Critical Review on Trends In Hydrotherapy Research
Dhananjay Arankalle, BNYS, FAN, APGDCR-MW1, Jincy Sundaran, BNYS2, Raghuraj Puthige, BNYS, PhD3
- Consultant (Technical), National Institute of Naturopathy, Pune, Maharashtra, India
- Lecturer, Zamorin’s Guruvayurappan College, Calicut, Kerala, India
- Honorary Consultant, Foundation for Assessment and Integration of Traditional Health Systems (F.A.I.T.H.S.), Bengaluru, Karnataka, India
All correspondence may be directed to:
Dr. Dhananjay Arankalle, BNYS, FAN, APGDCR-MW
National Institute of Naturopathy,
Division of Intramural Research,
Bapu Bhavan, Tadiwala Road,
Pune – 411 001
Word count (including tables; excluding abstract and references): 4898
Word count (only abstract): 263
Number of tables: 2
Number of figures: 0
Hydrotherapy, a modality of naturopathy that involves the use of water at different temperatures, pressure, states, and mode of application in the treatment, has been used since ancient times. Vinzenz Priessnitz and Wilhelm Winternitz are considered the creators of “world hydrotherapy”. It is believed that external application of water on the human body produces diverse physiological effects. The objective of this review is to summarize the validity of therapeutic findings based on research studies in hydrotherapy.
A Pubmed search was carried out with the key words “hydrotherapy”, “water therapy” and “physiological effects of water”. Papers were categorized based on the parameters studied, mechanisms discussed and their application in treating diseases. Full-papers or abstracts in English from the year 1975 to 2011 were included in the review.
Among all the hydrotherapeutic interventions, immersion bath, underwater massage, foot and arm bath, sitz bath and whirlpool bath (Jacuzzi) were the most studied. Cardiovascular hemodynamics, cellular immunity, psychological parameters, neonatal growth and risks of hydrotherapy were studied in depth. Studies attributed use of hydrotherapy in reduction of maternal anxiety and pain during labor, pressure ulcer healing, reduction of DSM (Diagnostic and Statistical Manual of Mental Disorders)-III scores, reduction of post-anorectic surgical pain, rehabilitation of myocardial infarct patients, enhancement of neuromuscular performance reduction in low density lipoproteins and total cholesterol, reduction of the physiological and functional deficits associated with delayed onset muscle soreness and improvement in performance recovery post strenuous training.
The physiological effects and therapeutic applications of hydrotherapy are diverse. The therapeutic effects of hydrotherapy based on previous research studies will be discussed.
Key words: Hydrotherapy Review Naturopathy
Hydrotherapy can be defined as a modality of naturopathy that involves the use of water at different temperatures, pressures, states, and modes of application in the treatment. It is also referred to as ‘water therapy’. The term ‘Ordnungstherapie’ was introduced by Bircher-Benner as an umbrella term in 1937 to describe a complex concept of natural healing.1 In the German naturopathic tradition, Ordnungstherapie is mostly considered as one out of five constituents of naturopathy (dietotherapy, hydrotherapy, exercise therapy, phytotherapy, Ordnungstherapie). Various modalities of hydrotherapy have been studied in the past and have shown diverse applications. The diverse use of water holds a significant place among the therapeutic means which had been developed in Western medicine ever since antiquity. Uses of ‘gush of water’ are mentioned in the relevant medical treatises based directly on Greek or Roman authors (Hippocrates, Galen, Celsus), commentaries of Arabic handbooks in their Latin translations (Avicenna, Rhazes), and antique medicine as well.2 The pouring of water, alone or in combination with other prescriptions, was applicable in a variety of illnesses such as fevers, pains of the joints, psychic diseases, or even headaches.2 Bathing in water without exercise has also been frequently used in alternative medicine as a disease cure.7 Vinzenz Priessnitz, a small-scale farmer from Gräfenberg (Austrian Silesia), from the 1820′s apparently aroused worldwide interest in hydrotherapy on the basis of empirical observations of his regimen of compresses; head, eye and foot baths; hip baths and full baths; showers and cold-water cures. This hydrotherapeutic impulse from Gräfenberg also influenced the Vienna Medical School. Wilhelm Winternitz, who became a lecturer in hydrotherapy in 1864, is referred to as the “father of scientific hydrotherapy”.3
The warmth and buoyancy of water may block nociception by acting on thermal receptors and mechanoreceptors, thus influencing spinal segmental mechanisms.4 In addition, warm water may enhance blood flow, which is thought to help in dissipating algogenic chemicals, and facilitate muscle relaxation. In addition, the hydrostatic effect may relieve pain by reducing peripheral edema5 and by dampening sympathetic nervous system activity.6 Although many studies have reported the effects of water as therapy, there is no review of evidence in this effect. Thus, this review was undertaken to understand and summarize the therapeutic findings and physiological effects based on previous research studies in hydrotherapy.
