Scientific Evidence-Based Effects of Hydrotherapy On Various Systems of The Body

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Scientific Evidence-Based Effects of

Hydrotherapy on Various Systems of the Body
Article in North American Journal of Medical Sciences · May 2014

DOI: 10.4103/1947-2714.132935 · Source: PubMed
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7/11/2015 Scientific EvidenceBased Effects of Hydrotherapy on Various Systems of the Body
N Am J Med Sci. 2014 May; 6(5): 199–209. PMCID: PMC4049052
doi: 10.4103/19472714.132935
Scientific EvidenceBased Effects of Hydrotherapy on Various Systems of the
Body
A Mooventhan and L Nivethitha1
Naturopathy Clinical, SDM College of Naturopathy and Yogic Sciences, Ujire, India
1
Department of Research and Development, SVYASA University, Bangalore, Karnataka, India
Address for Correspondence: Dr. Mooventhan A., Department of Naturopathy clinical, SDM College of Naturopathy and Yogic Sciences,
Ujire, Karnataka, India. Email: dr.mooventhan@gmail.com
Copyright : © North American Journal of Medical Sciences
This is an openaccess article distributed under the terms of the Creative Commons AttributionNoncommercialShare Alike 3.0 Unported, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
The use of water for various treatments (hydrotherapy) is probably as old as mankind. Hydrotherapy is one
of the basic methods of treatment widely used in the system of natural medicine, which is also called as water
therapy, aquatic therapy, pool therapy, and balneotherapy. Use of water in various forms and in various
temperatures can produce different effects on different system of the body. Many studies/reviews reported
the effects of hydrotherapy only on very few systems and there is lack of studies/reviews in reporting the
evidencebased effects of hydrotherapy on various systems. We performed PubMed and PubMed central
search to review relevant articles in English literature based on “effects of hydrotherapy/balneotherapy” on
various systems of the body. Based on the available literature this review suggests that the hydrotherapy has
a scientific evidencebased effect on various systems of the body.
Keywords: Evidencebased effects, Hydrotherapy, Various systems
Introduction
Hydrotherapy is the external or internal use of water in any of its forms (water, ice, steam) for health
promotion or treatment of various diseases with various temperatures, pressure, duration, and site. It is one of
the naturopathic treatment modality used widely in ancient cultures including India, Egypt, China, etc.[1]
Though many countries used water to produce different physiological/therapeutic effects on different part of
the system for maintaining health, preventing, and treating the diseases, the scientific evidencebased effects
are not well documented. There are many studies/reviews that reported either physiological or therapeutic or
combination of both the effects of hydrotherapy on particular system but did not report in all the major
systems of the body, which made us to do this review with the aim and objective to report scientific
evidencedbased effects of hydrotherapy on various systems of the body. In order to provide a general
overview, we performed PubMed and PubMed central search to review relevant articles in English literature
based on “effects of hydrotherapy/balneotherapy” on various systems of the body. Articles published from
1986 to 2012 were included in this review.
