HYDROTHERAPY PRINCIPLES & TECHNIQUES

HYDROTHERAPY
Contents-
o History
o Definition
o Properties of water
o Indications & contraindications
o Therapeutic & physiological effects
o Equipments
o Hydrotherapy techniques
o References
 HISTORY-
Near the end of the 19th century in Europe & soon after in the United States,
the use of an aquatic environment to facilitate exercise began to grow in
popularity.

Hippocrates used hot & cold water immersion to treat many diseases.

Romans used baths for hygiene.

 DEFINITION-
Hydro- Water (GREEK).
Therapy- Treatment (LATIN).
Simply means treatment by water.

It refers to the use of the multidepth immersion pools or tanks that facilitate
the application of various established therapeutic interventions , including
stretching , strengthening, joint mobilization ,balance , gait training &
endurance training.

It has been successfully used for a wide variety of rehabilitation

populations including pediatric , orthopaedic, neurological &
cardiopulmonary patients.
PHYSICAL PROPERTIES OF WATER
 1.DENSITY & SPECIFIC
GRAVITY(SG)-
Density is used to provide support of the body & its limb in the water.

SG is the weight of a particular substance compared with the weight

of an equal volume of water.

An object with low SG (less than 1.0) will float.

Objects with high SG (greater than 1.0) will sink.

SG of human body (0.87 to 0.97) & pure water at 4˚C is 1.0.

Density is proportional to its depth.

 2.BUOYANCY-
Upward force that works opposite to
gravity.

 ARCHIMEDES’ PRINCIPLE-It
states that an immersed body
experiences upward thurst equal to
the volume of liquid displaced.

The amount of fluid displaces

depends on the density of the
immersed body relative to the density
of the fluid.
 CLINICAL
BENEFITS-
Help exercise when weight bearing is contraindicated.

Can be used as assistive or resistive force.

Allows the practitioner three dimensional access to the patient.

Raise weakened body parts against gravity.

 CENTRE OF BUOYANCY-
It’s the reference point of an immersed
object on which buoyant (vertical) forces
of fluid predictably act.

In the vertical position , the human

centre is located at the sternum.
 3.HYDROSTATIC PRESSURE-
Pressure exerted by water on the
immersed body.

PASCAL’S LAW-It states that the

pressure exerted by fluid on an immersed
object is equal on all surfaces of the
object.

Tends to increase as depth & density

increases.
 CLINICAL BENEFITS-
Facilitate cardiovascular function.

The proportionality of depth & pressure allows patients to perform exercise

more easily when closer to the surface.

Support provided by hydrostatic pressure may help to brace unstable joints or

weak muscles.

The greatest effect occur with vertical positioning.

 4.VISCOSITY-
Friction occuring between molecules of liquid.

Leads to resistance to flow.

Dependent on-

Speed/velocity of movement of liquid.

Shape of the body.
 CLINICAL
BENEFITS-

Water’s viscosity creates resistance with all active movements.

Increasing the surface area moving through water increases resistance.

 5.SURFACE TENSION-

The surface of the fluid acts as a membrane under tension.

It’s measured as force per unit length.

The attraction of surface molecules is parallel to the surface.

 The resistive force of surface tension changes proportionally to the size

of the object moving through the fluid surface.
 CLINICAL BENEFITS-

An extremity that moves through the surface performs more work than it
kept under water.

Using equipment at the surface of the water increases the resistance.

 6.ADHESION-The tendency of water molecule to adhere to other
substances.

7.COHESION-The tendency of water molecule to adhere to each other.

 HYDROMECHANICS OF WATER-

Terms used to refer to movement

through water.

The faster the movement,the greater the

resistance.
 Water in motion

Flow Motion
1.Laminar

2.Turbulent
LAMINAR FLOW-All the molecules are parallel , typically
slow movement.

TURBULENT FLOW-
Molecules are not parallel , typically faster
movement.

DRAG- Cumulative effects of turbulence & fluid viscosity acting on an

object in motion.
 THERMODYNAMICS-
1.Specific Heat-
It’s the amount of heat , in calories , required to raise the temperature of
1 gram of substance by 1˚C.

Specific heat of water is 1.0.

Cool water temperature is best for long exercise session , warm water is
indicated for short duration exercises.

The specific heat of water is approximately 4 times that of air & its
thermal conductivity is approximately 25 times that of air.
 2.THERMAL CONDUCTIVITY-

Water can transfer heat by conduction (stationary water) & convection

(moving water) & can therefore be used as a superficial heating or cooling
agents.
 CLINICAL BENEFITS-

Clinically , during hydrotherapy, heat is generally transferred from warm

water to a patient by placing the patient’s limb in warm water.

