p*r*meters in AS p*tients.[46] Infr*red s*un*, * form of tot*l-body hyperthermi*
w*s well toler*ted; no *dverse effects; *nd no ex*cerb*tion of dise*se were
reported in p*tients with rheum*toid *rthritis (RA) *nd AS in whom p*in, stiffness,
*nd f*tigue showed clinic*l improvements during the 4 weeks tre*tment period
but these did not re*ch st*tistic*l signific*nce.[47]
Aqu*-jogging without c*loric restrictions in obese persons for 6 weeks w*s
*ssoci*ted with reductions in w*ist circumference *nd body f*t; improvement of
*erobic fitness *nd QOL.[48]
AE m*y be *n excellent *ltern*tive to l*nd exercise for individu*ls who l*ck
confidence, h*ve high risk of f*lling, or h*ve joint p*in.[49] W*ter buoy*ncy
reduces the weight th*t joints, bones, *nd muscles h*ve to be*r.[50] W*rmth *nd
pressure of w*ter *lso reduce swelling *nd reduces lo*d on p*inful joints, remotes
muscle rel*x*tion.[51] AE h*s signific*nt effects on p*in relief *nd rel*ted
outcome me*surements for locomotor dise*ses. P*tients m*y become more
*ctive *nd improve their QOL *s * result of AE.[52] W*ter-b*sed *nd l*nd-b*sed
exercises reduced p*in *nd improved function in p*tients with OAK *nd th*t
w*ter-b*sed exercise w*s superior to l*nd-b*sed exercise for relieving p*in
before *nd *fter w*lking.[53] Hydrother*py is highly v*lued by RA p*tients who
were tre*ted with hydrother*py (30-min session/week) reported feeling much
better/very much better th*n those tre*ted with l*nd exercises (simil*r exercises
on l*nd) immedi*tely on completion of the tre*tment progr*m (6 weeks). But this
benefit w*s not reflected on 10 m w*lk times, function*l scores, QOL me*sures,
*nd p*in scores by differences between groups.[51] Hot compress (HC) with
surrounding electro-*cupuncture needling w*s signific*ntly effective on re*r thigh
muscles str*in *nd it w*s superior to convention*l needling method *nd cupping
in improving symptoms *nd physic*l signs *s well *s recovery of w*lking function
of *thletes.[54]

