* HYDROTHERAPY

Principles, physiological basis, chemical effects

 Hydrotherapy (definition) = is the therapeutic method that use the water,
with different temperatures and different physical conditions (solid, liquid and
gas) for prophylactic and curative purposes; the association of chemical, thermal
and mechanical factors (with reflex action) broaden the definition:

1. cryotherapy = hydrotherapy that associate the “cold” factor (temperatures

below 0 Celsius degree);

2. hydrotherapy = uses the water with temperatures between 5 and 42 Celsius

degrees;

3. thermotherapy = the use of water or steam, with temperatures between 45

and 80 Celsius degrees.

When we replace the water with sand, mud or paraffin, for increasing of the
physical constants of the materials, we have the hydroionotherapy, included in
the hydrotherapy.
One can define the hydrotherapy as a non-specifically therapy, because one can
get the same effect (or reaction) using different applications of water associated
with electrical, chemical or physical factors and can have different reactions,
often opposite, depending on the dose of the exciting factor and the reactivity of
the body.

In any hydrotherapy procedure there is a main thermal exciting factor (warm

water) but also a secondary mechanical exciting factor (depending on the
pressure of the water spurt and the height of the water column and the mass of
the water volume).

At the same time, there is a chemical exciting factor, of little importance in the
hydrotherapy with pipeline water; the effect of hydrotherapy can be enhanced
by adding therapeutically agents (hay flowers, medicinal plants, starch) in the
bath water.

* In principal, in any hydroterapic procedure there are 2 mediums in contact: a

physical medium (water) and a biological medium (the human body, thanks its
skin).
* If we want to understand the effects of this interaction, we have to revise
the main characteristics of these two elements.
 The water has very favorable qualities for thermal applications.
1. Increased thermal capacity: water’s caloric capacity is 33 times bigger
than mercury’s and 8 times bigger than iron’s. That means that with low
qualities of water one can transport big quantities of thermal energy.

2. Thermal conductibility (the quality of conducting caloric energy) is high –

that means that in a unit of time, water receives and gives up a big amount
of warmth; this principle is used for “sauna” – as a thermotherapy procedure
that uses air’s thermal conductibility, when the human skin bears
temperatures over 50 Celsius degrees, that are unbearable in water (the
coagulation of proteins = burns). A basic principle derives from this one in
hydrotherapy – because of these qualities, high thermal capacity and
thermal conductibility, water is conducting in the time unit big quantities of
caloric energy (comparing with other mediums – air, metals).

3. High indifference temperature, because of the 2 previous qualities. For the

human body, this is around skin temperature (axillae 36.5 0C, on upper and
lower limbs around 340C, at the sole level around 300C), with some
particularities depending on the nutritional status. The indifference
temperature is around 33-340 Celsius degree. The indifference temperature
of a bath cannot be confounded with the “indifferent bath”, because even
with an indifferent temperature the bath will induce a reaction in the body,
because of 2 reasons:
 a)There are other physical factors of the bath (hydrostatic pressure, water
cohesion pressure) that act as mechanical exciting factors.

b)The reaction of the body is different, because the most important body
reaction is the difference of temperature between the bath water and the body,
and the body has different temperatures at different levels; this is the reason
why we understand that the bath with indifferent temperature is the bath with
the lowest exciting action.

The skin is a layer that has a mechanical protective action against the
aggression of the external environment. It has a complex structure and complex
functions that may explain the efficiency of the hydrotherapy:

1. Very rich vascular network – the vascular dynamics is influenced by the

hydrotherapy.

2. A very rich network of nervous termination (receptors) – following the effects

of hydrotherapy becomes one of local stimuli and reflex distance stimuli.

3. The skin has the main function in the heat exchange between the body and
the environment, the first one being able to give up almost 80% of his calories to
the external environment.
4. The sweat glands have the function of emergency valves against overheating of
the body and they are involved in the same time in the elimination of the
metabolic residues.

5. The immunity or decreasing of the body’s resistance against viral infections

after the cold baths regime is a confirmation for this theory.

One of the advantages of the hydrotherapy, as a non – specifically method

is its external action, without organic penetration; it can influence the organic
functions in the physiological way.

