Hydrotherapy

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Chapter 40 Hydrotherapy^*

Aimee Huyck, ND, PT, Kate Broderick, JD, ND, LAc

Introduction

Hydrotherapy may be defined as the use of water, in any of its forms, for the maintenance of health or the treatment of disease. It is a cornerstone of naturopathic therapeutics, drawing on the vitalistic roots of the nature cure tradition as it stimulates the body’s inherent self-healing mechanisms. The power of hydrotherapy is demonstrated by the persistence of its use now, two centuries after it was first systematized as a therapeutic modality in Western medicine. Naturopathic colleges and universities universally teach hydrotherapy as a core therapeutic modality and utilize it in their teaching clinics on general medicine, physical medicine, and specialized hydrotherapy shifts. Practicing naturopathic physicians utilize hydrotherapy widely in their practices, with some notable doctors, such as Cathy Rogers, ND; Nancy Welliver, ND; and Letitia Dick-Kronenberg, ND; having long-standing practices that emphasize hydrotherapy as their primary therapeutic modality. Additionally, many students at the various naturopathic colleges and universities seek preceptorships and supplementary education specific to hydrotherapy, as well as organizing campus clubs designed to give students greater exposure to and experience with this powerful medicine.

In his original chapter in the first edition of the Textbook of Naturopathic Medicine, Dr. Barry wrote: “Although one of the oldest known therapies, it [hydrotherapy] has received little attention from the research community, particularly recently. Much of the information presented here is compiled from older works which, although they lack the quantification available with current technology, show a remarkable attention to clinical effects and patient response.” What these older works tell us about the uses and effects of hydrotherapy and the specific details of the means employed is invaluable, and physicians practicing hydrotherapy will find its greatest effectiveness by mining the wisdom of the original practitioners of Western hydrotherapy. For example, the individualization of a particular treatment to suit the vitality, or lack thereof, in each patient, must be attended to for treatments to have their greatest impact. It is this need for individualization that, like other aspects of holistic medicine, confounds the conducting of modern hydrotherapy research. However, in the last few years, attention has increased around the topic of hydrotherapy research and practice.

History

As one of the ancient methods of treatment, hydrotherapy has been used to treat disease and injury by many different peoples, including the Egyptians, Assyrians, Persians, Greeks, Hebrews, Hindus, and Chinese. For example, in the Riga Veda, circa 1500 BC, we read that “water cures the fever’s glow.”

Hippocrates used hydrotherapy extensively around 400 BC, and his writings concerning baths contain some of the earliest dictums on the therapeutic uses of water ¹:

In general it suits better with cases of pneumonia than in ardent fevers; for the bath soothes the pain in the side, chest and back; cuts the sputum, promotes expectoration, improves the respiration, and allays lassitude; for it soothes the joints and outer skin, and is diuretic, removes heaviness of the head, and moistens the nose.

As these early writings show, the healing effects of water were observed and used therapeutically for centuries before the modern hydrotherapy movement. Modern hydrotherapy has had many contributors, including Sir John Floyer, William Winternitz, Johann Schroth, Johann Hahn, and J.H. Rausse to name a few.

Naturopathy grew out of the hydrotherapy movement, which traces its roots to two prominent hydrotherapists: Vincent Priessnitz of Austria and Father Sebastian Kneipp of Bavaria. Neither had formal medical training, but learned their craft through personal experience and astute observation. Priessnitz observed wounded animals bathing in cold water and was inspired to heal his own broken ribs using cold compresses. Father Kneipp healed his tuberculosis after reading Johann Hahn’s Lectures on the Wonderful Healing Power of Fresh Water.

Priessnitz opened his first hydrotherapy institution at Grafenburg in 1826 and successfully treated over 40,000 people with little loss of life. Many of his patients were very ill and unable to be helped by medical doctors. He was arrested many times for practicing medicine without adequate training but eventually was given all the privileges of a medical doctor because his treatments were so effective.

Father Kneipp became an ordained priest in 1852 and was assigned as a chaplain to a number of parishes. He began using the water cure to treat his parishioners who were unable to be helped by medical doctors. Although church leaders did not approve of his practices and forbade him continuing, still he continued. He was transferred to Worishofen, where his successes became known, and people came from near and far to receive the cure. He never charged for his services, believing care should be available to anyone in need. His first book, My Water Cure, was written for the common people in clear and plain language and is an excellent instructional manual for anyone interested in hydrotherapy today.

Priessnitz’s philosophy of water cure was brought to the United States in the mid-nineteenth century. Joel Shew, a medical doctor from New York, studied with Priessnitz and returned to the United States to start a hydropathy institute based on his teachings. An associate of Shew’s, Russell Trall, MD, started his own hydrotherapy institute in Manhattan in the 1850s and later published the Hydropathic Encyclopedia. John Harvey Kellogg attended Trall’s institute, and in 1900 published Rational Hydrotherapy,² in which he considered the physiologic and therapeutic effects of water, along with an extensive discussion of hydrotherapeutic techniques.