G.strointestin.l system
Drinking w*ter signific*ntly elev*tes the resting energy expenditure (REE) in
*dults but in overweight children tr*nsient decre*se in REE w*s observed
immedi*tely *fter drinking 10 ml/kg cold w*ter (4°C). Then * subsequent rise in
REE w*s observed, which w*s signific*nt *fter 24 min *nd the m*xim*l me*n REE
v*lues were seen *fter 57 min, which w*s 25% higher th*n b*seline. The
recommended d*ily *mount of w*ter consumption in children could result in
energy expenditure equiv*lent to *ddition*l weight loss of *bout 1.2 kg/ye*r
suggesting th*t w*ter drinking could *ssist overweight children in weight loss or
m*inten*nce.[55] Exposure to cold incre*ses MR, for ex*mple, he*d-out
immersion in cold w*ter of 20°C *lmost doubles MR, while *t 14°C it is more th*n
qu*drupled.[3]
When very-HC *pplied to lumb*r region of he*lthy fem*le for 10-min blood flow to
the b*ck incre*sed to 156% with incre*sed blood flow to upper *rm. Immedi*tely
*fter HC, bowel sounds incre*sed 1.7 times comp*red with before *pplic*tion,
which suggest th*t * very HC c*n be useful to promote fl*tus or defec*tion.[56]
Low miner*l w*ter int*ke norm*lizes the intestin*l perme*bility of p*tients with
*topic derm*titis.[57]
W*rm w*ter is effective for colonic sp*sm in which signific*ntly less discomfort
w*s reported comp*red with control group *nd this m*y be useful *s *n
*ltern*tive for gluc*gon (expensive) *nd hyoscy*mine (h*s side effects) bec*use
it h*s no side effects *nd costs pr*ctic*lly nothing.[58]
In p*tients with *cute *n*l p*in due to hemorrhoids or *n*l fissures, neither cold
w*ter (<15°C) nor hot w*ter (>30°C) sitz b*th (SB) did control p*in st*tistic*lly.
[59] Simil*rly, *fter sphincterotomy for *n*l fissure, SB produced no signific*nt
difference in p*in but signific*nt relief in *n*l burning *nd better s*tisf*ction
score with no *dverse effects were observed comp*red with control group.[60]
He*ling *nd p*in relief w*s not signific*nt in SB but it improved p*tient
s*tisf*ction in *cute *n*l fissures.[61]
Though there w*s no strong evidence to support the use of SB for p*in relief *nd
to *cceler*te fissure or wound he*ling *mong *dult p*tients with *norect*l
disorders (ARDs), p*tients were s*tisfied with using SB *nd no severe
complic*tions were reported.[62] In contr*st, w*rm-w*ter SB (40°C, 45°C, *nd
50°C for 10 min e*ch time) in ARD, p*in relief w*s more evident *nd l*sted longer
*t higher b*th temper*tures. P*in relief *fter SB might *ttribute to intern*l *n*l-
sphincter rel*x*tion, which might be due to thermosphincteric reflex, resulting in
diminution of the rect*l neck pressure. The higher the b*th temper*ture, the
gre*ter the drop in rect*l neck pressure *nd intern*l sphincter electromyogr*phic
*ctivity, *nd longer the time needed to return to pretest levels.[63]
In posthemorrhoidectomy c*re, w*ter spr*y method could provide * s*fe *nd
reli*ble *ltern*tive to SB *s * more convenient *nd s*tisf*ctory form of
tre*tment.[64]
Sp* tre*tment with miner*l w*ter Nizhneivkinsk*y* (sulf*te c*lcium) induced
clinic*l remission of the dise*se, norm*liz*tion of the echoscopic picture of
stom*ch *nd g*llbl*dder, their motor function, tesiocryst*lloscopic
ch*r*cteristics of s*liv* suggest its effectiveness in reh*bilit*tion of p*tients with
g*stric *nd g*llbl*dder motor-ev*cu*tory dysfunction.[65] Int*ke of sulf*te-
chloride-sodium miner*l w*ter *ctiv*tes regul*tion of c*rbohydr*te met*bolism
by insulin *nd cortisol due to the form*tion of *d*ptive re*ctions. It promoted
trophic effects of insulin *nd g*strin in *nim*ls with signific*nt reduction in peptic
ulcer size *nd enh*nced resist*nce to stressful f*ctors.[66]
Immersion in De*d Se* w*ter produced signific*nt reduction in blood glucose in
type-2 di*betes mellitus (DM) *nd no signific*nt differences in insulin, cortisol,
*nd c-peptide levels were observed between DM p*tients *nd he*lthy volunteers
following immersion.[67]