That is why hydrotherapy is not only a simple therapeutic method, but also a
rational functional therapy.
PHYSIOLOGICAL BASIS
 
The effects of hydrotherapy are due to 2 very important functions: the thermal
regulation and the peripheral circulation. The influencing of these two functions
with simple hydrotherapy procedures is extremely important. There is a tendency
of underestimating the value of thermal hydrotherapy (TH), because of its use in
the empirical medicine. The physiological studies proved scientifically the value of
the method.
THE PHISIOLOGY OF THE TERMAL REGULATION
Before the thermal hydrotherapy (TH) procedure, we will need a thermal diagnosis,
established after the measurement of temperature. A constitutional type of
thermal regulation is described, that affects the behavior at TH procedures.
Supplementary, the thermal diagnosis is necessary for getting the adapting results.
There are 3 adapting modalities at the environmental thermal influences:

1. The thermal regulation behavior – refuge in cold environment

2. Chemical thermal regulations represents the capacity of the body to increase

or decrease the metabolic exchanges, in other words, the calories production. This
mechanism differs at different species. Some animals have bigger thermogenetic
capacities that human being. Shivers and active movements represent
thermogenetic actions; this is the tissue and metabolic part, and its explanation is
due to the activity of cytocromoxidase and due to the adrenal gland’s influence: -
through adrenaline, increases the consume when it is cold.
 Adrenal gland
ADRENALIN

Metabolic changes

Cellular burning

Output - warmth

The non – shivering thermogenesis takes place 50% in the muscles, 25% in the
liver, 10% in the tissue and the rest at the level of myocardium and the brain,
excepting the kidney – where the metabolic processes do not change because of
the cooling. The thermogenesis process of the animals starts after the hibernation
as non-shivering thermogenesis, then as shivering thermogenesis and last as
movement thermogenesis.
3. Physical thermal regulation: against the cooling, the body protects itself by increasing the
insulating capacity of the body (at the swimming contest across the channel the most participants
are fat persons); against the overheating, the body protects itself by transferring warmth in the
superficial layers, through the activating of the superficial circulation = vasodilatation. This
increases the evaporation of the perspiration, the breath steams, the salivary secretion; in cold
temperature, all this processes are diminished.

Kem and Schaller developed two modern concepts for the human thermal behavior; they are more
functional, that anatomic concepts: “the cover, the shell”, that is polikilothermal (changes its
temperature regarding the environment) and “the core, the nucleus”, homeothermal, important
condition for good functioning of internal organs.

The shell that is almost half of the body’s volume is regarded as a wadding organ, depending on
the external environment temperature.
The thermal regulation resistance can be appreciated according to the critical
temperature of the body:

- inferior critical temperature = the external temperature below which the body
is unable to keep the thermal balance and the constant homeothermy of the
core
- superior critical temperature = the external temperature above which the body
is unable to preserve the core homeothermy and the central temperature
increases
- the thermal regulation interval = is the interval between the inferior and the
superior critical temperatures.

In the hydro-thermal therapy one uses air and water as external environment.
The air has a lower thermal conductibility, comparing with the water, that means
that the thermal regulation interval is bigger in air (the sauna is more demanding
than other procedures); the water has a thermal conductibility 30 times smaller
than air’s and the thermal regulation interval also smaller.
The thermal regulation behavior is due to:

- inherited topological features (cold or warm extremities, individual sensitive or

not too cold);

- the efficiency of the peripheral circulation, depending on constitution and age

(at older persons, the efficiency of the circulation can be 5-6 times slower);

- the efficiency of the respiration;

- movements;

- the clothing;

- the microclimate.

 
The PHYSIOLOGIAL BASIS of the TH refers to the functions of “the shell” and of
“the core”.
THE FUNCTIONS OF THE SHELL
 
1. Thermal wad = giving up and receiving the external temperature, until the
thermolisis and thermogenesis mechanism start to function

2. Variable thermal insulator, different from clothing which are a stable (fixed)
insulator, the transmission of the warmth through the “sell” tissues is
performed through:

- conduction (the warmth transmission from here there)

- internal convection (by the blood flow)

In this way there is a transmission of 0.10 cal/min from the external environment
in the skin for every degree of difference between central and superficial
temperature.

