Hydrotherapy For Arthritis

Introduction

What is hydrotherapy?

Hydrotherapy, which is also known as water therapy, aquatic therapy, pool therapy, or balneotherapy, is using water outside the body through different techniques to treat a variety of symptoms (for example pain and joint stiffness), or conditions such as cancer, fibromyalgia, and arthritis-related diseases.

However, hydrotherapy is not limited to diseased people, on the contrary, it is well-known among athletes that they use both hot and cold water as part of their recovery process from intense exercises, promoting fast healing and pain relief. Additionally, some mental health problems such as depression and anxiety can also benefit from hydrotherapy as it relieves stress and has a direct effect on mood. 

Brief overview of arthritis

Arthritis is a medical term that describes inflammation of any joint in the body. It could be due to infections (viral or bacterial), or even auto-immunological as a result of a faulty gene. There are common symptoms of arthritis for example pain, hotness, swelling, and loss of function of that joint.¹ Examples of Arthritis related conditions: 

• Gout
• Rheumatoid arthritis
• Ankylosing spondylitis
• Joint replacement surgeries
• Osteoarthritis
• Psoriatic arthritis
• Reactive arthritis
• Juvenile arthritis

Patients of arthritis usually are movement-restricted and in pain. The long-term treatment includes painkillers, anti-inflammatory drugs such as corticosteroids, immunosuppressants, weight management, and sometimes diagnostic or corrective surgeries. Hydrotherapy has been suggested as a short-term complementary treatment to alleviate pain and therefore decrease the use of painkillers which have variable side effects.

What are the types of arthritis that hydrotherapy is used for?

Hydrotherapy can help in almost all types of arthritis-related conditions, whether in single or multiple joints, whether sessions are taken individually or in a group of people with similar conditions.² Studies showed improved outcomes in many aspects of the disease such as pain improvement and increased range of motion along with many other short-term benefits. 

While water temperature is a personal preference, warmer water is considered better for loosening stiff joints and for swelling relief as well. Pools specifically designated for therapeutic exercises may be kept at higher temperatures than pools primarily used for lap swimming.

How effective is hydrotherapy for arthritis?

According to Sarah McKeown, committee member of the Aquatic Therapy Association of Chartered Physiotherapists and expert in Aquatic therapy, hydrotherapy such as aqua therapy can be highly beneficial for patients with arthritis due to the unique effect of water. Numerous benefits were concluded from the studies that observed patients with arthritis performing hydrotherapy:

Pain relief

Using the physical properties of water (including buoyancy, hydrostatic pressure, viscosity, refraction, and specific heat) water decreases the weight of the body (especially if this person is overweight) which helps in relieving weight from the joint affected and thus relieves arthritis pain.³ Moreover, warm water relaxes muscle fibres that are usually in a contraction state with the diseased joint leading to pain relief.⁴

Improved joint function

Exercising in warm water improves joint stiffness by decreasing pain and relaxing muscles so that in the end the range of motion of the joint increases. This happens because warm or hot water causes blood vessels to widen and thus increases the blood flow to the affected joint which means more nutrients (such as oxygen and minerals) reach the diseased joint and inflammatory agents(for example plasma lactate concentration, elevation of intracellular calcium) are washed away.^5,6

Musculoskeletal benefit

Numerous studies showed that contrast water therapy has the following effects:⁷

• Eases muscle tension 
• Relieves the stress on muscles
• Relaxes ligaments and sore muscles 
• Shortens the recovery time from any exercise, trauma or inflammation

Nevertheless, building muscles around the affected joint occurs when exercising regularly in water as it exerts weight on the muscles promoting its further growth. In general, exercise strengthens muscles and improves the blood supply to the joints while this effect is doubled when using warm water due to the effect of water temperature on blood vessels.⁸

Types of hydrotherapy for arthritis

Not all types of hydrotherapy require physical exercise as some are passively done in water. These include:

Aquatic exercise

It is a low-impact environment that takes place in a pool with equipment and a specialist along with other patients with arthritis. It includes performing light physical exercise using the weight of water to strengthen muscles and improve vascularity.⁹  Water aerobics, lap swimming, and group exercise classes are examples of aquatic exercises. However aquatic physical therapy is performed by a licensed physical therapist tailored to each person. Despite its usefulness, according to a review study conducted in 2011, there is not much difference between land exercises and aquatic therapy for arthritis patients and it's only a personal preference if tolerated.¹⁰

Warm water immersion

Warm water immersion is similar to taking a long bath in warm water to improve circulation and vascularity of the body as a whole and the affected joint in particular. Some baths add minerals or sea salt to add more benefit to the water used and to achieve relaxation. Hydromassage differs in that there is a jet of water coming out of a small pool causing a pressure effect on the muscles. Both use warm water but the pressure is higher in hydromassage, which does not suit some patients with fragile skin.