2.1 Criteria for study inclusion
2.1.1 Types of studies
Available full papers or abstracts of treatment studies and observational studies irrespective of randomization and systematic reviews (with or without a meta-analysis) were eligible.
2.1.2 Types of participants
Studies were not excluded based on the disease status of participants (ill vs. healthy people).
2.1.3 Types of intervention and language
Studies that had at least one treatment group in which any classical hydrotherapy modality was used were included. Studies with underwater exercises / water-based exercises as an intervention were excluded. Studies had to include information on use of medication, alternative therapies, and lifestyle changes, and these had to be comparable among groups. When comparing different programs, type of exercise, type of water, water depth, and water temperature were considered. The medium of language was restricted to English.
2.2 Methods used to identify studies
2.2.1 Bibliographic database
We searched Medline Database (via PubMed) from 1975 for articles published up to the year 2011.
2.2.2 Search strategies
The search strategies contained the following elements and terms:
(I) Search “hydrotherapy” or “water therapy” or “physiological effects of water”
Only keywords related to intervention were used for searching. First, titles and abstracts of identified published articles were reviewed to determine the relevance of the articles. Next, the references in relevant reviews were screened.
2.2.3 Reference checking and hand searching
We did not check the references of included studies, nor did we perform any hand searches or contact institutions, societies, specialists with expertise in hydrotherapy, or the authors of included studies to identify any additional published or unpublished data.
2.3 Review methods
2.3.1 Selection of trials
For the final selection of studies for this review, the authors (DA and JS) independently applied all criteria to the full text of the articles that had passed the initial eligibility screening. Disagreements and uncertainties were resolved by discussion between the authors.
Studies were selected when one of the interventions was a classical form of hydrotherapy. Effectiveness of cure or health improvement was used as a primary outcome measure. Health improvement was defined broadly, and encompassed improvements in blood pressure, serum lipid profile, immunity, and quality of life. Systematic reviews of non-RCTs or observational studies were not excluded.
2.3.2 Quality assessment of included studies
To ensure that variation was not caused by systematic errors in study design or execution, two review authors (DA and JS) independently assessed the quality of articles using a broad criteria set for inclusion based on the parameters studied, mechanisms discussed and their application in treating diseases. Disagreements and uncertainties were resolved by discussion between the review authors.
One author (DA) selected the summary from each of the structured abstracts and extracted the results for analysis. The primary outcome measurement was always chosen for analysis.
The literature search included 212 relevant articles. Abstracts from those articles were assessed and full-papers wherever possible were retrieved. Twenty studies met the criteria set by the authors (Table 1). Among all the hydrotherapeutic interventions, immersion bath, underwater massage, foot and arm bath, sitz bath and whirlpool bath (Jacuzzi) were the most studied. Cardiovascular hemodynamics, cellular immunity, psychological parameters, neonatal growth and risks of hydrotherapy have been studied in depth. Studies attributed use of hydrotherapy in reduction of maternal anxiety and pain during labor, pressure ulcer healing, reduction of DSM (Diagnostic and Statistical Manual of Mental Disorders)-III scores, reduction of post-anorectic surgical pain, rehabilitation of myocardial infarct patients, enhancement of neuromuscular performance, reduction in low density lipoproteins and total cholesterol, reduction of the physiological and functional deficits associated with delayed onset muscle soreness (DOMS) and improvement in performance recovery post strenuous training. A single double-blinded, placebo-controlled, crossover study (n=14) conducted in Japan, suggests that mild-stream bathing (hot water) induces improved working memory processing, diminished waist muscle tone, and attenuated mental stress, thus concluding that mild-stream bathing is more effective for alleviating mental fatigue than normal bathing.8 Four studies were identified giving a description of adverse effects and safety measures in relation to the use of hydrotherapy (Table 2).
