Hydrotherapy PDF

1 What is hydrotherapy? Use of water in any of its three forms for therapeutic benefit, to enhance impairment or wellness-based massage. How is hydrotherapy used in massage therapy? o Enhances...

1 What is hydrotherapy? Use of water in any of its three forms for therapeutic benefit, to enhance impairment or wellness-based massage. How is hydrotherapy used in massage therapy? o Enhances impairment and wellness-based massage treatments o Important part of self-care for the therapist o Used as part of self-care for the patient Core concepts (pp 13 – 23) The body is always trying to maintain balance in all its functions. This is known as homeostasis. Hydrotherapy (hot or cold applications of water, ice or steam) creates a stimulus that causes the body to react Specific physiological processes including changes in blood flow/circulation occur in the body in order to maintain homeostasis. When choosing which type of hydrotherapy is indicated, we ask the questions: o “Where do we want blood to flow from and/or to? Standards of practice: Standard 17 THERMOREGULATION The term given to the body’s system for maintenance of body temperature is thermoregulation Homeostasis maintains and readjusts the body temperature to keep it within a narrow temperature window: o The body’s core temperature is around ___________degrees o Shell temperature (the periphery) is usually 1-6 degrees cooler than the core. How does the body regulate our temperature? The largest organ in the body is the ________. It has four functions: ___________, ________________, ______________, _______________.  2 Changes in temperature are detected by thermoreceptors located in the skin and within the body When a temperature stimulus is applied to the body or when core body temperature begins to increase or decrease, thermoreceptors send signals via the nervous system to the brain. The part of the brain that acts as our thermostat (monitoring body temperature) is the ______________. It controls our heat conserving and heat releasing mechanisms in our bodies. Blood vessels just below the skins surface play a vital role in thermoregulation by changing diameter (and therefore controlling blood flow) in response to temperature stimuli. Heat conserving mechanisms When our core body temperature decreases due to exposure to a cold temperature stimulus, the hypothalamus triggers the following heat conserving mechanisms: o VASOCONSTRICTION: blood vessels narrow in response to COLD to minimize heat loss from the skin’s surface; blood is moved from superficial tissues and extremities towards the core o Systemic metabolism increases in order to generate more heat in the body o Shivering: skeletal muscles contract rapidly; increased muscular activity results in the generation of heat o Goosebumps/piloerection: this provides a non-moving layer of air close to the surface of the skin which helps retain heat  3 Heat releasing mechanisms When our core body temperature increases due to exposure to a hot temperature stimulus, the hypothalamus triggers the following heat releasing mechanisms: o VASODILATION: blood vessels widen in response to HEAT so that more blood moves towards the skin’s surface o Perspiration: sweat glands secrete water and waste products and as moisture evaporates from the skin, heat is also removed from the body o Skeletal muscle tone is decreased o Systemic metabolism decreases: reduces the amount of internally generated heat  4 Properties of water (pp24 – 25): 1. Specific heat and thermal conductivity: o Water has a high capacity to absorb, store and release heat. o Hydrotherapy applications (water, ice or steam) applied at temperatures above or below that of the body can carry heat to the body or remove heat from the body o Skin surface can tolerate temperatures from 0 – 44 degrees C o Water has highest heat capacity of any liquid. 2. Mechanical effects o An external stimulus of water pressure e.g. whirlpool or friction increases the stimulating effects of water on the body and exerts pressure on the surface of the body o Mechanical effects of water can impact the lymphatic, circulatory, musculoskeletal and nervous systems  5 3. Water resistance and hydrostatic pressure o Immersion of the body in a bath or a whirlpool (or any body of water) will result in hydrostatic pressure being exerted upon the body. The pressure of water will increase venous and lymph flow from the periphery o Exercising in water adds resistance and exerts forces against the muscles with less impact on the joints o Buoyancy: Salt water provides more buoyancy and creates more resistance as it heavier than fresh water 4. Chemical effects (solubility) o Water is an essential and large part of our body structure o Water can be used to dissolve or carry added ingredients o When taken internally, water transports needed nutrients to the body and removes waste products Heat transfer (pp 26 – 29): An exchange of energy between two materials that occurs in relation to the temperature difference between the two materials. Occurs as a result of: o CONDUCTION: the exchange of heat between two surfaces that are in direct contact with each other e.g. thermophore o CONVECTION: result of movement of heated gas or liquid between two surfaces at a different temperature e.g. sauna o RADIATION: the transfer of heat between objects via infrared rays that are not in direct contact e.g. the heat the body absorbs in the sunshine o EVAPORATION: conversion of a liquid to a vapor e.g. perspiration – as sweat evaporates from the skins surface, it removes heat from the body o CONVERSION: no externally applied heat e.g. ultrasound Physiological effects of hydrotherapy (pp 29 – 33): 1. Local effects Local effects occur in the specific area of a hydrotherapy application: Local effects may include increasing or decreasing blood