Sitz bath

Although it is originally used for persons with haemorrhoids, an anal fissure, or healing from an episiotomy, a sitz bath is a good option for anyone who suffers from cramps that results from exaggerated muscle function around an affected joint. It entails sitting in warm water shallow baths for about 15 minutes to relieve pain.

Wraps, compresses, and fomentation

Wraps and compresses using hot, warm, or cold water are also a form of hydrotherapy. These may provide selected relief from mild symptoms such as pain and swelling around the joint, and support local treatment application by enhancing its absorption. This happens due to increased vascular supply to the joint by the effect of hot water. Most of the patients already do compresses and hot fomentations at home which makes it a commonly used type of hydrotherapy.

Balneotherapy

Commonly known as medical spas, balneotherapy uses minerals and mud in water to combine the merit of both water and minerals. It is an effective complementary therapy for diseases that are caused by low or moderate grade of inflammation (such as Rheumatoid arthritis). However, studies are still unclear about its mechanism of effectiveness.^11,12

Precautions and Considerations

Consultation with a healthcare professional

 You should consult your physician before hydrotherapy if you have one of the following:

• Skin conditions:  open/new wound or skin infection
• Cardiovascular disease
• Illnesses such as the common cold with or without raised temperature
• Respiratory illnesses such as Asthma
• A renal problem that requires dialysis
• Urinary incontinence
• Chlorine allergy
• Aquaphobia
• Ear problems such as labyrinthitis or ear infection. 
• Chronic illnesses such as epilepsy, tracheotomy, and recent surgery.

Gradual progression in intensity and duration

Your physiotherapist is the best person who can advise you before you join a class to make sure it’s suitable for your condition. You should also speak to the hydrotherapy instructor about your condition and its effect so they can tailor some of the exercises according to your needs and monitor their effect in addition to the progress. A gradual increase in the intensity of the exercises must be done to avoid injuries.

Monitoring water temperature

Water temperature could vary as high as 33℃ to 36℃ and in cold water therapies could be as low as 15 ℃. Therefore, the temperature of water should be monitored to avoid burns and should be regulated according to every patient's tolerance level.

FAQs

Do I have to learn to swim first before starting hydrotherapy?

Hydrotherapy can be done in waist- or chest-deep water, so swimming skills are not necessarily required.  An instructor or lifeguard is always present regardless of your swimming ability. There may be safety concerns when mobilising around the poolside, particularly for people who may require walking aids but these can usually be evaluated and addressed.  Usually, handrails around the edge are present in pools where hydrotherapy takes place, and floats are available to use. Steps descend into the pool, and a mechanical hoist helps people enter and exit the water if need be.

Is hydrotherapy similar to spa therapy?

Yes, spas usually have centred jets of water where the pressure required in hydrotherapy applications is higher than in pool applications and a central jet outlet could cause damage to the skin, particularly with old aged delicate skin. Some spas use mineral water as part of the therapy but there are not enough studies that show additional benefit from this to arthritis patients.

Where can I apply for hydrotherapy?

Different types of hydrotherapy are available after being referred by your physician/ physiotherapist. First, you go through an assessment of your condition then a tailored programme is set for you in a local facility or a private one if you request.

Can I combine both hydrotherapy and land exercises?

Studies showed that both hydrotherapy and land exercises nearly have the same effect and that land exercises if tolerated by the patient would result in the same outcome as hydrotherapy. Mixing both of them as concluded by other studies did not result in augmented outcomes related to pain or joint mobility.¹³ Therefore, it is your choice whether you would like hydrotherapy or land exercises, what's important is to integrate it according to your condition. 

Summary

Since the 19^th century, hydrotherapy has been used in the management of pain and its use has been recently increasing. The value of hydrotherapy for arthritis is that it decreases pain in the short term and enhances musculoskeletal performance along with a better joint range of motion. All types of hydrotherapy are beneficial when they are customised to each patient according to their disease and their level of tolerance.

Hydrotherapy is safe to practise, provides an opportunity to exercise for patients who do not tolerate land-based exercises, and holds both physical benefits and psychological ones.