Table 1. Description of studies
|Digiesi V, et al.||Pre-Post evaluation among 17 healthy participants who underwent immersion bath;Duration of intervention: 30 minutes.||Head out immersion bath at 38.41 +/- 0.04 degrees Celsius (mean +/- S.E.)
Healthy subjects aged 21-65 years (mean age 29.8 +/- 2.6)
|Hemorheological, haematic and hemodynamic parameters||
||Immersion bath can be an effective treatment modality for hypertensives especially for reducing systolic blood pressure.However, studies assessing long-term effects need to be carried out.|
|Digiesi V, et al.||Pre-Post evaluation among 17 healthy participants who underwent immersion bath;Duration of intervention: 30 minutes.||Head out immersion bath at 38.41 +/- 0.04 degrees Celsius (mean +/- S.E.)
Healthy subjects aged 21-65 years (mean age 29.8 +/- 2.6)
|Beta-endorphin,renin activity, aldosterone, cortisol, HGH, FSH, LH, TSH, T3, T4 and prolactin haematic levels||
||Immersion bath causes definitive hormonal changes; however, a single session causes the effects to return to baseline post thirty minutes.Studies with stronger controls and larger sample sizes need to be addressed.|
|Muc M, et al.||Single case study||Immersion bath
Ascites (caused by liver cirrhosis resistant to therapy)
|Not available||Short improvement demonstrated (Possible mechanism hypothesized to short term natriuretic effect)||Strong single-case study evidence demonstrates the natriuretic effect of hydrotherapy and its efficacy in the treatment of ascites caused by liver cirrhosis.|
|De Lorenzo F, et al.||Prospective pre-post study involving 68 (35F and 33M) participants; Duration of intervention: 90 days||Cold water exposure (immersion, gradual temperature reduction from 22 to 14 degrees C and increase in duration from 5 to 20 minutes over 90 days)
|TSH, FT4, total T3, total cholesterol, LDL, HDL, triacylglycerols and total fat mass||1. Significant reduction in total cholesterol (-0.2 mmol/l, P=0.006) and LDL (-0.2 mmol/l, P=0.004)2. Serum FT4 level was higher than baseline results in 30 of these hypercholesterolemic patients (15.5 pmol/l to 17.3 pmol/l)
3. No significant change in serum TSH and total T3
|Immersion baths can be a good treatment modality in reducing cholesterol in blood caused notably by cardiovascular disease.|
|Blazícková S, et al.||Pre-post assessment of 10 participants;Duration of intervention unavailable.||Hyperthermicwater bath
(both topical and whole-body)
(lymphocyte subpopulations, NK cell counts and their activity)
|1. Reduction in relative total T lymphocyte counts, increased relative CD8+ T lymphocyte and NK cell counts and increased NK activity2. Increase in STH activity in eight out of 10 volunteers
3. In five volunteers STH was released in response to local hyperthermic water bath and the NK activity of lymphocytes also increased not their relative counts.
