Loganathan Chandrasekar PHT 328 – 1435 -1436H – 1st Semester Physiological & therapeutic Effects, advantages & disadvantages, indications & contraindications, modalities & application of Hydrotherapy Loganathan Chandrasekar PHT 328 – 1435 -1436H – 1st Semester

Lecture Outline Physiological effects of Hydrotherapy Therapeutic effects of Hydrotherapy Advantages & Disadvantages of Hydrotherapy Modalities used Application for different conditions PHT 328 - HYDROTHERAPY - 1435 - 1436H - 1st Semester 9/20/2018

Learning Objectives At the end of this lecture, the students will be able to Recall the physiological & therapeutic benefits of water & List down some of it. Describe the physiological & therapeutic effects, advantages & hazards, indications & contraindications & different modalities. Demonstrate the application for different conditions PHT 328 - HYDROTHERAPY - 1435 - 1436H - 1st Semester 9/20/2018

Physiological Effects – Circulatory effects Increase in blood circulation Hydrostatic Pressure Heat

Physiological Effects - Wound care Cleansing Pressure Dissolved antimicrobial agents, etc. (Wounds)

Physiological Effects - Musculoskeletal Effects Decreases weight-bearing (Arthritis) 75% immersion ↓ WB 75% Increases blood flow to muscles – Hydrostatic pressure Strengthening – Resistance / Hydromechanics Decreased bone density loss Good for obese secondary to non-weight bearing exercise

Physiological Effects - Musculoskeletal Effects OFF-LOADING INCREASES AS THE DEPTH OF IMMERSION INCREASES CLINICALLY, LESS JOINT COMPRESSION IS PRODUCED & IMPACT STRAIN over the joint is DIMINISHED

Physiological Effects - Cardiovascular Effects Water immersion to chest or higher Venous compression Lymphatic compression Increased hydrostatic pressure Central blood volume increases Arterial pressure raises Pulmonary arterial pressure raises Cardiac volume Increases Stroke volume Increases Cardiac Output increases

Cardiovascular Effects Increased cardiac output Up to 30% while upright to neck Decreases HR and Systolic BP (cool water) May increase in warm or hot water

Physiological Effects - Respiratory Effects Increases work of breathing Due to hydrostatic pressure on lungs up to 60% May need to be very careful with respiratory and/or cardiac patients Decreases exercise-induced asthma High humidity

Physiological Effects - Renal Effects Increases urine production Increases sodium and potassium excretion May be used to patient’s advantage with hypertension, peripheral edema

Physiological Effects - Psychological Effects Relaxing Warm water

Proposed physiologic & therapeutic effects of Hydrotherapy HYDROTEHRAPY THERMAL ENERGY MECHANICAL ENERGY Cleansing & Debridement Wound Management CRYO THERMAO Water Vasoconstriction Vasodilation Hydrostatic pressure Limb Compression Edema Management ↓ Blood flow ↑ Blood flow Buoyancy force Body weightlessness Body Unloading ↓ Metabolism ↑ Metabolism Stimulation sedation Drag force Assisting / Resisting effect Aquatic Exercise

Indications Musculoskeletal conditions; Control of Pain & swelling – Cold whirlpools Acute Sprains & strains - Cold whirlpools Facilitate motion & ex’s for Sub acute & chronic stages of sprains & strains - Warm whirlpools Facilitation of stretching of contracture (simultaneous or immediate pre application of Warm whirlpools) Postsurgical repair of joints (after post surgical wounds are healed fully – to help soften scar tissue, ↓ pain & promote restoration of motion )

Indications f. Healing fractures of bones – after clinical union has been achieved. g. Assist in ↑ of mobility – thermal & buoyancy of warm whirlpools h. OA & RA – Buoyancy effects of warm whirlpools – off loading of the affected joints – leading to decrease in pain & ↑ in mobility. i. Help to ↓ post operative peripheral oedema – Hydrostatic pressure. j. Psychological effect – Relaxing & ↓ of anxiety k. Wound care – Mechanical debriding by removing necrotic material & cleansing.