There were other notable individuals who were influenced by Priessnitz’s water cure philosophy. Robert and William Wesselhoeft studied with Priessnitz and opened a sanitarium in Vermont after immigrating to the United States from Germany. David Ruggles, a black abolitionist who was treated by the Wesselhoefts, opened his own clinic; his patrons included fellow abolitionists Sojourner Truth and William Lloyd Garrison. Mary Gove Nichols, a woman denied any formal education but with a keen interest in medical science and determination to learn, opened her own institute in New York in 1845. She studied with both the Wesselhoefts and Joel Shew.

Benedict Lust, considered to be the father of naturopathy, was successfully treated by Father Kneipp and was charged with introducing the water cure to the United States. Lust successfully combined water cure with other nature cure modalities, establishing the foundation of naturopathic medicine. Henry Lindlahr, a wealthy U.S. banker suffering from diabetes, visited Kneipp after being told by his physicians that there was nothing they could do for him. He was put on a strict diet and daily regimen of cold water treatments. Once cured, he returned to the United States, completed medical training and opened a sanitarium in Chicago in 1906. He believed the vis medicatrix naturae was the true physician and wrote Nature Cure,³ the definitive guide to the philosophy and practice of nature cure medicine.

Otis G. Carroll, one of the modern forefathers of naturopathic medicine, studied with Lindlahr and Alex Ledoux, another student of Sebastian Kneipp. He pioneered constitutional hydrotherapy, the combining of compresses with electrical stimulation, believing this therapy changed the constitution of the body’s cells. Carroll’s work was continued by Harold Dick, a naturopath in Spokane, Washington. His daughter, Letitia Dick-Kronenberg, worked with her father after completing her studies at the National College of Naturopathic Medicine and continues to practice and teach the hydrotherapy practices passed on to her.

Hydrotherapy has a long, rich history, and naturopathy is rooted in its practice. Thus, it is still taught in naturopathic educational institutions and practiced in their associated teaching clinics as a highly effective, fundamental naturopathic modality.

Physiologic Effects of Water

The physiologic effects of hydrotherapy may be classified as thermal, mechanical, and chemical. Thermal effects are produced by the application of water at temperatures above or below body temperature. The greater the variation from body temperature, the greater the effect produced, other factors being equal and allowing for individual patient variability. Mechanical effects are produced by the impact of water acting on the body surface in the form of sprays, douches, frictions, immersions, whirlpools, etc. Chemical effects are produced when water is taken by mouth or used to irrigate a body cavity, such as the large colon. Thermal effects are the most commonly used therapeutically and are, thus, the main subject of this chapter.

In general, hot relaxes and sedates, whereas cold stimulates, invigorates, and tonifies. However, very hot can stimulate and also be destructive, whereas prolonged cold can be depressive and destructive. A comparison of the effects of hot and cold on several body systems is given in Table 40-1.

TABLE 40-1 Comparison of the Effects of Hot and Cold on Several Body Systems

Principles of Blood Movement with Hydrotherapy

To promote healing, either locally or systemically, it is important to maximize circulation of well-oxygenated, nutrient-rich blood, which also has the effect of carrying away metabolic and other waste products. Hydrotherapy techniques are one of the most effective means of accomplishing this, especially when used in conjunction with proper levels of activity, optimal nutritional intake, and adequate detoxification.

Using different temperatures of water, one can either increase or decrease the rate of blood flow (BF) through an organ or area of the body and can either increase or decrease the total volume of blood in an organ or area of the body, according to whether the area is anemic or congested. To accomplish these changes, five relevant physiologic principles must be considered:

• Revulsive effect

• Derivative effect

• Spinal cord reflex

• Collateral circulation

• Arterial trunk reflex

Revulsive Effect

The revulsive effect provides a means of increasing the rate of BF through an organ or area of the body and is most effectively accomplished using contrast hydrotherapy: alternating hot and cold in the form of compresses, baths, showers, sprays, etc. Local contrast applications produce marked stimulation of local circulation. A 30-minute local contrast bath produces a 95% increase in local BF when the lower extremities alone are immersed. When all four extremities are immersed at the same time, there is a 100% increase in BF in the upper extremities and a 70% increase in the lower extremities.⁴

Contrast applications to the area of skin that is in a reflex relationship (see Spinal Reflex Effect, following) to an organ increase the functional activity of that organ. Hence, liver function is increased by contrast application over the right upper quadrant of the abdomen.

Several studies have researched the optimal treatment times for revulsive effects. Woodmansey et al ⁵ found 6 minutes of hot application and 4 minutes of cold to be optimal for the British subjects he studied. Krussen⁶ found 4 minutes of hot and 1 minute of cold to be the best treatment protocol. Moor⁷ stated that 3 minutes of hot followed by 30 to 60 seconds of cold provided satisfactory clinical results. These variations create an inference that, due to variations in patients and locales, it is best for practitioners to determine their own ideals, based on their own observations of clinical results. Most importantly, the cold application needs to be long enough to produce vasoconstriction, which can occur in as short a period as 20 seconds. Additionally, the course of treatment should always end on cold to discourage congestion in the area.

