Aquatic Therapy

/Hydrotherapy
Hydrotherapy is the Internal or external use of water
in any of its three forms to treat diseases or
traumas.
Water : colorless, transparent, odorless, tasteless
compound of oxygen and hydrogen
Characteristics: Universal solvent. Readily
accessible. Ability to absorb large amount of heat.
Good conductor of heat. May be applied with simple
and inexpensive equipment
Density and specific gravity
Specific gravity of human body = 0.97
density of body Vs density of water
density = mass divided by volume
Hydrotherapy may be defined as the use of
water, in any of its forms, for the maintenance of
health or the treatment of disease.
Hydrotherapy has been used to treat disease
and injury by many different peoples.
Also called( Hydrothermal therapy) additionally
uses its temperature effects, as in hot baths,
saunas, wraps, etc.
Properties of Water
Various static and dynamic properties of water are
Physical / Mechanical properties of water
Hydromechanics
Thermodynamics
Centre of buoyancy


Mechanical Properties of Water
Buoyancy
Hydrostatic Pressure
Cohesion
Adhesion
Viscosity
Surface Tension

PHYSICAL PROPERTIES
Buoyancy;
The force is equal to the weight of water displaced by
the volume of the object
Equal to the force of gravity affecting the object on
land
Equal to the sum of weight of the object in water and
land
Archimedes principle
Clinical significance
It provides the patient with relative
weightlessness and joint unloading allowing
performance of active motion with increased
ease.
Allows the practitioner 3-D access to the pt
Variables used to alter amount of Assistance /
Resistance provided by Buoyancy
Position or direction of movement
Water depth
Lever arm length
Flotation or weighted equipment
Hydrostatic pressure
It is the pressure exerted on immersed objects
Force of the water per unit area of the body
Fluids exert pressure in all directions equally
(Pascals Law)
Directly proportional to both liquid density and
the depth of immersion
(1mm Hg/1.36cm)
120cm depth=88.9 mm Hg=> diastolic BP
Is greater upwards than downwards.
Equal to the diastolic pressure when standing
up in the water .

Clinical Significance
Increased pressure reduces or limits effusion,
assists venous return, induces bradycardia &
centralizes peripheral blood flow.
Allows pts to perform ex more easily when
closer to the surface.
Cohesion
It is the tendency of water molecules to adhere to each
other. Water is attracted to water. It is Directly
proportional to VISCOSITY.
Sig: contributes to resistance when moving through
water
Adhesion
Tendency of water molecules to adhere to molecules of
other substances. Water is attracted to other materials .

Viscosity
Friction occurring b/w molecules of liquid
resulting in resistance to flow
Resistance from viscosity is proportional to the
velocity of movement through liquid
Clinical Significance
Creates resistance with all active movts
A shorter lever arm results in increased
resistance.
Increasing the surface area moving through
water will increase resistance.
Variables to alter resistance provided by Viscosity
Velocity of movt :- Slow movt produces little drag
and resistance is minimal. During fast movt
resistance encountered is proportional to speed
of movt

Surface area ;- more the surface area greater is
resistance encountered eg less resistanceis
encountered in side walking than frwd or
backward walking
Surface Tension
The surface of liquid acts as a membrane under
tension. It is measured as force per unit length.
Cohesion of water molecules at the surface of a
body .
The attraction of water 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 significance
An extremity that moves through the surface will
perform more work than if kept under water.
Horizontal movts are easier to perform in the
water beneath the surface.
Using equipment at the surface of water will
increase the resistance.
Water and Motion
Hydro mechanics
Water in motion has 2 types of fluid flow:-
Laminar/ streamline
Turbulent

Laminar/ streamline
When liquid flows through a long smooth vessel it flows in
straight lines, with each layer of liquid remaining the same
distance from the walls of the vessel throughout its length.
All molecules move parallel to each other, typically slow movt

In laminar flow, the different layers flow at different rates
creating a parabolic profile.