Contraindications & its Rationale Acute inflammatory conditions - ↑ intravascular pressure - ↑ in oedema. Hyperpyrexia - ↑ tissue temperature Malignancies – Spreading - ↑ blood flow Active bleeding – Prolonging arterial blood flow Cardiac dysfunction – Not able to adapt to thermal homeostasis Respiratory dysfunction – Not able to resist hydrostatic pressure, tolerate heat or both

Contraindications & its Rationale ↓ thermal sensation – Inability to sense too much heat / cold PVD – Not able to meet ↑ metabolic demand X-ray therapy – Not able to meet ↑ metabolic demand Venous ulcers – May promote venous congestion Acute RA – Heat C.I. Surface infections – Cross contamination Uncontrolled bowels – Contaminate water Dermatological conditions(Atopic eczema) – Exacerbate Severe epilepsy – Risk of drowning (Full body immersion)

Precautions & its Rationale Impaired thermal sensation in area to be immersed – Burns Infection in area to be treated – Need additional infection control measures Impaired cognition – Not able to report problems or discomfort Recent skin grafts – May not able to tolerate agitation or not able to compensate for extremes of heat or cold After ingestion of alcohol– Impaired judgment – risk of drowning. Limited strength, endurance, balance or ROM (full body immersion) – Safety hazard – risk of drowning Medications – May alter CVS

Precautions & its Rationale Urinary incontinence (full body immersion) – Risk of UTI Fear of water (full body immersion) – May refuse to participate Respiratory problems – ↑ respiratory distress Pregnancy (1st trimester - full body immersion) – CNS abnormalities in child Multiple sclerosis (full body immersion) – ↑ fatigue & weakness Poor thermal regulation (full body immersion) – Risk of thermal shock Previously existing oedema (full body immersion) – ↑ oedema Seasickness – Cause anxiety

Modalities

WATER IMMERSION MODALITIES Whirlpool bath Hubbard tank Pool/Aquatic Therapy

Low Boy Whirlpool High Boy Whirlpool Extremity Whirlpool Chair for Whirlpool

Whirlpools These are stainless steel or acrylic tanks of various sizes. It has an attached motor called – TURBINE. The turbine – AGITATES the water in the tank to create the whirlpool effect. These WP are intended to used as single-patient treatments & must be drained & cleaned after each use.

WP Parts in general Agitator/ Turbine ejector/ Aerator Hot and cold water mixing valve Temperature gauge Gravity drain Seat / Chair

TURBINE It is the electrical motor pump that creates agitation in a WP. A switch on the top of the turbine turns the motor on/off. The turbines are attached with 2 or 3 tubular metal shafts. One of these tubes is the drive shaft, which contains an impeller housed in a casing at the bottom of the tube. The amount of water ejected at the base of the drive shaft will determine the force of the ejected water.

Components of the Turbine

TURBINE Adjusting the throttle near the top of the shaft can control the amount of water ejected. The other tube is called the breather tube. The amount of air mixing with the ejected water (Aeration) at the base of the breather tube can be adjusted by turning the butterfly valve near the top of the shaft. Agitation of water in WP tank can be controlled by; 1. Adjusting the force of the ejected water. 2. Amount of aeration of the water.

Care of the turbine Near the bottom of one of the shafts of the turbine is a small hole on the side of the shaft. This hole must under the surface of the water whenever the turbine motor is turned on. Make sure the turbine ejector is not blocked by bandages, wound packing or patient fingers or toes.

Parts of a Whirlpool Bath On / Off switch Motor Pump/Turbine Motor Thermometer Steel Tank Wheels

Objectives for use stimulation of circulation promotion of muscle relaxation and pain relief debridement facilitation of exercise

Additives wounds: (Anti microbial agent help to reduce infection) - Povidone-iodine solution - sodium hypochlorite or Chloramine-T - saline solution dry skin: - bath oil burn patients: - 4% solution Lidocaine

TYPES OF WHIRLPOOL BATH According to shape: Low boy tank High boy tank Extremity tank According to mobility: Movable Fixed

LOW BOY WP tank It is designed for ease of transfer in & out of the tank by virtue of low walls & length. Patients in a low boy are usually in a long sitting position.

