HYDROTHERAPY

Calvary Health Care Sydney

Updated May 2013

Outline

• What is hydrotherapy?• Therapeutic and Physiological Effects of

Hydrotherapy• Beneficial properties of water• Evidence Based Practice for different

conditions

What is hydrotherapy?

• According to Hydrotherapy Association of Chartered Physiotherapists (2006), Hydrotherapy is “a therapy programme using the properties of water, designed by a suitably qualified physiotherapist, to improve function, ideally in a purpose-built and suitably heated hydrotherapy pool”.

What is Hydrotherapy?

• Used in the treatment of a wide variety of conditions

• The warmth of the water promotes muscle relaxation and pain relief

• Buoyancy may be used to assist or resist joint movements as well as minimising the compressive forces of gravity

Beneficial properties of water1.1 Buoyancy• Provides upward pressure of water

on the body, opposing gravity.• Therefore reduces body weight: - AAROM for UL and LLs- Decrease pressure on joints1.2 Turbulence• Irregular motion or swirling

agitation of water. • An environment for static and

dynamic balance.• Increase level of challenge can be

raised by increasing the water agitation.(e.g. perform faster or larger movements)

Beneficial properties of water1.3 Hydrostatic pressure• Force exerted by water on an

immersed object is proportional to

the depth of water. Hydrostatic pressure on limbs may help reduce

swelling. • Increased Central Blood Volume

20-40%

(Aquatic exercise for people with multiple sclerosis MS Australia June, 2009)

1.4 Resistance• Water is dense providing greater

resistance to movement. More surface area in the direction of the movement more resistance more force needed to overcome resistance. (Important for strength training in water.)

• Consideration in designing an aquatic exercise program for facilitating movement and vary the intensity of the exercises.

The physiological effects of immersion evoke:

(Hydrotherapy in adult neurology By Johan Lambeck PTEWAC Medical http://www.ewac.com)

• Mobilisation of interstitial and lymph fluids to the central cavities

• Increased blood supply to the muscles• Reduced sympathetic output• Increase in elasticity of connective tissue

The physiological effects of immersion evoke:

• Decrease of muscular contraction forces• Mechano-sensory effects on nociception/pain

transmission: less pain• Decrease of joint compression forces• Isokinetic resistance, provided by turbulent drag• Altered proprio-/exteroceptive input• Effects on the vestibular system

Effects of water properties

Cardiovascular Effects• central blood

volume• blood pressure• stroke volume• cardiac output• heart rate or

remains unchanged

• Hydrotherapy pool water temp. between 33-36oC. Thermoneutral at 35oC.

• CO as temperatures 33⁰C - 30% at; 39⁰C -

121% • Peripheral resistance

reduced with higher temperatures with increased vasodilation

Effects of water properties

• Systolic Pressure has no significant change but Diastolic blood pressure decreases

• Thus Mean blood pressure decreases by:

- 9mmHg at 33 & 35 ⁰C - 18mmHg at 37 ⁰C - 30mmHg at 39 ⁰C

• Renal EffectsIncrease in central venous

pressure is stimulus for: - Diuresis: increased

urine excretion - Natriuresis: increased

Na excretion - Kaliuresis: increased K

excretion

Respiratory effectsHydrostatic Pressure of 2ocmH2O

Compression of chest wall Increased Circulation

Decreased Vital Capacity Decreased Lung Compliance

Increased Work of Breathing

Respiratory effects

• Decreased Lung Volume (3-10%)• Decreased Vital Capacity (3-10%)• Decreased Functional Residual Capacity (30-60%)• Increased airways resistance (up to 58%)

BUT• No significant change in respiratory rate• No significant change in oxygen saturations

Effects on PainWarmth of water reduces pain via:• Vasodilation- increased circulation and dissipation of allogenic

chemicals; Increased collagen extensibility; Activation of large diameter myelinated fibres from thermal sensation and mechanoreceptor stimulation from exercise –closes the gate to predominantly small nociceptive impulses.

Buoyancy:• Reduced compressive force on joints Less mechanical stress

and reduced nociception; Movement is easier- moves through bigger joint ROM which mobilises synovial fluid across articular cartilage and therefore improves nutrition.

Hydrostatic Pressure:• Reduces oedema; Dampened SNS- may help to decrease

spasm; Enhanced sense of wellbeing (opioid activity)

Clinical Implications:

Need to consider:

Pool temperature and exercise intensity in relation to:Blood pressureHeat gain and loss

Renal functionTo keep well hydrated

Others:Infection control

Wounds to be covered up and incontinence

Conventional Hydrotherapy(Hydrotherapy in adult neurology By Johan Lambeck PTEWAC

Medical http://www.ewac.com)

• No specific philosophy The exercises are classified in:• Buoyancy assisted/resisted exercises• Exercises with neutral buoyancy• Exercises that make use of a change of

lever/speed/frontal plane

Conventional Hydrotherapy

• In many cases these exercises are focused on one joint and/or one muscle group. This is why the exercises with these variables can be easily used in group therapy and self- organised exercise schemes.

• Specific equipment as chairs, plinths, bars and smaller aids belonging to the conventional land based exercise are often used.