The parabolic profile arises because the fluid molecules
touching the walls barely move because of adherence to the
vessel wall. The next layer slips over these, the third layer slips
over the second and so on.
The shape of the velocity curve
(the velocity profile across any given section of the pipe)
depends upon whether the flow is laminar or turbulent. If the
flow in a pipe is laminar, the velocity distribution at a cross
section will be parabolic in shape with the maximum velocity at
the center being about twice the average velocity in the pipe.
Turbulent flow
Movt where all molecules do not move parallel to each other,
typically faster movt
Related to velocity,density and viscosity of the liquid
Wake formation in front of the object moving in water
Increases when movement is stops
In turbulent flow, a fairly flat velocity distribution exists across
the section of pipe, with the result that the entire fluid flows at
a given single value. The velocity of the fluid in contact with
the pipe wall is essentially zero and increases the further
away from the wall.

Drag
It is the cumulative effect of turbulence and fluid
viscosity acting on an object in motion
Clinical significance
As the speed of movt through water increases, resistance to
motion will increase.
Moving water past the pt will require the pt to work harder to
maintain his/her position in pool.
Application of equipment (glove paddle/boot) will increase the
drag and resistance as the pt moves the extremity through water
These drop immediately when movt stops.
Meta-centre (MC)

Balance in water ; centre of gravity and centre of buoyancy in the
same vertical line
Metacenter is the point where line of gravity and line of buoyancy
meet
not the same as Centre of Body (CB)
The centre of Buoyancy is the reference point of an immersed object
upon which buoyant (vertical) forces of fluid predictably act.
Vertical forces that do not intersect the centre of buoyancy create
rotational motion.
If MC is above the CG the CG will move under CB
If MC is below the CG the CG will move above CB

Clinical Significance
In the vertical position, human centre is located at the
sternum
In vertical position, post placed buoyancy devices will
cause the pt to lean forwd; ant placed will cause pt to
lean back.
During unilat manual resistance ex the pt revolves
around practitioner in a circular manner
A pt with unilat L/E amputation will lean toward the
residual limb side when in a vertical position
Pts bearing wt on the floor of the pool (ie sitting,
knelling, standing) will experience aspects of both the
centre of buoyancy and CG
Heat / Thermo Dynamics

Heat :may be transferred from one object to
another in several different ways, including
conduction, convection, or conversion.
the heating and cooling effects are produced by
conduction of heat from the water to the body.
The contact of water with the body is
accomplished by means of baths, showers,

Thermodynamics
Specific heat
Waters specific heat capacity =1
Airs specific heat capacity =0.001
Water retains heat 1000 x same volume of air

Rate of temp change is dependent upon mass & sp
heat of object
Heat transfer
Increases as a function of velocity
Differences in temp b/w an immersed object & water
will equilibrate with minimal change in temp of water
Swimmer loses more heat in cold water than a
stationary person ; convection
Water releases heat (cold) more easily to the body
than air

Physical Principles
Achieves affects through:
Forces Existing in Water
Buoyancy
Archimedes Principle of Buoyancy
Pressure (hydrostatic Pressure)
Cohesion
Viscosity
Biophysical Effects
Thermal Effects
Local and systemic effects
Mechanical Effects
Agitation
Analgesic effects
Counterirritant
Altering agitation
Movement of Water (agitation)
Mechanical stimulation to skin receptors
sedative
counter-irritant

Stimulus to large afferents
pain block


Thermal effects: are produced by the application of
water at temperatures above or below that of the body.
The mechanical: effects are produced by the impact of
water upon the surface of the body in the form of
sprays, douches, frictions, whirlpools, etc.
The chemical: effects are produced when it is taken by
mouth or used to irrigate a body cavity, such as the
large colon.
Vascular system
Dive reflex = constriction of blood vessels
Compression of all body tissues
Immersion to neck level; 700cm
3
of blood from
extremities and abdominal vessels to veins in thorax
and heart
Causes increase in right atrial pressure, Stroke
Volume and Cardiac Output
Soft tissue effects
Soft tissues compressed
Lymphatic return enhanced
Oedema resolution
Joint effects
Offloads pressure on joints
Immersion to neck level; 7kg compressive force on
spine, hips and knees
In floating buoyancy counterbalances the effect of
gravity force
Percentage of wt bearing at various
immersion depths
Static standing at
C7 level = 10% BW
Xiphoid = 33% BW
ASIS = 50% BW
Fast walking increases weight bearing up to 76%
of the static stance
Muscle tone
heat reduces tone
buoyancy reduces tone
tone influenced by proprioceptive input
stimulated by gravitational force
after 15 minutes immersion tone
automatically decreases>>> relaxation