Heat also may be transferred from the patient to cooler water by immersion of
a limb or part of it in cold or ice water.
 THERAPEUTIC EFFECTS OF WATER-

A. THERMAL -1.Cold application.

2.Heat application.

B. Agitation.
MECHANICAL
-
COLD APPLICATION-
 Increased blood viscosity.
Decreased blood flow.
Decreased heart rate.

HEAT APPLICATION-
Vasodilation of arteries & arterioles.
Increased blood flow.
Increased heart rate.
Increased tissue extensibility.

AGITATION- Analgesia.
Facilitation of exercise.
Muscle relaxation.
FACTORS AFFECTING THERMAL EFFECTS-
Temperature difference between water & skin.

Method of heat transfer.

Thermal conductivity of the structure.

Surface area covered.

Duration of exposure.

Rate of rise in initial temperature.

Weight , age & general condition of the patient.

INDICATIONS-
Facilitate range of motion exercise.
Facilitate weight bearing activities.
Initiate resistance training.
Enhance patient relaxation.
Facilitate cardiovascular exercise.
Relief muscle spasm.
Reduce muscle tone.
Wound care.
CONTRAINDICATIONS-

Patients with cardiac failure & unstable

angina.
Patients with respiratory dysfunction.
Danger of haemorrhage.
Severe peripheral vascular diseases.
Severe kidney diseases.
Uncontrolled bladder or bowel.
Dermatologic conditions.
Fever.
PRECAUTIONS-

Fear of water.

Seizures.

Neurological disorders.

Cardiac dysfunctions.
 PHYSIOLOGICAL EFFECTS OF
HYDROTHERAPY-
1.CLEANSING EFFECTS-
Pressure.
Dissolved surfactants & antimicrobials.

2.MUSCULOSKELET Decreased weight bearing.

AL- EFFECT Strengthening.
Slowed body density loss.
Less fat loss than other forms of exercise.

3.CARDIOVASCULAR EFFECT.
4.RESPIRATORY Decreased vital capacity.
EFFECT- Increased work of breathing.
Decreased exercise induced asthma.

Diuresis.
5.RENAL EFFECT-
Increased sodium & potassium excretion.

6.PSYCHOLOGICA Relaxing depending on temperature.

L- EFFECT
SPECIAL EQUIPMENTS FOR
HYDROTHERAPY
 a)Collars , rings, belts, vests-
Assist the patient positioning by providing buoyancy assistance.
Applied to the neck , extremity or trunk.
Collar is used in supine position to keep the neck out of water.
Rings are of different sizes & used to support extremity.
Belts & vests are used for supporting trunk in supine , prone, vertical
position,

COLLAR BUOYANCY FLOTATION RINGS

BELT
 b)Swim bars-
These are available in short &
long lengths.

They are useful for supporting

upper body or trunk in upright
positions & the lower
extremities in supine or prone
positions.
 c)Gloves, hand paddles & hydro-tone balls-
Resistance to upper limb
movements is achieved by
gloves/progressively larger
paddles to the hands.

Hydro-tone balls are large

HAND PADDLES
slotted plastic devices that
increase drag during upper
extremity motions.
HYDRO-TONE
BALLS
 d)Fins, hydro-tone boots-
Applied to feet during lower extremity
motions.

Generates resistance by increasing

surface area.

Fins are useful for challenging hip, knee

& ankle muscle strength.

Boots are effective during deep water

walking / running.
 e)Kickboards-
Different shapes & sizes are
available.

Provide buoyancy in prone & supine

position.

Provide resistance for seated,

kneeling or standing balance in deep
water.
 f)Buoyancy resisted & assisted-
If one is working against the
tendency of a limb to float, then the
movement is referred to as resistive.

When one is working with the

tendency of a limb to float, it is
assistive.
 MODALITIES-
A. Whirlpool Bath.
WATER IMMERSION MODALITIES-
B. Hubbard Tank.

C. Hydrotherapy Pool.
A.WHIRLPOOL BATH-
 TYPES-
1.Low Buoy
Tank-
Dimensions-

Width-24 inches.
Length-52-66
inches.
Depth-18 inches.
2.High Buoy Tank-
Dimensions-

Width-20-24 inches.

Length-36-48 inches.

Depth-28 inches.
 3.Extremity Tank-
Dimensions-

Width-15 inches.
Length-28-32 inches.

Depth-18-25 inches.
Dosage- Whirlpools are generally applied for 10-30 minutes , although
shorter periods may be sufficient for softening wound eschar ,
while longer periods will increase the amount of heat transferred
to the patient.