In a room with 220 C body, during rest is in thermal rest, all the warmth
being eliminated by convection – conduction; the transfer is entirely through
conduction, because of the reduction of the peripheral circulation.
 4. Thermal receptor (Ruffini – cold receptors and Krause – warm receptors): the
warm temperature is easier perceptible (at 1/1000 =0,001 sec), while for cold the
perception is at 4/100 =0,004 /sec. The distribution of the receptors is different
for warm and cold (e.g. at the level of the forearm there are 13-15 points/ for
warm); in the same time, the warm receptors are deeper situated than the cold
receptors.

This receptors are sending signals with different frequencies, according with
the recepted temperature level (optimal specifically level); once this level is
overpassed, the receptivity of the receptor disappears. There are regions of the
human epidermis with a certain degree of independence – they are not sending
easily stimulus to the superior level (the skin on the palms, soles and head). The
skin on the forehead has one of the most constant temperatures; the cheeks
instead are sensitive to weather changes and they are influencing the reactivity to
the general thermal regulation.

In cold: when a large surface of the skin is being cooled, the cold stimulus
are summed up, they reach the centers from the posterior hypothalamus and
through certain mechanism (vasoconstriction in skin, the stoppage of the glands
function, chemical thermal production shivering and non-shivering) will regulate
the temperature.
The action of the cold stimulus will produce a vascular reaction, which develops
itself in 3 phases:
a. vasoconstriction phase, which last for 1-2 minutes; the skin becomes pale.
b. vasodilatation phase (at the level of small arteries and veins); the skin becomes
reddish – it is the phase of active hyperemia
c. the phase of stasis, when the blood remains in capillaries, there is a slowing
down of the blood flow and also a spasm of the small arteries: there is local
ischemia and cyanosis.

The cold stimulus is split in 2 categories:

1) 35 - 18 - cold baths, which produces vascular specifically reactions:
vasoconstriction
2) 18℃ - 5℃ - produces an intense vasodilatation, caused by the paralysis of the
vasomotor and the release of histamine locally, followed by vasospasm of the small
arteries: cyanosis.

The regulation of the quantity of blood transported to periphery, in order to avoid

the sufferance of internal organs is performed by well-known mechanisms:

d. Dastre-Morat law = the vessels of the skin and mucous are functioning antagonist
with the internal organs vessels
b. the mechanism of the blood deviation from the internal organs
c. vasoconstriction with cooling at distance = consensual reaction (in the same
direction).
 At warm the activity of the centers is inhibited. When the temperature
increases over 37℃ the centers from the anterior hypothalamus come into action;
they block the simpatic vasoconstrictor action at the periphery circulation, so there
come the skin vasodilatation and the secretions of the sudoripary glands. For
evaporation of the perspiration it needs 580 cal for 1 l of water. We understand
that for the warm regulation the main mechanism is the central one, the reception
of warm being directly through the temperature of the blood.

5. Executor organ for cooling using:

a) the perspiration
b) the passive diffusion of water in the skin
c) the active elimination –
in the function of perspiration glands.

Perspiration is regulated by 2 ways:

a reflex one and an enzymatic one.
THE FUNCTIONS OF THE CORE
 
The temperature of the central region is not uniform and stable, being around
35 – 37.5℃ (the liver has a temperature a little bit higher than the core’s). The
most close to the central temperature is the rectal and the mouth (under tongue)
temperature. The closest to the core temperature is that of the inner ear (timpani)
and the axilary temperature is the least close to the central temperature. One uses
the mouth (under tongue) temperature for estimating the core temperature; there
are special procedures when the patient keeps the instrument in mouth all the
time.

The equilibrium of the difference of temperature between the regions of the

core is performed through conduction (between organs) and the circulation of
blood. In the blood vessels the heat is not transmitted cross-sectional, but
longitudinal. In the right part of the heart there is a mixture of blood with different
temperatures. This mixture continues in the lung and only in the arterial flow there
is a correction of the temperature differences.