Repetition of applications is another important variable to consider when applying revulsive treatments. A series of three hot/cold applications seems to be practical. Most individuals show a decreasing reaction to repeated applications of cold.

The revulsive effect is ideal for treating situations presenting primarily as congestion, for example, the use of alternating hot/cold compresses over the face for sinus congestion. As a powerful decongestant, the revulsive effect also acts as an analgesic for pain resulting from congestion. Because of its marked stimulation of local circulation, the revulsive treatment is an exceptionally effective hydrotherapeutic procedure, and one of the most generally useful considering its simplicity.

Derivative Effect

Congestion can also be treated using the derivative effect, which moves blood from one area of the body to another. This effect is best obtained by the prolonged use of either cold or heat, depending on whether one wants to draw blood into an area (hot application) or to drive blood out of an area (cold application). For example, prolonged application of heat to the feet, as with a hot foot bath, will decrease congestion in the head by increasing BF to the feet. Alternatively, a cold compress can be applied to the forehead or back of the neck to restrict BF in the head, or the two treatments can be combined for even greater effect. This form of treatment is often quite effective for certain forms of congestive headaches.

Spinal Reflex Effect

A sufficiently intense local application of hot or cold not only affects the immediate skin area but also causes remote physiologic changes, mediated through spinal reflex arcs (see Moor ⁷), thus providing a means of affecting a distant area of the body through a local application. These effects have been carefully observed over many years and have led to a mapping that correlates each surface area with a corresponding internal area and/or organ. Most texts on hydrotherapy contain such a diagram.^2,⁷

Hewlett,⁸ Stewart,⁹ and Briscoe¹⁰ all noted changes in BF in the opposite arm and hand when one arm and hand were placed in hot or cold water. Poulton¹¹ demonstrated that esophageal function could be influenced by irritation of the skin over the sternum. Bing and Tobiassen¹² showed reflex relationships between the skin of the abdominal wall and the colon. They also demonstrated a reflex relationship between the lungs and the skin of the chest wall.

Fisher and Solomon ¹³ stated: “externally applied heat not only decreases intestinal blood flow, but also diminishes intestinal motility and decreases acid secretion in the stomach, while cold has the opposite effect.” This is an example of a contrary effect, in which the reflex effect is the opposite of that observed in the local reflex skin area (i.e., local heat increases BF to the local skin, but decreases BF to the reflex organs).

Tables 40-2 to 40-4 show some of the observed reflex effects of hydrotherapeutic procedures.⁷

TABLE 40-2 Reflex Effects of Prolonged Heat

APPLICATION LOCATION	EFFECT
One extremity	Vasodilation in contralateral extremity
Abdominal wall	Decreased intestinal blood flow, intestinal motility, and acid secretion
Pelvis	Relaxes pelvic muscles, dilates blood vessels, and increases menstrual flow
Precordium	Increases heart rate, decreases its force, and lowers blood pressure
Chest	Promotes ease of respiration and expectoration
Trunk	Relaxes ureters or bile ducts and relieves renal or gallbladder colic
Over kidney	Increases production of urine

TABLE 40-3 Reflex Effects of Prolonged Cold

APPLICATION LOCATION	EFFECT
Trunk of an artery	Contraction of the artery and its branches
Nose, back of neck	Contraction of the blood vessels of the feet and hands and nasal mucosa
Precordium (ice bag)	Slows the heart rate and increases its stroke volume
Abdomen	Increases intestinal blood flow, intestinal motility, and acid secretion
Pelvic area	Stimulates muscles of the pelvic organs
Thyroid gland	Contracts its blood vessels and decreases its function
Hands and scalp	Contraction of brain–blood vessels
Acutely inflamed areas	Vasoconstriction and relief of painful joints or bursae

TABLE 40-4 Reflex Effects of Short Cold

APPLICATION LOCATION	EFFECT
Local application of intense cold as brief as 30 s	General peripheral vasoconstriction
Face, hands, and head	Increase in mental alertness and activity
Precordial area	Increase in heart rate and stroke volume
Chest, with friction or percussion	Initial increase in respiratory rate, then slower, deeper respiration

Collateral Circulation Effect

The collateral circulation effect may be considered a special case of the derivative effect.² In general use, the derivative effect involves blood volume changes from one area of the body to another, as previously discussed. The collateral circulation effect, in contrast, more specifically considers the local circulatory effects on deep (rather than superficial) collateral branches of the same artery.

Considering the circulatory patterns of a large body part, such as the thigh, it is clear that both superficial and deep areas are supplied by the same artery. A hot application to this area dilates the surface vessels, drawing blood to the superficial areas and concurrently decreasing the BF to the deep areas. A cold application causes the opposite effect. Local compresses and fomentations are the most commonly used techniques to affect collateral circulatory changes.