Hydrotheraphy in general
Superficial cold application may cause physiologic reactions such as decrease in local metabolic function,
local edema, nerve conduction velocity (NCV), muscle spasm, and increase in local anesthetic effects.[2]
One hour headout water immersions (WI) in various temperatures (32°C, 20°C, and 14°C) produced
various effects. Immersion at 32°C did not change metabolic rate (MR) and rectal temperature (Tre), but it
lowered the heart rate (HR) by 15%, systolic blood pressure (SBP) and diastolic blood pressure (DBP) by
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049052/?report=printable 1/15
11% and 12%, respectively, compared, with controls at ambient air temperature. Along with HR and blood
pressure (BP), the plasma renin activity, plasma cortisol, and aldosterone concentrations were also lowered
by 46%, 34%, and 17%, respectively, while diuresis was increased by 107%.[3]
Immersion at 20°C produced similar decrease in plasma renin activity, HR, SBP, and DBP, in spite of
lowered Tre and increased MR by 93%. Plasma cortisol concentrations tended to decrease, while plasma
aldosterone concentration was unchanged. Diuresis was increased by 89%. No significant differences in
changes in plasma renin activity, aldosterone concentration, and diuresis compared with subjects immersed in
32°C.[3]
Immersion at 14°C lowered Tre and increased MR by 350%, HR, SBP, and DBP by 5%, 7%, and 8%,
respectively. Plasma noradrenaline and dopamine concentrations were increased by 530% and by 250%,
respectively, while diuresis increased by 163%, which was more than at 32°C. Plasma aldosterone
concentrations increased by 23%. Plasma renin activity was reduced. Cortisol concentrations tended to
decrease. Plasma adrenaline concentrations remained unchanged. Changes in plasma renin activity were not
related to changes in aldosterone concentrations.[3]
WI in different temperatures did not increase blood concentrations of cortisol. There was no correlation
between changes in Tre and changes in hormone production. The physiological changes induced by WI are
mediated by humoral control mechanisms, while responses induced by cold are mainly due to increased
activity of the sympathetic nervous system (SNS).[3]
Regular winter swimming significantly decreased tension, fatigue, memory, and mood negative state points
with the duration of swimming period; significantly increased vigoractivity scores; relieved pain who
suffered from rheumatism, fibromyalgia, or asthma; and improved general wellbeing in swimmers.[4]
Cardiovascular system
Cold exposure (CE) to small surface area produced compensatory vasodilatation in deeper vascular system
resulting increased blood flow to the tissues underlying the site of exposure. This vascular reaction occurs
mainly to maintain constant deep tissue temperature.[2]
In patient with chronic heart failure (CHF), thermal vasodilatation following warmwater bathing and low
temperature sauna bathing (LTSB) at 60°C for 15 min improves cardiac function;[5] repeated saunatherapy
(ST) increased left ventricular ejection fraction; increased 6min walk distance in association with
improvement in flowmediated dilation and increase in number of circulating CD34 (+) cells; reduced plasma
levels of norepinephrine and brain natriuretic peptide. These indicates that ST improves exercise tolerance in
association with improvement in endothelial function.[6] LTSB improves peripheral circulation in cerebral
palsy (CP).[5]
After ST reduced level of total and low density lipoprotein (LDL)cholesterol concentration, while increased
level of high density lipoprotein (HDL)cholesterol was observed. These changes are good prognoses for the
prevention of ischemic heart disease.[7] ST increases endothelial nitric oxide synthase (eNOS) activity and
improves cardiac function in heart failure and improve peripheral blood flow in ischemic limbs. In
myocardial infarction (MI)induced Wistar rats ST increases myocardial eNOS, vascular endothelial growth
factor mRNA levels. It attenuates cardiac remodeling after MI through improving coronary vascularity in the
noninfarcted myocardium and thus ST might serve as a novel noninvasive therapy for patients with MI.[8]
Acute MI was thought to result from thrombosis or plaque rupture because of coronary artery spasm. The
vasospasm might be induced by stimulation of the alphaadrenergic receptors during alternating heat
exposure during sauna bath followed by rapid cooling during cold water bath. This effect showed the
dangers of rapid cooling after sauna bathing in patients with coronary risk factors.[9] Regular ST (either
radiant heat or farinfrared units) appears to be safe and produce multiple health benefits but use of ST in
early pregnancy is a potential concern because evidence suggesting that hyperthermia might be teratogenic.
[10]
Cold water immersion (CWI) induces significant physiological and biochemical changes in the body such as
increase in HR, BP, metabolism, and peripheral catecholamine concentration; and decrease in cerebral blood
flow.[11]
Reduction in HR, and increases in systolic and diastolic biventricular functions, were observed during acute
warmWI.[12] In contrast, increase in HR and a decrease in SBP and DBP were observed in 30 min of
headout WI (38.41 ± 0.04°C).[13]
Hyperthermic immersion (HI) produced shortening of activated partial thromboplastin time. During HI
plasminogen activator inhibitor (PAI) activity was decreased; thrombocyte count was increased; increases in
tissuetype plasminogen activator concentration and leukocytes count were attributed to hemoconcentration.