flow, altering local immune responses, improving tissue pliability, decreasing pain etc.  6 2. Reflex effects A reflex effect is an effect that occurs via the nervous system (CNS) When a hydrotherapy modality is applied to part of the body, reflex effects can cause physiological changes in deeper tissues/organs or in other parts of the body Reflex effects may occur either directly below the modality or in areas further away from the stimulus 3. Systemic effects Hydrotherapy modalities can be applied to the whole body causing systemic effects on the body as a whole e.g. changes in blood pressure, venous return Temperature Therapy Guidelines (Chapter 5 - pp 99 – 122): Case history and assessment (summary page 107): Taking a thorough case history, the patient’s chief complaint and the intake process will help you decide which hydrotherapy modality to use and where to apply it. C/I’s and/cautions are taken into consideration.  7 Assessment is performed. Skin Discrimination test (pp 101 – 103): responses to different temperatures applied to skin. Can they feel a temperature stimulus accurately? Is it different in one area of the body compared to another? Patch test (p106): E.g. is there an allergy to ice? Nail bed test (capillary refill) (pp 104 – 105) – used for patients with vascular disorders or to ensure compression from an ice bandage is not restricting blood flow to distal tissues too much. Other general rules of hydrotherapy application include (pp 116 – 122): Always adapt the treatment to the patient Prepare your treatment space (draft-free, clean, calm) and have all the necessary equipment ready for use CONSENT for hydrotherapy (p. 115): o Explain the procedure o Explain the rationale o Explain the risks and benefits o Describe briefly the draping involved for the hydrotherapy application o Stop/modify o Any questions? o Ask for consent Have the patient void before the treatment Stay with the patient Watch for any negative reactions, check tissue response Stop the treatment if a negative reaction occurs More is not better: do not over-tax the patient with a tx that is too extreme/prolonged The same hydrotherapy application is not recommended to be done daily, the same way or at the same time (the body adapts to the same application). A PATIENT SHOULD NEVER LAY ON A HYDROTHERAPY APPLICATION. Be safe and effective Start with a less intense treatment, increasing the stimulus over the course of several treatments. The rule is “as warm as necessary, as cold as possible”.  8 Treatment variables (pp 108 – 113): Variable that you cannot control: Reaction of the patient or patient’s skin General body type State of mind of the patient pre-treatment Age of the patient Execution of self-care instructions (self-care compliance) You can control (i.e. these are the treatment variables that you can modify if and when necessary: Temperature of the hydrotherapy application: o Increased temperature difference between skin and water temperature will increase stimulus o There must be a minimum 10 degrees C difference between the stimulus and the skin to create a reaction Duration of application Location and size of the treatment Frequency of application What modality you choose Time of day Post treatment care of the patient Negative reactions (pp 123-129); A negative reaction is an unexpected and undesirable response to a hydrotherapy treatment. Negative reactions are most likely to occur during: o Hot or contrast treatments o Treatments that are too long in duration o Treatments that are too short or incomplete o Patient was chilled before treatment o Patient too debilitated or fatigued o Treatment is too intense for patient Common signs and symptoms of negative reactions Tissue discoloration (indicating poor local blood flow) Itchiness, pain or sensory changes Shivering, dizziness, low or high blood pressure, headache, nausea, hyperventilation, disorientation, feeling faint How to respond to a negative reaction  9 Stop the treatment - sips of water, blanket if patient is cold or shivering. It is important to avoid further over treatment for at least 4 hours. Try either a less intense modality next time you see the patient. If patient is red, raise her head; if the patient is pale, raise their tail Hydrotherapy Contraindications (Chapter 6 – pp 132 - 159): Hydrotherapy contraindication: Hydrotherapy is inappropriate and potentially harmful to the patient and should NOT be administered. C/Is include: o Absolute general C/I (usually systemic issue) OR o Absolute local C/I (hydrotherapy should not be used in a specific area but can be applied elsewhere) Hydrotherapy caution – Hydrotherapy is appropriate BUT adaptations MUST be made to ensure patient safety. (These can be general or local also). 1. ABSOLUTE GENERAL C/I’s to hydrotherapy: hydrotherapy is not appropriate anywhere on the body: conditions listed are those that affect the system. ▪ undiagnosed or unknown systemic condition ▪ inebriation (e.g. alcohol, drugs) ▪ fainting, shock, dizziness ▪ severe chronic congestive heart failure (CCHF) ▪ hemorrhage (substantial or internal) ▪ very high or unstable blood pressure ▪ advanced kidney failure ▪ advanced liver disease ▪ immediately post miscarriage ▪ immediately post MI, cardiac surgery, stroke (CVA) (until medical permission) ▪ septicaemia/systemic infection ▪ fever 2. ABSOLUTE LOCAL C/I’s to hydrotherapy: hydrotherapy is not appropriate on a specific area of the body: conditions listed are those that affect a specific area. (Hydrotherapy can be applied elsewhere) ▪ gangrene ▪ acute arteritis, phlebitis ▪ vasomotor paralysis (e.g. median or sciatic nerve lesions) ▪ open wounds, lesions, burns, ▪ during radiation therapy 3. GENERAL CAUTIONS to hydrotherapy: modifications and/or medical consultation will be required for the following general/systemic conditions; ▪ asthma ▪ aneurysm in major blood vessel ▪ moderate and severe emphysema, COPD  10 ▪ epilepsy ▪ spinal cord Injury ▪ diabetes ▪ hypertension and hypotension ▪ mild to moderate CCHF, weakened heart, history of MI, CVA cardio surgery ▪ pacemaker or artificial parts in the heart ▪ kidney disease ▪ multiple sclerosis ▪ post-surgery, to avoid promoting infection or overstressing injured tissue ▪ pregnancy ▪ weakened or debilitated condition ▪ excessive fatigue ▪ cachexia ▪ patient is fasting ▪ medications that affect perception of pain or metabolism 4. LOCAL CAUTIONS to hydrotherapy: modifications and/or medical consultation will be required for the following local conditions: ▪ absent or altered sensation ▪ history of arteritis, phlebitis, other vascular condition ▪ gastrointestinal conditions, e.g. Crohn's Disease, IBD, digestive upset ▪ impaired local circulation, for example diabetes, pitted edema ▪ patient is menstruating ▪ Raynaud's disease/phenomenon ▪ partial vasomotor paralysis (median or sciatic nerve lesions) ▪ severe varicosities ▪ where the pressure of the application may be painful or damage the area (e.g. joint dislocation, osteoporosis) LOCAL absolute C/Is for heat modalities ▪ acute inflammation ▪ pre-gangrene ▪ neuritis ▪ skin is burned ▪ during vascular headaches for example migraine and cluster headaches LOCAL cautions for heat applications: ▪ the presence of pins, wires, staples, artificial joints or other implants ▪ Sub-acute inflammation GENERAL C/Is for cold applications: ▪ patient is chilled, intense dislike or fear of cold LOCAL C/Is for cold applications: ▪ frostbite (either current or previous) ▪ Raynaud's disease/phenomenon  11 Hydrotherapy equipment CLEANING: Paraffin wax baths (cleaned when dirty or wax level is low) 1. Unplug the unit (best to do to a couple rather than all of the units so that there are still units available to student clinics) 2. Place a wire coat hanger in the wax with half of it clearing the surface of the wax 3. Leave overnight to let wax harden 4. Pull the wax out with the wire hanger and throw away, then clean out the unit thoroughly with a non-abrasive disinfectant 5. Clean up the cart and the sides of the wax bath 6. Place a couple of blocks of fresh wax into the unit and plug in. Top up the unit if necessary 7. The wax unit will heat up as soon as you plug it in so it will be at a higher temperature than is considered therapeutic for an hour Hydrocollator units (clean every month or when dirty) 1. Unplug the unit and place the hydrocollator packs in a bucket of water 2. Remove the metal rack and scrub it 3. Attach the “garden hose” end of the hose to the back of the unit and place the other end near a drain, open the valve in the back of the unit and allow the water to drain out (you may need a few people to lift the unit slightly to allow it to empty completely) 4. Wash and rinse out the unit inside and out with non-abrasive disinfectant 5. Close the valve before refilling 6. Remove the hose and insert “rubber cap” end around tap and other end in unit. Turn the water on and refill the unit up to the line. 7. Put the rack and then the hydrocollator packs back in, before plugging in the unit Steam cabinets (the unit should be cleaned after every use) 1. Unplug the unit 2. Remove the seat and clean with disinfectant 3. Clean inside and out with a non-abrasive disinfectant and rinse 4. Clean the heating unit as well as possible 5. Put seat back in Bath tubs and whirlpools (the units should be cleaned after every use) 1. Clean inside and out with a non-abrasive disinfectant 2. Rinse with hot water 3. Dry to avoid water marks Freezers (once a month or as needed) 1. Unplug the freezer 2. Remove all the ice trays, cups and gel packs 3. Rinse the ice trays and cups 4. Pull the freezer into the shower cubicle and let defrost overnight 5. Re-fill the freezer 6. Plug the unit back in 7. Please defrost only one freezer at a time to ensure that there is still ice available for student clinics  12 HEAT (chapter 3 pp 61 - 84) Hot applications produce physiological responses which are attempts by the body to eliminate heat. The effects produced by hot applications depend on: ▪ Type of modality ▪ Temperature of the modality ▪ Duration of the application ▪ Location of the application ▪ Condition of the patient. Warm: raises the target tissue temperature to 33 – 38 degrees C Hot: raises the target tissue temperature to above 38 degrees C PASSIVE DERIVATION The PRIMARY RESPONSE of the body to HEAT is PASSIVE DERIVATION: In the area that has been heated, superficial blood vessels dilate - VASODILATION allows blood to move towards the skins surface which allows heat to escape. Hydrostatic pressure will decrease in blood vessels that are dilated. Blood will move passively down a pressure gradient from other parts of the body (areas of higher hydrostatic pressure) towards the dilated blood vessels (lower hydrostatic pressure) in the heated area. Blood will move passively from a congested area or from the core towards the area which has been heated. The resulting increase in blood flow in the area can be seen as redness of the skin. This is known as Passive Hyperemia PHYSIOLOGICAL EFFECTS of LOCAL HEAT: Passive derivation and passive hyperemia: increased local circulation via vasodilation Increased local tissue temperature and metabolism Decreased PAIN, muscle spasm Direct effects on soft tissue structures: mediated through nervous system. Heat increases fascial excursion, decreases joint stiffness. Sedation/relaxation with optimal temperatures  13 Increased local sweat production leading to detoxification Reflex effects on organs Local blood pressure decreases (through vasodilation) Note: with more systemic/extensive heat treatments heart rate and breathing rate may increase. INDICATIONS for HEAT Chronic pain, chronic muscle