Arterial Trunk Reflex

The arterial trunk reflex effect is a special case of the general reflex effect.² Prolonged cold applied over the trunk of an artery produces contraction of the artery and its branches distal to the application. Prolonged hot applications have the opposite effect, producing dilatation in the distal arterial bed. For example, prolonged cold application over the femoral artery in the groin will decrease BF in a foot or ankle with an acute injury involving either internal or external hemorrhage. After the acute phase, prolonged hot applications can be used to increase circulation and speed healing of the injured part.

Local and Systemic Effects of Cold Applications

Local cold applications produce vasoconstriction in the local tissues, leading to a decrease in local circulation. If the cold application is long, intense, and covering a large enough area, a slowing of the general circulation may occur. The migration of leukocytes and inflammatory agents from the vascular system into the local tissues and local metabolic activity are decreased, leading to a more moderated healing response to acute injury. Nerve conduction velocities are diminished, resulting in decreased sensation, including pain, as well as slowed motor response. Muscle tissue tends to contract, and connective tissues become less plastic. Thus, cold applications may assist in the tonification of muscle tissue, leading to benefits such as increased urinary sphincter tone. General applications of cold are hypothermic and produce a peripheral vasoconstriction with shunting of the blood to the core.

Water temperatures below 50°F are considered very cold and may be depleting to many patients if used generally, although ice packs can be an effective local treatment for swelling and pain. Temperatures between 50°F and 70°F are considered cold and are often the more desired range for many cold water treatments.

Cold applications are often prescribed for the relief of pain. Saeki ⁵ found cold, but not hot, applications to be useful in the relief of prickly pain sensations experimentally induced in study subjects. Pain sensations were measured on the visual analog scale, and skin BF and skin conductance levels (SCL) were also measured. Cold applications decreased pain, BF, and SCL, whereas hot applications increased pain, BF, and SCL.

In 2002, a small (19 patients) study entitled “To Evaluate the Effect of Local Application of Ice on Duration and Severity of Acute Gouty Arthritis” was published.¹⁴ Treatment and control groups both received oral prednisone 30 mg tapered to 0 mg over 6 days and colchicine 0.6 mg daily. The treatment group received daily ice applications, whereas the control group did not. After 7 days, treatment group participants had a significant reduction in pain compared with the control group.

Cold water is very effective in lowering body temperature caused by fever due to illness or increased core temperature from exposure or exercise. Cold sponging has often been recommended for the reduction of fevers in children. Two articles published in 1997 ^15,¹⁶ compared the use of sponging to oral antipyretics. Both studies concluded that sponging was more effective than medication in the first 30 minutes, but after that, the antipyretic medications were more effective. This makes sense, because it takes time for the medications to be absorbed and circulate in the body, whereas the body responds immediately to the application of water to the skin. One of the primary precepts of naturopathic medicine is to work with the vis medicatrix naturae, and fever is one of the body’s responses to acute illness, assisting in the healing process. Lindlahr stated, “every so called acute disease is the result of a cleansing and healing effort of nature.”³ The benefit of sponging to reduce fever versus use of antipyretic medication is the ability to better control how much we reduce the fever, if at all.

After a cold application, a secondary, or indirect, effect occurs, also termed the “reaction.” This effect is in contrast to the primary effects, as the body responds over time to the general decrease in circulation from the application of cold. Secondary effects include peripheral vasodilation, increased white blood cell and red blood cell circulation, increased metabolism, increased muscle tone, and sense of vigor and well-being. If the cold application is a short one, the reaction follows quickly, its intensity reflecting the intensity (i.e., coldness) of the application. The reaction to a brief cold application produces a slowing of the heart rate with a mild increase in blood pressure. The secondary effects are what is utilized primarily in nonacute cold water treatments.

Local and Systemic Effects of Hot Applications

Heat may be applied to the body in various ways, including hot packs, fomentations, steam, baths, and showers. All hot applications produce physiologic responses that are attempts by the body to eliminate heat to prevent a damaging rise in local and systemic temperatures. The effects produced by hot applications depend on the mode, temperature, and duration of the application and the condition of the patient.

Water at 98° F or above is generally perceived as hot, and water higher than 104° F is considered very hot. At 120° F, an immersion bath becomes unendurable, although small areas of the body, such as the hand, may be conditioned to endure a temperature of 10° to 15° higher for short periods. The mucus membranes, unlike the skin, may endure temperatures as high as 135° F, which accounts for our ability to drink very hot liquids or benefit from steam inhalation treatment. Although exposure to the high temperatures of hot tubs and saunas has become quite popular in recent years, Kneipp, Preissnitz, and Kellogg all believed that repeated and prolonged use could weaken the individual unless counteracted by frequent cold applications, such as showers or ablutions.²

Local hot applications result in vasodilation, with resulting increase in capillary BF, oxygen delivery to the tissues, local metabolic activity, and migration of lymphocytes through vessel walls and into the local tissues. Local sweating is increased, and muscle relaxation occurs. Intense moist heat applied for a long period of time (several minutes) has a depth of penetration not exceeding about 3.4 cm. The increased BF through the area carries away heat conducted into the tissues from a hot application and limits the depth of penetration. (This “radiator-like” effect can be overcome by more intense applications of heat, and deep tissue destruction can occur.)