Renal Effects of Immersion
Increased urine output with loss of plasma
volume, sodium, potassium and suppression of
some related hormones
Homeostatic compensatory mechanism to counter
distended cardiac receptors
Clinical application
Toilet before immersion
Drink water before and after
Check deficiencies in sodium and potassium
Cold water increases diuresis, exercise reduces
Physiologic Responses to
Exercise in Water
Aerobic energy expenditure
May be greater, the same or less than on land
depending on depth, temperature, speed, position in
water and type of activity
VO2 max
Often lower due to lower maximal HR
Max HR <20 than land
Stroke Vol and Cardiac Output
Greater than on land
Problems most likely to benefit from
aquatic rehabilitation
Orthopedic conditions :- OA, RA, AS,
replacements, fractures, spinal operations,
chronic LBP and instability, amputation
Neurological conditions :-SCI, Polio, CP, mobility
impairment, balance impairment
Miscellaneous :- Obesity, burns
Clinical Indications for
Hydrotherapy
Facilitate ROM
Initiate resistance training
Facilitate wt bearing activities
Enhance delivery of manual techniques
Provides 3-D access to the pt
Facilitate cardiovascular exercise
Initiate functional activity replication
Minimize risk of injury or re-injury during rehabilitation
Enhance relaxation
Risks, Cautions, and
Contraindications
Persons with impaired temperature sensation
run the risk of scalding or frostbite at
temperature extremes.
Fear of water
Neurological disorders eg ataxic pts, MS
Seizures
Cardiac dysfunction
Small open wounds and lines
Cont

If pt has diabetes, avoid hot application to the feet or legs. Also
avoid full body heating treatments, such as body wraps.
Avoid cold application if pt is diagnosed with Raynaud's disease.
Hot immersion baths and long, hot saunas are not recommended
for those with diabetes or multiple sclerosis, women who are
pregnant or anyone with abnormally high or low blood pressure.
Don't take cold foot baths if pt is prone to bladder or rectal
irritation. People suffering from sciatica, pelvic inflammation or
rheumatism in the toes or ankles should avoid cold foot baths.
Elderly people and young children may be exhausted by too
much heat and should avoid long full-body hot treatments such
as immersion baths and saunas.
Precautions

Precautions
Ground fault interrupter
Patient should not turn on/off
Dont leave patient alone
Gravity dependent position
Do not run turbine dry
Do not run turbine with ice still melting
Watch for signs of fainting
CONTRAINDICATIONS
Infectious or contagious conditions
Uncontrolled Hyper- or hypotension
Severe kidney, cardiac or respiratory disease, acute TB
Uncontrolled epilepsy
Uncontrolled movements, behavior or cognitive problems
Infectious skin condition or sensitivity to pool chemicals, large
open wounds
Fever
Acute Conditions
Severe peripheral vascular disease
Danger of bleeding or hemorrhage
Open wounds, colostomy & skin infections
Gravity dependent position and agitation
Aims of Exercise
Increase mobility
Unloading of joint forces, muscular relaxation
due to heat
Buoyancy, quantity and direction
Position and available range of the joint motion in
relation to the direction of buoyancy
The direction of movement
Use of floatation aids
Maximise muscle function

Resistance provided by
Buoyancy
volume of the body part, floatation aids, lever arm
assisted, supported, resisted
Turbulence
surface area, speed of motion, drag effect
streamline, turbulent flow
slow, fast, change of direction
Facilitate posture and balance
reactions
Density and hydrostatic pressure
slows down movement
Turbulence
challenges balance reactions
Metacentre and moment of inertia
small movement causes rotation round the Centre of
Buoyancy (CB)
longer radius more stable
Reduce pain and spasticity
Heat
Tone reduction due to buoyancy
Tactile sensory input by pressure, buoyancy,
turbulence and heat
weight reduction on joints due to buoyancy
General Guidelines for Clinical
Administration of Hydrotherapy
Preparatory Considerations
ID treatment objectives
Evaluate patient
Treatment temp
Treatment Duration
General Description and Unit
Operation
Types of Whirlpool
Hydrotherapy Area
Turbine
Whirlpool Care and Safety
Cleaning
Blood-borne pathogens
Electrical Safety
Equipment
Extremity tanks
Smallest tanks which holds up to 25 gallons of water
Low boys:
Full-body tanks; resemble a bathtub resting on the floor with
enough room for pt to long-sit
Hold as much as 200 gallons of water
Hubbard tank:
Tanks that were created to accommodate a pt in supine
position, and allow range of movement in both upper & lower
extremities
Has lifting devices to get pt in and out of whirlpool
Equipment cont.
Turbines:
Mix air & water to provide agitation & turbulence to
the water
Stimulation from the agitation to the skin receptors
may promote an analgesic effect
Turbines have adjustable; height, direction of flow, &
strength of flow
Assessment
On land +
Swimmer/non
Body shape
Body density
Precautions and relative contraindications
Assessment in Water
Pain
ROM
Tone
Muscle strength
Vital capacity
Balance
Weight bearing
gait
Recording Rx
Rx time
Water Temp C
Depth of water
Exs :- FITT, position, size of floats, equips.
Progression
Cardiac output in and out of water
Outcomes
Modified Oxford Scale
1 = Buoyancy assisted (B.A)
2 = B. Counteracted/neutral (B.N)
2+ = Slowly against B.
3+ = Against B. at speed
4 = Against B. with a small float
5 = Against B. with a large float