Immediately after HI, fibrinogen concentration decreased but increased during recovery. During thermo
neutral immersion prothrombin time, PAI activity and granulocyte count ecreased. Warm water bathing leads
to hemoconcentration and minimal activation of coagulation; decrease in PAI1 activity. During warm water
bathing, marked risk for thrombotic or bleeding complications in healthy males could not be ascertained.[14]
During contrast baths, longer duration in the second heating phase was required to produce sufficient
fluctuation in blood flow.[15]
WI upto shoulder levels at different temperatures (25°C, 34°C, and 40°C) showed no significant effect on
cardiac output in 25°C compared with 34°C, but in 40°C a considerable increase in cardiac output was
observed.[16]
Carbon dioxide (CO2) enriched WI reduced free radical plasma levels, raised antioxidants levels, and induce
peripheral vasodilatation suggests improvement in microcirculation.[17,18] Decrease in tympanic
temperature; increase in cutaneous blood flow at immersed site was significantly greater in CO2WI
compared with fresh WI.[18] The three main effects of CO2 enriched WI are decline in core temperature,
increase in cutaneous blood flow, and elevation of score on thermal sensation, which were analyzed.[19]
Respiratory system
WI upto shoulder levels at different temperatures (25°C, 34°C, and 40°C) showed increased MR, oxygen
(O2) consumption (VO2) only at 25°C. Two main factors affecting O2 transport during immersion are
temperature and hydrostatic pressure. O2 transport was improved above neutral temperature, because of
increase in cardiac output resulting from the combined actions of hydrostatic counter pressure and body
heating. Below neutral temperature, O2 transport is altered. At any of the temperatures tested, the pulmonary
tissue volume and arterial blood gases were not significantly affected.[16]
Significant decrease in vital capacity (VC) with bath temperature was observed (i.e., VC at 40°C >34°C
>25°C). Significant increase in tidal volume (VT) in cold or hot water compared with thermo neutral water
(i.e., VT 40°C >34°C< 25°C). Alterations in respiratory muscles functioning might produce variations of the
pulmonary volumes as a function of water temperature.[20]
CWI was associated with increase in respiratory minute volume and decrease in end tidal CO2 partial
pressure.[11] Repeated cold water stimulations reduced frequency of infections; increased peak expiratory
flow, lymphocyte counts, and expression of gammainterferon; modulated interleukin expression; and
improved quality of life (QOL) in patients with chronic obstructive pulmonary disease.[21]
In children suffering from recurrent and asthmatic bronchitis in remission, a single total air bath, or douche
and local (cooling of the feet with water) exposure to mild cold did not raise noticeable disorders of the
respiratory function. Local cold procedures improve bronchial patency but heat exposure resulted in its
worsening.[22]
Inhaling hot air while in a sauna produced no significant impact on overall symptom severity of common
cold.[23] A male track and field athlete, a case of breathing difficulties at rest and during exercise, was
exacerbated in the supine position and during WI.[24]
Nervous system
Three cold modalities such as ice massage, ice pack, and CWI applied to right calf region for 15min reduced
skin temperature (Tsk) (mean 18.2°C); reduced amplitude and increased latency and duration of compound
action potential. It also reduced sensory NCV by 20.4, 16.7, and 22.6 m/s and motor NCV by 2.5, 2.1, and
8.3 m/s, respectively. Even though all three modalities effectively reduced Tsk and sensory conduction at a
physiological level, CWI is the most indicated, effective modality for inducing therapeutic effects associated
with the reduction of motor nerve conduction.[25]
Temperature and pressure of water in aquatic or hydrotherapy can block nociceptors by acting on thermal
receptors and mechanoreceptors and exert positive effect on spinal segmental mechanisms, which is useful
for painful condition.[26] Forty sessions of Ai Chi aquatic exercise (AE) program improves pain, spasms,
disability, fatigue, depression, and autonomy in patient with multiple sclerosis.[27]
In a study on physiotherapy on land or water in patient with Parkinson's disease (PD), functional reach test
was improved in both therapies, but Berg Balance Scale (BBS) and Unified Parkinson's Disease Rating
Scale (UPDRS) were improved only in aquatic therapy group. It indicates improvement in postural stability
in PD was significantly larger after aquatic therapy.[28]
Sauna bath on paraplegic (P) group and tetraplegic (T) group, HR increased significantly during sauna but
decreased significantly during postsauna phase in P group. DBP significantly reduced in T group during
postsauna phase but no significant changes in SBP in both the groups.[29]
In a study on CP, LTSB produced increase in HR and cardiac output; decrease in BP and total peripheral
resistance; significant improvement in skin blood flow, blood flow velocity, pulsatile index, and resistive
index; decrease in numbness and chronic myalgia of the extremities with no adverse effects.[5]
