Whirling and Healing
Traditional hydrotherapy and its close cousins can be effective treatment adjuncts to hands-on care
By Mike LePostellec
By the time Jane Doe made it to Jerry Whitaker's clinic, she could hardly stand up straight. Years of physical assault resulting from her work as a nurse at a state mental hospital had left its mark on her body--myofascial tightness, muscle spasms, a retracted pelvis and serious abnormalities in her spine and posture--and leisure activities that were once a welcome relief were now painful labors. More vexing was the fact that chronic pain had severely limited Doe's ability to perform her physically demanding job, and any future injuries were certain to worsen the condition.
Supported by instruction from the PT and the buoyancy of an unusual modality, however, Doe was soon exercising and back on the job, pain-free. "With this patient, I used a floatation tank as a form of biofeedback that would allow her to make minute adjustments while she was in the tank that would carry over to her day-to-day life," recalled Whitaker, PT, owner of Stress Busters, a private practice based in San Luis Obispo, CA. "And using the device along with manual therapy and Myofascial ReleaseTM techniques, we totally straightened out the abnormalities in her movement and posture so that when she finished therapy, she was able to resume jogging, bicycling and other activities that were not possible for her before."
While flotation tanks are hardly the status quo in physical therapy, they do fall under the larger umbrella term of hydrotherapy, one of the most versatile groups of modalities at PTs' disposal. Unfortunately, few PTs and far fewer insurers are aware of the full scope of these modalities' therapeutic benefits. As a result, hydrotherapy often plays a much more limiting role in treatment than it could. With this in mind, ADVANCE recently asked practitioners to explain how versions of hydrotherapy have benefited their practice.
The floatation tank used to heal Doe, Whitaker explained, is actually an open-topped, customized version of sensory deprivation tanks commonly used for psychology research during the 1970s. Holding a 600-pound solution made of water and very dense Epson salts, floatation tanks offer patients a feeling of weightlessness by allowing them to ride about two to three inches into the water line. As the patient's body adjusts to the temperature of the solution, he said, lying inside the tank feels "almost as if they were lying on a cloud." Although floatation tanks are not standard therapy modalities, the PT immediately saw the therapeutic applications and purchased one for his clinic in the early 1980s.
Since that time, Whitaker has successfully used the floatation tank in conjunction with more hands-on treatments to treat patients with a range of back, neck and general repetitive stress injuries. The benefit to the floatation tank, he said, is that the buoyancy allows patients to approximate day-to-day activities in a weightless atmosphere. "The density of the solution allows patients to decompress their lumbar region while floating on top of the water, and we also maintain a temperature of about 102 degrees to promote elasticity of the soft tissue and relief of muscle spasms," he said. "And the combination of the heat and the buoyancy of the salt water would help relax the patient, especially at the paravertebral muscle level. This would allow patients to decompress points of pressure, and as they did that there would be a subsequent reduction of their radicular symptoms, sometimes completely."
Unlike traditional hydrotherapy, Whitaker noted that patients with open wounds are contraindicated for this form of treatment, as are pregnant women due to the potential for infections.
Patients with referred symptoms such as radiculitis and abnormal sensory symptoms in the lower extremities, however, are ideal candidates for this form of treatment. Whitaker will generally guide these patients through a series of minute movements in the tank designed to correct the patients' posture and movements in a pain-free environment. When complemented by Myofascial Release and other hands-on therapies, Whitaker said that treatments in the floatation tank can have excellent long-term carryover in patients' day-to-day function.
Traditionally, warm whirlpool treatments have been used for the benefits of relaxation, pain relief and decreased stiffness, and "contrast baths" of two whirlpools (one cold and one lukewarm) were used to reduce edema in the extremities. In recent years, however, whirlpools have taken on a larger role in wound care, and are commonly used to soften necrotic tissue and prepare wounds for debridement. Although it's just one modality among e-stim, ultrasound and other wound care tools, the heat and water movement offered by whirlpools often makes hydrotherapy a starting point for wound care.
"The main reason I use whirlpools in treatment is that it can soften the debris to prepare the wound for mechanical or sharp debridement. The heat also helps to stimulate the tissue, which aids oxygen and nutrient transport to heal the wound; and movement of the water can create an analgesic effect, which will increase the patient's comfort and aid in the healing process," explained Tove Sorensen, PT, of Overlake Hospital Medical Center, Bellevue, WA.