|Hot water (hyperthermic) water baths seem to increase CD8+ lymphocyte and NK cell counts. This increase can be attributed to the increase in STH production.|
|Viitasalo JT, et al.||14 junior track and field athletes;Duration: Training session – 3 days; Intervention – 20 minutes (thrice).||Warm underwater water-jet massage
Track and field athletes
|Neuromuscular functioning, selected biochemical parameters (serum creatine kinase, lactic dehydrogenase, serum carbonic anhydrase, myoglobin, urine urea and creatinine) and muscle soreness||1.Continuous jumping power decreased and ground contact time increased significantly less (P < 0.05)2.Serum myoglobin increased||Underwater water-jet massage in connection with intense strength/power training increases the release of proteins from muscle tissue into the blood and enhances the maintenance of neuromuscular performance capacity.|
|Fiscus KA, et al.||Crossover trial with repeated measures. 24 healthy men participated in the study. Parameters from baseline measurements were recorded in a 3-minute to 1-minute on-off ratio; Duration of intervention: 20 minutes.||Four randomly assigned treatments performed on each subject on consecutive days.(Warm, cold, contrast water therapy and control)||Arterial blood flow (mL per 100mL/min) by using strain gauge plethysmography.||1.Warm-water therapy (40 degrees C) resulted in significant (P < .001) changes in blood flow compared with the control and contrast conditions.2.Cold-water therapy (13 degrees C) did not produce significantly decreased blood flow.
3.Contrast therapy produced fluctuations in blood flow throughout the 20-minute treatment.
|Contrast water (alternate warm and cold water application), warm water and cold water have distinct effects on blood flow during twenty minute applications.Also, warm water application may be used effectively in conditions with limited blood supply to particular body parts.|
|Elmståhl S, et al.||Prospective study with repeated measurements before and 1, 4 and 12 months after treatment;Duration of intervention: 25 minutes, thrice weekly.||Alternate hot and cold hydrotherapy of the legs
|Maximal walking ability (MW), walking ability before pain (PW) and systolic blood pressures of toe, ankle, arm and AAI||
||Showering the legs of claudicants improves walking ability and blood pressures which can be sustained.This therapy might be an additional alternative to conservative treatment of intermittent claudication.|
|Dodi G, et al.||Pre-Post assessment among control (n=26) and intervention group (n=31);Duration of intervention: 5 minutes.
|Wet heat application to anus (immersion in water – similar to Sitz bath) at varying temperatures (5 degrees C, 23 degrees C, and 40 degrees C)
Anorectal conditions – hemorrhoidal disease, anal fissure, and proctalgia fugax
|Resting anal canal pressures using manometry||
|Wet heat (in the form of Sitz bath) applied to the anal sphincter apparatus significantly and reproducibly decreased resting anal canal pressures over time, and therefore is likely to benefit patients after anorectal operations and those with anorectal pain.|
|Shafik A||Pre-Post assessment among control (n=18) and intervention group (n=28);Duration of intervention: 10 minutes.||Warm-water bath (Sitz) at temperatures of 40, 45, and 50 degrees CPainful anorectal disease (18 patients with fissures and 10 with hemorrhoids)||Rectal and interstitial sphincter temperature, rectal and rectal neck pressures, and electromyographic activity of external and internal anal sphincters||
||Pain relief after Sitz bath seems to be the result of internal anal-sphincter relaxation with a resulting diminution of the rectal neck pressure. The relaxation of the internal sphincter following the warm bath postulates a relationship, but direct action is ruled out. A neural pathway through a “thermosphincteric reflex” seems most likely.|
|Burke DT, et al.||Prospective study with random allocation of subjects in to conservative treatment group (A; n = 18) or the conservative treatment plus whirlpool group (B; n = 24);Duration of intervention: 20 minutes for 2 or more weeks.||Whirlpool bath (in addition to conservative treatment)
Stage III or IV pressure ulcers
|Ulcer dimension changes over time||Conservative treatment plus whirlpool group improved at a significantly faster rate than did the conservative treatment only group (P < 0.05).||Whirlpool bath can be effective in the management of pressure ulcers and can be as an adjuvant to conservative management.|