Turbulence
Hydrotherapy Treatment
Methods
Conventional treatment
Aquatic Feldenkrais
Bad Ragaz Technique
Hallwick method
Watsu

Conventional method
buoyancy and turbulence assist, support or resist the
movement

isotonic concentric and eccentric, isometric
with and without floatation and resistance equipment

Common techniques
baths and showers
neutral baths
sitz baths
contrast sitz baths
foot baths
cold mitten friction rub
steam inhalation
hot compresses & cold compresses
alternating hot and cold compresses
body wrap
wet sheet pack

Soak a linen cloth in cold water wring out and
briskly rub the upper and lower trunk, or the
entire body. Go to bed until warm and dry .
Indications:- For invigoration, to tone up the
body, to promote blood flow, for use in problems
of circulation, or infections of the respiratory
system.
Cold Whirlpool
Treatment
50-60 F
Tx time = 15-20 min
Physiological Responses

Warm Whirlpool
Treatment
Agitation = 6-8 inches from segment
Temperature
Arm and hand = 98-110
Lower extremity = 98-104
Full body = 98-102
Tx time
Physiological Considerations
Saunas and steam baths are similar in effect; the
decision to take one rather than the other will be guided
by personal preference.
acts more quickly to eliminate toxins through the skin.
Saunas are deeply relaxing and are a great way to melt
away stress.
it stimulates blood flow, increases the heart rate .
has an immune-modulating effect
cont
promotes hormone production .
encourages mucosal secretions in the
respiratory system, opens the airways reduces
resistance to respiration .
relaxes, and can improve mental outlook.
Children can start to take saunas at two or three
years of age.
cont
Warnings:
should not be taken by persons with acute rheumatoid
arthritis, acute infection, active tuberculosis, sexually
transmitted diseases, acute mental disorder,
inflammation of an inner organ or blood vessels,
significant vascular changes in the brain or heart,
circulatory problems or acute cancer.
Do not spend more than 15 to 20 minutes at a time in a
sauna.
Wipe the face frequently with a cold cloth to avoid
overheating.

Guidelines for Contrast Bath
Temperatures
Warm = 104-106 F
Cold = 50-60 F
Sequence
Warm = 10 min
Hot:cold ratio = 3:1 or 4:1
Cold for 1 min
Warm for 4 min
Continue for 30 min
Modifications
Indications
Contraindications

Various substances can be added to warm and rising
temperature baths. The following are the different kinds
of bath used:
Rising temperature hip bath:- This is taken in a tub
filled with a hand's breadth of tepid water. Hot water is
then gradually added until the level reaches the navel.
The final temperature should be 103-104'F. Following
this procedure, the patient is wrapped warm and
proceeds to bed. It should last 15-30 minutes, not more
than three times per week.
Indications: incipient and abating common colds, back
pain (sciatica).
Warning: to be used with caution by persons with heart
or circulation problems, hemorrhoids, or varicose veins.