Genito urin.ry system

Me*n l*bor p*in scores were signific*ntly higher in control group th*n immersion
b*th (IB) group suggest th*t use of IB *s *n *ltern*tive form of p*in relief during
l*bor.[68] WI in primip*r* *t *ny st*ge of l*bor, from 2 cm extern*l opening of the
uterine cervix, signific*ntly decre*sed p*rturition dur*tion comp*red with
tr*dition*l delivery. It r*ised both the *mplitude *nd frequency of uterine
contr*ctions proportion*l to uterine cervix g*ping with no disturb*nces in
contr*ction *ctivity of the uterus. A 3-cm g*ping of uterine cervix is the optim*l
timing for WI in the primip*r* bec*use e*rlier WI *t 2-cm uterine cervix g*ping
*lso *cceler*ted the l*bor but required repetitions of WI or use of oxytocin for
correcting we*kened uterine contr*ction.[69]
In contr*st, IB did not influence the length of l*bor *nd uterine contr*ctions
frequency. However, contr*ctions length w*s st*tistic*lly shorter in IB *nd it c*n
be *n *ltern*tive for wom*n's comfort during l*bor, since it provides relief to her
without interfering on l*bor progression or jeop*rdizing the b*by.[70]
WI during first st*ge of l*bor reduces the use of epidur*l/spin*l/p*r*cervic*l
*n*lgesi*/*nesthesi* comp*red with controls *nd there is no evidence of
incre*sed *dverse effects to fetus/neon*te or wom*n from l*boring in w*ter or
w*ter birth.[71] Neon*t*l swimming c*n *cceler*te b*bies growth in e*rly st*ge.
[72] In * microbiologic*l study, comp*ring neon*t*l b*cteri*l coloniz*tion *fter
w*ter birth to convention*l bed deliveries with or without rel*x*tion b*th showed
no signific*nt difference between three groups in neon*t*l outcome, inf*nt's *nd
m*tern*l infection r*te.[73]
Cold-SB but not w*rm-SB, signific*ntly reduced edem* during postepisiotomy
period[74] *nd perine*l p*in, which w*s gre*test immedi*tely *fter the b*th.[75]
B*ker*, * ste*m b*th prep*red with v*rious pl*nts (commonly the essenti*l oil
pl*nts) is tr*dition*lly used in Min*h*s* (Indonesi*) m*inly for recuper*tion *fter
childbirth. It is b*sed onthermother*py with *rom*ther*py which *ttribute for its
ther*peutic effects. Thermother*py soothes symptoms such *s he*viness in
limbs, edem*, muscul*r str*in, loss of *ppetite, *nd constip*tion. Essenti*l oils of
the pl*nts used h*ve *ntiseptic, *ntiphlogistic, *nd immunostimul*nt effect.
Hence it c*n be *n effective *nd s*fe method for recuper*tion *fter child birth.
[76] In postn*t*l mothers, *ltern*te (hot *nd cold) compress *nd cold c*bb*ge
le*ves were equ*lly effective in reducing bre*st engorgement, but in relieving
bre*st engorgement p*in, *ltern*te compresses were more effective th*n cold
c*bb*ge le*ves.[77]
W*rm-SB (40-45°C) for 10 min, for *t le*st 5 d*ys immedi*tely *fter the remov*l
of Foley urethr*l c*theter in p*tient undergone tr*nsurethr*l resection of
prost*te, signific*ntly reduced urethr*l stricture comp*red with no SB group who
h*d 1.13-fold incre*sed risk of re-hospit*liz*tion within 1 month *fter surgery due
to postoper*tive complic*tions comp*red with w*rm-SB group.[78] Thirty he*lthy
volunteers *nd 21 p*tients with urin*ry retention *fter hemorrhoidectomy
underwent SB *t 40°C, 45°C, *nd 50°C where the number of spont*neous
micturitions incre*sed with higher-temper*ture b*ths *nd it seems to be initi*ted
by reflex (thermo-sphincter reflex) intern*l urethr*l sphincter rel*x*tion. The
urethr*l pressure both in norm*l *nd retention subjects showed signific*nt
reduction, which incre*sed with higher temper*ture; *nd vesic*l pressure or EMG
*ctivity of the extern*l urethr*l sphincter did not show signific*nt differences.[79]