LOW BOY Dimensions width: 24 inches length: 52 – 66 inches depth: 18 inches

HIGH BOY WP tank It’s also referred as “HIP” tanks. It requires a chair or lift to transfer the patient in & out of the tank. Patients in a high boy tank usually sit on a removable seat attached to rungs on the side of the tank or may sit on a chair outside the tank with their lower extremity dangling in the tank.

HIGH BOY Dimensions width: 20 – 24 inches length: 36 – 48 inches depth: 28 inches

Extremity WP tank The WP tank is smaller in size, designed especially to treat distal extremities. (Ankle/foot/hand) It is often portable with attached wheels for ease of movement.

EXTREMITY TANK also called UPPER EXTREMITY TANK Dimensions width: 15 inches length: 28 – 32 inches depth: 18 – 25 inches

Hubbard Tank These are large whirlpools designed for full body (Head out) immersion & for pt’s who are unable to stand. Mainly designed for under water ex’s. The wide top & bottom & narrow middle allow room for ex’s for the extremities & PT access to the patient for assistance with ex’s. Pt’s are typically lowered into tank on a stretcher by an over head hydraulic hoist. It is equipped with 2 turbines, that can be moved around the perimeter of the tank to direct & control the agitation pattern.

HUBBARD TANK Dimensions length: 7 feet 2 inches upper wing width: 6 feet middle wing width: 35 inches lower wing width: 4 feet 2 inches depth: 22 inches

ADDITIONAL EQUIPMENT Walk trough Adjustable seat Motorized chair lift Hydro stretcher with hydraulic lift

Non – Immersion technique – Irrigation technique Pressured water irrigation system:- It is mainly used for wounds, where it is impossible or not required to immerse the body part treated. It should range between 4 & 15 pounds /square inch (psi). Used to treat one patient at a time. Reusable.

Therapeutic Effects - Wound Care WP is recommended for Delayed primary wound – Wounds that are surgically closed after 5 days. Secondary intention – Wounds are allowed to close by granulation, marginal or budding epithelialization & wound margin contracture.

Therapeutic Effects - Wound Care WP application – facilitates; Cleansing Softening and debridement of necrotic tissue Removal of wound debris Antibacterial action Circulation enhancement The WP could be carried out until the wound closes.

Treatment of Burns Similar, but burns particularly painful when debrided Wounds sometimes less deep, sensory nerves intact Monitor patient closely often high-dose analgesics Hubbard Tank for large body surface area Chance of contamination Greater loss of sodium (add salt) Shower (non-immersion) in early stages After re-epithelialization, water for exercise

Skin grafts & tissue flaps WP is best recommended by 5th post operative day of grafting. If would like to give WP within 3-5 days post grafting, then agitation is adjusted to minimal levels & only administered for 5 minutes. It allows softening of tissues & cleansing with antibacterial agent in preparation for mechanical debridement. It also removes superficial wound exudates. As the graft ages & stability improves, the duration & aeration may be increased. In general, the younger the flap, the less turbulence & shear force it will be able to tolerate.

Pain & muscle spasm Control Increased sensory stimulation to peripheral mechanoreceptors Pain gate Theory Cold water decreases inflammation Decreases weight-bearing, increases “ease of movement”.

Edema Control Hydrostatic pressure Cool water Vasoconstriction Decreased vascular permeability Hot water increases edema Increased arterial blood flow, increased vasodilation.