spasms Chronic elevated resting tension Trigger points (use pre and post treatment) Chronic stage of injury repair To warm a chilled patient Before a very cold treatment Pre- or post-massage treatment For sedation where there is general stress and tension (larger applications, especially full body heat) To encourage sweating and detoxification (full body treatments) Heat applications over the sacrum or abdomen may alleviate menstrual cramping, intestinal cramping or mild diarrhea in some patients Local heat treatments: Fomentations (alternating hot towels/hot compress, thermophore, paraffin wax, hydrocollator) A fomentation is a hot moist compress either encased in or covered with a dry layer that provides prolonged heat  14 1. Hydrocollator (pp 204 – 206) A clay or silica-gel filled pack soaked in hot water to provide prolonged, moist heat. (ITB’s, hyperkyphosis (across chest) The pack must be wrapped in 3 – 5 layers of towels or in a hydrocollator cover. As the pack cools down, towels can be removed one at a time to prolong the heat Hydrocollators are heavy and provide an intense heat; they may be contraindicated for certain conditions where there is fragile bone or unstable joints in the treatment area. Duration 10 – 20 minutes 2. Thermophore (pp 202 - 203): A fomentation that creates deep moist electric heat. The flannel cover traps moisture from the air. Do not roll up or fold the thermophore, other than to hang it up. Gently wash the flannel cover in cold water when appropriate. Always cover the pack with a pillow case for hygienic reasons Duration 10 – 20 minutes  15 3. Paraffin wax (pp 207 - 211): Paraffin wax is used for smaller treatment areas such as a scar, adhesions or over a specific area of tension e.g. tendon, ITB, joint. The wax units contain paraffin wax that is maintained at a therapeutic temperature. If the wax unit is unplugged, please note that on plugging it back in, it will heat up to a temperature higher than therapeutic temperature in order to self-sterilize. Use caution and wait 10 minutes before using it. 8 – 10 layers of wax are either painted on the treatment area using a silicone pastry brush/paint brush or strips of paper towel are dipped in the unit and applied to the skin. To treat the foot, elbow or hand with wax it is better to have to patient “dip” the body part into the wax unit carefully. The first layer of wax is the largest to create a seal. The wax application must be covered in saran wrap, followed by a towel andthen an additional heat source and is left on for 10 – 20 minutes.  16 4. Alternating Hot Towels (hot compress) (pp173 – 175): An application of a series of hot moist towels to a specific area. Towels mold easily to the treatment area Towels are soaked in a bucket of hot water Wring out the towel and apply to the area of the body to be treated. When the towel begins to cool, place a dry towel over the application and apply a fresh hot towel on top. Turn all three towels over and remove the cooled towel that is now on top. Repeat for 10 – 20 minutes. Hot foot bath (p 184 – 185) Feet and lower legs are soaked in a bucket/container of warm or hot water for 10 – 20 minutes. A cold compress to the neck and a blanket is recommended. Can be used to treat chronic conditions in the lower legs/ankles and feet or for its powerful reflex effects: o Can increase systemic circulation, increases core temperature o Reflexly effects circulation to pelvic region, upper respiratory passages, throat and head. o Used to warm up a chilled patient, can help to abort a cold, alleviate congestive headaches, sinus problems, lung and chest congestion, pelvic congestion (menstrual cramping), chronic insomnia.  17 Hot arm bath Hands and forearms are soaked in a bucket/container of warm or hot water for 10 – 20 minutes. Increases local circulation, decreases muscle resting tension, fascial restrictions. Used for chronic arthritis, tight forearms (from massage therapy, lifting, manual work etc). Reflex effects occur in the brain/nasal mucosa See also castor oil compresses, heating compresses and full body heat treatments  18 COLD HYDROTHERAPY (Chapter 2 pp 37 – 59) Cold treatments in hydrotherapy do not “CHILL” the patient, but are used to cause a reaction in the body to a potentially harmful stimulus Cold treatments may be short, moderate or prolonged in duration. Cold may be combined with friction to increase the stimulus Water can be used at cool or cold temperatures OR ice can be used (cryotherapy) RETROSTASIS The PRIMARY RESPONSE of the body to a cold stimulus is RETROSTASIS: o VASOCONSTRICTION of superficial blood vessels occurs. o Blood is moved from skin (PERIPHERY) to the CORE ACTIVE DERIVATION The SECONDARY RESPONSE to a cold stimulus is ACTIVE DERIVATION o Once the cold stimulus/friction is removed, the body will attempt to restore blood flow to the cooled/frictioned skin by actively moving blood towards the cooled/frictioned peripheral tissues. It is an active process because the body has to work to move circulation from the core/congested tissues towards the cooled peripheral tissues. o Blood is moved to the cooled/frictioned tissues from either: ▪ the deeper organs/core or ▪ from an area of congestion in the body o The blood that is actively moved towards the cooled/frictioned tissues brings fresh nutrients and oxygen to the cooled tissues. and local metabolism is increased in order to maintain homeostasis o This increase in blood flow to the peripheral tissues is seen as redness of the skin and is known as active hyperemia.  