Hydrotherapy - Reduce Stress and Relax

Hydrotherapy is supposed to alleviate body tension, muscle soreness and joint stiffness and instill a sense of calm. Here's what the science says.

Before engaging in any complementary medical technique, you should be aware that many of these techniques have not been evaluated in scientific studies. Often, only limited information is available about their safety and effectiveness. Each state and each discipline has its own rules about whether practitioners are required to be professionally licensed. If you plan to visit a practitioner, it is recommended that you choose one who is licensed by a recognized national organization and who abides by the organization's standards. It is always best to speak with your primary health care provider before starting any new therapeutic technique.

• Background
• Theory
• Evidence
• Unproven Uses
• Potential Dangers
• Summary
• Resources

Background

Hydrotherapy (also called balneotherapy) involves the use of water in any form or at any temperature (steam, liquid, ice) for the purpose of healing. Water has been used medicinally for thousands of years by many cultures, including ancient China, Japan, India, Rome, Greece, the Americas and the Middle East. Modern hydrotherapy can be traced to the development of "water cure" spas in 19th century Europe.

Today, a wide variety of water-related therapies are used:

• Immersion in a bath or body of water (for example, the ocean or a pool)
• Placement of wet towels (hot or cold) over the skin
• Douches with watering cans or hoses
• Water birth
• Arm and foot baths
• Rising-temperature hip baths
• Sitz baths (soaking in hot or cold water below the hips)
• Steam baths or saunas
• Rubbings with cold, wet towels
• Spa-, hot tub-, whirlpool- or motion-based hydrotherapy
• Purifying mineral baths with additives such as sea salt or essential oils
• Dead Sea water treatments

Some therapies include the use of water as only one aspect of the technique:

• Nasal irrigation
• Colonic irrigation or enema
• Physical therapy in pools (Physical therapy or exercise in water makes use of the ability to float and resistance of water against motion.)
• Drinking of mineral water or "enriched" water
• Steam inhalation or humidifiers
• Coffee infusions
• Aromatherapy or baths with added essential oils
• Water yoga
• Water massage (including Watsu, a form of bodywork conducted in pools)

Theory

Various theories have been proposed to explain how hydrotherapy works, depending on the specific technique used. Some hydrotherapy practitioners and textbooks suggest that water treatments and wraps may detoxify the blood, stimulate blood circulation, enhance the immune system and improve digestion. Scientific research is limited in these areas.

Some theories are based on the observation that applying warmth to the skin causes vasodilation (expansion of blood vessels), which brings blood to the body's surface. Warmth can also cause muscle relaxation. Cold temperatures have the opposite effect.

Evidence

Scientists have studied hydrotherapy for the following uses:

Low back pain
Several small studies in humans report that regular use of hot whirlpool baths with massaging jets reduces the duration and severity of back pain when used with standard medical care. Additional research is needed to make a strong conclusion.

Anorectal lesions (hemorrhoids, anal fissures)
There is early evidence that sitz baths may help relieve symptoms of anorectal conditions, although research is not definitive. Sitz baths are often available in hospitals.

Skin bacteria
There is not enough research to determine if hydrotherapy reduces bacteria on the skin, or if hydrotherapy offers any benefit.

Knee rehabilitation
Limited research is available. Further study is needed to make a conclusion. td>

Labial edema during pregnancy
Limited research is available. Further studies are needed.

Fibromyalgia
Research results are mixed. Further well-designed trials are needed to make a recommendation.

Heart failure
Study results are mixed in this area. For example, one randomized controlled trial suggests repeated sauna treatment may reduce the risk of arrhythmias. Another randomized trial suggests this therapy may improve heart failure-related symptoms and heart rate response to exercise. However, some studies report no benefits. Further well-designed research is needed before firm conclusions can be drawn.

Arthritis
Hydrotherapy is traditionally used to treat symptoms of rheumatoid arthritis and osteoarthritis. There is evidence that hydrotherapy may reduce pain and increase functional activity. Several studies have been published, but because of design flaws, the benefits remain unclear.

Atopic dermatitis
Research is limited, and no clear conclusions can be drawn.

Burns
Research is limited, and no clear conclusions can be drawn.

Chronic obstructive pulmonary disease (COPD)
It is not clear if deep breathing exercises in heated pools are beneficial in people with COPD. There is evidence that suggests water training may improve overall physical fitness, but additional research is needed to confirm these results.

