Aila Nica J. Bandong, PTRPInstructor

Department of Physical TherapyClinical Supervisor

CTS- Pediatric SectionCollege of Allied Medical Professions

Learning ObjectivesAt the end of the lecture, the students should be able to:Define hydrotherapyIdentify the chemical, physical, and thermal properties of

waterEnumerate the therapeutic effects of hydrotherapyIdentify the factors that affect thermal effects of waterDifferentiate the types of water immersion modalitiesIdentify the parts of a whirlpool bathEnumerate the indications, contraindications, and

precautions/guidelines for the use of the modalitiesIdentify common additives in whirlpool therapyUse clinical decision making skill in choosing appropriate

water immersion modalityLearn how to operate a high-buoy tankApply evidence regarding use of water immersion

modalities in practice

CHEMICAL PROPERTIESPure water is a

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

CONSTANTSfreezing point: 0 degree Celsiusboiling point: 100 degrees Celsiusdensity:

at 0 degree Celsius- .999868

at 4 degrees Celsius- 1.0000pH: 7specific heat: 1.00

FORCES EXISTING IN WATER

buoyancy hydrostatic pressure cohesion viscosity surface tension

Buoyancyupward 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

Pascal’s 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

FLUIDITY

Dependent on:

• speed/velocity of movement of liquid

• shape of the body

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

EVAPORATION

CONVECTION

RADIATION

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 Thermal

Mechanical

Cold application

Heat application

Agitation

COLD APPLICATIONincreased cardiac toneperipheral vasoconstrictionincreased blood viscositydecreased HRlonger diastoledecreased vasodilator metabolitesdecreased blood flow

HEAT APPLICATIONvasodilation of arteries and arteriolesincreased capillary permeabilityrelease of vasoactive agentsincreased metabolism (Van’t Hoff’s Law)increased blood flowincreased tissue extensibilityincreased HRincreased RR

FACTORS AFFECTING THERMAL EFFECTStemperature difference between water and

skinmethod of heat transferthermal conductivity of the structurerate of rise in initial temperaturesurface area coveredduration of exposureweight, age, and general condition of the

patient

AGITATIONdebridementanalgesiafacilitation of exercisemuscle 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

Motor Pump/Turbine Motor

Thermometer

Steel Tank

Turbine Engine/Motor

Switch

Suspension Bracket

Throttle

Butterfly Knob

Drive Shaft

Breather Tube

Objectives for usestimulation of circulationpromotion of muscle relaxation and pain relief

debridementfacilitation of exercise

Indicationswound care:

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

arthritislimited ROM

muscle spasmmuscle

weaknesspost fracturestension, anxiety,

or other psychological problems

Contraindicationspatient with

cardiac dysfunctionpatient with

respiratory dysfunction

patient with decreased thermal sensation

severe peripheral vascular disease

bleeding or hemorrhage

acute Rheumatoid arthritis

fevermalignanciesuncontrolled boweldermatologic

conditions, infections

Additiveswounds:

- povidone iodine

- saline solution

- antibacterial agents

- sodium hypochlorite

dry skin:

- bath oil

burn patients:

- 4% solution Lidocaine

TYPES OF WHIRLPOOL BATHAccording to shape:

Low buoy tank

High buoy tank

Extremity tank

According to mobility:

Movable

Fixed

LOW BUOYDimensions

width: 24 inches

length: 52 – 66 inches

depth: 18 inches

HIGH BUOYDimensions

width: 20 – 24 inches

length: 36 – 48 inches

depth: 28 inches

EXTREMITY TANKalso called UPPER EXTREMITY TANK

Dimensions

width: 15 inches

length: 28 – 32 inches

depth: 18 – 25 inches

DOSAGETemperature:

39.9 – 46.1 degrees Celsius or103 – 115 degrees Farenheit

Duration:20 minutes if used as heating modality15 minutes if used as cooling modality5 – 20 minutes if used for debridement10 – 20 minutes if used for exercise

Clinical Decision-makingimmersion of LE can be done using high

and low buoy tanksHigh 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 TANKDimensions

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

DOSAGETemperature:

32.2 – 38.8 degrees Celsius

90 – 102 degrees Farenheit

(in the clinics)36.1 – 38 degrees Celsius

97 – 100 degrees Farenheit

Duration:20 minutes

Ambient temperature25.5 degrees Celsius

50% humidity

ADDITIONAL EQUIPMENTWalk troughAdjustable seatMotorized chair liftHydrostretcher with hydraulic lift

Contrast BathsAlternately immersing extremity in hot and

cold bathAka “vascular exercise”IndicationsArthritis, joint sprains, s/p amputation, musculo- tendinous strainsTemperatureHot: 38-44 degrees CelsiusCold: 10-18 degrees Celsius

Treatment Duration30 minutes

Warm whirlpool: 10 minutes

Cold whirlpool: 1 minuteWarm whirlpool: 4

minutesCold whirlpool: 1 minute

Sitz BathWater only covers the pelvic regionHotIncreases circulation in the pelvic area enhance

tissue healing and reduce painTemperature: 40.5- 46 .C or 105-115 .F for 2-10

minutesIndications: hysterectomy, hemorrhoidectomy,

chronic pelvic inflammatory disease

ColdIncreases tone of smooth muscles reduce uterine

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

Guidelines to Treatmentdetermine objectives for using the modalityselect appropriate temperatureinspect the area to be treatedexplain procedure ad operation to the

patientposition the patient comfortablymonitor vital signsadjust level of agitation accordinglyturn agitator off after treatment

Guidelines to Treatmentdon’t allow finger or loose bandage to clog

the openingscheck for any breakage in the wiringsensure that the motor is securely fasteneddon’t allow the patient to operate the

machinedon’t direct agitation to the area that

could be further damagedcontrol ventilation and humidity of

surrounding area

Evidence in PracticeA 25-year old male suffered from Colle’s 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 PracticeClinical Question:Will use of whirlpool bath improve range of

motion post-Colle’s 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?

ReferencesBalicanta, 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.