Ten minutes of immersions in whirlpools produced increases in pulse and finger temperature with increased
feelings of wellbeing and decreased state anxiety.[30] CO2WI activates parasympathetic nerve activity in
humans.[18]
Adapted cold shower might have antipsychotic effect similar to that of electroconvulsive therapy because it
could work as mild electroshock applied to sensory cortex. Additionally, cold shower is example of stress
induced analgesia and would also be expected to “crowd out” or suppress psychosisrelated
neurotransmission within mesolimbic system.[31]
CE can activate components of reticular activating system such as locus ceruleus and raphe nuclei, which
can result in activation of behavior and increased capacity of central nervous system (CNS) to recruit
motoneurons.[32] CE activates SNS; increase blood level of betaendorphin and noradrenaline; and increase
synaptic release of noradrenaline in brain. Antidepressive effect of cold shower attributed to presence of high
density of cold receptors in skin expected to send an overwhelming amount of electrical impulses from
peripheral nerve endings to the brain. It has significant analgesic effect and it does not cause dependence or
noticeable side effects.[33] Most narcotics administered rectally can cause intoxication. There is a significant
comorbidity of schizophrenia with intestinal illnesses and thus colon cleansing can significantly improve
mental state.[31]
Musculo skeletal system
Walking in water at umbilical level increases the activity of erector spinae and activates rectus femoris to
levels near to or higher than walking on dry ground.[34] CWI <15°C is one of the most popular intervention
used after exercise,[11,35] which significantly lowered ratings of fatigue and potentially improved ratings of
physical recovery immediately after immersion with reduction in delayed onset muscle soreness at 24, 48,
72, and 96 h followups after exercise compared with passive interventions involving rest or no intervention.
[35]
Rate of decrease in plasma lactate concentration over 30 min recovery period after intense anaerobic exercise
was significantly higher in contrastWI [hot (36°C) and cold (12°C)] compared with passive recovery on bed
for both genders.[36]
Leg immersion in warm water (44 ± 1°C) for 45 min before stretchshortening exercise reduced most of the
indirect markers of exerciseinduced muscle damage, including muscle soreness, creatine kinase activity in
the blood, maximal voluntary contraction force, and jump height. Decreasing muscle damage did not
improve voluntary performance, therefore clinical application of muscle prewarming may be limited.[37]
Contrast water therapy (CWT) [alternating 1min hot (38°C) and 1min cold (15°C)] for 6/12/18 min
lowered subjective measures of thermal sensation and muscle soreness compared with control (seated rest)
but no consistent differences were observed in whole body fatigue. It indicates CWT for 6 min assisted acute
recovery from highintensity running and CWT duration did not have doseresponse effect on running
performance recovery.[38] Contrast baths have been suggested for reducing pain; hand volume; and stiffness
in affected extremities but it had no significant effect on pre and/or postoperative hand volume in carpal
tunnel syndrome.[39]
Cold water or cold/thermoneutral water did not induce modifications of inflammatory and hematological
markers. The performances of athletes were not negatively influenced by CWI or CWT. Reduced perception
of fatigue after training session was the principal effect of CWI[45] because CE increases opioid tone and
high MR, which could diminish fatigue by reducing muscle pain and accelerating recovery of fatigued
muscle, respectively,[32] which can improve training and competitions in young soccer players.[40]
A systematic review on management of fibromyalgia syndrome (FMS) through hydrotherapy described as
“there is strong evidence for the use of hydrotherapy in the management of FMS” and it showed positive
outcomes for pain; tender point count; and healthstatus.[41] Combination of ST (once daily for 3
days/week) and underwater exercise (once daily for 2 days/week) for 12 weeks significantly reduced pain
and symptoms (both short and longterm); and improved QOL in patients with FMS.[42] Poolbased
exercise using deep water running three times/week for 8 weeks is safe and effective intervention for FMS
because it showed significant improvement in general health and QOL compared with control; and
significant improvement in fibromyalgia impact questionnaire score, incorporating pain; fatigue; physical
function; stiffness; and psychological variables.[43]
Hydrotherapy may have some shortterm benefit to passive range of movement in rehabilitation after rotator
cuff repair.[44] Spa water (37°C) and tap water heated to 37°C for the duration of 20 min/day for 5
days/week for the period of 2 weeks with homebased exercise program improved the clinical symptoms and
QOL in patient with osteoarthritis of knee (OAK). However, pain and tenderness statistically improved in
spa water.[45] It may be due to that spa waters are not only naturally warm, but their mineral content is also
significant. Spa water has mechanical, thermal, and chemical effects.