Chronic venous insufficiency
Hydrotherapy is used in Europe for chronic venous insufficiency, a syndrome that may include leg swelling, varicose veins, leg pain, itching and skin ulcers. A few studies report benefits of leg stimulation with cold water alone, or in combination with warm water. However, this research is only preliminary, and additional study is necessary to make a firm conclusion.

Common cold
Research is limited, and no clear conclusions can be drawn.

Diabetes mellitus
Research is limited, and no clear conclusions can be drawn.

Claudication (painful legs from clogged arteries)
Research is limited, and no clear conclusions can be drawn.

High cholesterol
One randomized controlled trial suggests that repeated sauna therapy may protect against oxidative stress, which leads to the prevention of atherosclerosis. Further research is needed before firm conclusions can be made.

Insomnia
Preliminary study of hydrotherapy for insomnia shows inconclusive results.

Labor, childbirth
There is preliminary research examining whether giving birth in water reduces labor pain, the duration of labor, perineal damage to the mother and birth complications. However, this research is not reliable enough to form clear conclusions about safety or benefits.

Pain
Hydrotherapy has been studied for various types of pain, with inconclusive results.

Pelvic inflammatory disease
Research is limited, and no clear conclusions can be drawn.

Pressure ulcers, wound care
Research is limited, and no clear conclusions can be drawn.

Psoriasis
Evidence regarding hydrotherapy for psoriasis is varied. There is not enough research available to make a recommendation.

Spinal muscular atrophy
There is not enough research available to make a recommendation.

Varicose veins
There is not enough research available to make a recommendation.

Bone density in menopause
There is preliminary evidence suggesting that aquatic exercises, like other forms of weight-bearing exercises, may help increase bone mass.

Unproven Uses

Hydrotherapy has been suggested for many uses, based on tradition or on scientific theories. However, these uses have not been thoroughly studied in humans, and there is limited scientific evidence about safety or effectiveness. Some of these suggested uses are for conditions that are potentially life-threatening. Consult with a health care provider before using hydrotherapy for any use.

Potential Dangers

The safety of some hydrotherapy techniques is not well studied.

Sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas or other types of hydrotherapy should be avoided, particularly by patients with heart disease or lung disease or by pregnant women. Warm temperatures can lead to dehydration or low blood sodium levels, and hydration and electrolyte intake should be maintained. Cold temperatures may worsen symptoms in people with circulatory disorders, such as acrocyanosis, chilblains, erythrocyanosis or Raynaud's disease.

Water temperature should be carefully monitored, particularly for patients with temperature-sensitivity disorders, such as neuropathy. People with implanted medical devices such as pacemakers, defibrillators or liver infusion pumps should avoid high temperatures or therapies that involve electrical currents.

Contact with contaminants or additives in water (such as essential oils or chlorine) can irritate the skin. Skin infections may occur if water is not sanitary, particularly in patients with open wounds. There are several reported cases of dermatitis and bacterial skin infections after hot tub or whirlpool use.

People with fractures, blood clots, bleeding disorders, severe osteoporosis or open wounds and pregnant women should avoid vigorous therapy with water jets in. Although water births are popular, safety is not well studied. The effects of prolonged labor in hot or cold water are not known.

Hydrotherapy should not delay the time it takes to see a health care provider for diagnosis or treatment with more proven techniques or therapies. And hydrotherapy should not be used as the sole approach to illness. Consult with your primary health care provider before starting hydrotherapy.

Summary

There are many hydrotherapy techniques used for a wide variety of health conditions. Early evidence suggests that regular use of hot whirlpool baths with massaging jets improves the duration and severity of low back pain. Additional research is necessary to make a strong recommendation. There is no conclusive evidence for any other condition.

Prolonged treatments, particularly in extreme temperatures, should be avoided. Skin irritation or bacterial infections may result from additives or contaminants in the water. People with fractures, blood clots, bleeding disorders, severe osteoporosis or open wounds and pregnant women should avoid vigorous therapy with water jets. Although water births are popular, safety has not been well studied. Hydrotherapy should not be used as the sole approach to any illness. Consult with your primary health care provider before starting hydrotherapy.

The information in this monograph was prepared by the professional staff at Natural Standard, based on thorough systematic review of scientific evidence. The material was reviewed by the Faculty of the Harvard Medical School with final editing approved by Natural Standard.

Resources

1. Natural Standard: An organization that produces scientifically based reviews of complementary and alternative medicine (CAM) topics
2. National Center for Complementary and Alternative Medicine (NCCAM): A division of the U.S. Department of Health & Human Services dedicated to research

Selected Scientific Studies: Hydrotherapy, Balneotherapy

Natural Standard reviewed more than 920 articles to prepare the professional monograph from which this version was created.