19 SUMMARY OF PHYSIOLOGICAL EFFECTS of LOCAL COLD HYDROTHERAPY PRIMARY RESPONSE: o RETROSTASIS: VASOCONSTRICTION of superficial blood vessels occurs. Blood is moved from skin (PERIPHERY) to the CORE o Decreased sweating o Decreased local metabolism (tissue needs less oxygen) o Decreased nerve conduction – decreased pain (ANALGESIA) o Increased skin and muscle tone o Decreased tissue temperature o Increases blood flow to core organs SECONDARY RESPONSE - ACTIVE DERIVATION : o ACTIVE DERIVATION: Blood flow leaves the deeper organs (or a congested area) and is actively moved back towards the cooled skin shown as redness of the skin (ACTIVE HYPEREMIA) o Increased local metabolism as body attempts to re-warm the area o Increased digestive processes (for local abdominal cold treatments) o Increased function of adrenal and thyroid glands o Increased nutrition and elimination functions of the skin o Improved function of the immune system  20 USES (indications) for COLD TREATMENTS: 1. ACUTE INJURY MANAGEMENT – treatment of the cardinal signs of inflammation o Inflammation is an important part of the healing process but is often excessive and non-specific to the injury. o An injury causes VASODILATION AND INCREASED PERMEABILITY of local blood vessels o BRIEF COLD/CRYOTHERAPY treatments applied regularly to an injured area help to “contain” the inflammatory process rather than stopping it. o Brief cold hydrotherapy applications or ice (cryotherapy) modalities are used because they cause RETROSTASIS (primary response of the body to cold). o The VASOCONSTRICTION in the area minimizes excessive blood pooling at the injury site (decreases SHARP) CARDINAL SIGNS OF INFLAMMATION (S.H.A.R.P) ▪ ▪ ▪ ▪ ▪ 2. Treatment of stubborn CHRONIC conditions 3. Other uses/indications for local cold applications of hydrotherapy include: o Poor skin tone o Sluggish digestion or constipation (local application of cold to abdomen) o Insomnia (local application to abdomen) o Poor immune system function o Spasticity o Hypothyroidism or sluggish organ function (prolonged treatment) CONTRAINDICATIONS to COLD HYDROTHERAPY See lecture 1: C/I’s and cautions Fear, dislike of cold or any cold treatment  21 Local – do not put cold hydrotherapy over the abdomen if patient has diarrhea Hyperthyroidism (prolonged or extensive treatments) Caution with bony areas and superficial nerves where there is little tissue insulation Avoid placing cryotherapy over the anterolateral neck Local Raynaud’s disease or phenomenon Patient is already chilled ACUTE INJURY MANAGEMENT AND RULES of CRYOTHERAPY 1. When we are treating the cardinal signs of inflammation in an area, we use P.I.E.R. (referred to as R.I.C.E. in textbook and other resources) PIER P I E R 2. Patch test: it is possible that a patient will have an allergy when ice is in direct contact with the skin; to test for a negative reaction/allergy prior to a cryotherapy treatment: a) Apply a small amount of oil to the patient’s skin and apply a small piece of ice to the area for several seconds. b) Observe the area for any allergy (raised bumps/wheals/rash) which indicates an allergy 3. C.B.A.N. When applying ice directly on the skin, the duration of the treatment will depend on the patient’s feedback. IT IS VERY IMPORTANT TO EXPLAIN TO THE PATIENT WHAT THEY ARE LIKELY TO FEEL THROUGHOUT THE TREATMENT C.B.A.N. C B A N  22 Important note: not every patient will experience all 4 sensations; nor will every patient’s tissue become numb. After several minutes if the patient is not reporting numbness, the treatment is ended. 4. The Hunting response The hunting response occurs in response to prolonged and extreme cold temperatures (e.g. winter temperatures) or direct ice applications (longer than 12 - 15 minutes). The Hunting Response is a protective mechanism which causes the superficial blood vessels to intermittently vasodilate and vasocontrict. It allows superficial tissues that are cooled to a very low temperature to maintain perfusion, thus avoiding cold-induced cellular damage/frostbite and replenishing oxygen and nutrients to the cooled tissues. We do not apply ice/gel packs for more than 10 minutes at a time and therefore do not usually encounter the Hunting Response. 5. Ice is applied at regular intervals When treating an acute injury we apply ice massage for several minutes (C.B.A.N.) or a gel pack for 10 minutes followed by a 30 – 50 minutes break before repeating the ice application. The ice creates regular retrostasis in the inflamed tissues whilst the break allows some perfusion of superficial tissues via active derivation too occur. 6. THERE MUST BE A MINIMUM OF 10 DEGREES DIFFERENCE IN TEMPERATURE BETWEEN THE SKIN AND THE COLD OR ICE APPLICATION TO CREATE A REACTION  23 CRYOTHERAPY Static cryotherapy (gel packs, ice packs, ice bandage): 10 minutes duration. MUST be applied with a COLD WET towel between the skin and the ice pack/gel pack. Oiling the skin lightly is recommended. 1. Gel packs and Ice packs (p164) Use an ice bag (or a bag of frozen vegetables) or a reusable gel pack. Ensure that if you are using a bag of ice chips that you remove the air pockets from the ice. 2. Ice bandage (pp168 – 169) A gel pack or ice bag applied with pressure using a tensor bandage or wrap. Tension of elastic wrap should be enough to provide adequate compression without too much pressure (use capillary refill test to ensure circulation is intact) 3. Cold frozen towels (ice towels)  24 4. Dynamic ice massage(pp 166 - 167) Popsicle/ice cube or cryocup (plastic or Styrofoam)) Most effective for muscle spasm, contusion and other minor well-localized areas Lightly oil the skin first Use a towel to wipe any drips of water as you ice, pat dry and re-drape when treatment is complete Duration: CBAN 5. Cold compress (pp170 – 172): These cold alternating towels are applied to the body in the same way as the hot compresses (see lecture 2) These compresses are renewed frequently (every 1-5 minutes) in order to maintain retrostasis and can be applied for 5 - 10 minutes. Indications: used in conjunction with a full body heat treatment headache or headache prevention (placed on back of neck or forehead) used after a heat treatment to restore tone to the skin ideal for patients who may not tolerate very cold or ice treatments Used with patients who have an ice allergy Good for treating seniors where cold is indicated but ice is too intense; Used to treat acute inflammation or injury where the weight or pressure of ice or an ice pack is too painful 6. Cold arm bath Submerge hands and forearms in a cold or cool water for 45 seconds – 2 minutes or until mild aching is felt. Pat dry and ensure the arms stay warm after the treatment is complete Effects Strengthens the body and helps to prevent illness. Very stimulating Decongests the head, sinuses Stimulates circulation in arms Revitalizes the body Uses Headaches, nose bleeds Tired, achy arms and hands Sleepiness, lethargy Acute injuries to hand, forearm Acute flare up of arthritis  25 7. Cold foot bath (p186) Submerge feet and lower legs (ideally up to proximal calf) in cold or cool water for 45 seconds – 2 minutes or until mild aching is felt. Pat dry and ensure the feet stay warm after the treatment is complete Effects Strengthens the body and helps to prevent illness. Can be sleep-inducing Decongests the head, chest, pelvic areas Stimulates circulation in legs Revitalizes the body Uses Headaches, nose bleeds Tired, achy feet and legs Heavy menstrual flow (cool is best) Insomnia Depressed immune system Acute injuries to foot, ankle, Acute flare up of arthritis (e.g. gout) Mild low blood pressure 8. Ice immersion d/w: Snow walking Indicated for chronic headaches, weariness and fatigue, excessive foot perspiration. Walk barefoot in the snow (fresh powder snow) beginning with a few seconds and building up to 3 minutes. Ensure the feet are warmed up afterwards with socks, being rubbed dry or a brisk walk. d/w: Water treading Indicated for problems falling asleep, mild poor circulation, hot flashes, vascular headaches, sensitivity to weather changes, congestion, anxiety, sluggish metabolism Stork walk in cold water for 1 – 5 minutes. Water should reach just distal to knees (basin of water, bathtub, sea, lake, water treading pit or river). Can be done seated. Wipe off water and put on socks before walking or resting. d/w: Dew walking Indicated for mild poor circulation, morning fatigue Strengthens immune system, improves circulation Begin with warm feet and walk for 5 – 10 minutes in dew-moistened grass. Finish with warm socks/bed rest C/Is for water treading/dew walking/snow walking: coldness, chills, cold feet, menstruation, urinary infection, acute bladder and kidney conditions, severe arterial and circulatory conditions.  26 TONIC FRICTION TECHNIQUES (p188) Tonic friction techniques include COLD MITTEN FRICTION, DRY BRUSHING, SALT GLOWS and WASHINGS. Tonic friction techniques use varying amounts of FRICTION most often combined with COLD water applied to the skin. Tonic refers to the stimulation of a “STRENGTHENING REACTION” which improves skin tone, the efficiency of the skins elimination function and tolerance of cold temperatures GENERAL EFFECTS OF TONIC FRICTION TECHNQIUES The effects and indications of each tonic friction modality are similar but vary depending on the degree of friction applied to the body and the temperature of the water if used. With an application of rapid friction and/or a cold stimulus to the skin, retrostasis (primary response of the body to cold) occurs. The brief vasoconstriction of superficial blood vessels is followed by the secondary response of the body to cold – ACTIVE DERIVATION (blood flow is directed back towards the cooled skin) Blood flow returns to the skin bringing nutrients and oxygen to the treated tissues (increased perfusion). PHYSIOLOGICAL EFFECTS OF TONIC FRICTION TECHNQIUES Stimulates and increases efficiency of the circulation to the skin Improves skin tone Stimulates nervous system via cutaneous nerves (nerves in the skin) Exfoliates the skin Cold tonic friction techniques can increase the tolerance of the vascular system to react positively to cold Can improve skin elimination functions Can improve immune system function Congestion in deeper areas of the body can be relieved with the reflex effects of active derivation. GENERAL USES/INDICATIONS OF TONIC FRICTION TECHNIQUES Post-cast removal Bed-ridden patients  27 In preparation for ice massage/cryotherapy In preparation for a full body heat treatment For patients with poor tolerance to cold temperatures To improve immune system function For mild depression, fatigue, lethargy To alleviate symptoms resulting from withdrawal (from alcohol, tobacco, drugs) Tonic friction modalities applied over the abdomen (especially cold) can help with insomnia, restless sleep, constipation, flatulence and poor digestion CI’s and cautions (Refer to lecture 1 C/I and caution list) Recent scar tissue Patient is chilled Skin lesions/open sores/acne Freshly shaven skin (particularly with dry brushing and salt glows) Body areas with excessive hair may be irritated by dry brushing Some tonic friction applications are extremely stimulating on the nervous system: dry brushing especially is best avoided if relaxation required Cutaneous nerve hypersensitivity Very few CI’s for washings (tonic friction technique with minimal friction 1. DRY BRUSHING (pp 192 – 195) The use of a dry, natural fibre brush to massage the body, partially or completely, to stimulate the circulation of the skin. Good for patients who don’t like cold. EXCELLENT FOR PHYSICAL and MENTAL WAKE-UP PROCEDURE o Brisk, CIRCULAR, long strokes with pressure towards the heart*. o Limbs are brushed from joint to joint, beginning on lateral aspect of limb and then medial aspect. Start at the distal aspect of each limb. o A soothing hand stroke between brushings especially along the medial aspect of the limbs can be added for sensitive