General hot applications can have dramatic effects on the cardiovascular system. Peripheral dilation occurs with a marked increase in BF (as much as 400%), pulse rate (6 to 10 beats/min per 1° F rise in body temperature) and pulse pressure, and a decrease in cardiac stroke volume. Respiratory rate increases 5 to 6 breaths/min per 1° F rise in body temperature. Hyperventilation may occur and result in respiratory alkalosis. The blood volume increases as a result of the uptake of fluids from the tissues, leading to a decrease in the hematocrit. A transient leukopenia occurs in the first few minutes after a hyperthermia treatment, followed thereafter by leukocytosis. Sweating increases, leading to a loss of water, salt, urea, uric acid, creatinine, sulfates, lactic acid, and other metabolites.

A 2009 study of congestive heart failure patients showed improved biventricular cardiac function, increased output, decreased heart rate, and decreased blood pressure during warm water therapy over an 8-week period. The beneficial effects were found statistically significant during the therapy but did not change cardiac function overall. Authors concluded that warm water therapy is safe for patients with congestive heart failure.¹⁷ Similarly, a 2003 study showed improved mood, physical capacity, enjoyment, and heart failure-related symptoms (subjective), as well as significant decreases in heart rate and rate–pressure product at rest in patients with congestive heart failure. This study used warm water baths and cold water pours, which might account for the sustained therapeutic effect.¹⁸

In addition to the local hot applications discussed in previous sections, local hot applications are common and varied. For example, inhalation of steam for the treatment of the common cold has often been prescribed. Four studies ¹⁹^–²² published between 1987 and 1994 demonstrated the benefit of steam inhalation for nasal symptoms, with one of these studies²¹ demonstrating a decrease in inflammatory mediators in the local tissues.

A recent study of the treatment of benign prostatic hypertrophy using thermotherapy demonstrated a significant decrease in bladder outlet obstruction by using heated water in a closed loop catheter system.²³ A Cochrane Review²⁴ of interventions for chronic abacterial prostatitis concluded: “The routine use of antibiotics and alpha blockers for chronic abacterial prostatitis is not supported by the existing evidence. The small studies examining thermal therapy appear to demonstrate benefit of clinical significance and merit further evaluation.”

Physicians do not normally think of hot applications in the treatment of acute sports injuries. However, one recent study ²⁵ compared the use of hyperthermia to therapeutic ultrasound. In comparing 21 randomized patients with acute muscular injuries of different sites and severity to 19 controls, researchers discovered that after 2 weeks of treatment, the hyperthermia group had significantly less pain and faster hematoma resolution.

The presence of fever has long been associated with better survival and shorter duration of disease in cases of infection. Although the concept of modulating fevers in acute illness using sponging rather than antipyretics was discussed previously, hydrotherapy can also be used to enhance or induce a fever in acute or chronic infections to mimic or increase the body’s natural infection fighting capacity. Many studies have demonstrated the causes of that beneficial response. Four studies reviewed for this chapter ²⁶^–²⁹ demonstrated the activation and mobilization of blood mononuclear cells with hyperthermia treatments. One of these studies²⁶ demonstrated significantly increased serum cortisol, plasma norepinephrine, and plasma epinephrine, and hypothesized that these elevated stress hormones were responsible for the rise in mononuclear cells. One study²⁸ concluded that “fever-induced Hsp70 expression may protect monocytes when confronted with cytotoxic inflammatory mediators, thereby improving the course of the disease.”

General Guidelines for Hydrotherapy

1. The first rule of hydrotherapy is the same as for any therapy: treat the whole person. This involves considering all aspects, including medical history, current condition, current medications, and any other relevant information.

2. Use hydrotherapy treatments in a coordinated and integrated manner with any treatments or medications the individual is receiving.

3. To provide as precise a treatment as possible, grade the patient in terms of age, severity of problems, vitality, emotional state, circulatory condition, etc. A patient’s body temperature, along with their subjective general feeling of warmth or chilliness, should be used as a guide as to how intense the hot or cold used in a treatment should be. Be especially careful with young or elderly persons, and individuals who are chilly, have cardiac problems, are weak or debilitated, are obese, or have other severe physical compromises.

4. If a patient becomes chilled during a treatment, it may be necessary to stop the treatment and warm the person. Sometimes it may suffice to warm the person (by such means as hot drinks, friction rubs, additional blankets, or a hot water bottle to the feet) while continuing the treatment. If the person fails to warm after these attempts, then stop the treatments and warm him or her. Never allow a patient to become chilled to the point of shivering.