General training principles for neurological patients are:

• To prevent soft tissue contractures and mobilise stiff joints, preferably by active means

• To elicit muscle activity by e.g. compensating for gravity ( use of buoyancy)

• To train motor control using concrete goals as standing, walking, reaching etc.

• To increase muscle strength: repeat with relevant movements• To change the environment to modify maladaptive movement

strategies• To train endurance (Carr

& Shepherd, 1998)

Evidence for EffectiveHydrotherapy by Jenny Geytenbeek (2002)

The balance of evidence from high to moderate quality trials indicates that hydrotherapy offers benefit toward improving pain, strength, flexibility, function, self-efficacy and affect, and with a lesser representation, balance and fitness, in patients with generally chronic conditions such as rheumatic diseases and hip osteo-arthritis, chronic low back pain, and among elderly people. Hydrotherapeutic rehabilitation in neurological conditions, such as multiple sclerosis, traumatic brain injury, stroke, paediatric neurology, and rehabilitation from acute orthopaedic injury have received little attention from researchers to date.

TKR and THR• Hydrotherapy after total knee arthroplasty. A follow-up study(S. Giaquinto , E. Ciotola, V. Dall’Armi, F. Margutti 2010)Hydro vs land base – recommend hydro for elderly with TKR• Hydrotherapy after total hip arthroplasty: A follow-up study(S. Giaquinto , E. Ciotola, V. Dall’Armi, F. Margutti 2010)Hydro vs land base – recommend hydro for elderly with THR• Multicenter Randomized Controlled Trial Comparing Early Versus Late

Aquatic Therapy After Total Hip or Knee Arthroplasty(T.R. Liebs, W Herzberg, W Rüther, J Haasters, M Russlies, J Hassenpflug

2012)Early TKR is recommended but not late. Early THR did not show

improvements

TKR and THR• A Specific Inpatient Aquatic Physiotherapy Program Improves Strength

After Total Hip or Knee Replacement Surgery: A Randomized Controlled Trial

(A.E. Rahmann, S.G. Brauer, J.C. Nitz 2009)Early recovery of hip strength after joint replacement surgery. Aquatic

physiotherapy can be safely considered in this early postoperative phase.

• Land-Based Versus Water-Based Rehabilitation. Following Total Knee Replacement: A Randomized, Single-Blind Trial

(A.R. Harmer, J.M. Naylor, J Crosbie, T Russell 2009)Hydro vs land base – similar outcomes• Effects of Aquatic Resistance Training on Mobility Limitation and Lower-

Limb Impairments After Knee Replacement(A Valtonen, T Pöyhönen, S Sipilä, A Heinonen 2010)Favourable effects on mobility limitation: wide-ranging positive effects on

patients after knee replacement surgery.

References:Carr, J & Shepherd, R. (1998).Neurological Rehabilitation: Optimizing Motor

Performance, Sydney: Butterworth Heinemann.Geytenbeek, J. (2002), Evidence for effective hydrotherapy. Physiotherapy, 88(9), 514-

529.Giaquinto, S, Ciotola, E, Dall’Armi, V & Margutti, F. (2010). Hydrotherapy after total

knee arthroplasty. A follow-up study. Archives of Gerontology and Geriatrics, 51, 59–63.

Giaquinto, S, Ciotola, E, Dall’Armi, V & Margutti, F. (2010). Hydrotherapy after total hip arthroplasty: A follow-up study. Archives of Gerontology and Geriatrics, 50, 92–95.

Hall, J, Bisson, D & O’Hare, P. (1990). The Physiology of Immersion. Physiotherapy, 76(9), 517-521.

Hall, C.M, & Brody, L.T. (2005). Therapeutic Exercise: Moving towards Function. Philadelphia: Lippincott, Williams & Wilkins.

Harmer, A.R, Naylor, J.M, Crosbie, J & Russell, T. (2009). Land-Based Versus Water Based Rehabilitation. Following Total Knee Replacement: A Randomized, Single-Blind Trial. Arthritis & Rheumatism (Arthritis Care & Research), 61 (2), 184–191.

References:Hydrotherapy Association of Chartered Physiotherapists, HACP (2006). Guidance on

good practice in hydrotherapy. Retrieved 23rd May 2012, from http://www.csp.org.uk.

Lambeck, J. (2004-2013). Hydrotherapy in adult neurology, retrieved 27th March 2012, from http://www.ewac.com.

Liebs, T.R, Herzberg, W, Rüther, W, Haasters, J, Russlies, M & Hassenpflug, J. (2012). Multicenter Randomized Controlled Trial Comparing Early Versus Late Aquatic Therapy After Total Hip or Knee Arthroplasty. Archives of Physical Medicine and Rehabilitation, 93, 192-199.

Mehrholz, J, Kugler, J & Pohl, M. (2011). Water-based exercises for improving activities of daily living after stroke (Review). The Cochrane Collaboration. p 1-25.

Rahmann, A.E, Brauer, S.G & Nitz, J.C. (2009). A Specific Inpatient Aquatic Physiotherapy Program Improves Strength After Total Hip or Knee Replacement Surgery: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 90, 745-755.

Valtonen, A, Pöyhönen, T, Sipilä, S & Heinonen, A. (2010). Effects of Aquatic Resistance Training on Mobility Limitation and Lower-Limb Impairments After Knee Replacement. Archives of Physical Medicine and Rehabilitation, 91, 833-839.