Aila Nica J.

Bandong, PTRP
Instructor Department of Physical Therapy Clinical Supervisor CTS- Pediatric Section College of Allied Medical Professions

Learning Objectives
At the end of the lecture, the students should be able to: Define hydrotherapy Identify the chemical, physical, and thermal properties of water Enumerate the therapeutic effects of hydrotherapy Identify the factors that affect thermal effects of water Differentiate the types of water immersion modalities Identify the parts of a whirlpool bath Enumerate the indications, contraindications, and precautions/guidelines for the use of the modalities Identify common additives in whirlpool therapy Use clinical decision making skill in choosing appropriate water immersion modality Learn how to operate a high-buoy tank Apply evidence regarding use of water immersion modalities in practice

CHEMICAL PROPERTIES
Pure water is a

polar molecule consisting of 2 molecules of Hydrogen and 1 molecule of Oxygen

CONSTANTS
freezing point: 0 degree Celsius
boiling point: 100 degrees Celsius density:

at 0 degree Celsius- .999868 at 4 degrees Celsius- 1.0000

pH: 7 specific heat: 1.00

FORCES EXISTING IN WATER

buoyancy hydrostatic pressure cohesion viscosity surface tension

Buoyancy
upward force exerted on an immersed object OPPOSITE to gravity

Archimedes Principle: a body immersed in a liquid experiences an upward force equal to the weight of the displaced liquid
affected by postural alignment, surface area, weight of bones in relation to muscle and fat, and vital capacity

Hydrostatic Pressure
ratio of magnitude of force per surface area

Pascals Law: pressure exerted by water is equal in all parts of the object
tends to increase as depth and density increases

Cohesion
force between same molecules tendency to attract each other

Viscosity
friction between molecules

property of water that resists motion within it

leads to resistance to flow

Dependent on: speed/velocity of movement of liquid

shape of the body

FLUIDITY

Surface Tension
surface of liquid acts as a membrane under tension

increased attractive forces on the surface

HYDROMECHANICS
laminar flow All molecules are parallel
turbulent flow Molecules are erratic/not parallel drag Cumulative effect of turbulence and fluid viscosity

SPECIFIC HEAT
amount of heat (calories) needed to raise the temperature if 1 gram

of substance by 1 degree Celsius 1 calorie high specific heat prevents sudden changes in temperature

THERMAL CONDUCTIVITY
ability of a substance to

conduct heat water: 0.6

METHODS OF HEAT TRANSFER

CONDUCTION

CONVECTION

RADIATION

EVAPORATION

Conduction
Exchange of thermal energy between bodies in contact with each other

Convection
Heat transfer by mass motion of water when the heated fluid is caused to move away from the source of heat, carrying energy with it

Radiation
Exchange of electromagnetic energy due to difference in temperature between the skin and surrounding environment

Evaporation
Occurs through loss of fluid from sweating and by the pulmonary system during exhalation

the use of water as a therapeutic agent

Therapeutic Effects of Water

THERAPEUTIC EFFECTS

Thermal
Cold application

Heat application

Mechanical
Agitation

COLD APPLICATION
increased cardiac tone
peripheral vasoconstriction increased blood viscosity

decreased HR
longer diastole

decreased vasodilator metabolites

decreased blood flow

HEAT APPLICATION
vasodilation of arteries and arterioles
increased capillary permeability release of vasoactive agents

increased metabolism (Vant Hoffs Law)

increased blood flow increased tissue extensibility increased HR increased RR

FACTORS AFFECTING THERMAL EFFECTS

temperature difference between water and

skin method of heat transfer thermal conductivity of the structure rate of rise in initial temperature surface area covered duration of exposure weight, age, and general condition of the patient

AGITATION
debridement

analgesia
facilitation of exercise muscle relaxation

Modalities

WATER IMMERSION MODALITIES

Whirlpool bath

Hubbard tank Pool/Aquatic Therapy

Parts
Agitator/ Turbine ejector/ Aerator
Water thermometer Hot and cold water mixing valve Temperature gauge Gravity drain Seat

Parts of a Whirlpool Bath

Motor Pump/Turbine Motor
Thermometer

Steel Tank

Components of the Turbine

Switch Turbine Engine/Motor Suspension Bracket

Throttle
Butterfly Knob Drive Shaft Breather Tube

Objectives for use

stimulation of circulation
promotion of muscle relaxation

and pain relief debridement facilitation of exercise

Indications
wound care:

decubitus ulcers, sub-acute or chronic soft tissue injury, burns arthritis limited ROM

muscle spasm muscle

weakness post fractures tension, anxiety, or other psychological problems

Contraindications
patient with cardiac bleeding or

dysfunction patient with respiratory dysfunction patient with decreased thermal sensation severe peripheral vascular disease

hemorrhage acute Rheumatoid arthritis fever malignancies uncontrolled bowel dermatologic conditions, infections