Some of the more recent studies are listed below:

1. Aird IA, Luckas MJ, Buckett WM, et al. Effects of intrapartum hydrotherapy on labour related parameters. Aust N Z J Obstet Gynaecol 1997;May, 37(2):137-142.
2. Aksamit TR. Hot tub lung: infection, inflammation, or both? Semin Respir Infect 2003;Mar, 18(1):33-39.
3. Altan L, Bingol U, Aykac M, et al. Investigation of the effects of pool-based exercise on fibromyalgia syndrome. Rheumatol Int 2003;Sep 24.
4. Ay A, Yurtkuran M. Influence of aquatic and weight-bearing exercises on quantitative ultrasound variables in postmenopausal women. Am J Phys Med Rehabil 2005;84(1):52-61.
5. Barsevick A, Llewellyn J. A comparison of the anxiety-reducing potential of two techniques of bathing. Nurs Res 1982;Jan-Feb, 31(1):22-27.
6. Beamon S, Falkenbach A, Jobst K. Hydrotherapy for asthma. Cochrane Database Syst Rev 2001;(2):CD001741.
7. Benfield RD. Hydrotherapy in labor. J Nurs Scholarsh 2002;34(4):347-352.
8. Blazickova S, Rovensky J, Koska J, et al. Effect of hyperthermic water bath on parameters of cellular immunity. Int J Clin Pharmacol Res 200;20(1-2):41-46.
9. Bodner K, Bodner-Adler B, Wierrani F, et al. Effects of water birth on maternal and neonatal outcomes. Wien Klin Wochenschr 2002;Jun 14, 114(10-11):391-395.
10. Brucker MC. Management of the third stage of labor: an evidence-based approach. J Midwifery Womens Health 2001;Nov-Dec, 46(6):381-392.
11. Buman G, Uyanik M, Yilmaz I, et al. Hydrotherapy for Rett syndrome. J Rehabil Med 2003;Jan, 35(1):44-45.
12. Buskila D, Abu-Shakra M, Neumann L, et al. Balneotherapy for fibromyalgia at the Dead Sea. Rheumot Intl 2001;Apr, 20(3):105-108.
13. Burke DT, Ho CH, Saucier MA, et al. Effects of hydrotherapy on pressure ulcer healing. Am J Phys Med Rehabil 1998;Sep-Oct, 77(5):394-398.
14. Capoduro R. Does balneology still have gynecologic indications? Rev Fr Gynecol Obstet 1995;Apr-May, 90(4):236-239.
15. Cider A, Schaufelberger M, Sunnerhagen KS, et al. Hydrotherapy: a new approach to improve function in the older patient with chronic heart failure. Eur J Heart Fail 2003;Aug, 5(4):527-535.
16. Coccheri S, Nappi G, Valenti M, et al. Changes in the use of health resources by patients with chronic phlebopathies after thermal hydrotherapy: report from the Naiade project, a nation-wide survey on thermal therapies in Italy. Int Angiol 2002;Jun, 21(2):196-200.
17. Constant F, Collin JF, Guillemin F, et al. Effectiveness of spa therapy in chronic low back pain: a randomized clinical trial. J Rheumatol 1995;22(7):1315-1320.
18. Constant F, Guillemin F, Collin JF, et al. Use of spa therapy to improve the quality of life of chronic low back pain patients. Med Care 1998;36(9):1309-1314.
19. Crevenna R, Schneider B, Mittermaier C, et al. Implementation of the Vienna hydrotherapy group for laryngectomees: a pilot study. Support Care Cancer 2003;Nov, 11(11):735-738. Epub 2003;Sep 13.
20. Cunha MC, Oliveira AS, Labronici RH, et al. Spinal muscular atrophy type II(intermediary) and III(Kugelberg-Welander): evolution of 50 patients with physiotherapy and hydrotherapy in a swimming pool. Arq Neuropsiquiatr 1996;Sep, 54(3):402-406.
21. DiPasquale LR, Lynett K. The use of water immersion for treatment of massive labial edema during pregnancy. MCN Am J Matern Child Nurs 2003;Jul-Aug, 28(4):242-245.
22. Eckert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labor: a randomized controlled trial. Birth 2001;28(2):84-93.
23. Ekmekcioglu C, Strauss-Blasche G, Holzer F, et al. Effect of sulfur baths on antioxidative defense systems, peroxide concentrations and lipid levels in patients with degenerative osteoarthritis. Forsch Komplementarmed Klass Naturheilkd 2002;Aug, (4):216-220.