Sorensen treats a variety of wounds including diabetic and pressure ulcers, cellulitis and traumatic wounds such as "road rash" due to motorcycle accidents at Overlake. Many of these patients, she said, are candidates for hydrotherapy in one of the facility's three whirlpools: a smaller pool for wounds on the distal extremities, another tank that can accommodate multiple limbs, and a much larger tank suited for patients with large abdominal abscesses or pressure sores of the sacral or coccygial area.
For patients who are candidates for the whirlpool, Sorensen recommended placing the affected limb or area in the moving water for no more than 20 minutes of treatment (or less depending on the diagnosis) and over a number of sessions, depending on the modality's effect and the physician's orders. She added that PTs should begin the whirlpool on a very low setting and gradually increase the force of the water to ensure that patients can tolerate the force of the jets. "I try to use the jets as heavy as the patient can tolerate because that will work most aggressively at the wound, but if you have a patient who's in a lot of pain he might not be able to tolerate it," she said. "And PTs should be careful with the whirlpool because using it extensively can cause maceration of the healthy tissue surrounding the wound, as well as remove nutrients and viable tissue."
In most cases, hydrotherapy can help to cleanse the wound and soften dead tissue in preparation for debridement. Sorensen cautioned, however, that incontinence (that could be exposed to the water) is a clear contraindication for the whirlpool, as is moderate to severe edema in the affected extremity, particularly in warm whirlpools, since the heat of the pool, coupled with holding the limb in a dependent position, can worsen swelling and pain. For this reason, she recommended that PTs should always consider all of the modality options before making a decision. "A lot of our wound care [referrals] are still specifically for the whirlpool," she said. "But I think that's because some physicians are still unaware of some of the other modalities we can use for wound care, such as e-stim or ultrasound. Hydrotherapy is a very effective treatment for wound care, but it's not a recipe treatment--it's one of many choices."
A close relative of hydrotherapy, fluidotherapy works on the same principle as whirlpool treatments but replaces moving water with rapidly circulating soft particles, most often corn cob silks. Patients place the affected limb or area through a mesh netting that covers the inside of the unit, and as hot air circles the interior, warm particles massage the patient's skin, loosening tight muscles and joint stiffness and relieving pain. Since the affected area comes into direct contact with the silks, however, fluidotherapy is not an option for patients with open wounds. Instead, it's most often used to treat arthritis, carpal tunnel syndrome and other conditions that result in pain, stiffness, decreased range of motion and/or muscle spasms.
"They are very similar in nature, but the main difference between [fluidotherapy] and hydrotherapy is that fluidotherapy is strictly a heating agent, and is therefore used only to decrease stiffness, pain and muscle spasms, and to promote ROM," said Andrea Brennan, OTR/L, of Maryvale Hospital Medical Center, Phoenix.
Like whirlpool treatments, Brennan recommended using the fluidotherapy unit for no longer than 20 minutes at one time, and that practitioners should look toward other options if the patient has a low tolerance for the heat or any circulatory problems. Unlike hydrotherapy, however, fluidotherapy is often an active treatment. "When the patient's ankle is in the unit, he is encouraged to move that extremity through the full range of motion, and at times I will put my hand into the unit to help facilitate exercises--active assistive or resistive--while the air circulates," she said.
When used in conjunction with hands-on treatments and, when appropriate, with other modalities, fluidotherapy can not only decrease pain, increase elasticity and generally relieve arthritis symptoms, but it also aids nerve growth by improving the circulation of oxygen and nutrition to the affected area. Brennan warned therapists, however, to avoid using fluidotherapy and related modalities without first considering the patient's condition and any other options.
"The decision to use a thermal agent in treatment should be based on a number of factors including the patient's diagnosis and medical status and the objective findings of the PT or OT evaluation," she concluded. "Fluidotherapy and hydrotherapy are very effective modalities, but you have to fully understand the patient's condition and therapy goals before you decide to use them."
Mike Le Postollec is on staff at ADVANCE and can be reached at mlepostollec @merion.com.