|Juvè Meeker B||Quasi-experimental study of repeated measures of pain and surgical wound assessments involving 63 subjects (43 female and 20 male);Duration of intervention unavailable.||Whirlpool bath
Post-surgical pain and wound healing
|Pain (using rating scale) and surgical wound healing in adults post major abdominal surgery||
||Whirlpool bath promotes comfort and shows positive signs of post-surgical wound healing.|
|Robiner WN||Pre-post assessments in 40 healthy adult volunteers;Duration of intervention: 10 minutes.||Whirlpool baths and immersion baths
Physical and psychological reactions
|Pulse and finger temperature, well-being, blood pressure, respiration rate, muscle tension, pupil size, state anxiety. (Use of DSM III and Multiple Affect Adjective Checklist has been mentioned explicitly in the abstract)||
|Although whirlpool baths appear to be a popular form of recreation, this study reveals limited significant incremental relaxation beyond the effects due to warm water alone.|
|Benfield RD, et al.||Randomized, pretest-posttest control group design with repeated measures involving 18 term parturients;Duration of intervention: 1 hour (during early labour).||Tub bath of 37 degrees C water
|Anxiety, pain, plasma volume, urine catecholamines and maternal-foetal complications||
||Hydrotherapy in labour reduces acute, short-term anxiety and pain.|
|DiPasquale LR, et al.||Single case study;Duration of intervention unavailable.||Water immersion (bath)
Labial oedema (during pregnancy)
|Oedema and pain assessment||Reduction in oedema and the pain.||Single-case study demonstrating efficacy of hydrotherapy in reducing pain and edema in a pregnant woman with nephritic syndrome.|
|Vaile J, et al.||Strength trained males (n = 38) completed two experimental trials separated by 8 months in a randomised crossover design;Duration of intervention: 14 minutes||3 hydrotherapy interventions:cold water immersion (CWI: n = 12), hot water immersion (HWI: n = 11) and contrast water therapy (CWT: n = 15)
Delayed onset muscle soreness (DOMS)
|Weighted squat jump, isometric squat, perceived pain, thigh girths and blood variables were measured prior to, immediately after, and at 24, 48 and 72 hours post-exercise||
|CWI and CWT can be effective in reducing the physiological and functional deficits associated with DOMS. While HWI was effective in the recovery of isometric force, it was ineffective for recovery of all other markers compared to PAS.|
|Sellwood KL, et al.||Prospective randomised double-blind controlled trial was undertaken. 40 untrained volunteers performed an eccentric loading protocol with their non-dominant leg;Duration of intervention: 1minute.||Ice water (5+/-1 degrees C) or tepid water (24 degrees C)||Pain and tenderness (visual analogue scale), swelling (thigh circumference), function (one-legged hop for distance), maximal isometric strength and serum creatine kinase (CK) recorded at baseline, 24, 48 and 72 hours after exercise||
||The protocol of ice-water immersion used in this study was ineffectual in minimising markers of DOMS in untrained individuals.This study challenges the wide use of this intervention as a recovery strategy by athletes.|
|Morton RH||Single assessment(repeated measures) on 11 subjects;
Duration of intervention: 30 minutes.
|Contrast (alternating hot and cold) water immersion (CWI) and Passive recovery (PR).
Post-anaerobic exercise recovery
|Plasma lactate concentration (during recovery)||Rate of decrease in plasma lactate concentration over the 30-min recovery period was significantly higher (p<0.001) in CWI; 0.28(+/-0.02) mmol L (-1) min (-1) (CWI) compared to 0.22(+/-0.02) mmol L(-1) min (-1) (PR).||CWI is a valid method of hastening plasma lactate decrease during recovery after intense anaerobic exercise for both males and females.|
|Vaile J, et al.||Single assessmentmatched controlled trial among 12 cyclists.
Duration of intervention: 14 minutes.
|Cold water immersion (CWI), hot water immersion (HWI), contrast water therapy (CWT), and passive recovery (PAS)
Performance recovery following strenuous training
|Performance (average power), core temperature, heart rate (HR), and rating of perceived exertion (RPE)||
||CWI and CWT appear to improve recovery from high-intensity cycling as compared to HWI and PAS, with athletes better able to maintain performance across a five-day period.|
|Janssen RG, et al.||Randomized clinical trial(n=114);
Duration of intervention unavailable.
|Contrast baths with exercise, contrast baths without exercise, and exercise only.