Cold foot bath:- The feet are placed into a foot bath filled to
calf depth with cold water. Stop when a cold stimulus is felt
or when the water is no longer perceived as being
particularly cold. Stroke off excess water, dress, and walk or
run until dry. A special form of this treatment is "walking in
water," which involves walking stork-like on a non-slip mat
placed under the water.
Indications: Varicose veins, susceptibility to edemas,
headaches, low blood pressure, circulatory problems,
sleeplessness, proneness to the common cold, sweaty feet,
or a contused
Warning: This type of treatment is best avoided by people
who suffer from cold feet, very high blood pressure, an
irritable bladder, urinary tract infection, diabetes, or vascular
occlusion

Rising temperature foot bath, warm foot bath :- The feet are
immersed in a foot bath filled with water at body temperature.
Hot water is gradually added to give a final temperature of
103-104'F. In warm foot baths water of this temperature is
added straight away. Keep warm afterwards. The procedure
should last 10-15 minutes and can be done daily.
Indications: Cold feet, start of a common cold, for relaxation.
Warning: Best avoided by people with varicose veins,
lymphostasis, or edema.
Cold arm bath:- A basin is filled with cold water until it reaches
a depth several inches above the immersed elbow. If the
treatment becomes intolerable, stop and repeat as desired.
Indications: Headaches, sleeplessness.
Warning: Best avoided by people with heart or circulatory
problems.
Rising temperature arm bath:- In principle, this is the same as the
rising temperature foot bath. It should be followed by a cold arm
douche, then by half an hour's rest.
Indications: Bronchitis, asthma, incipient respiratory infection,
circulatory problems, angina pectoris.
Sitz bath:- This is generally taken in a hip bath as a cold, rising
temperature, or warm sitz bath. Prior to a sitz bath, warm the feet,
e.g. through a warm foot bath. Parts of the body not immersed in
water should be covered.
Indications: Cold sitz bath for hemorrhoids or inflammation of the
anus; warm or rising temperature sitz bath for difficulty in voiding
the bladder, an irritable bladder, inflammation or infection of the
prostate, preparation for pregnancy.
Warning: Do not use warm or rising temperature sitz baths for
hemorrhoids.
Douches
Gentle douches can be carried out with a watering can or hose. The
water should not splash, but gently envelop the skin. The water stream
should always be directed from the periphery toward the heart. After
douching, stroke off excess water, dress, and exercise. There are
various types of douche:
Knee douche:- The water stream is directed from the right small toe,
along the outside of the lower leg to the hollow of the knee, then back
along the inside and over the sole of the foot. The process is then
repeated for the left leg.
Useful for headaches and migraines, low blood pressure,
sleeplessness, contusions, and varicose veins. This treatment
influences the digestive and reproductive organs and can help ward off
vascular damage.
Do not use for urinary tract infections, irritable bladder, sciatica, or
during menstruation.

Thigh douche:- The procedure is as for a knee douche, but
includes the upper thigh. It can stimulate blood flow and help
improve poor circulation.
Useful for the treatment of varicose veins, muscular
rheumatism, crural paralysis, coxarthritis.
Do not use for urinary tract infection, irritable bladder, sciatica,
or during menstruation.
Lower trunk douche:- The procedure is as for the thigh
douche, but including the lower trunk.
Useful for diabetes mellitus, meteorism, enlargement of the
liver, enlargement of the gallbladder, stone formation.
Do not use for urinary tract infections, irritable bladder,
sciatica, or during menstruation.
Arm douche:- Direct the water stream from the outside of the
right hand to the shoulder, then back on the inside of the arm.
Repeat the process for the left arm.
Useful for cold hands, nervous disorders, neuralgia and
paralysis, rheumatism of the arms, heart problems, vertigo,
headaches, catarrh in the nose and throat.
Chest douche:- Douche the arms first.
Useful for chronic bronchitis and bronchial asthma, angina
pectoris.
Caution: Moderate the temperature if there is risk of
angiospasm

Upper trunk douche:- This involves the upper torso and
arms. It can be used to improve blood flow to the lungs,
heart, and pleura.
Useful for the treatment of bronchitis, bronchial asthma,
disease of the larynx and vocal cords, headaches, nervous
excitability, varicose veins of the legs, for toning-up, and for
stimulating cardiac and respiratory activity.
Caution: Do not use if there is blood stasis in the pulmonary
circulation.
Back douche:- Useful for the treatment of weakened back
muscles, back pain, spinal disease, multiple sclerosis,
bronchial asthma, nearly all diseases of the lung.
Warning: Do not use in debilitated patients or those with
neurasthenia.
Neck douche:- Useful for headaches, migraines,
tenseness in the shoulder and neck, hypersensitivity to
changes in the weather, mild depression, tinnitus,
vertigo, arthrosis of the hand and finger joints.
Warning: Not to be used in persons with high blood
pressure, enlargement of the thyroid, or raised
intraocular pressure.
Face douche:- Proceed from the right temple
downward to the chin, upward to the left temple, from
right to left over the forehead, and repeatedly from the
forehead to the chin, then in circles over the face.
useful for relieving headaches and migraines, trigeminal
neuralgia, toothaches, for relaxing tired eyes.
Caution: Keep the eyes closed.

