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Calvary Health Care Sydney
HYDROTHERAPY
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 water
1.1 Buoyancy
• Provides upward pressure of water
on the body, opposing gravity.
• Therefore reduces body weight:
- AAROM for UL and LLs
- Decrease pressure on joints
1.2 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 water
1.3 Hydrostatic pressure
1.4 Resistance
• Force exerted by water on an
• Water is dense providing greater
immersed object is proportional
resistance to movement. More
to
surface area in the direction of
the movement  more
the depth of water. Hydrostatic
resistance  more force needed
pressure on limbs may help
to overcome resistance.
reduce
(Important for strength training
swelling.
in water.)
• Increased Central Blood Volume
• Consideration in designing an
20-40%
aquatic exercise program for
facilitating movement and vary
(Aquatic exercise for people with
the intensity of the exercises.
multiple sclerosis MS Australia
June, 2009)
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 • Renal Effects
significant change but
Increase in central venous
Diastolic blood pressure
pressure is stimulus for:
decreases
- Diuresis: increased
• Thus Mean blood
urine excretion
pressure decreases by:
- Natriuresis: increased
- 9mmHg at 33 & 35 ⁰C
Na excretion
- 18mmHg at 37 ⁰C
- Kaliuresis: increased K
- 30mmHg at 39 ⁰C
excretion
Respiratory effects
Hydrostatic Pressure of 2ocmH2O
Compression of chest wall
Decreased Vital Capacity
Increased Circulation
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 Pain
Warmth 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 pressure
Heat gain and loss
Renal function
To 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 Effective
Hydrotherapy 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, selfefficacy and affect, and with a lesser representation,
balance and fitness, in patients with generally chronic
conditions such as rheumatic diseases and hip osteoarthritis, 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), 514529.
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, SingleBlind 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.