In ankylosing spondilitis (AS) patients, balneotherapy statistically improved pain; physical activity; tiredness
and sleep score; Bath Ankylosing Spondilitis Disease Activity Index (BASDAI); Nottingham Health Profile
(NHP); patient's global evaluation and physician's global evaluation at 3 weeks, but only on modified Shober
test and patient's global evaluation parameters at 24 weeks. It indicates the effect of balneotherapy in
improving disease activity and functional parameters in AS patients.[46] Infrared sauna, a form of totalbody
hyperthermia was well tolerated; no adverse effects; and no exacerbation of disease were reported in patients
with rheumatoid arthritis (RA) and AS in whom pain, stiffness, and fatigue showed clinical improvements
during the 4 weeks treatment period but these did not reach statistical significance.[47]
Aquajogging without caloric restrictions in obese persons for 6 weeks was associated with reductions in
waist circumference and body fat; improvement of aerobic fitness and QOL.[48]
AE may be an excellent alternative to land exercise for individuals who lack confidence, have high risk of
falling, or have joint pain.[49] Water buoyancy reduces the weight that joints, bones, and muscles have to
bear.[50] Warmth and pressure of water also reduce swelling and reduces load on painful joints, remotes
muscle relaxation.[51] AE has significant effects on pain relief and related outcome measurements for
locomotor diseases. Patients may become more active and improve their QOL as a result of AE.[52] Water
based and landbased exercises reduced pain and improved function in patients with OAK and that water
based exercise was superior to landbased exercise for relieving pain before and after walking.[53]
Hydrotherapy is highly valued by RA patients who were treated with hydrotherapy (30min session/week)
reported feeling much better/very much better than those treated with land exercises (similar exercises on
land) immediately on completion of the treatment program (6 weeks). But this benefit was not reflected on
10 m walk times, functional scores, QOL measures, and pain scores by differences between groups.[51] Hot
compress (HC) with surrounding electroacupuncture needling was significantly effective on rear thigh
muscles strain and it was superior to conventional needling method and cupping in improving symptoms and
physical signs as well as recovery of walking function of athletes.[54]
Gastrointestinal system
Drinking water significantly elevates the resting energy expenditure (REE) in adults but in overweight
children transient decrease in REE was observed immediately after drinking 10 ml/kg cold water (4°C).
