HYDROTHERAPY

SUBMITTED BY:-
HIMANSHU
NISHAD
MPT SPORTS
II YEAR
 INTRODUCTION1,2
 The term HYDROTHERAPY in Greek implies for Hydro-Water,
Therapia- Healing.
 Also popularly known as “AQUATIC THERAPY/ WATER
THERAPY/ POOL THERAPY”.
 Father Sebastian Kneipp is said to be the father of hydrotherapy.
 The term encompasses a broad range of approaches and therapeutic
methods that take advantage of the physical properties of water.
 Hydrotherapy is believed to be beneficial in the treatment of:-
 Orthopedic injuries
 Spinal cord damage
 Chronic pain
 Cerebral palsy
 Multiple sclerosis and many other conditions.
 THERAPEUTIC PROPERTIES OF WATER1,3,4

 TONIC:-Water increase the vital activities, body function, blood

circulation and nutrition to body normal tone.
 ANTISPASMODIC:- Relax muscles thus releasing spasm.
 ELIMINATIVE:- Promotes elimination of toxic products from
kidney, skin and lungs.
 ANTIPYRETIC:- Effective in reducing increased body
temperature.
 REFRIGERANT:- Helps in relieving thirst and restoring alkaline
property of blood.
 DIAPHORETIC:- Act as an agent and helps in production of
sweat.
 DIURESIS:- Increase excretion of urine and thus help in
detoxication.
 PHYSICAL PROPERTIES OF WATER4
1. SPECIFIC HEAT:- 4 times as that of air
2. THERMAL CONDUCTIVITY:- 25 times more rapidly than
air
3. TRANSFER OF HEAT :- done by 2 ways
CONDUCTION :- In stationary water
CONVECTION :- Moving water transfer heat by conduction
and convection.
4. Specific Gravity:- Determines whether the object will float.
Humans have a specific gravity slightly less than that of water.
Any object with a specific gravity less than that of water will
float. An object with a specific gravity greater than that of water
will sink.
5. BUOYANCY:- It is a force experienced as an up thrust which acts in the
opposite direction to the force of gravity.
• According to Archimedes’ principle, when a body is entirely or
partially immersed in fluid at rest, it experiences an upward thrust
equal to the weight of the fluid it displaces.
• Buoyancy decrease stress and compression to body tissue and assist
weak muscles
5. RESISTIVE FORCES
• Water has 12 times the resistance of air.
• Viscosity of water provide resistance to motion i.e. speed dependent.
• This resistance occurs against the direction of the motion of the body
and increases in proportion to the relative speed of the body’s motion
and the frontal area of the body part(s) in contact with the water.
7. HYDROSTATIC PRESSURE
• Pressure exerted by fluid on body immersed in fluid.
• Greater the depth more hydrostatic pressure
 CLINICAL USES OF HYDROSTATIC PRESSURE
• Similar effects as compression bandages
• Helpful in decreasing edema
• Greatest effect of hydrostatic pressure occur in vertical position
PHYSIOLOGICAL EFFECTS 4,5
 CLEANSING EFFECTS
• Water can be used as a cleanser.
• Water is most commonly used as cleansing agent for skin.
• Hydrating effects and friction of water used to soften and remove the
debris.
• Water is used clinically both as wound exudate or necrotic tissue, and
as a cleanser to remove exogenous waste.
 MUSCULOSKELETAL EFFECTS
• The Buoyancy of water unload the weight-bearing of anatomical
structures & allow patients to perform exercise with less trauma and
pain.
• Buoyancy effect can help patients with
• Decrease weight bearing (Arthritis)
• Increase blood flow to muscles
• Muscle Strengthening
• Ligamentous instability
• Degenerative or traumatic conditions.
 CARDIOVASCULAR EFFECTS
• The Cardiovascular benefits of hydrotherapy are primarily due to
the effects of hydrostatic Pressure.
 PSYCHOLOGICAL EFFECTS
• Water immersion can be invigorating(energetic) and/or Relaxing.
• RELAXING:-Hot water
• INVIGORATING:-Cold water
• The Variation in the Psychological effects depends primarily on the
temperature of water.
 RESPIRATORY EFFECTS
• Increases the Work of Breathing due to immersion.
• Hydrostatic Pressure on the chest wall increases the resistance to
lungs expansion.
• Recommended for patients with EXERCISE-INDUCED ASTHMA
because it appears that High Humidity of the air inspired during
water exercise, which prevents drying and/or cooling of the
Respiratory mucosa.
 RENAL EFFECTS
• Increase Sodium and Potassium excretion.
• Increase Urine Production.
• May be used to treat the patient with hypertension and peripheral edema.
THERMOREGULATION