Wraps
A wrap is primarily used as a supportive measure for treating
fever and local inflammation. The person receiving treatment
should first adopt a relaxed position. Then a linen cloth is
moistened with cold water (warm water for respiratory diseases),
well wrung out, and then wrapped tightly around the appropriate
part of the body, but not so tightly as to cause constriction. The
moist linen cloth is in turn wrapped with a dry cotton or linen
cloth. The patient is then usually wrapped in a blanket or another
cloth, and should rest for 45-60 minutes or, if the intention is to
induce sweating, for up to three hours.
If the wrap is not felt to be warm after a quarter of an hour, heat
should be applied in the form of a hot water bottle or by giving
warm tea. The wrap should be removed immediately if the
person complains of feeling unwell.
Indications:
Neck wrap: sore throat
Chest wrap: bronchitis, lung disease, neuralgia
Body wrap (between costal arch and pubic bone):
inflammatory disease of the upper abdomen, gastric and
duodenal ulcers, cramps, sleeplessness, fever
Trunk wrap (between pubic bone and armpits): high fever
Hip wrap (with gap between the legs): prostatitis, vaginitis,
hemorrhoids, anal eczema, inflammation in the pelvic cavity
Calf wrap (between foot and knee): lymphostasis, edema,
for withdrawing heat in fever and phlebitis; in varicose veins
the effect can sometimes be amplified through the use of
healing earth or loam poultices
Joint wraps: rheumatoid arthritis, arthrosis


Packs
Warm packs:- A wrapping cloth is soaked in a hot
infusion or decoction of herbs, then wrung out and
applied to the patient's body. Alternatively, the wrap
may receive a coating of hot mud mustard flour, or
fango. As a further alternative, hayseed may be
placed in a sack and steamed.
Indications: Painful chronic diseases such as
arthrosis, renal disease, or cystitis, and for
stimulating blood flow.
Warning: Always check that the temperature is
tolerable before applying a wrap.
Cold packs:- Cooled cataplasm is spread onto
the wrapping cloth and placed on the part of the
body. Crushed ice in a plastic bag may also be
repeatedly applied for one minute, then removed
for four.
Indications: Various inflammatory arthropathies,
sprains and strains, pleurisy. Ice packs can also
be used for headaches.
Warning: When using ice packs, place a thin
cloth between the pack and the skin to prevent
frostbite.
Herbal baths
Can be particularly soothing when experiencing a
period of stress. There are several ways to prepare an
herbal bath:
1. Simmer 1/2 cup of herbs in 1 quart of water in a
covered pot for fifteen minutes. While the herbs are
simmering, take a short shower to cleanse body, then
fill the tub with hot or warm water. Strain the liquid
from the decoction into the bath water, and wrap the
herbs in a washcloth. Soak in the tub for at least
twenty minutes, using the "herbal washcloth" to rub
over your body.
2. Add 1/2 cup of herbs to running bath water, preferably hot. Soak in
the tub for twenty to thirty minutes.
3. Fill a thin cloth bag with 1/2 cup of herbs, either placing it in the bath
water or tying it to the spigot so that the hot water runs through it as it
fills the tub. Again, soak for twenty to thirty minutes.
Certain herbs are quite effective for creating soothing baths. Combine a
handful each of valerian, lavender, linden, chamomile, hops, and
burdock root, and add it to bath according to one of the preceding
methods.
Soak for thirty minutes in the tub. Another soothing herbal bath calls for
a handful each of hops, linden, valerian, chamomile, yarrow, and
passionflower. Prepare this bath according to one of the preceding
methods, or simmer the herbs in a quart of water, then drink 1/2cup of
the liquid (with lemon and honey added, if you wish) and pour the rest in
the tub. While soaking in an herbal bath, one can read, meditate, listen
to peaceful music, or just sit quietly, concentrating on relaxing yourself.
Importance of Drinking Sufficient
Water
It is very important that we drink sufficient amount of
water in a day to make up for the water lost. The
benefits of drinking water is widely recognized. Drinking
pure, fresh water is essential to our health and well-
being.
Our need for water increases as we grow older. As we
age, our skin and mucus membranes become thinner
and lose more water, and our kidneys function less
efficiently. So our need for water increases. One may
not feel thirsty. But should get into the habit of drinking
water, nevertheless.
World War II nuclear physicist Moshe Feldenkrais
developed series of techniques now known as
Feldenkrais after he tore the cartilage in his knees while
playing soccer in the 1930s.
They are usually performed with the patients back or
side against the pool wall to enable him to receive
feedback from touch receptors.
The patient performs the moves slowly as the therapist
gives verbal (and occasionally tactile) cues.
The intent of these exercises is usually to promote
greater flexibility and better body awareness.
Suggested Patient Populations: Patients with
balance or proprioceptive dysfunction (e.g., post-
ACL reconstruction, frail Elderly ,CVA or head injury.
Chronic pain patients who need to be weaned from
hands-on intervention. Patients with restricted
extremity ROM (e.g., adhesive capsulitis, stiff knee
syndrome).
Needed Equipment: Warm water pool (with walking
lane) at about 86 to 94 degrees Fahrenheit, with
water depth of 4 to 5 feet
Badragaz method
In 1957, the work of German physician Knupfer was
brought to the thermal spas in Bad Ragaz, Switzerland
(from which the techniques name was taken).
Knupfer developed exercises in which the patient was
supported by rings or floats around his neck, arms,
pelvis and knees while lying horizontal in the water.
The doctor felt that the hydrodynamic and thermal
properties of the water, combined with unique non-
weight-bearing exercises, would promote excellent
patient results.
His exercises were later modified and used to
make a closed kinetic chain possible while
floating supine in the water.