5. After a hydrotherapy treatment, avoid excessive heat or cold and/or drafts. The patient should be warmly dressed but not overly so.

6. It is best to do the treatment at an optimal time of day for that patient. It is best to do treatments before meals or at least one hour after a meal.

As with any therapy, it is important to practice hydrotherapy with a critical eye, noting unusual reactions and physiologic effects. Many physiologic parameters, such as urine chemistries and microscopic components, specific gravity, body temperature, and blood sugar levels, may be easily monitored and recorded during treatment. This information helps to optimize the treatment protocols, stimulates further research, and validates hydrotherapy as an effective and useful therapeutic modality.

Cautions and Contraindications

Although hydrotherapeutic procedures are generally low force and gentle treatments, they may in some situations produce unexpected or undesired effects. These effects may be the result of improperly applied treatments, but they may, in some cases, result simply from the individual’s reaction to the treatment. They may, in the long term, be beneficial. Anytime an individual experiences an undesired effect after a treatment, the therapist should review the treatment’s length, intensity, and appropriateness for the individual. If more treatments are considered, they may need to be adjusted to modulate the effects.

Some of the possible side effects of hydrotherapy treatments are headache, vertigo, nervousness, aches and pains, insomnia, hyperventilation, nausea, palpitations, lightheadedness, and chilliness. In most cases, these effects are self limiting and often respond well to simple intervention and/or rest.

If a patient has an adverse reaction, discontinue the treatment and assess the patient’s needs. If the patients are chilled, warm them; if lightheaded or dizzy, make sure they are well hydrated, assess for low blood sugar, and allow them to rest. If complaining of headache or nausea, the patient could be detoxifying, so encourage plenty of water and rest. Coaching the person in deep, slow-breathing exercises for several minutes often relaxes them and decreases the reaction.³⁰ As with any treatment, use professional judgment as to the significance and cause of the patient’s response and employ appropriate intervention. Although undesired effects may occur during or immediately after treatments, they may also occur as long as 24 hours later. Therefore, it is important for practitioners to be available to patients during off-duty hours.

Pregnancy

What to do or take in pregnancy is always a concern. Bathing in hot water is no exception. Ridge and Budd,³¹ in a letter to the editor of the New England Journal of Medicine, summarized these concerns and concluded “that for pregnant (or potentially pregnant) women using a spa pool at a water temperature of 40° C (104° F), any immersion longer than 10 minutes may be too long.”

Hypertension and Cardiovascular Disease

Two studies published in 1998 ^32,³³ demonstrated no adverse cardiovascular effects from bathing in water above 40° C and a response to heat stress no different from normotensive subjects.

Cancer

A synergistic effect has been demonstrated with hyperthermia and radiation treatments given in cancer care. Any patient receiving radiation therapy should not be indiscriminately treated concurrently with hyperthermia.

Diabetes

For individuals with insulin-dependent diabetes, the application of heat to the extremities is to be approached with caution. As discussed previously, increased BF with hot application serves to conduct heat away from the area of application. In diabetics with poor circulation to the extremities, less heat is dissipated, and the local tissue temperature rises more than in tissues with normal circulation. It is safer to use less extreme temperatures in individuals with impaired circulation. Additionally, the application of heat increases tissue metabolism. With impaired circulation, tissue metabolic needs can quickly exceed the nutrients and oxygen available from the blood, and cells may die from oxygen depletion.³⁰ Therefore, very hot applications to the extremities are generally contraindicated in diabetics, whereas mild to moderately hot applications can be quite effective for improving circulation and increasing healing of diabetic ulcers.

For diabetics with conditions in which a hot application to the feet would normally be the treatment of choice but is contraindicated for the patient, a large hot compress to the lower abdomen, groin, and thighs can be used instead to get a reflex reaction in the lower extremities.

Diabetics may also display peripheral neuropathies that decrease their ability to sense heat, thereby increasing the possibility of causing a burn with hot applications. Likewise, individuals with neurologic injury or disease should also be treated with caution during hot applications and be guided to test the water with some part of their body that does not have decreased sensation.

Hydrotherapy Techniques

The various ways in which water may be applied to the human body therapeutically are only limited by the imagination of the practitioner. J.H. Kellogg, in his seemingly exhaustive treatise on hydrotherapy,² devoted 541 pages to describing the techniques of hydrotherapy.

Compresses

Compresses are of four basic types: hot, cold, warming, and alternating hot and cold. They are each applied using cloth or other compress material, which is wrung out to the desired amount of moisture and then applied to any surface of the body. A single compress consists only of layers of the wet material, whereas a double compress is one in which the wet cloth is completely covered by dry material, usually wool, which acts to prevent cooling by evaporation or radiation.

Compresses are commonly referred to by the area of the body to which they are applied, such as the throat, head, joint, trunk, or limb.