The temperature of the core has a periodical variation:

a. daily: it is maximum in the afternoon and minimal during night and early in the
morning
b. monthly: linked by hormonal cycle – increases during progestative phase of the
hormonal cycle
c. every season.
THE HEAT EXCHANGES BETWEEN THE BODY AND THE ENVIRONMENT are performed
due to 3 processes: conduction, convection and radiation.

CONDUCTION take place in the direction of temperature interval, the

temperature difference is the one that determine the temperature flow. The air
layers close to the skin are fixed by the adhesion power, this power decreases with
the distance. The adhesive air layers, which are fixed, have a temperature close to
the skin and they resist to the temperature flow. In quiet environment this flow is
0.33 – 0.25 cal/min/ . For heat loss in basic conditions one needs 2 – 2.7℃. The
caloric resistance decreases with the speed of the air masses.

CONVECTION includes 2 compounds of the exchange modality of heat between

the body (the skin) and the environment:
internal convection – performed by the blood flow from the core to shell
external convection – performed through the movement of the air at the surface of
body. The air heated by the surface of the body become easier and will go up,
together with a loss of heat (the value of external convection is so close to that of
conduction).
RADIATION
All the heated body have an emission of an infrared radiation (Stephan
Boltzmann’s law). For the black body around 5.669729 x x x x m = cca. .
The human body acts like a black body having 97 – 98 % of the irradiating power
of an absolutely black body.
At the level of the body at a temperature of 34℃ the energy radiation has a 9.4
microns length of wave. In the same time the body receives the infrared radiation
from the surroundings.
At a 5℃ temperature difference one loses 25 cal/ /hour for 1.8 of body surface,
because every of the body loses around 5 cal in an hour.

EVAPORATION
The perspiration determines the loss of 580 cal for 1 liter, being the most
important way for cooling the body. The quantity of perspiration can be 1.5 l/hour.
The efficiency of the heat loses through this action decreases if the exposure lasts
longer. There is a certain order of staring this system for heat loses: the dorsal side
of foot, leg, tight, the upper extremity, the face – with individual variations.
The regulation mechanisms for the perspiration are controlled by the
hormons of adrenal glands.
The insensitive perspiration (without the intervention of the perspiration glands)
eliminates 18-25 g water/hour that is 10-15 cal/hour.
The evaporation is also a part of respiratory process, because of the
difference between the humidity of the inspired air (40 – 70%) and the expired air
(85 – 90%) = relative humidity. This is a way to eliminate 4 – 14 g steams per hour
that require 5 – 8 cal/hour. At the lung level we have up to 10% of the heat loses
of the body.
THE PHISIOLOGY OF THE ADAPTION AT COLD has 3 parts:
1. Temperature changes of the body through cold exposures
2. Changes produces by the environment (temperature changes, humidity, air
flows – their action on the human body determine the adaptive response)
3. The differences between different species in animals and races in humans.

For humans, there are many opinions. Some authors said that there is no cold
adaptive reaction. There is only and adjustment of the blood circulation in the
peripheral regions, that secure warm extremities during cold season.
The warm adaptive reaction is not blocked during the cold exposure, because
the 2 adaptive reactions have different mechanisms; they both can exist in the
same time.
The temperature measured under the tongue is very good in evaluating the blood
temperature from the left heart; it is higher than the rectal temperature with 0.2 –
0.4℃.
There is a daily evolution of the temperature, due to temperature
exchanges between the core and the shell. In persons in basic condition, the heat
elimination in periphery is bigger in the morning and decreased in the evening, so
the temperature of the core is increasing due central nervous regulation.
a) The increasing of the body temperature with normal metabolic reactions –
when the body receives the heat passively in a warm bath, steam, light,
paraffin, mud – the heat elimination through evaporation being very limited;
when heat applications with very high temperatures are used, then the
metabolic reaction increases up to 25%, with alkalosis as outcome.

b) The increasing of the temperature with high metabolic reactions is a result of

the forced kinetotherapy with an increase of the metabolic reaction up to 15%
and acidosis as an outcome. The heart and lungs functions are extremely
intense (the breath frequency, the pulse and the blood pressure are
increased).