Advantages-
Can be used for heat transfer, for cleansing & debriding open wounds or
for exercise.

Patient can be positioned securely & comfortably.

Weaker muscles can move more freely than on dry land.

 Disadvantages-
Size of tank limits the amount of exercise & the size of the area that can be
treated.

Large quantity of water used.

Risk of infection.

Costs associated with cleaning.

Costs associated with heating water.

Time expended assisting the patient to dress & undress.

B. Hubbard Tank-Dimensions- Length-7 feet 2 inches.

Upper wing length-6 feet.

Middle wing length-35 inches.

Lower wing length-4 feet 2 inches.

Depth-22 inches.

Insets-15 inches.
Dosage- Water temperature is generally kept in the slightly lower
range of 36•C to 39•C (97•F to 100•F).

Duration-20 minutes.
Advantages-

Can treat large area / multiple areas of body.

Can be used for heat transfers , for cleaning & debriding open wounds or
for water exercises.
 Disadvantages-
 Costly to provide the treatment.

 Costly equipments & space requirements.

 Uses large amount of warm water.

 Time- cosuming to fill, empty & clean tank , to place patient in the tank.

 Requires extra-caution with regard to possible systemic effect of

overheating with a large body area exposed.
C. Hydrotherapy Pool- At least 100 feet long & 25 feet wide &
have a maximum depth of 8 feet (&
minimum 3.5 feet).

 Sloping bottom to produce a gradual

descent.

 The temperature of the water in a exercise

pool should be kept at 26•C to 36•C (79• to
97•F).

 A room temperature 25•-30•C(77•-86•F)

with relative humidity of 50% is
recommended.
 Advantages-
Patient can move freely with less risk of falling.

Decrease weight bearing on joints.

Disadvantages-
 Risk of falling when the patient gets into & out of the water because
water around the pool can make the floor slippery.
 Risk of infection from other individuals who have been in the water.
 Difficulty stabilising the body parts during exercise.
 Fear among some patients of water immersion.
AQUATIC POOL CARE-For preventing infections-
Tanks & turbines must be thoroughly cleaned in between patients.

Most common agents used to prevent or reduce chances of infection

are Chloramines-T , bleach.

Important to run turbine with disinfectant agents in water.

 SAFELY IN & AROUND POOL-
The area surrounding pool should have nonslip surface.

Means of entering the pool should be appropriate for patient’s ambulatory

ability & may include stairs , ramps or ladder for non-ambulatory or
impaired patients.

The depth of water should be clearly marked at intervals around pool edge.

There should be hand grip bars all the way around edge of the pool.

Emergency equipments should be available e.g, like ring ,rescue tube ,

blanket & first aid kit.
HYDROTHERAPY
•TECHNIQUES-
Watsu Technique.

• Bad Ragaz Ring Method.

• Halliwick Method.

• Ai Chi.

• Burdenko Method.

• Water Pilates.

• Back Hab Aquatic Therapy.

 1.WATSU
TECHNIQUES-
 Developed as the first form of
aquatic body work by Harold Dull
in 1980.

 Watsu is a form of aquatic

bodywork used for deep relaxation
& passive aquatic therapy.

 It’s characterized by one-on-one

sessions in which a therapist gently
moves, stretches & massages a
receiver in chest-deep warm water.
 Benefits- Deep relaxation.
Reduced pain , stress & fatigue.
Increased energy.
Increased ROM.
Increased body posture , breathing & circulation.

Suggested patient profile- Neurological impairment.

Fibromyalgia.
 2.BAD RAGAZ RING METHOD-
It’s a type of aquatic therapy used for
physical rehabilitation based on PNF.

It’s a water based technique in which

therapist assisted strengthening &
mobilizing exercises are performed
while the patient lies horizontally in the
water, with support provided by rings or
floats around the neck, arms, pelvis &
legs.
Suggested Patient Profile-

Orthopaedic & rheumatology conditions.

Soft tissue injuries.

Neurological conditions.
 3.HALLIWICK METHOD-
 Developed by James McMillan in
1950

 Encourages active participation

without flotation devices.

 He began a sequential method

known as 10 point program for
teaching children with disabilities
to swim.
1. Mental Adjustment.
2. Disengagement.
3. Transversal Rotation Control.
4. Saggital Rotation Control.
5. Longitudinal Rotation Control.
6. Combined Rotation Control.
7. Upthrust & Mental Inversion.
8. Balance In Stillness.
9. Turbulent Gliding.
10.Simple Progression & Basic Swimmimg Movement.
Suggested patient profile-
Balance disorder.