Another option for contrast therapy is a shower or affusion. Having patients end their daily hot shower with a full body cold rinse is tonifying to the circulation and immune system. Ernst et al ³⁶ performed a long-term prospective study called “Prevention of Common Colds by Hydrotherapy.” The researchers compared 25 volunteers to 25 controls. Volunteers were asked to work up to a 5-minute hot shower followed by a 2-minute cold rinse. The study demonstrated a decrease in both the frequency and intensity of common colds in the treatment group compared with the control group.

Sitz Bath

The sitz bath is a partial immersion bath of the pelvic region. It is more easily given in a specially constructed tub, but may also be effectively done in a regular bath tub. Often it is taken with the feet immersed in a separate tub of hot water before or during the bath. A sitz bath may be taken hot, neutral, cold, or contrasting hot and cold.

The primary effect of the hot sitz bath is analgesic. It may be helpful in cramps of the uterus or ureters, pain from hemorrhoids, ovaries or testicles, sciatica, urinary retention, and after cystoscopy or hemorrhoidectomy. It is followed by cool sponging or affusion of the area. Hot sitz baths are not indicated in cases of acute inflammation but may be appropriate for chronic pelvic inflammatory disease (PID). Hot applications to the pelvis are also contraindicated during menses in most instances.

Neutral sitz baths are more appropriate for situations of acute inflammation, such as cystitis and acute PID, as well as being effective for pruritus of the anus or vulva. The cold sitz bath is given immediately after a warm-to-hot sitz bath for 30 seconds to 8 minutes. It is important to ensure that the water level of the hot bath on the body is at least 1 inch above the level of the cold water. This ensures adequate warming of the area, thereby preventing chilling. Friction rubs to the hips during the cold sitz bath promote an increased reaction. The cold sitz bath is used mainly for its tonifying effects. It may be used for subinvolution of the uterus, metrorrhagia, atonic constipation, enuresis, atony of the bladder, and chronic prostatic congestion. Because it increases the tone of the smooth muscles of the uterus, bladder, and colon, it lessens the tendency to bleed from the uterus, the lower bowel, and rectum. It is necessary to provide adequate coverings during neutral and cold sitz baths to avoid chilling.

Contrast sitz baths are much like immersion contrast baths but with only the pelvic region submerged in water. As an alternative, the cold application can be performed with a towel wrung from cold water, with the patient standing in the hot bath and pulling the cold towel into the groin, holding it like a diaper for the time prescribed. Care should obviously be taken when standing in a tub of water, especially when standing up from a hot bath. The contrast sitz bath increases pelvic circulation and tone of the smooth muscles of the region. It is indicated in chronic PID, chronic prostatitis, atonic constipation, and other atonic conditions of the pelvis. The strong revulsive effect created increases the BF in the pelvic region dramatically.

Cold Friction Rubs

Cold friction rubs, or ablutions, consist of frictioning the body in a predetermined sequence with cold water. They differ from sponging in that they are more tonifying and are done more vigorously with rougher materials. A woolen bath mitt works well, but if this is not available, a coarse washcloth or loofa may also be used.

The primary effect of a cold ablution is tonic. Therefore, it may be used for any condition in which tonification is desired, such as fatigue after illness or surgery or after hot applications, such as saunas, whirlpools, or hot baths. It is an excellent prophylactic hydrotherapy technique when used regularly along with saunas, hot tubs, and massage.

A whole body ablution is carried out with the patient lying supine, covered completely and not chilly. Using cool to cold water, the therapist dips the mitt into the water and vigorously causes friction on a portion of the body. Depending on the cooling effect desired, the mitt may either be saturated or wrung dry before the friction occurs. The body part is treated until reddening occurs. If the patient is weak, it is best to dry the areas as one proceeds using a coarse dry towel. If the patient is strong and vigorous, one can wait and dry all areas at the end of the treatment.

One sequence for an ablution treatment would be to proceed from the chest to the arms and then the legs, then, turning the patient prone, to do the back of the legs and feet, the buttocks, and finally the back. Only the part being treated is exposed at any time.

Constitutional Hydrotherapy

Constitutional hydrotherapy was, as stated previously, developed by O.G. Carroll as an application of first hot, then cold, to the trunk, both front and back, along with low volt electrical stimulation to tonify the digestive organs and enhance the effects of the water applications. This therapy utilizes both contrast hydrotherapy and warming compress effects. Apart from contrast hydrotherapy applications, it is the most generally useful of the various hydrotherapy treatments and is commonly used to balance body functions, strengthen the immune system, and promote healing, as well as being a useful adjunct to detoxification. A pilot study ³⁷ completed in 2008 at the Bastyr Center for Natural Health on human immunodeficiency virus positive patients showed a statistically significant increase in energy and decrease in body fat and a trend toward increased physical function along with a decrease in pain after a course of treatment with constitutional hydrotherapy. Fifty-eight percent of participants showed a decrease in systolic blood pressure. There was also a sizable decrease in C-reactive protein levels.