skin. o Brush the area until hyperemia occurs (different for each area)  28 2. COLD MITTEN FRICTION (pp 189 – 191) An application of cool or cold water to the skin with friction using a wash mitt or small towel. PROCEDURE o Soak a flannel wash mitt in cool, cold or very cold water. Wring the mitt out so that it is wet but not dripping o Undrape the area of the body to be treated. o Rapidly rub the cold mitt over the skins surface covering all areas o Do not dry off the area. Re-cover. The thin layer of water left on the skin will stimulate the body to re-warm the area. o If you are applying the modality to the whole body, ensure that you re-wet the mitt when it stops feeling cold  29 3. SALT GLOW (pp 196 – 197) Application of slightly moistened cold/cool salt to the body using friction PROCEDURE o Use 1-2 cups coarse salt, pickling salt, Epsom salts, sea salt. o Apply a salt glow standing in tub or in shower before finishing with a salt bath or cool shower/rinse o Salt is applied in a saw-like motion with more or less pressure depending on the area 4. WASHINGS (pp 198 – 201) A gentle application of cool or cold water to the skin with minimal friction. Can be very energizing first thing in the day. Good for improving digestion and promoting restful sleep when applied over the abdomen. Washings are applied to the full body or specific area in a specific pattern A thin film of water is left on the skin. The area is allowed to air dry. Temperature of the water is cold or cool.  30 CONTRAST HYDROTHERAPY (Chapter 4 – pp 87 – 95) Alternating heat and cold applications that are used to enhance peripheral blood flow. Contrast hydrotherapy creates a vascular pump (vascular “whip”) which greatly increases local circulation (up to 100% increase). o Vascular Flushing/ circulatory “whip”: This is the pumping action that occurs during a contrast treatment that results from the alternating vasodilation and vasoconstriction ▪ Heat applied to an area causes vasodilation (via passive derivation); ▪ Cold applied to an area causes vasoconstriction (via retrostasis). A contrast application generally begins with a hot/warm modality and finishes with a cold/cool modality. Generally the sequence of heat and cold is repeated at least 3 times (if combined with massage treatment); the sequence should be repeated 6 – 8 times if used alone without a massage treatment. The standard ratio of heat/cold is 3 – 5 minutes of heat and 30 seconds – 1 minute of cold. Alter the ratio when working with the early and late sub-acute stages of healing. Use your observations of the tissue to alter the ratio of hot to cold. o For early sub-acute stages of healing you would emphasize cold and reduce heat. o As healing continues and the tissue moves towards a chronic presentation you would increase the heat gradually building up to the standard 3 minutes hot: 1 cold). Contrast applications are more effective than heat or cold alone. Ensure sufficient temperature difference between hot and cold application (minimum 10 degrees C)  31 Indications/uses: Sub-acute injury/sub-acute inflammation and edema May be helpful in treating chronic conditions and injuries (where there is unresolved chronic edema) Tissue congestion (e.g. poor circulation, ischemia, tired achy muscles) Excellent for DOMS To minimize post treatment soreness: contrast treatments can be applied to an area that has been treated with specific techniques. Contrast hydrotherapy given as self-care can be very effective in reducing kickback pain. Pre-menstrual breast soreness and congestion, fibrous breast tissue Cautions: Any caution/C/I to heat or cold applications PVD/diabetes Compromised CV system (keep applications modified and local) Contrast modalities Contrast alternating towels/compresses (pp 178 – 180) Indications/uses: Chest – respiratory congestion/ lactation problems/congested breast tissue Head/throat – congestion from colds/sinus problems/stress Procedure: Two buckets (one containing hot/warm water, other containing cold/cool water and plenty of towels are needed. Follow the procedure for hot alternating towels (hot compresses) for 3 – 5 minutes (replacing towels that are cooling down with fresh ones thereby maintaining the heat to the area) Then switch to cold alternating towels (cold compresses) for around 1 minute (replenishing them when necessary). Repeat this sequence 3 – 5 times finishing with cold.  32 Contrast foot bath (pp 186 – 187) Indications/uses: Poor circulation/ischemic or tired achy legs Arthritis (non-acute) of feet, ankle and toe joints Eczema Sluggish metabolism Muscular fatigue/DOMS of lower legs/feet Sub-acute or chronic injuries of the feet/ankles and toes Chronic unresolved edema Pelvic congestion: in some patients, a contrast foot bath may work to reflexly relieve pelvic congestion Procedure: Two tubs (large enough to fit both legs up to proximal calf); one cold/cool, the other warm/hot Time: 3 – 5 minutes warm/10 – 60 seconds cold Repeat 3 times, finishing with cold Note: Contrast foot baths affect pelvic/systemic blood flow and it is strongly suggested that a patient has access to drinking water and a blanket over their shoulders during treatment; the pulse should be checked every 5 minutes (see full body heat treatments) Pat dry (do not friction to dry) and put warm socks on feet Contrast arm bath Indications/uses: Poor circulation/ischemic or tired, achy arms Arthritis (non-acute) of hands/wrists/fingers/elbows joints Exhaustion Eczema Muscular fatigue/DOMS of forearms, hands Sluggish metabolism Procedure: Two tubs (large enough to fit both arms up to the elbows); one cold/cool, the other warm/hot Time: 3 – 5 minutes warm/10 – 60 seconds cold Repeat 3 times, finishing with cold Pat dry (do not friction to dry)  33 Contrast showers/Contrast baths/whirlpools Please refer to full body treatments