Hem.tology/immunology
Subsequent CE induced incre*se of leukocytes, gr*nulocytes, circul*ting levels of
interleukin (IL)-6, *nd n*tur*l killer (NK) cells *nd its *ctivity. Leukocytes,
gr*nulocyte, *nd monocyte responses were *ugmented by pretre*tment with
exercise in w*ter (18°C) *nd thus *cute-CE h*s immune-stimul*ting effects.[80]
D*ily brief cold stress c*n incre*se both numbers *nd *ctivity of peripher*l
cytotoxic T-lymphocytes *nd NK cells, the m*jor effectors of *d*ptive *nd inn*te
tumor immunity, respectively. It (for 8 d*ys) improved surviv*l of intr*cellul*r
p*r*site Toxopl&sm& gondii infected mice, with consistent enh*ncement in cell-
medi*ted immunity. The sust*ined/longer-term effects of cold stress repe*ted
d*ily over the period of 5 d*ys to 6 weeks incre*sed pl*sm* levels of tumor
necrosis f*ctor-α, IL-2, IL-6. A hypothesis describes, d*ily brief cold-w*ter stress
over m*ny months could enh*nce *ntitumor immunity *nd improve nonlymphoid
c*ncer surviv*l r*te. The possible mech*nism of nonspecific stimul*tion of
cellul*r immunity might *ttribute to tr*nsient *ctiv*tion of SNS, hypoth*l*mic-
pituit*ry-*dren*l (HPA) *nd hypoth*l*mic-pituit*ry-thyroid *xes. Though d*ily
moder*te cold hydrother*py does not *ppe*r to h*ve notice*ble *dverse effects
on norm*l subjects, some studies showed th*t it c*n c*use tr*nsient *rrhythmi*s
in p*tients with he*rt problems *nd c*n *lso inhibit humor*l immunity. Sudden
ice-cold WI c*n produce tr*nsient pulmon*ry edem* *nd incre*se blood-br*in
b*rrier perme*bility, thereby incre*sing mort*lity of neurovirulent infections.
Studies *re required to w*rr*nt this hypothesis for immunother*py development
for some (nonlymphoid) c*ncers, including those c*used by vir*l infections.[81]
W*rm w*ter (28°C) tre*tment could not only cure b*cteri*l cold-w*ter dise*se
but *lso immunize *g*inst c*us*tive *gent Fl&vob&cterium psychrophilum.[82]
He*d-out WI (38.41 ± 0.04°C) for 30 min decre*sed blood viscosity; red blood
cells count; *nd me*n hem*tocrit without signific*nt ch*nges in leukocytes *nd
pl*telets count; me*n corpuscul*r volume; pl*sm* viscosity; erythrocyte filtr*tion
time *nd red cell deform*bility index.[13] Applic*tion of hyper-thermic w*ter b*th
produced signific*nt reduction of rel*tive B-lymphocyte. Whole-body
hyperthermic w*ter b*th reduced rel*tive tot*l T-lymphocyte counts; incre*sed
rel*tive CD8+ lymphocyte; NK cell counts *nd its *ctivity, which were prob*bly
dependent on incre*sed som*totropic hormone production.[83]

Endocr.ine/hormon.l system
During CE incre*se levels of circul*ting norepinephrine w*s observed[80] *nd
exercising HPA system by repe*ted CE could potenti*lly restore its norm*l
function in chronic f*tigue syndrome, or *t le*st incre*se net HPA *ctivity
(without ch*nging b*seline *ctivity).[84] It produces tempor*ry incre*se in
pl*sm* levels of *drenocorticotropic hormone (ACTH), bet*-endorphin, *nd
cortisol.[32] The sust*ined/longer-term effects of cold stress repe*ted d*ily
produced incre*se in ACTH, corticosterone, *nd decre*se in α-1-*ntitrypsin *nd
testosterone.[81] Cold stress reduces level of serotonin in most regions of br*in
(except br*instem).[32] Cold stress-induced *n*lgesi* might be medi*ted by
incre*sed production of opioid peptide bet*-endorphin (*n endogenous p*in-
killer).[85,86]
Exposure to s*un* *nd ice-WI signific*ntly elev*ted epinephrine levels in winter
swimmer.[87] Ste*m b*th produced incre*se in blood serum concentr*tions of
g*stric *nd *ldosterone, with decre*se in concentr*tions of cortisol in *thlete-
fighters.[88] Whole-body hyperthermic b*th incre*sed STH *ctivity in 8 out of 10
volunteers.[83]

Eye, skin, .nd h.ir

W*rm moist *ir device seems to be s*fe *nd produced improvement in te*r
st*bility *nd symptom*tic relief in ocul*r f*tigue in p*tients with meibomi*n gl*nd
dysfunction.[89] S*un* (80°C) produced st*ble epiderm*l b*rrier function;
incre*se in str*tum corneum hydr*tion; f*ster recovery of both elev*ted w*ter
loss *nd skin pH; decre*se in c*su*l skin sebum content on skin surf*ce of
forehe*d; incre*se in ionic concentr*tion in swe*t *nd epiderm*l blood perfusion
in volunteers. It suggests protective effect of ST on skin physiology.[90] Clinic*l
remission of *topic derm*titis h*s been reported *fter int*ke of low-s*lt w*ter.
[57] Applic*tion of he*ted must*rd compress produced second-degree, p*rti*l-
thickness burn followed by hyperpigment*tion *nd hypertrophic sc*rring.[91]
Persistent use of cold pillow compress could reduce h*ir follicles inhibition or
d*m*ge c*used by chemother*peutic *gents. So *lopeci* c*n be decre*sed or
prevented.[92]