Constitutional hydrotherapy may be used as an adjunct to the treatment of any condition. It may be used to treat acute conditions such as upper respiratory infections, bronchitis, asthma, and gastrointestinal infections, and chronic conditions such as irritable bowel, ulcerative colitis, pre-menstrual syndrome, and arthritis, as well as conditions related to nervous system dysregulation such as insomnia or anxiety. (As a general rule of thumb “when in doubt, try constitutional hydrotherapy.”) Boyle and Saine’s Lectures in Naturopathic Hydrotherapy contains an excellent write-up on the constitutional hydrotherapy procedure.³⁸

Wet Sheet Pack

The wet sheet pack is one of the most useful of all hydrotherapy procedures. It may be done either in the office or as a home treatment, if adequate direction is provided. It requires from 1 to 3 hours, depending on the patient’s condition. Understanding the process completely before using this treatment is important. Lectures in Naturopathic Hydrotherapy by Boyle and Saine outlines the wet sheet pack procedure in detail for practitioners.³⁸

The wet sheet pack proceeds through four stages: tonic or cooling, neutral, heating, and eliminative. Depending on the desired effect, the therapist may wish to prolong any one specific stage:

• Tonic stage. This stage may last from 2 to 15 minutes and is finished when the patient no longer perceives the sheet as being cold. This phase is intensely alterative to the body due to the intense thermic reaction induced. The length of this stage is directly dependent on the amount of water left in the sheet. For weak or exhausted patients, the sheet should be wrung out as completely as possible. For young, strong individuals for whom a more tonifying treatment is desired, more water may be left in the sheet.

• Neutral stage. Once the sheet reaches body temperature, the person no longer feels cold. At this time, the neutral phase begins. It may last from 15 minutes to an hour or longer, depending on the vitality of the patient. During this phase, there is a sense of calm that is similar to that experienced during a neutral bath. Often the patient falls asleep during this phase. This stage is indicated in cases of insomnia, anxiety, and delirium. To prolong the neutral phase, provide only adequate covering to prevent the patient feeling cool. Greater amounts of blankets trap more heat, and the neutral phase finishes sooner.

• Heating stage. As heat accumulates beneath the blankets, the patient gradually senses the warming and eventually begins to show light perspiration on the forehead. The time between the patient feeling warm and the beginning of perspiration is known as the heating phase. This may last from 15 minutes to an hour.

• Elimination stage. The final stage begins when the body begins to perspire. In a febrile patient, this stage is reached sooner. This stage is especially beneficial for those patients in a detoxification process, such as from alcohol, tobacco, coffee, or other toxins. It may also be used with acute infections, such as colds, flu, or bronchitis. Certain conditions that affect the skin, such as jaundice, may also benefit from this stage, as well as acute inflammatory conditions, such as arthritis.

During the elimination phase, it is important to provide adequate fluid to the patient. Herbal teas, used for either their diaphoretic or therapeutic effects, are most appropriate. This phase may last up to an hour. The treatment should be ended quickly if the patient begins to feel chilled or becomes uncomfortable.

The treatment is ended by quickly removing the patient from the pack, frictioning the skin briskly with a dry towel, and having the patient dress. As this is often an intensive treatment, it should be followed with rest or appropriate activity. Lying in a warm room for an hour is an ideal follow-up to this treatment. If done at home, it is best done in the evening just before retiring.

Colonic Irrigation

Colon hydrotherapy utilizes warm water moved through the colon to aid in waste elimination. Colonics are primarily utilized in cases of chronic constipation to both eliminate waste and improve colonic action, or as part of a detoxification protocol supporting excretion of toxins through the gastrointestinal system. The therapy requires a colonic irrigation unit and some training on proper use. Ulcerative colitis, diverticulitis, inflamed hemorrhoids, intestinal bleeding, colon cancer, pregnancy, and hypertension are contraindications to colonic irrigation.

Sauna

Saunas can be wet or dry depending on their heat source. Steam saunas use water as their source of heat and are an excellent general hyperthermic treatment. Saunas have also shown efficacy in detoxification protocols supporting excretion of toxins through the skin. A recent review of the benefits and risks of sauna bathing ^39,⁴⁰ concluded the following:

• It is well tolerated by most healthy adults and children.

• It is safe during uncomplicated pregnancy.

• It may help lower blood pressure and increase left ventricular ejection in patients with congestive heart failure.

• It produces transient improvement in pulmonary function, which may be helpful for patients with asthma and chronic bronchitis.

• It decreases pain and increases mobility in patients with rheumatic diseases.

• It may be contraindicated in patients with unstable angina pectoris, recent myocardial infarction, and severe aortic stenosis.

• It is safe for patients with stable angina pectoris and old myocardial infarction.

• Krop ⁴⁰ published a case study in 1998 demonstrating the usefulness of sauna in the detoxification of a patient with 20 years’ duration chemical sensitivity resulting from low-level exposure to solvents.