THERAPEUTIC EFFECTS OF EXERCISE IN WATER: summary 1. THE RELIEF OF PAIN & MUSCLE SPASM 2. MAINTANANCE OR INCREASE IN RANGE OF MOTION OF JOINTS 3. THE STRENGTHENING OF WEAK MUSCLES & AN INCREASE IN THEIR TOLERANCE TO EXERCISE 4. THE RE-EDUCATION PARALYSED MUSCLES 5. THE IMPROVEMENT OF CIRCULATION

THERAPEUTIC EFFECTS OF EXERCISE IN WATER: summary 6. THE ENCOURAGEMENT OF FUNCTIONAL ACTIVITIES 7. THE MAINTANANCE & IMPROVEMENT OF BALANCE, CO- ORDINATION & POSTURE 8. WOUND HEALING IS ENHANCED 9. SEDATIVE EFFECT & RELAXATION 10. FACILITATES CARDIOVASCULAR EXERCISES 11. FACILITATES THE WEIGHBEARING ACTIVITIES

AGITATION (Mechanical) - therapeutic effects of WP debridement analgesia facilitation of exercise muscle relaxation

DEMERITS / HAZARDS Burns, Fainting, Bleeding INFECTIONS – UNCLEANLINESS Increased edema Use of hot water Dependent positioning FATIGUEBILITY IMBALANCE SUDDEN CHANGE IN B.P. MAY OCCUR ANY ALLERGY

Application of Hydrotherapy Practical point of view Application of Hydrotherapy

Application, General Rules Assess problem and set goals of treatment Determine if most appropriate treatment Make sure no contraindications Select appropriate form of hydrotherapy Whirlpool Hubbard Tank Contrast bath Non-immersion device Pool Explain the procedure, purpose, sensations Apply appropriate form of hydrotherapy Assess outcome Document

Selection of Hydrotherapy Base decision on Desired effects Size of area to be treated Allowance for safety, control of infection Cost-effectiveness

Whirlpool Tanks Low-Boy High-Boy Extremity Hubbard Tank

Temperature Range Cold (32-790 F) Tepid (79-920 F) Acute inflammation Tepid (79-920 F) Exercise Acute inflammation if cold not tolerated Neutral warmth (92-960 F) Open wound Medically compromised patients Decrease tone

Temperature Range Mild warmth (96-980) Hot (99-1040) Increase mobility Burn Hot (99-1040) Pain, Increase ROM Increase soft tissue extensibility Very Hot (104-1100) Limited body area Chronic conditions DO NOT use WP at temperatures > 1100 F !!

Safety considerations for Hydrotherapy Prevention of falls Precautions for prevention of drowning Electrical safety

Treatment duration - WP 20 min when strictly used as a heating modality – skin muscle & joint temperature. 5 – 20 min when used for debridement – depending on amount of necrotic tissue. 10 – 20 min for ex’s – depending on pt’s medical status.

Lower Extremity / mid thorax level immersion Technique High boy tank:- it requires the pt’s to flex their hip & knee & limits the amount of ROM ex’s. But its depth allows a greater body surface area to be submerged safely & comfortably to as high as the mid thorax region. Low boy tank:- Not deep but allows the pt’s to fully extend their lower extremity & perform full ROM ex’s. Extremity tank:- When only distal portion of the lower extremity has to be immersed, then extremity tank with use of chair will be appropriate.

Upper Extremity Technique The pt’s should be seated comfortably next to the extremity tank, with a towel or other form of padding on the tank edge to avoid compression of axillary area. Special consideration – Oedema can form.

Full body immersion – Hubbard tank E.g. 1. Pt’s with arthritis & is unable to negotiate transfers. 2. Pt’s with neurologically involved – paralysis, who can actively move the limbs in water with the help of water & unable to do the same in air. 3. A burn pt, 4. An elderly or debilitated pt’s with an open wound.

Key treatment parameters to be documented in pt’s file after hydrotherapy Pt’s skin thermal sensory discrimination testing Skin status Health & mental status Hydro equipment Accessories Water temperature Water Additives (When applicable) – Name & concentration of solution. Body part treated Treating method – non immersion or immersion If immersion – level – partial or full If immersion - Duration