In some local procedures one can increase significantly the local

circulation without the increasing of the metabolic reactions.

THE TERMAL GENESIS WITHOUT TREMBLING is one of the responses to cold,

being represented by the muscular tones. On the EMG after medium exposures to
cold one can notice in the apparently unmoved muscle an electrical activity (5 –
10 – 50 – 100 micro –V) with very weak muscular vibrations, 25-45/sec. In the
same time there is an increasing of the O2 using and in the local blood flow.
 During the cold exposure (below 14 – 15℃) the central region increases
because the shivering produces a functional transmission of the muscular body
from periphery in the central region – in order to protect the core. The muscular
contractions are extremely economical because they are taking part during the
vascular spasm at the skin level (while the muscular contraction in gymnastics
there is a heat loss because of the dilatation of the vessels).
Shivering are periodical spasms of the muscles, that produces quick
contractions of some muscular groups (200 – 500 mili –V EMG), requiring oxygen
consumption and increased blood supply (the cardiac flow increases up to 170 %).
There is a higher consumption of energy than in trembling, but the heat production
is also higher. Shivering, compared to trembling are quick heat producing
mechanisms. After shivering the central temperature increase, that means there is
a febrile response.

Termoregulation
What will this man experience?
THE REACTION IN HYDROTERAPY
The hydro-thermal therapy (HT) procedures have as goal an effect on the
circulation of blood. One has to take in to account the specificity of reaction of
myocardium. There are 2 important types (Lambert):
microkinetics = slow answer for a long period of time
a) The thermal stimuli produce low blood pressure, stasis in the veins with
circulatory break-down. These people have cold extremities and a tendency to
vascular spasm.
That is why the cold procedures have to be carefully used.
b) macrokinetics = strong answer for a short period of time

At this type, the hot bath irritates the skin (”chicken skin”), followed by
intense, uniform redness; the systolic blood pressure increase and there is
tachicardy with a tendency to blood vessels dilatation in periphery.

THE ASSESSMENT OF HT EFFECT

I) the changing of pulse

pulse increasing with 10 – 20 beats during procedure - favorable reaction
pulse increasing with 120 – 140 beats or irregular pulse – not-favorable reaction
For the evaluation of the reaction one uses Hildebrand formula = AV/AR
(pulse/breath frequency); this figure has not to overpass 4.

II) SENSATIONS (“SUBJECTIVE”)

PAIN

- in the extremities, in cold – which disappear at the end of the procedure – is

normal
- when the pain lasts after the procedure and comes together with whitening or
cyanosis of the skin – then there is a wrong reaction and the treatment must be
stopped.

BURNING SENSATION

- the burning sensation during hot procedures (steams, paraffin, mud) is a

reaction at the level of the extremities (in persons with problems of peripheral
circulation), or heart burning pain (in persons with heart problems) or abdominal
pains. When it occurs the treatment must be stopped.

III) DELAYED SIGNS

- sleep disorders, decreasing of the appetite, thermal regulation problems – occur

due to overdosing. One has to change the intensity, the length of period and the
rhythm of the procedure.
IV) THE SKIN AND VESSELS REACTION depends on the general reactivity of the
blood vessels:

- a good reaction is when there is dilatation of vessels; there is a reddish color at

the level of the skin where applied the stimuli; with an easy heating and gentle
pleasant sensation, after the cold procedures.

- a negative, wrong reaction means a wrong dose, especially when cold or very
warm. At the skin there is a “chicken skin” sensation, whitening, cyanosis,
cooling and cold sensation with shivering. One can have also general symptoms:
weakness, headache, lack of appetite, lack of sleep.

The reaction of skin and vessels depends on:

1. The intensity of the thermal factor (cold or warm)

2. The thermal exchange on the time and surface unity
3. The thermal loss of the shell in the moment of performing the procedure
4. The thermal balance of the body (for e.g. cold over cold is a negative reaction)
5. The thermal ratio = central temperature / periphery temperature
6. The speed of the procedure
7. The process of getting used with the procedure; one can increases the
temperature from one session to another
8. The mechanical (supplementary) factor (brushing, showers, Halbad, friction).