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

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

3. 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 HYDROTHERAPY H - 1st Semester
9/20/2018

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

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

6. 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

7. 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

8. 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

9. 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

10. 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

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

12. Physiological Effects - Psychological Effects
Relaxing
Warm water

14. 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

15. 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 )

16. 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.

17. 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

18. 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)

19. 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

20. 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

21. Modalities

22. WATER IMMERSION MODALITIES
Whirlpool bath
Hubbard tank
Pool/Aquatic Therapy

23. Low Boy Whirlpool
High Boy Whirlpool
Extremity Whirlpool
Chair for Whirlpool

24. 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.

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

26. 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.

27. Components of the Turbine

28. 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.

29. 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.

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

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

32. 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

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

37. 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.

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

39. 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.

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

41. 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.

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

43. 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.

44. 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

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

46. 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.

47. 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.

48. 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.

49. 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

50. 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.

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

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

53. 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

54. 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

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

56. 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

57. Application of Hydrotherapy
Practical point of view
Application of Hydrotherapy

58. 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

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

60. Whirlpool
Tanks
Low-Boy
High-Boy
Extremity
Hubbard Tank

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

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

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

64. 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.

65. 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.

66. 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.

67. 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.

68. 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