Then a subsequent rise in REE was observed, which was significant after 24 min and the maximal mean
REE values were seen after 57 min, which was 25% higher than baseline. The recommended daily amount
of water consumption in children could result in energy expenditure equivalent to additional weight loss of
about 1.2 kg/year suggesting that water drinking could assist overweight children in weight loss or
maintenance.[55] Exposure to cold increases MR, for example, headout immersion in cold water of 20°C
almost doubles MR, while at 14°C it is more than quadrupled.[3]
When veryHC applied to lumbar region of healthy female for 10min blood flow to the back increased to
156% with increased blood flow to upper arm. Immediately after HC, bowel sounds increased 1.7 times
compared with before application, which suggest that a very HC can be useful to promote flatus or
defecation.[56] Low mineral water intake normalizes the intestinal permeability of patients with atopic
dermatitis.[57]
Warm water is effective for colonic spasm in which significantly less discomfort was reported compared with
control group and this may be useful as an alternative for glucagon (expensive) and hyoscyamine (has side
effects) because it has no side effects and costs practically nothing.[58]
In patients with acute anal pain due to hemorrhoids or anal fissures, neither cold water (<15°C) nor hot water
(>30°C) sitz bath (SB) did control pain statistically.[59] Similarly, after sphincterotomy for anal fissure, SB
produced no significant difference in pain but significant relief in anal burning and better satisfaction score
with no adverse effects were observed compared with control group.[60] Healing and pain relief was not
significant in SB but it improved patient satisfaction in acute anal fissures.[61]
Though there was no strong evidence to support the use of SB for pain relief and to accelerate fissure or
wound healing among adult patients with anorectal disorders (ARDs), patients were satisfied with using SB
and no severe complications were reported.[62] In contrast, warmwater SB (40°C, 45°C, and 50°C for 10
min each time) in ARD, pain relief was more evident and lasted longer at higher bath temperatures. Pain
relief after SB might attribute to internal analsphincter relaxation, which might be due to thermosphincteric
reflex, resulting in diminution of the rectal neck pressure. The higher the bath temperature, the greater the
drop in rectal neck pressure and internal sphincter electromyographic activity, and longer the time needed to
return to pretest levels.[63]
In posthemorrhoidectomy care, water spray method could provide a safe and reliable alternative to SB as a
more convenient and satisfactory form of treatment.[64]
Spa treatment with mineral water Nizhneivkinskaya (sulfate calcium) induced clinical remission of the
disease, normalization of the echoscopic picture of stomach and gallbladder, their motor function,
tesiocrystalloscopic characteristics of saliva suggest its effectiveness in rehabilitation of patients with gastric
and gallbladder motorevacuatory dysfunction.[65] Intake of sulfatechloridesodium mineral water activates
regulation of carbohydrate metabolism by insulin and cortisol due to the formation of adaptive reactions. It
promoted trophic effects of insulin and gastrin in animals with significant reduction in peptic ulcer size and
enhanced resistance to stressful factors.[66]
Immersion in Dead Sea water produced significant reduction in blood glucose in type2 diabetes mellitus
(DM) and no significant differences in insulin, cortisol, and cpeptide levels were observed between DM
patients and healthy volunteers following immersion.[67]
Genito urinary system
Mean labor pain scores were significantly higher in control group than immersion bath (IB) group suggest
that use of IB as an alternative form of pain relief during labor.[68] WI in primipara at any stage of labor,
from 2 cm external opening of the uterine cervix, significantly decreased parturition duration compared with
traditional delivery. It raised both the amplitude and frequency of uterine contractions proportional to uterine
cervix gaping with no disturbances in contraction activity of the uterus. A 3cm gaping of uterine cervix is
the optimal timing for WI in the primipara because earlier WI at 2cm uterine cervix gaping also accelerated
the labor but required repetitions of WI or use of oxytocin for correcting weakened uterine contraction.[69]
In contrast, IB did not influence the length of labor and uterine contractions frequency. However,
contractions length was statistically shorter in IB and it can be an alternative for woman's comfort during
labor, since it provides relief to her without interfering on labor progression or jeopardizing the baby.[70]
WI during first stage of labor reduces the use of epidural/spinal/paracervical analgesia/anesthesia compared
with controls and there is no evidence of increased adverse effects to fetus/neonate or woman from laboring
in water or water birth.[71] Neonatal swimming can accelerate babies growth in early stage.[72] In a
microbiological study, comparing neonatal bacterial colonization after water birth to conventional bed
deliveries with or without relaxation bath showed no significant difference between three groups in neonatal
outcome, infant's and maternal infection rate.[73]
ColdSB but not warmSB, significantly reduced edema during postepisiotomy period[74] and perineal pain,
which was greatest immediately after the bath.[75] Bakera, a steam bath prepared with various plants
(commonly the essential oil plants) is traditionally used in Minahasa (Indonesia) mainly for recuperation after
childbirth. It is based onthermotherapy with aromatherapy which attribute for its therapeutic effects.
Thermotherapy soothes symptoms such as heaviness in limbs, edema, muscular strain, loss of appetite, and
constipation. Essential oils of the plants used have antiseptic, antiphlogistic, and immunostimulant effect.