In these exercises, the therapist holds the
patient at a fixed point; this is the point about
which all movement will occur.

The Bad Ragaz Ring Method (or Ring Method,
as it is alternatively called) is used predominately
for active and stabilization exercises.
Suggested Patient Populations: Patients with
poor spinal stabilization skills. Patients with
neurological disorders (CVA; spinal cord injury,
incomplete; or head injury). Patients with weight-
bearing restrictions for lower extremities who still
need to work in a closed kinetic chain.
Needed Equipment: Warm water pool (at least 7-
by-8-foot diameter) at 92 to 98 degrees Fahrenheit,
with water depth of 3 to 4 feet. Cervical flotation
collar. Buoyancy cuffs for ankles and wrists.
Flotation belt for waist.
Bad Ragaz techniques
Uses a buoyant ring to assist the patient in floating in
the water
therapist is the fixing point
isometric, isotonic concentric and eccentric, isokinetic
Modified PNF using 3-D movements and special techniques
Ring may be placed around the trunk, under the
extremities, or may support the head and neck
Halliwick method
In London, England, around 1951 James McMillan began an
effort to teach severely disabled girls to swim. He had no
medical training and thus met with great opposition. By 1952, a
national
Halliwick teaching organization was created. The basic tenets
of that organization formed the concepts we now know as the
Halliwick Method (named for the school). McMillan taught
these basic tenets and expanded their application from
swimming to rehabilitation by teaching both a basic and
advanced course throughout Europe,
Goal = total independence
The Halliwick Method has the following purposes:
to teach people how to maintain balance control in the
water and
to teach them to swim.
The tenets of the Basic Halliwick Course are written as
a Ten-Point Program, which, if followed in order, is
designed to enable the student to learn to swim.
McMillan suggested that these steps would best be
mastered through the use of games.
Each patient is paired with an instructor and treatment
occurs within a group format (ideally) consisting of five
patient-instructor pairs. No flotation devices are used in
order to allow the disabled patient to be barrier-free in
water.
The Ten-Point Program is divided into four
phases.
Phase One:- addresses mental adaptation to
being in water.
Phase Two:- deals with the patients ability to
restore balance from all positions in the water.
Phase Three:- concentrates on teaching the
patient to master inhibition of unwanted
movement and to remain stable in the water.
Phase Four:- teaches the patient to move (swim)
from that stabilized position.
Suggested Patient Populations:
Patients with developmental disorders.
Patients unable to ambulate or exercise on land.
Advanced Halliwick: Patients with spinal pain,
head injury.