Carpal Tunnel Syndrome
|Hand volumetry (before and after treatment at two different data collection periods-pre- and postoperatively)||
|The use of contrast bath treatment has no significant effect on increase or decrease of hand volume in Carpal Tunnel Syndrome patients, pre-and/or postoperatively.|
(RBC-Red Blood Cells; DBP-Diastolic Blood Pressure; SBP-Systolic Blood Pressure; HGH-Human Growth Hormone; FSH-Follicle Stimulating Hormone; LH-Luteinizing Hormone; TSH-Thyroid Stimulating Hormone; T3-Triiodothyronine; T4-Thyroxine; LDL-Low Density Lipoprotein; HDL-High Density Lipoprotein; STH- Somatotropin Hormone; NK cells-Natural Killer cells; AAI-Ankle Arm Index; DSM-III- Diagnostic and Statistical Manual of Mental Disorders-III; PAS-Passive Recovery; ANOVA- Analysis of variance)
Table 2. Description of adverse effects and safety measures
|Chandrasekar PH, et al.||A healthy, 27-year-old man had development of a maculopapular, pustular rash due to Pseudomonas aeruginosa, serotype 0:4, after bathing in a hot tub.||Case report emphasizing the importance of hygiene in a hydrotherapy department to prevent Pseudomonas aeruginosa infection.|
|ArledgeRl||Hydrotherapy is an especially dangerous area and should be equipped with ground fault detector receptacles with ground fault interrupters that cut the current when the electrical ground is lost.An external isolation transformer may be required to modify older ultrasonic units before they meet present standards||Special care is required in hydrotherapy section to prevent electrical shocks.|
|Dadswell JV||A well-managed section with an adequate disinfectant level, a pH value within the recommended range, regular filter backwashing, and satisfactory microbiological parameters will not present a significant infection risks.||If management or design is poor, conditions can occur in which bathers become infected. Most infections reported in association with pools (and bath tubs) happen in these circumstances.|
|Tan MP, et al.||Following the use of colonic hydrotherapy, a patient developed life-threatening perineal gangrene due to rectal perforation.||There is no legislation governing naturopathy medical practice. Such incidences need to be addressed to.|
According to this review, research in hydrotherapy has covered a vast area in terms of physiological effects and its therapeutic applications. A summary of the findings follows.
4.1 Cardiovascular system
A single session of immersion bath (neutral temperature – 38.4 degrees C, for thirty minutes duration) can effectively help in reduction of systolic blood pressure. Cold immersion bath (gradual temperature reduction from 22 to 14 degrees C and increase in duration from 5 to 20 minutes) can help in the reduction of cholesterol levels caused notably by cardiovascular disease. Warm water (at 40 Degrees C) baths seem to cause significant changes in arterial blood flow in the legs when administered for twenty minutes, whereas contrast (alternate hot and cold) baths produce fluctuations.
4.2 Endocrine system
A single session of immersion bath (neutral temperature – 38.4 degrees C, for thirty minutes duration) can cause a reduction in follicle-stimulating hormone and luteinizing hormone concentrations in blood.
4.3 Immune system
A single session of hyperthermic (or hot) immersion bath has shown to increase CD8+ lymphocyte and natural killer (NK) cell counts. The possible mechanism of action could be the increased production of somatotropic hormone on exposure to hot water.
4.4 Musculoskeletal system and performance
Warm underwater jet massage seems to improve neuromuscular performance among athletes. This improvement is attributed to the release of proteins (increased production of serum myoglobin) from muscle tissue into the blood. Cold water immersion (bath) can be an effective modality in reducing physiological and functional deficits in delayed onset muscle soreness (DOMS). This can be a strong management strategy for athletes especially those involved in endurance training. However, ice-water immersion was ineffectual in minimising markers of DOMS in untrained individuals, thus, challenging its use in recovery in athletes.
Contrast (alternating hot and cold) water immersion (CWI) has shown to hasten plasma lactate decrease during recovery after intense anaerobic exercise for both males and females. Cold water immersion (CWI) appears to improve recovery from high-intensity cycling, allowing athletes to better maintain performance.