Additives
wounds:
- povidone iodine - saline solution - antibacterial agents - sodium hypochlorite

dry skin:
- bath oil

burn patients:
- 4% solution Lidocaine

TYPES OF WHIRLPOOL BATH

According to shape:
Low buoy tank High buoy tank

According to mobility:
Movable

Fixed
Extremity tank

LOW BUOY
Dimensions
width: 24 inches length: 52 66 inches depth: 18 inches

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

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

DOSAGE
Temperature:
39.9 46.1 degrees Celsius or 103 115 degrees Farenheit

Duration:
20 minutes if used as heating modality 15 minutes if used as cooling modality 5 20 minutes if used for debridement 10 20 minutes if used for exercise

Clinical Decision-making
immersion of LE can be done using high

and low buoy tanks High buoy tank requires the patient to be able to flex both hip and knee but does not allow full extension (adult) Low buoy tank allows full-motion exercises of the knee Both high and low buoy tanks can be fitted with hydraulic chair lift

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 insets: 15 inches

DOSAGE
Temperature:
32.2 38.8 degrees Celsius 90 102 degrees Farenheit

Duration:
20 minutes

Ambient
(in the clinics)
36.1 38 degrees Celsius 97 100 degrees Farenheit

temperature
25.5 degrees Celsius 50% humidity

ADDITIONAL EQUIPMENT
Walk trough Adjustable seat Motorized chair lift Hydrostretcher with hydraulic lift

Contrast Baths
Alternately immersing extremity in hot and cold bath
Aka vascular exercise

Indications Treatment Duration Arthritis, joint sprains, 30 minutes Warm whirlpool: 10 minutes s/p amputation, musculo Cold whirlpool: 1 minute tendinous strains Warm whirlpool: 4 minutes Temperature Cold whirlpool: 1 minute Hot: 38-44 degrees Celsius Cold: 10-18 degrees Celsius

Sitz Bath
Water only covers the pelvic region

Hot Increases circulation in the pelvic area enhance tissue healing and reduce pain
Temperature: 40.5- 46 C or 105-115 F for 2-10 minutes Indications: hysterectomy, hemorrhoidectomy, chronic

pelvic inflammatory disease

Cold Increases tone of smooth muscles reduce uterine bleeding

Temperature: 17-24 C or 25-75 F for 2-10 minutes

Guidelines to Treatment
determine objectives for using the modality select appropriate temperature inspect the area to be treated explain procedure ad operation to the

patient position the patient comfortably monitor vital signs adjust level of agitation accordingly turn agitator off after treatment

Guidelines to Treatment

dont allow finger or loose bandage to clog

the openings check for any breakage in the wirings ensure that the motor is securely fastened dont allow the patient to operate the machine dont direct agitation to the area that could be further damaged control ventilation and humidity of surrounding area

Evidence in Practice
A 25-year old male suffered from Colles fracture 2 months ago. Patient reported falling on outstretched arm after making a lay-up during a basketball game. He was put on plaster cast for 6 weeks during which no therapeutic intervention was provided. Upon medical consult 2 weeks ago, he was advised by his doctor to seek physical therapy for management of complications following prolonged immobilization specifically limitation of motion. Referral letter included whirlpool bath as part of management.

Evidence in Practice
Clinical Question:
Will use of whirlpool bath improve range of motion post-Colles fracture?

Search Strategy: In which database will you search? Why? What keywords will you use? Limits?
What types of articles will you look for? Why?

Do you have any questions?

References
Balicanta, R. E. (2004). Lecture notes on water immersion modalities for PT 156: Physical agents I. Hayes, K. W. (1993). Manual for physical agents (4th Ed). Connecticut: Appleton and Lange. Hecox, B., Mehreteab, T. A., and Weisberg, J. (1994). Physical agents: A comprehensive text for physical therapists. Connecticut: Appleton and Lange. Kisner, C. and Colby, L. A. (2002). Therapeutic exercise: Foundations and techniques (4th Ed). Philadelphia: F. A. Davis Company. Michlovitz, S. L. (1996). Thermal agents in rehabilitation (3rd Ed). Philadelphia: F. A. Davis Company. Sussman, C. (1998). Whirlpool in wound care. Collaborative practice manual for physical therapists and nurses. (no place): Aspen Publishers. Pictures retrieved June 21, 2008 from the following websites: www.hospimedicaintl.com, www.theratek.com, www.medicaloutfitters.net, www.mtstjosephhome.com, www.lakeeriemed.com, www.wannatowel.netkennel.com, www.ecu.edu, www.lifetecinc.com, www.advantagemedical.com, www.cchosp.com.