HOT WATER

HR is increased

Increase cardiac output

Rise in core temperature

Muscle blood flood increases
CLINICAL USES OF HYDROTHERAPY1,4
 SUPERFICIAL HEATING AND COOLING
Warm or cold water can be used clinically to heat or cool the
superficial tissues.
 ADVANTAGES
• Even contact with skin
• Does not need to be fastened
• Allows movement of heat/cold
 DISADVANTAGES
• Extremity often in dependent position

 WOUND CARE
 Cleansing properties facilitate
 Rehydration
 Softening and debridement of necrotic tissue
 Removal of wound debris
 Hydrostatic pressure and heat increase circulation
 Provides moist environment to optimize healing
 PAIN CONTROL
 Increased sensory stimulation to peripheral mechanoreceptors
 Cold water decreases inflammation
 Decreases weight-bearing, increases "ease of movement".

 EDEMA CONTROL
 Water immersion has shown to reduce peripheral edema.
 This effect is due to Hydrostatic pressure.
 Contrast Baths are frequently used to control edema.
 TYPES OF HYDROTHERAPY1

 IMMERSION

 NON-IMMERSION
 APPLICATION OF HYDROTHERAPY1,2,3
Certain factors need to be considered before starting a hydrotherapy
treatment. The main factors for consideration are:-
 Assess problem and set goals of treatment
 Determine if most appropriate treatment
 Make sure no contraindications
 Select appropriate form of hydrotherapy
 Pool, design and dimension:- There are different varieties of pool
like underground, below ground deck level, semi raised or raised.
Entry to pool can also be by different means like steps, ramp, hoists,
over the side. The best suitable depth of the pool is 4-6 feet(patient is
able to maintain vertical balance).
 Surface should be non slippery and easy to clean.
 Proper lighting
 Explain the procedure, purpose, sensations.
 Temprature and Ventilation:-
 Apply appropriate form of hydrotherapy
 Facilities
• Changing Area
• Showers
• Resting spaces
• Toilets
 STAFFING, CARE AND MAINTAINANCE:- along with
physiotherapist the hydrotherapy department consists of a bath side
assistance, cleaning and maintenance staff.
 Safety and Emergency Procedures
 During treatment assistant must be kept for help.
 There must be emergency kit and every staff member must
know how to handle it.
 Water must be checked regularly (for chlorine an pH level).
 Assess outcome
 Document
 EQUIIPMENTS FOR HYDROTHERAPY3

