introduction

Hydrotherapy is a tool for rehabilitation that was used in the past

centuries and it is as important now as it was in the past. It is the
use of the power of the water in treating many conditions using
specific exercises. Its history as a method of treatment goes back to
many thousands year. The first time that the
hydrotherapy was used is unknown, bu t it was
reported that it was used at 2400 BC by proto-
Indian culture as hygienic installations, and also
the Mohammedans, early Egyptians and
Assyrians used mineral waters for curative
reason. In medieval times the use of
hydrotherapy was suppressed, but by 15 th, 16 th, and 17th
centuries the use of hydrotherapy for healing propose have
recognized from few European physicians (Campion & Towomey,
1990; Campion, 1997; Ruorti & Morris& Cole, 1997; Campion, 1991).
Today hydrotherapy is used in rehabilitation for neurological,
rheumatic, obstetric, sport injury, pediatric, and musculoskeletal
.problems
Aquatic physics
Physiotherapists must have knowledge about properties and
characteristics of water mass, density, weight, buoyancy, specific
gravity, hydrostatic pressure, surface tension, viscosity and
refraction, which are the physical properties of water. The most
important hydrodynamic principles are those related to turbulence,
relative density, metacentere, friction and hydrostatic pressure
.((Campion & Towomey, 1990; Campion, 1997; Campion, 1991
Relative density●
Density is known as mass per unit volume. The density of water
is one. Therefore any object with density less than one will float. The
relative density of human body differs with age, the relative density
of young kid is approximately 0.86.In adulthood and adolescence
the density increases to 0.97.Later with time the relative density
become approximately 0.85. Each part of the body has different
density. The upper limb is less dense than the lower limb. (Campion
& Towomey, 1990; Campion, 1997; Ruorti & Morris& Cole, 1997;
(Becker & Cole, 1997; Campion, 1991
:Buoyancy ●
Immersed object has less apparent weight than when
it is on land. This is because of a force that acting
opposite to gravity on the body. This force is called
buoyancy and it is equal to upward force that is
exerted by the displaced volume of water, so buoyant
force is equal to weight of displaced fluid (Archimedes'
principle) .Because the pressure in fluid is directly
proportional to depth of immersed body, so when an object is
immersed more in the water the pressure will increase leading to
increasing in displaced water and therefore the buoyant force will be
more. The buoyant force will be more in the bottom of a surface
than the top of it. Because the gravity force is counterbalanced by
buoyant force, the compression on joints will be nearly eliminated.
This effect can be utilized when gravity-loaded places a risk on
joints
:Hydrostatic pressure ●

Pressure is defined as force per unit area. When the body at rest,
at given depth there will be equal pressure exerted in all direction
by water. When unequal pressure is exerted the body will move.
The more the object is immersed in the water the more pressure will
be exerted; this is beneficial for the patients who suffer from edema.
The hydrostatic pressure can be also useful for
breathing. There will be pressure exert ed on the
chest wall to resist expansion of the chest So
that the muscle can be strengthen by this way
and work of breathing will be increased. It also
can fasten removal of lactic acid leading to decrease in muscle
soreness. (Campion & Towomey, 1990; Campion, 1997; Ruorti &
Morris& Cole, 1997; Becker & Cole, 1997; Campion, 1991)

:Reynolds' theory ●

Reynolds' theory indicates that there are two types of flow; laminar
(streamline) and turbulent flow
(unstreamlined). In the former the
molecules flow evenly and regularly, and water molecules move
parallel to each other at same speed and slowly. In the latter the
movement is irregular and rapid creating eddies. The movement in
water can be more difficult when changing from streamlined
movement to unstreamlined one. (Campion & Towomey, 1990;
Campion, 1997; Ruorti & Morris& Cole, 1997; Becker & Cole, 1997;
Campion 1991)

:Prandtl's theorem●

Boundary layer is when fluid is flow on surface a layer is seen

adjacent to the surface and the speed of this fluid in relation to the
surface is decreased as it not existent so that the fluid stick to
surface rather than slip over it. In the river for example the fastest
flow is in the center and it is reduced at banks. The same situation
can exit in the pool. The way of getting out should be taught in the
pool to ensure safety of patients. (Campion & Towomey, 1990;
Campion, 1997; Ruorti & Morris& Cole, 1997; Becker & Cole ;
Campion 1991)