Hence it can be an effective and safe method for recuperation after child birth.[76] In postnatal mothers,
alternate (hot and cold) compress and cold cabbage leaves were equally effective in reducing breast
engorgement, but in relieving breast engorgement pain, alternate compresses were more effective than cold
cabbage leaves.[77]
WarmSB (4045°C) for 10 min, for at least 5 days immediately after the removal of Foley urethral catheter
in patient undergone transurethral resection of prostate, significantly reduced urethral stricture compared with
no SB group who had 1.13fold increased risk of rehospitalization within 1 month after surgery due to
postoperative complications compared with warmSB group.[78] Thirty healthy volunteers and 21 patients
with urinary retention after hemorrhoidectomy underwent SB at 40°C, 45°C, and 50°C where the number of
spontaneous micturitions increased with highertemperature baths and it seems to be initiated by reflex
(thermosphincter reflex) internal urethral sphincter relaxation. The urethral pressure both in normal and
retention subjects showed significant reduction, which increased with higher temperature; and vesical
pressure or EMG activity of the external urethral sphincter did not show significant differences.[79]
Hematology/immunology
Subsequent CE induced increase of leukocytes, granulocytes, circulating levels of interleukin (IL)6, and
natural killer (NK) cells and its activity. Leukocytes, granulocyte, and monocyte responses were augmented
by pretreatment with exercise in water (18°C) and thus acuteCE has immunestimulating effects.[80]
Daily brief cold stress can increase both numbers and activity of peripheral cytotoxic Tlymphocytes and NK
cells, the major effectors of adaptive and innate tumor immunity, respectively. It (for 8 days) improved
survival of intracellular parasite Toxoplasma gondii infected mice, with consistent enhancement in cell
mediated immunity. The sustained/longerterm effects of cold stress repeated daily over the period of 5 days
to 6 weeks increased plasma levels of tumor necrosis factorα, IL2, IL6. A hypothesis describes, daily brief
coldwater stress over many months could enhance antitumor immunity and improve nonlymphoid cancer
survival rate. The possible mechanism of nonspecific stimulation of cellular immunity might attribute to
transient activation of SNS, hypothalamicpituitaryadrenal (HPA) and hypothalamicpituitarythyroid axes.
Though daily moderate cold hydrotherapy does not appear to have noticeable adverse effects on normal
subjects, some studies showed that it can cause transient arrhythmias in patients with heart problems and can
also inhibit humoral immunity. Sudden icecold WI can produce transient pulmonary edema and increase
bloodbrain barrier permeability, thereby increasing mortality of neurovirulent infections. Studies are required
to warrant this hypothesis for immunotherapy development for some (nonlymphoid) cancers, including those
caused by viral infections.[81]
Warm water (28°C) treatment could not only cure bacterial coldwater disease but also immunize against
causative agent Flavobacterium psychrophilum.[82]
Headout WI (38.41 ± 0.04°C) for 30 min decreased blood viscosity; red blood cells count; and mean
hematocrit without significant changes in leukocytes and platelets count; mean corpuscular volume; plasma
viscosity; erythrocyte filtration time and red cell deformability index.[13] Application of hyperthermic water
bath produced significant reduction of relative Blymphocyte. Wholebody hyperthermic water bath reduced
relative total Tlymphocyte counts; increased relative CD8+ lymphocyte; NK cell counts and its activity,
which were probably dependent on increased somatotropic hormone production.[83]
Endocraine/hormonal system
During CE increase levels of circulating norepinephrine was observed[80] and exercising HPA system by
repeated CE could potentially restore its normal function in chronic fatigue syndrome, or at least increase net
HPA activity (without changing baseline activity).[84] It produces temporary increase in plasma levels of
adrenocorticotropic hormone (ACTH), betaendorphin, and cortisol.[32] The sustained/longerterm effects of
cold stress repeated daily produced increase in ACTH, corticosterone, and decrease in α1antitrypsin and
testosterone.[81] Cold stress reduces level of serotonin in most regions of brain (except brainstem).[32] Cold
stressinduced analgesia might be mediated by increased production of opioid peptide betaendorphin (an
endogenous painkiller).[85,86]
Exposure to sauna and iceWI significantly elevated epinephrine levels in winter swimmer.[87] Steam bath
produced increase in blood serum concentrations of gastric and aldosterone, with decrease in concentrations
of cortisol in athletefighters.[88] Wholebody hyperthermic bath increased STH activity in 8 out of 10
volunteers.[83]
Eye, skin, and hair
Warm moist air device seems to be safe and produced improvement in tear stability and symptomatic relief in
ocular fatigue in patients with meibomian gland dysfunction.[89] Sauna (80°C) produced stable epidermal
barrier function; increase in stratum corneum hydration; faster recovery of both elevated water loss and skin
pH; decrease in casual skin sebum content on skin surface of forehead; increase in ionic concentration in
sweat and epidermal blood perfusion in volunteers. It suggests protective effect of ST on skin physiology.