Temper.ture regul.tion
Very-HC *pplied to lumb*r region of he*lthy fem*le for 10 min incre*sed b*ck Tsk
to 41.1-43.1°C under HC, followed by decre*sed r*pidly but no ch*nges observed
in BT.[56] A c*se of 20% of 2nd degree burns *nd severe he*t stroke followed by
temper*ture rose up to 40.5°C *nd p*tient developed severe multiorg*n f*ilure
*nd critic*l polyneurop*thy w*s reported *fter exposure to extreme he*t in s*un*
for unknown period of time.[93] The most effective method of reducing body core
temper*ture *ppe*rs to be immersion in iced w*ter, m*in predictor of outcome in
exertion*l he*tstroke is the dur*tion *nd degree of hyperthermi* where possible
p*tients should be cooled using iced-WI, but if it is not possible, combin*tion of
other techniques m*y be used to f*cilit*te r*pid cooling[94] such *s f*n-ther*py,
CWI, iced-b*ths, *nd ev*por*tive cooling.[95]
Wet-ice, dry-ice, *nd cryogen p*cks *pplied to skin overlying right triceps sur*e
muscle for 15 min on 10 fem*les decre*sed me*n Tsk 12°C, 9.9°C, *nd 7.3°C,
respectively. None of the mod*lities produced Tsk cooling below 17°C *nd no
cooling w*s demonstr*ted 1 cm proxim*l or dist*l to *ny mod*lities *fter 15 min of
*pplic*tion. Signific*nt me*n Tsk reduction in between pretre*tment rest interv*l
(time 0) *nd 15 min *fter remov*l of mod*lity (time 30) w*s observed only in wet-
ice. It suggests wet-ice w*s signific*ntly more efficient in reducing Tsk th*n dry-
ice *nd cryogen p*cks.[96]
After exercise *t 65% m*xim*l oxygen consumption *t *mbient temper*ture of
39°C until Tre incre*sed to 40°C produced no difference in cooling r*te between
WI *t 8°C, 14°C, *nd 20°C but cooling r*te w*s signific*ntly gre*ter during 2°C,
which w*s *lmost twice *s much *s other conditions. It suggests th*t 2°C WI is
the most effective tre*tment for exercise-induced hyperthermi*.[97] When
hyperthermic individu*ls *re immersed in 2°C w*ter for *pproxim*tely 9 min to
Tre cooling limit of 38.6°C neg*ted *ny risk *ssoci*ted with overcooling.[98]
Whole body immersion in moder*tely cold w*ter is effective cooling m*neuver for
lowering BT *nd body he*t content of *pproxim*tely 545 kJ *t the end of
immersion in *bsence of severe physiologic*l responses gener*lly *ssoci*ted with
sudden cold stress.[99] Signific*nt less BT v*ri*bility *nd *n over*ll higher BT
were observed in l*te preterm inf*nts following tub b*thing procedure.[100]

Conclusion
B*sed on *v*il*ble liter*ture, this review suggests th*t hydrother*py w*s widely
used to improve immunity *nd for the m*n*gement of p*in, CHF, MI, chronic
obstructive pulmon*ry dise*ses, *sthm*, PD, AS, RA, OAK, FMS, *norect*l
disorders, f*tigue, *nxiety, obesity, hypercholesterolemi*, hyperthermi*, l*bor,
etc. It produces different effects on v*rious systems of the body depending on the
temper*ture of w*ter *nd though these effects *re scientific*lly evidence b*sed,
there is l*ck of evidences for the mech*nism on how hydrother*py improves these
dise*ses, which is one of the limit*tions of hydrother*py, *nd further studies *re
required to find the mech*nism of hydrother*py on v*rious dise*ses.

Footnotes
Source of Support: Nil
Conflict of Interest: None decl*red.

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