:Froud-Zahm's experiment●

Froud and Zahm study skin friction of a body that passed through
air and water. They found that skin friction and resistance, viscosity,
in the water is 790 times more than in the air. Viscosity is a
resistance that occurs between the molecules of a liquid, effecting
how a liquid flows. As mentioned, that the water is more viscous
than air, therefore movements in the water is more difficult than
movements in the air. (Campion & Towomey, 1990; Campion, 1997;
Ruorti & Morris& Cole, 1997; Becker & Cole, 1997; Campion 1991)

:Adjustment to water●
Asymmetry can lead to balance problems. In case of disability,
asymmetry in shape and density can be noticed; this will
affect balance and stability in water. The water reacts and floats
object according to its shape and density. Particular shapes are less
stable than other shapes
in water. Cube and ball
shape are more stable in
water. Horizontal and
vertical stick and triangle
shapes are less stable in water. In disabled people their will be
alteration in shapes that affect stability ; unequal quadrilateral,
triangular, adducted, and extended are all shapes that may result
from disability leading to disturb balance in water. (Campion &
(Towomey, 1990; Campion, 1997; Campion, 1991

:Mental adjustment
It is the patients' ability to respond appropriately and
independently to different situation. It involves
knowing some properties of water like
buoyancy. It is physiotherapist responsibility to
teach patients how to respo nd in different
situations. One such example is adjusting to
moving in water compared to moving on the side of the pool
(Campion & Towomey, 1990; Campion, 1997; Campion, 1991)

Physiological effect of immersion in water

Several effects result from immersion in water; two systems will be

.discussed here; cardiovascular and renal system
:Cardiovascular system●
When immersed in the water the hydrostatic pressure that
exerted by water will increase the venous return, the more the body
mmersed the more hydrostatic pressure will i
e exerted, which in turn leads to increase in b
ight arterial pressure, pulmonary blood flow, r
nd cardiac volume which increase the a
ontractility. All of these changes will lead to c
increase in cardiac out put and stroke volume. So that more blood
and oxygen will go to muscles which will enhance lactic and waste
.product removal
All the above responses are dependent on water temperature for
example immersion in warm and hot water increase heart rate and
in cold water decrease heart rate. Vasoconstriction also depends on
temperature; it increases with decrease in temperature. (Ruorti &
(Morris& Cole, 1997; Becker & Cole, 1997
:Renal effects●
The immersion in the water can affect the renal system. Buoyant
force counteract the venous pooling and when the body immersion
increase the buoyant force and the hydrostatic pressure that
exerted by water increased leading to raise in the pressure at the
lower part of the body therefore reducing venous pooling, so that
the blood will move centrally. Also the lower the temperature the
more vasoconstriction will occur, this will lead to shift the blood
entrally. When the blood moves c
entrally, ven ous return will increase c
eading to arterial distension which l
timulating several cardiopulmonary s
eceptors. This will lead to changing in r
enal hormones concentrations. r
ldosteron, a hormone which regulates A
odium and potassium, and Anti Diuretic s
hormone (ADH), a hormone which increases water retention, will be
suppressed when immersed in the water. Arterial natriuretic
peptide, which increase sodium and water loss, will be raised .Renal
prostaglandin concentration will raise and renine secretion will lower
which in turn decrease aldosterone release. All of these hormonal
changes will lead to diuresis, rising in urine out put, natriuresis,
increased sodium loss, kaliuresis, and increased potassium loss. This
physiological effect is useful when treating edema. (Ruorti & Morris&
(Cole, 1997; Becker & Cole, 1997

Physiological effects of excising in water

Most responses to aquatic exercise are similar to those resulting

from exercising on land. But aerobic energy expenditure during sub
maximal exercise in water can increase or decrease according to
water temperature and depth, type of activity, and the speed of
movements. Also the energy expenditure can be altered by buoyant
force, greater viscosity, and increased heat conduction. VO2 max is
often lower in aquatic exercise than exercise that done on land
because of lower heart rate, So that we must be careful when using
heart rate in determining and prescribe the exercise intensity in
water . The relation ship between VO2 max and heart rate is
variable depending on water depth and temperature, exercise
intensity, and exercise mode. In cold water, VO2 max is higher due
to effect of shivering. Because of the hydrostatic pressure that
increases venous return, the cardiac out put and stroke volume will
be greater at higher exercise intensities than those performed on
.the land