24. Elkayam O, Wigler I, Tishler M, et al. Effect of spa therapy in Tiberias on patients with rheumatoid arthritis and osteoarthritis. J Rheumatol 1991;Dec, 18(12):1799-1803.
25. Elmstahl S, Lilja B, Bergqvist D, et al. Hydrotherapy of patients with intermittent claudication: a novel approach to improve systolic ankle pressure and reduce symptoms. Int Angiol 1995;Dec, 14(4):389-394.
26. Embil JM, McLeod JA, Al Barrak AM, et al. An outbreak of methicillin resistant Staphylococcus aureus on a burn unit: potential role of contaminated hydrotherapy equipment. Burns 2001;27(7):681-688.
27. Eriksson M, Mattsson LA, Ladfors L. Early or late bath during the first stage of labour: a randomized study of 200 women. Midwifery 1997;Sep, 13(3):146-148.
28. Erler K, Anders C, Fehlberg G, et al. [Objective assessment of results of special hydrotherapy in inpatient rehabilitation following knee prosthesis implantation]. Z Orthop Ihre Grenzgeb 2001;Jul-Aug, 139(4):352-358.
29. Evcik D, Kizilay B, Gokcen E. The effects of balneotherapy on fibromyalgia patients. Rheumatol Int 2002;Jun, 22(2):56-59.
30. Filippov EG, Bukhny AF, Finogenova NA, et al. [Experience in using hydrotherapy in children with acute lymphoblastic leukemia at a sanatorium]. Vopr Kurortol Fizioter Lech Fiz Kult 1995;May-Jun, (3):14-16.
31. Foley A, Halbert J, Hewitt T, et al. Does hydrotherapy improve strength and physical function in patients with osteoarthritis: a randomised controlled trial comparing a gym based and a hydrotherapy based strengthening programme. Ann Rheum Dis 2003;Dec, 62(12):1162-1167.
32. Gerber B, Wilken H, Barten G, et al. Positive effect of balneotherapy on post-PID symptoms. Int J Fertil Menopausal Stud 1993;Sep-Oct, 38(5):296-300.
33. Gotz HM, Tegnell A, De Jong B, et al. A whirlpool associated outbreak of Pontiac fever at a hotel in Northern Sweden. Epidemiol Infect 2001;Apr, 126(2):241-247.
34. Green JJ. Localized whirlpool folliculitis in a football player. Cutis 2000;Jun, 65(6):359-362.
35. Hall J, Skevington SM, Maddison PJ, et al. A randomized and controlled trial of hydrotherapy in rheumatoid arthritis. Arthritis Care Res 1996;9(3):206-215.
36. Hartmann BR, Bassenge E, Pittler M. Effect of carbon dioxide-enriched water and fresh water on the cutaneous microcirculation and oxygen tension in the skin of the foot. Angiology 1997;Apr, 48(4):337-343.
37. Haskes PJ. Beneficial effect of climatic therapy on inflammatory arthritis at Tiberias Hot Springs. Scand J Rheumatol 2002;31(3):172-177.
38. Hawkins S. Water vs conventional births: infection rates compared. Nurs Times 1995;Mar 15-21, 91(11):38-40.
39. Horne JA, Reid AJ. Night-time sleep EEG changes following body heating in a warm bath. Electroencephalogr Clin Neurophysiol 1985;Feb, 60(2):154-157.
40. Inston N, Lake S. Pneumoperitoneum following Jacuzzi usage. Ann R Coll Surg Engl 2000;Sep, 82(5):350-351.
41. Jensen SL. Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. Br Med J (Clin Res Ed) 1986;May 2, 292(6529):1167-1169.
42. Juve Meeker B. Whirlpool therapy on postoperative pain and surgical wound healing: an exploration. Patient Educ Couns 1998;Jan, 33(1):39-48.
43. Kihara T, Biro S, Ikeda Y, et al. Effects of repeated sauna treatment on ventricular arrhythmias in patients with chronic heart failure. Circ J 2004;68(12):1146-1151.
44. Klemenkov SV, Davydova OB, Levitskii EF, et al. [The effect of sodium chloride baths on the physical work capacity and extrasystole of patients with ischemic heart disease and stable stenocardia]. Vopr Kurortol Fizioter Lech Fiz Kult 1999;May-Jun, (3):19-21.
45. Kovacs I, Bender T. The therapeutic effects of Cserkeszolo thermal water in osteoarthritis of the knee: a double blind, controlled, follow-up study. Rheumatol Int 2002;Apr, 21(6):218-221.