[90] Clinical remission of atopic dermatitis has been reported after intake of lowsalt water.[57] Application
of heated mustard compress produced seconddegree, partialthickness burn followed by hyperpigmentation
and hypertrophic scarring.[91] Persistent use of cold pillow compress could reduce hair follicles inhibition or
damage caused by chemotherapeutic agents. So alopecia can be decreased or prevented.[92]
Temperature regulation
VeryHC applied to lumbar region of healthy female for 10 min increased back Tsk to 41.143.1°C under
HC, followed by decreased rapidly but no changes observed in BT.[56] A case of 20% of 2nd degree burns
and severe heat stroke followed by temperature rose up to 40.5°C and patient developed severe multiorgan
failure and critical polyneuropathy was reported after exposure to extreme heat in sauna for unknown period
of time.[93] The most effective method of reducing body core temperature appears to be immersion in iced
water, main predictor of outcome in exertional heatstroke is the duration and degree of hyperthermia where
possible patients should be cooled using icedWI, but if it is not possible, combination of other techniques
may be used to facilitate rapid cooling[94] such as fantherapy, CWI, icedbaths, and evaporative cooling.
[95]
Wetice, dryice, and cryogen packs applied to skin overlying right triceps surae muscle for 15 min on 10
females decreased mean Tsk 12°C, 9.9°C, and 7.3°C, respectively. None of the modalities produced Tsk
cooling below 17°C and no cooling was demonstrated 1 cm proximal or distal to any modalities after 15 min
of application. Significant mean Tsk reduction in between pretreatment rest interval (time 0) and 15 min after
removal of modality (time 30) was observed only in wetice. It suggests wetice was significantly more
efficient in reducing Tsk than dryice and cryogen packs.[96]
After exercise at 65% maximal oxygen consumption at ambient temperature of 39°C until Tre increased to
40°C produced no difference in cooling rate between WI at 8°C, 14°C, and 20°C but cooling rate was
significantly greater during 2°C, which was almost twice as much as other conditions. It suggests that 2°C
WI is the most effective treatment for exerciseinduced hyperthermia.[97] When hyperthermic individuals are
immersed in 2°C water for approximately 9 min to Tre cooling limit of 38.6°C negated any risk associated
with overcooling.[98]
Whole body immersion in moderately cold water is effective cooling maneuver for lowering BT and body
heat content of approximately 545 kJ at the end of immersion in absence of severe physiological responses
generally associated with sudden cold stress.[99] Significant less BT variability and an overall higher BT
were observed in late preterm infants following tub bathing procedure.[100]
Conclusion
Based on available literature, this review suggests that hydrotherapy was widely used to improve immunity
and for the management of pain, CHF, MI, chronic obstructive pulmonary diseases, asthma, PD, AS, RA,
OAK, FMS, anorectal disorders, fatigue, anxiety, obesity, hypercholesterolemia, hyperthermia, labor, etc. It
produces different effects on various systems of the body depending on the temperature of water and though
these effects are scientifically evidence based, there is lack of evidences for the mechanism on how
hydrotherapy improves these diseases, which is one of the limitations of hydrotherapy, and further studies are
required to find the mechanism of hydrotherapy on various diseases.
Footnotes
Source of Support: Nil
Conflict of Interest: None declared.
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