Equipment used for aquatic running or exercises

1. Collar, Rings And Belts

2. Swim bars or Buoyant Dumbbell
3. Gloves, Hand Paddles

4. Kickboards
 INDICATIONS
 Muscle weakness due to an injury, surgical procedure, or a period of
restricted movement.
 Difficulty in walking on land or not able to perform ADLs.
 Muscle deconditioning.
 To progress the patient towards strengthening exercises on land.
 CONTRAINDICATIONS
 Open or infected wounds.
 Skin infection.
 Cold/flu or infectious disease.
 Incontinence.
 Uncontrolled heart condition.
 Heart disease.
 Uncontrolled high blood pressure.
 Kidney disease.
 AQUATIC TECHNIQUES 1
 Aquatic techniques and activities can be designed to begin as active assistive
movements and progress to strengthening and eccentric control.
 Activities are selected based on several factors:
 Type of injury/surgery/condition
 Treatment protocols, if appropriate
 Results/muscle imbalances found in evaluation
 Goals/expected return to activities as stated by the patient
 Aquatic programs are designed similar to land-based programs, with the
following components:
 Warm-up
 Mobility activities
 Strengthening activities
 Balance or neuromuscular-response type of activities
 Endurance/cardiovascular activities
 Cool down/stretching
 WARM UP
 Warm up should be gradual.
 It allows body to adjust & to meet the necessary physical demand.
 The warm water of the pool allows body’s muscle & core
temperature to increase quickly.
 Warm water increases the circulation of the muscles without causing
fatigue. This in turn, make muscle more pliable and decreasing the
chances of injury.
 STRETCHING
 To restore normal ROM of the joint & mobility to the soft tissues.
 To facilitate muscle relaxation.
 To prevent irreversible muscle tightness or shortening.
 To reduce risk musculotendinous injury.
 MUSCLE STRENGTH AND ENDURANCE
• Muscular strength is the maximal tension a muscle can exert in a
single contraction. A contraction may be statically or dynamically
produced and specific for the muscle involved.
• Muscle restoration is critical after surgery or injury, water gives an
environment to produce fine exercise progression at early stage, as it
provide more resistance than air while supporting unstable or healing
structures.
• Muscular endurance is the ability of the muscle group to perform
repeated contractions over a period of time. It is specific to the muscle
groups.
 RELAXATION
 Effort to decrease tension in the muscle.
 During exercise, active skeletal muscle contraction is followed by
a reflex relaxation response, the stronger the contraction, the more
the relaxation.
 UPPER EXTREMITY 1
 The goal of rehabilitation is to restore function by restoring motion and
rhythm of movement of all joints of the upper extremity.
 Aquatic therapy may be used for treatment of the shoulder complex,
elbow, wrist, and hand as one of the interventions to accomplish goals
along with a land-based program.
 INITIAL LEVEL:
 The patient can be started at chest-deep water to allow for support of the
scapular/thoracic area.
 Walking forward, backward, and sideways will allow for warm-up,
working on natural arm swing, and restoration of normal scapulothoracic
motions, rotation, and rhythm.
 Initiation of activities to work on glenohumeral motions can be started at
the wall (patient with back against the wall); having the patient in neck-
or shoulder-deep water gives the patient physical cues as to posture and
quality of movement.
 The primary goal during the early phase is for the athletic trainer and patient
to be aware of the amount of movement available without compensatory
shoulder elevation.
 Supine activities include stretching, mobilization, and ROM. Stabilizing the
scapula with one hand, the athletic trainer can work on glenohumeral motion
with the patient . The patient can initiate active movement in shoulder
abduction and extension.
 Prone activity can be done depending on the patient’s comfort in water. The
patient can perform pendulum type movements, PNF diagonals, and straight-
plane movement patterns (flexion/extension) in pain-free range.
 INTERMEDIATE LEVEL:-
 Progress to challenge strength by using equipment to resist motion through
the pain-free range.
 The patient will be able to progress with scapular stabilization from standing
to supine and prone positions. Supine and prone positioning can allow for
more functional movement patterns and core stabilization of the scapular
muscles.
• PNF diagonal patterns can be performed with resistance in the pain-free
range.
• The goal of treatment in the intermediate-level activities is development of
strength and eccentric control throughout increasing ranges of motion.
• FINAL LEVEL-
• Goal of this level of treatment is high-level functional strengthening and
training. Equally important is the transition from the aquatic environment
to the land environment.
 LOWER EXTREMITY 1
 Aquatic therapy is useful for lower extremities rehabilitation because of
properties like unloading of joint, hydrostatic pressure, limited weight
bearing, etc.
 INITIAL LEVEL-
 Expected goals at this phase is to return to normal motion and early
strengthening of affected and unaffected muscles along with
restoration of normal and functional gait pattern. (forward, backward,
sideways walking)
 Range-of-motion activities may involve active motions of the hip,
knee, and ankle. Utilizing cuffs or kickboards under the foot will assist
with increasing motion.
 Standing activities are to be performed with attention to maintaining
the spine in a neutral position as well as to challenging balance and
neuromuscular control in the lower extremity.
• The athletic trainer can also incorporate activities performed in the
supine position. The patient will need to be supported with flotation
equipment that will allow him or her to float evenly.
• The athletic trainer can stabilize at the feet and have the patient work
on active hip and knee flexion and extension to work on increasing
range of motion at the affected joint.
• INTERMEDIATE LEVEL-
• At the initial level, resistance may need to be placed more proximally
with anterior crucial ligament injuries/surgeries and other ligament
injuries. Performing circuits of straight-plane and diagonal patterns
with both lower extremities can be progressed by performing with
upper-extremity support on the wall and progressing to no support.
• Patient can do single and bilateral leg reverse squat, can perform deep-
water forward & backward running using a tether.
• Supine activities can be continued with emphasis on strengthening and
stabilization of the trunk, pelvis, and lower extremities.
• Prone position provides increased challenges to the patient to perform