Scoliosis.

CVA.

Cerebral Palsy.
 4.AI CHI-
 It’s a form of aquatic exercise used for relaxation , fitness & physical
rehabilitation.

 It’s a combination of deep breathing & slow broad movements while

standing in chest deep water.

Suggested patient profile- Osteoporosis.

Balance deficits.
AI CHI
 5.BURDENKO METHOD-
 This method was developed by
Dr. Igor N. Burdenko .

 It can improve balance , co-

ordination , flexibility, speed &
strength.

 It’s a complete system that

combine water & land exercises.
 6.WATER PILATES-
Pilates exercises have been adopted for
the pool; created by joseph pilates , this
body conditioning program is designed
to improve strength , flexibility, ROM
& also encourages musculoskeletal
alignment.

The main purpose are resisting own

weight , controlled breathing , spine
alignment & abdominal strengthening.
 7.BACK HAB AQUATIC THERAPY-
This form of aquatic therapy is
based on walking programs in the
pool.

This is a great form of therapy for

individuals with back pain ,
hamstring injuries or those
looking to increase abdominal
strength.
UNDER WATER TREADMILL-
It’s motor-driven
treadmill & pump-
driven water jets
providing frontal
resistance.

The UTM water depth

was standarized to the
level of each subject’s
fourth intercostal space
& the jets were directed
at the umbilicus.
EXERCISE PROGRAM FOR 30 MINUTES
IN AQUATIC CLASS-
A. Warm up-

Water walking 8 to 10 minutes-Begin by having the class to walk forward ,

B.Upper body
then backward exercise-
& then side step.

Horizontal arms apart/together.

Side arms raise.
Forward arms raise.
Overhead reach.
Arm crossover.
Shoulder shrugs.
C. Concentrate on trunk flexibility-
Trunk rotation.
Lateral trunk flexion.
Pelvic tilt.
Hip circles.
D. Concentrate on lower extremities-
Squats.
Hip flexion , extension , abduction , adduction , knee flexion & extension.
Ankle circles.
E. Face & neck exercises-
Chin tucks.
Neck lateral flexion.
Neck rotation with eyes wide.
VARIATIONS IN HEART RATE & PERCEPTION OF
EFFORT DURING LAND & WATER AEROBICS IN
Kelly Heithold
OLDER WOMEN. et al,2002;5(4):22-28.
PURPOSE-To compare heart rate & perceptual responses in
healthy ,active women while performing the same aerobic exercise routine
on land & in the water at a self-selected intensity level.

SUBJECTS-Seven (performed an aerobic exercise routine on land & in the

water on two consecutive occasions).

PERFORMANCE-3 minutes above the shoulder arm exercise,3 minutes

leg exercise,3 minutes below shoulder arm exercise,3 minutes total body
exercise & was performed twice for a total of 24 minutes of aerobic
exercise.Heart rate was recorded after each individual exercise & RPE was
recorded every 3 minutes.
RESULTS-HRs were significantly higher on all land exercise
compared to water exercise.RPE was not different between land
exercise & water exercise.
 AQUATIC PHYSICAL THERAPY FOR HIP &
KNEE OSTEOARTHRITIS:RESULTS OF A
SINGLE BLIND RANDOMIZED CONTROLLED
TRIAL. Rana S Hinman et al,2007.

PURPOSE- To evaluate the effects of aquatic physical therapy on hip

or knee OA.

SUBJECTS- 71 volunteers with hip or knee OA .

METHOD- Randomly received 6 weeks of aquatic physical
therapy or no aquatic physical therapy .Outcome
measures included pain,physical function,physical
activity level,quality of life & muscle strength.

 RESULTS-Benefits were maintained 6 weeks after the completion of

aquatic physical therapy.The intervention resulted in less
pain & joint stiffness & greater physical function,quality
of life & muscle strength.
 REFERENCES-
1.KISNER C & COLBY L A.Therapeutic exercise,5th
ed.Philadelphia:F.A.Davis Company;2007.chapter-9,Aquatic
exercise;p.273-94.

2.CAMERON H M.Physical agents in rehabilitation from research to

practice,2nd ed.United states of America:Saunders;2003.chapter-
9,Hydrotherapy;p.261-306.
3.Heithold K,Glass S.C.Variations in heart rate & perception of effort
during land & water aerobics in older women.JEP.2002;5(4):22-28.

4.Hinman R S,Heywood S E,Day A R.Aquatic physical therapy for hip

& knee OA:Results of a single-blind randomized controlled
trial,Physical therapy.2007 JAN 1;87(1):32-43.
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