Needed Equipment: Swimming or therapy pool
with swimming lanes and room for at least rive
patient-instructor pairs (each pair requires about
5 square feet of room).
Watsu = Water Shiatsu
Watsu was developed by Harold Dull, a body-worker
and poet, in 1980 in Middletown, Calif.
Birthed from a mixture of Zen shiatsu and its
creators natural affinity for water, the term Watsu
was coined from the phrase water shiatsu.
Watsu is performed in a warm water pool and is a
wholly passive technique.
The patient is usually cradled in the providers arms
(beginning in a fetal position), while stretches and
other bodywork is performed.
.
It was created by Dull as a method for healthy
people to work with other healthy people, not for
health care professionals to provide a service to
patients.
passive stretching with rhythmic rotational
movements through water are intiated
Suggested Patient Populations:
Patients with restricted ROM of spine or extremities.
Patients exhibiting high tone or spasticity.
Patients with a predominant symptom of pain.
Note: Because Watsu is passive, it should be used only
to break the pain cycle and then discontinued in order to
prevent patient reliance on one-to-one intervention.
Needed Equipment: Warm water pool (at least 10-by-
l10-foot diameter) at 93 to 98 degrees Fahrenheit, with
a water depth of 4 to 5 feet and no steps.
Woggle or noodle to put under patient knees if
patient is larger than provider.
Deep water exercises
Open chain exercises are performed here
Buoyancy-assistive devices can be worn to help
pt maintain an upright posture in water
Middle-level to shallow-level
exercises
Promotes some weight bearing
Considered closed-chain exercises
Pain with exercises can be minimized


TREATMENT IN WATER


Debridement
Is the rapid removal of necrotic & devitalized tissue to
allow reepithelialization & granulation
Necrotic & devitalized tissue impedes granulation &
prevents or slows migration of epithelial cells across the
wound
This tissue delays healing & provides potential for
bacterial growth
Hydrotherapy can be utilized to debride, soften, &
loosen adherent tissue
Hydrotherapy for wound care
Cleansing
Removes dirt, foreign bodies, exudates, or residue
from topical agents & bacteria
Hydration
Provides a moist wound bed that will proceed more
rapidly through the phases of healing
Circulatory stimulation
Increased circulation obtained with hydrotherapy is
the result of thermal effects
Hydrotherapy for wound care cont.
Analgesia & sedation
Mechanical stimulation of skin receptors can assist in decreasing
pain
Thermal effects also assist
Condition of surrounding tissues
Assess for: color, edema, temp, areas of pain or sensory
changes, & pulses
Description of wound:
Document & describe: location, size, shape, margins, exudates
Additives to whirlpool:
Most frequently used bactericidal additives are betadine, salt, and
chlorazine
Follow these steps for an Effective
Hydrotherapy:
For overall tension reduction, use a neutral bath
(temperature between 92 to 94 degree F) that is close
to the skin temperature.
Use water temperature between 102 to 106 degree F
for loosening tight, tense muscles and reducing the pain
of stress-related conditions such as backache. (Using
temperatures higher than 106 degrees is not
recommended as it can raise your body temperature
very fast, inducing an artificial fever.)

Take a cold shower after stepping out of the bath. This
brings and immediate rush of blood through the system,
as well as a rush of energy. (Try alternating cold and
hot shower to get a similar effect. 3 minutes of hot water
followed by 30 seconds of cold water and the 3 minutes
of hot water, etc.)
Stay in the bath no more than 15 to 20 minutes. If pt
has high blood pressure or cardiovascular problems,
don't stay long enough to raise the body temperature.
Evening is the best time to soak in water. A study
conducted in England found that people who took a
soaking bath before going to bed slept more readily and
deeply.
Aquatic pools & infection control
If Water not emptied from pool following every
patient
Recommendations
Pts shower before entering pool to remove excess
soil
Have filtration system that is chlorinated
Do not use with pts who are incontinent
Do not use with pts with open wounds
Additives to prevent infection
Tanks & turbines must be thoroughly cleaned in
between pts
Most common agents used to prevent or reduce
chances of infection are providone-iodine,
chloramines-T, & bleach
Important to run turbine with disinfectant agent in
water