Anaerobic metabolism occurs at beginning of exercise and at higher

intensity. The end product of anaerobic metabolism is lactic acid
and accumulation of it indicates amount of anaerobic metabolism.
At sub maximal exercise, intensities between 40% and 80% VO2,
there is no difference in blood lactic accumulation in water and on
land. But at maximal intensities the lactic acid is lower in the water.
reduced sympathetic activity and epinephrine. (Ruorti & Morris&
Cole, 1997; Becker & Cole, 1997)

Psychological effect

The ability to acquire skills that may be difficult or impossible on

the land and being independent in water can improve self
confidence and morale which can be later carried in the land. Being
in the pool with other and sharing in group activity can improve
social aspect and encourage patient to perform better. (Campion,
(1991; Campion & Twomey, 1990; Campion, 1997

:Therapeutic effect

:(The therapeutics effects include (Campion 1997

,Maintain or improve posture and balance -1
,Reduce pain and muscle spasm -2
,Maintain or increase range of motion -3
Increase endurance to excise-4
,Strength muscles and re-educate paralyzed muscle-5
Improve circulation -6
Enhance functional activities -7

Methods in practicing hydrotherapy

:The Bad Ragaz ring methods ●

It is therapeutic technique that used for relaxation, strengthening,
muscle re-education, spinal traction, and improves tone. The client
is floats in the water by flotation rings that are placed
around the neck, pelvis, knees, and ankle. The
thermal and hydrodynamic properties of the water, in
addition to unique non-weight-bearing exercises, would promote
excellent patient results. The therapist uses the properties of water
for passive, isometric, isotonic, and isokinetic exercises. Here
fundamentals of PNF are also used. The suggested populations are:
patients with weight bearing problems that need to work in a closed
kinetic chain, and neurological cases. (Ruorti & Morris& Cole, 1997;
(www.badragazringmethod.org
Halliwick methods:
The Halliwick Concept is an approach that can be used with all
people focusing on those with physical and/or
learning difficulties. It aims to make them moving
independently in water, to do water activities, and
to swim. It is based on a belief in the benefits that
resulting from activities in water. These benefits
include social, physical, recreational, personal, therapeutic aspects.
It involves four basic principles. First mental adaptation, which is
the ability to respond appropriately to different tasks and situations.
Secondly, balance restoration; by using specific pattern of
movements to restore balance. Thirdly, inhibition, which is the
ability to hold the position. Finally, facilitation; moving in the water.
Suggested populations: patients with neurological cases,
developmental disorders, and patients who are unable to exercise or
ambulate on land (Ruorti & Morris& Cole, 1997; www.special-
(education.hum.ro/halliwick_method.html
● WATSU
It refers to water shiatsu. It involves using of massage, joint
mobilization, shiatsu, and muscle stretching. It is
performed in warm water and it is done passively.
The patient is supported by therapist arms in
cradled position while being stretched. Suggested
populations are: patients with pain, patients with
restricted ROM, and Hypertonic patients. (Ruorti & Morris& Cole,
(1997; www.watsu.com
 Absolute contraindication
:(Absolute contraindications include (www.holycross.org.uk
Shortness of breath at rest-1
Fever -2
Resting angina-3
Proven chlorine-6
Uncontrolled cardiac failure-7
Uncontrolled fecal incontinence-8
Renal failure -9
Known aneurism-10
Tuberculosis -11

Relative contraindication
:(Relative contraindications include (www.holycross.org.uk
Irritated skin-1
Poorly controlled epilepsy -2
Open wound-3
Unstable diabetes -4

:Precautions
:(Precautions include (www.holycross.org.uk
Behavioral problems-1
Contact lenses-2
Infections-3
Hemophilia -5
Fear of water-6
Hearing aids-7
Hypo or hypertension-8
Pregnancy if temperature more than 35-9
Widespread MRSA-10
Sexually transmitted infections-11
Fungal infection-12
Early kidney disease -13