4.5 Labour and pregnancy
Tub bath at 37 Degrees C in parturients for one hour during labour has shown to significantly reduce acute, short-term anxiety and pain. Water immersion bath has also shown to reduce labial oedema and associated pain in a pregnant woman with nephritic syndrome in a single case study.
4.6 Specific conditions
Natriuretic effect of immersion bath demonstrated in a single case study has shown to be of significant application in the treatment of ascites caused by liver cirrhosis. Alternate hot and cold showering on legs has shown to be effective in the treatment of intermittent claudication.
Wet heat application to anus (immersion in water – similar to Sitz bath) at varying temperatures (5 Degrees C, 23 Degrees C, and 40 degrees C) to the anal sphincter apparatus is likely to benefit patients with anorectal pain and in post anorectal surgery. Pain relief after warm-water (Sitz) bath at temperatures of 40, 45, and 50 degrees C for 10 min each, seems to be the result of internal anal-sphincter relaxation with a resulting diminution of the rectal neck pressure. A neural pathway through a “thermosphincteric reflex” is proposed as the likely mechanism of action.
Whirlpool bath can be a strong adjuvant to conservative management of pressure ulcer healing. It has also shown its efficacy in effectively reducing post-surgical pain and hastening wound healing in those patients who recently underwent major abdominal surgeries.
4.7 Adverse effects and safety measures
Maintaining hygiene in the hydrotherapy section is of utmost importance. Tubs, when shared between two people can cause rash with Pruritus, malaise, and low-grade fever. Although a number of reports of whirlpool- or hot tub-related Pseudomonas aeruginosa have appeared in the literature in recent years, the most effective preventive measures to be taken are not completely clear at the present time. Continuous water filtration, automatic chlorination to maintain a free residual chlorine level of 1 ppm, frequent monitoring of the disinfectant level, maintenance of water at a pH of 7.2 to 7.8, and the frequent changing of water, especially during heavy use, are some helpful measures that should be applied not only in hydrotherapy sections, but also in all public and private bath places to prevent this disease.
Hydrotherapy is an especially dangerous area in terms of electricity and should be equipped with ground fault detector receptacles with ground fault interrupters that cut the current when the electrical ground is lost. Special care is required in hydrotherapy sections to prevent electrical shocks.
A case study of a patient who developed life-threatening perineal gangrene as a result of rectal perforation following colonic hydrotherapy has also been reported.
4.8 Study limitations
This review is limited by the heterogeneity of the studies cited, multiple outcome measures and restriction of full-text articles to English language. Furthermore, we did not contact institutions, societies, naturopaths known to have expertise in hydrotherapy, and authors of included studies to identify any additional published or unpublished data. The quality of studies was not commented upon considering that this was a critical review rather than a systematic one.
There is confusion around international definitions of hydrotherapy and balneology. The use of plain (tap) water for therapy is termed as hydrotherapy, whereas, balneotherapy comprises of the use of medical mineral waters, medical peloids, and natural gases (bathing, drinking, inhalation, etc.)37. The scope of this critical review is limited to the inclusion of hydrotherapy modalities as per these definitions due to which some well-known studies specifically in balneotherapy may not have been included in this particular review, despite the crossover.
The findings suggest that hydrotherapy is an important component of naturopathy considering the variety of physiological effects that can be generated and may have applications in treating different systemic disorders. However, the findings mentioned in this critical review should be regarded with caution in prescription-making as they may not necessarily be conclusive.
A vast amount of work has been done in the field of hydrotherapy. This review outlines the physiological effects of hydrotherapy and probable management strategies for different conditions along with mechanism of action wherever possible. There is a need for hydrotherapeutic research for standardization of line of management in disorders and exploring the physiological effects using relevant parameters to make the naturopathic medical system more scientific and evidence-based. Properly structured controlled trials on large sample sizes examining the effect of particular hydrotherapeutic modalities are required to enable formation of standard treatment protocols. Systematic reviews assessing hydrotherapy modalities for particular conditions may be helpful in determining duration and frequency of individual modalities.
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