hip abduction and adduction along with hip and knee flexion and
extension. The patient can use mask and snorkel or flotation equipment
to help with positioning while in the prone position.
• Sport-specific activities can be integrated into the program for the athlete
like turning or jumping. While practicing movement patterns needed for
sport, the patient can start at chest depth and progress to shallow water.
• FINAL LEVEL-
• Aquatic program should be used to complement the land program.
• Endurance training in an aquatic environment is a good alternative for
the healthy athlete’s conditioning programs and may help prevent further
injuries.
 SPINE DYSFUNCTION 1
 In spine dysfunction, activities od trunk, upper extremities and lower
extremities challenges trunk stability, strength, total body balance, and
neuromuscular control.
 INITIAL LEVEL
 The patient in neutral spine position is instructed to take a partial
squat position with back against the wall. Use of the pool wall
provides the patient with a mechanism to monitor his or her ability to
maintain the neutral position during activities.
 Flotation support of the upper body and trunk and placement of light
weights on the ankles allows for gentle distraction of the lumbar
spine.
 Working on normalizing the gait pattern and developing the ability to
bear weight equally on the lower extremities.
 Gentle stretching and rotation movements can be performed in the
pain-free range to increase pelvic and lumbar spine mobility.
 INTERMEDIATE LEVEL
 Kickboards can be used to mimic pushing, pulling, and lifting
motions Equipment that resists upper extremity or lower-extremity
movements in a single-leg stance or lunge positions challenges the
patient’s balance and stabilization of abdominal and pelvic muscles.
 Activities can be incorporated to work on diagonal and rotational
motions of the spine and trunk, while maintaining the neutral
position in supine position.
 FINAL LEVEL
 For athletes, specific challenging exercises needs to be developed by
using aquatic equipment and should use equipment specific to the
athlete’s sport to challenge him or her to a higher level of trunk
stabilization.
 It is important to integrate movement patterns that are opposites of
the ones the athlete normally performs in his or her sport.
 BAD RAGAZ RING METHOD 1,5
 Bad Ragaz technique originated in the thermal pools of Bad Ragaz,
Switzerland in the 1930s, it focuses on muscle reeducation,
strengthening, spinal traction/elongation, relaxation, and tone inhibition.
 The properties of water provide dynamic environmental forces during
activities.
 Requirements of the pool environment are a warm water temperature of
33.3-36.6 degree Celsius, at least an 8 feet by 8 feet pool area 3 to 4 feet
in depth, and the water level should not exceed axillary (T8-T10) level
of therapist.
 The client should wear neck ring float, body ring at the L5-S2 level and
extremity rings.
 While the patient is in this position, the therapist will use aquatic
principles to interact with the patient, creating progressive exercises.
 Stretching and lengthening responses can be obtained with passive or
relaxed response from patient.
 Outcomes and Contraindications
 The benefits are tone reduction, trunk alignment and stability, pre-
weight bearing activation, and improved range of motion. Patients that
would benefit from this technique include those with pain with
movement, decreased range of motion, spasticity, decreased
coordination, proprioceptive or sensory deficits, weakness or low tone,
and restricted weight bearing.
 Precautions and contraindications;-
 Patients with ear problems and frequent ear infections.
 Make sure to monitor the patient’s breathing that they are not holding
their breath.
 Awareness of body mechanics and prevention of injury are important
to the athletic trainer when performing resistive Bad Ragaz type
activities.
 The athletic trainer should stand with one foot in front of the other,
with knees slightly bent and legs shoulder-width apart, to compensate
for the long-lever arm force of the patient.
 Period of restoration
 The minimum time should not be shorter than 15 minutes.
 The exercises are designed to strengthen these patients and should
not exceed a few minutes each time, because fatigue occurs rapidly at
high load (less than 80% of one repetition maximum intensity).
 The period of rest after each set of exercises should be 1.30 - 3
minutes when using contractions with large loads.
 Muscle contractions in the series should not exceed 20 submaximal
contractions, with a break of 1 minute between sets.
 BURDENKO METHOD 1,5
 The Burdenko method utilizes motion as the principle healing intervention.
 According to Burdenko, the components of dynamic healing include
patterns of movement, injury assessment, and rehabilitation exercises that
occur with the patient in a standing position, the psychology of the injured
patient benefiting from pain-free movement, and blood flow and neural
stimulation being enhanced by activity.
 Six essential qualities are necessary for perfecting and maintaining the art of
movement: balance, coordination, flexibility, endurance, speed, and strength.
The activities are designed to challenge the center of buoyancy and center of
gravity.
 Treatments/activities are initiated in deep water and incorporate shallow-
water activities as the patient succeeds by demonstrating control of
movement while maintaining neutral vertical position.
 This is based on the principles of fitness intelligence utilizing water and land
exercises in order to achieve optimum results in rehabilitation, conditioning
and training.
 HALLIWICK METHOD1,5
 Developed by James McMillan, and is based on a ‘TEN POINT
PROGRAMME’.
 The Halliwick method is commonly used to teach individuals with
physical disabilities to swim and to learn balance control in water.
 This method is frequently used with pediatric population and there
can be use of turbulence forces which can assist in developing
strategies for maintaining balance, or challenge the patient to
maintain a stable posture during a change in the direction of force.
 REFERENCES
1. William E. Prentice ,Rehabilitation techniques for sports medicine and athletic
training, Aquatic therapy in rehabilitation,2011
2. "Hydrotherapy – What is it and why aren't we doing it?“. International
SPA Association. Kansas. 3 October 2009. Retrieved 17 December 2009.
3. Bruce E. Becker, MD, MS 6 Aquatic Therapy: Scientific Foundations and
Clinical Rehabilitation Applications, 6 march 2018
4. Electrotherapy for physiotherapists, virendra kr. Khokhar.
5. Michelle H. Cameron Physical agents in rehabilitation from research to
practice 2009