46. Kubota K, Machida I, Tamura K, et al. Treatment of refractory cases of atopic dermatitis with acidic hot spring bathing. Acta Derm Venereol 1997;Nov, 77(6):452-454.
47. Kurabayashi H, Machida I, Kubota K. Improvement in ejection fraction by hydrotherapy as rehabilitation in patients with chronic pulmonary emphysema. Physiother Res Int 1998;3(4):284-291.
48. Li DK, Janevic T, Odouli R, Lui L. Hot tub use during pregnancy and the risk of miscarriage. Am J Epidemiol 2003;Nov 15, 158(10):931-937.
49. Mancini S Jr, Piccinetti A, Nappi G, et al. Clinical, functional and quality of life changes after balneokinesis with sulphurous water in patients with varicose veins. Vasa 2003;Feb, 32(1):26-30.
50. Masuda A, Miyata M, Kihara T, et al. Repeated sauna therapy reduces urinary 8-epi-prostaglandin F (2alpha). Jpn Heart J 2004;45(2):297-303.
51. McIlveen B, Robertson VJ. A randomised controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain. J Manip Physiol Ther 1998;21(6):439-440.
52. Mcllveen B, Robertson VJ. A randomised controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain. Physiotherapy 1998;84(1):17-26.
53. Meldrum R. Survey of Staphylococcus aureus contamination in a hospital's spa and hydrotherapy pools. Commun Dis Public Health 2001;4(3):205-208.
54. Michalsen A, Ludtke R, Buhring M, Spahn G, et al. Thermal hydrotherapy improves quality of life and hemodynamic function in patients with chronic heart failure. Am Heart J 2003;Oct, 146(4):E11.
55. Miller MS. Pharmacotherapy as adjunctive treatment for serious foot wounds in the patient with diabetes: a case study. Ostomy Wound Manage 2003;Apr, 49(4):52-55.
56. Moore JE, Heaney N, Millar BC, et al. Incidence of Pseudomonas aeruginosa in recreational and hydrotherapy pools. Commun Dis Public Health 2002;Mar, 5(1):23-26.
57. Nagai T, Sobajima H, Iwasa M, et al. Neonatal sudden death due to Legionella pneumonia associated with water birth in a domestic spa bath. J Clin Microbiol 2003;May, 41(5):2227-2229.
58. Nagiev IuK, Davydova OB, Zhavoronkova EA, et al. Effects of underwater massage douche on left ventricular diastolic function in patients with chronic cardiac failure and postinfarction cardiosclerosis. Vopr Kurortol Fizioter Lech Fiz Kult 2002;Jul-Aug, (4):11-15.
59. Neumann L, Sukenik S, Bolotin A, et al. The effect of balneotherapy at the Dead Sea on the quality of life of patients with fibromyalgia syndrome. Clin Rheumatol 2001;20(1):15-19.
60. Nikodem VC. Immersion in water in pregnancy, labour and birth. Cochrane Database Syst Rev 2000;(2):CD000111.
61. Penny PT. Contact dermatitis due to BCDMH in a hydrotherapy pool. Occup Med 1999;49(4):265-267.
62. Stener-Victorin E, Kruse-Smidje C, Jung K. Comparison between electro-acupuncture and hydrotherapy, both in combination with patient education and patient education alone, on the symptomatic treatment of osteoarthritis of the hip. Clin J Pain 2004;20(3):179-185.
63. Verhagen AP, de Vet HC, de Bie RA, et al. Balneotherapy for rheumatoid arthritis and osteoarthritis. Cochrane Database Syst Rev 2000;(2):CD000518.
64. Wadell K, Sundelin G, Henriksson-Larsen K, et al. High intensity physical group training in water—an effective training modality for patients with COPD. Respir Med 2004;98(5):428-438.
65. Winthrop KL, Abrams M, Yakrus M, et al. An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon. N Engl J Med 2002;May 2, 346(18):1366-1371.
66. Yilmaz B, Goktepe SAS, Alaca R, et al. Comparison of a generic and a disease specific quality of life scale to assess a comprehensive spa therapy program for knee osteoarthritis. Joint Bone Spine 2004;71(6):563-566.

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