Regional contrast hydrotherapy Fomentation (deep moist heat modality e.g. thermophore/hydrocollator) followed by a cold/cryotherapy application (ice massage, gel pack, cold alternating towels) Excellent to “flush” a region that has just been treated with specific myofascial and massage techniques CASTOR OIL COMPRESS (pp 259 – 261) This is a compress made of wool flannel saturated with castor oil. A heat source is used to facilitate absorption of the oil. FYI: Castor oil (“Palma Christi”) “the Hand of Christ” Castor oil is a vegetable oil obtained from the castor bean. It is a triglyceride consisting mostly of Ricinoleic acid (which has anti-inflammatory effects). Castor oil penetrates deep into the skin due to its low molecular mass. Castor oil is added to many modern drugs Physiological effects Exceptionally healing Increases circulation locally (mainly when used with a heat source) Potentially regulates metabolism locally (when used regularly) Improves elimination in the GI tract/genito-urinary tract (when applied over abdomen) Improves organ function locally/reflexly Improves lymphatic flow locally/reflexly Can enhance detox of organs and tissues Recent studies suggest that castor oil can strengthen the immune system. Indications/uses Chronic muscle/tendon/ligament condition/injury Scar tissue (incisions from surgery/scar tissue from injury in chronic stage of tissue healing) Chronic arthritis Headaches Insomnia (applied over the abdomen)  34 Ovarian cysts/PCOD/menstrual cramps/menopausal symptoms (apply over lower abdomen) Digestive conditions (atonic constipation) Kidney/liver or gall bladder conditions May help with inflammatory bowel disease e.g. colitis/Crohns (between flare-ups) Skin disorders Sinusitis. Varicose veins (applied overnight) Cystic breast disease Procedure 1. Fold wool or soft cotton flannel into several layers to fit the area to be treated. 2. Liberally apply warmed oil to flannel (pack should be saturated but not dripping) Castor oil packs can be re-used. If re-using, apply more oil before use each time. 3. Place compress on saran wrap, lay these on heat source to allow pack to heat up 4. Apply compress to area with the oiled cloth against the skin and the plastic over top. 5. Secure with a cotton cover (towel, T-shirt, socks, gloves) and add the heat source. Pack is left on for 1 to 1 ½ hours if using a heat source. If not, pack can be left on overnight. 6. Remove castor oil pack and store in fridge wrapped in plastic. To remove the oil, wash skin with warm water and baking soda if available. Note: Although not as cost effective, castor oil can be applied directly to the treatment area and covered as above by saran wrap, a towel and a heat source. Paraffin wax may be used with castor oil when treating significant adhesions in an area. Note: Always use a high-quality, cold-pressed castor oil, available in health food stores. Commercially extracted castor oil contains hexane which is a carcinogen. Regular use is important: Castor oil packs should be used in a series: every day for 1 week, alternate days the second week and 3 days on/3 days off the third week and onwards.  35 HEATING COMPRESS (pp 181 – 183) Also called a cold double compress A towel is soaked in COLD or COOL water, wrung out and applied to the area to be treated in a SINGLE layer. It is COVERED with a dry towel, secured and LEFT ON THE BODY to heat up. Aim is to use the secondary response of the body to cold (active derivation) to increase circulation locally (in the treated area) and/or to increase blood flow in an area distant/deep to the treatment area (i.e. reflex effects): 1. Primary response of the body to the cold stimulus occurs (retrostasis) 2. The body will begin to re-warm the cooled area by shunting blood from other parts of the body towards the cooled treatment area. Blood flow via active derivation will be moved from the core or from a congested area in the body towards the cooled skin. 3. This will be seen in the treated area as active hyperemia. 4. The resulting heat from the derivative effect is trapped next to the skin under the dry towel leading to heat accumulation and a general heating effect. Colder temperatures and damper applications will create a stronger secondary response. Double layers of towel will be difficult for the body to heat up. A heating compress should start to warm up after 5 minutes and should be left on for at least 30 minutes. It can be left on overnight. Although heating compresses begin at cold temperatures, they should be used in chronic stages of healing. Physiological effects: Sedation and relaxation of the nervous system Increased local circulation (increased nutrition and oxygenation of local tissues) Decreased local muscle resting tension and pain (as blood flow increases locally) Decreases deep congestion by moving circulation towards skin surface (increases elimination of metabolic waste locally and reflexly) Increased local sweating (can lead to detoxification)  36 USES/INDICATIONS Throat/neck/head heating compress: laryngitis, sore throats, non-vascular headaches, chronic sinusitis Chest heating compress: chronic bronchitis Joint and/or muscle heating compress: e.g. gastrocnemius/soleus, forearms Abdominal heating compress: insomnia, low back pain, atonic constipation, Crohns/colitis (non- inflammatory stages), mild menstrual cramping (may increase menstrual flow) Sock heating compress: aborting head colds (draws Congestion from the head and/or chest and reflexly increases the circulation in the upper respiratory tracts and pelvic area. Insomnia. PROCEDURE: 1. Wet a cotton or linen towel with COLD OR COOL water and wring out very well: Treatment variables - The wetter the towel, the harder it will be for the body to re-warm it; - Thicker layers of towel or double layers will be harder for the body to re-warm; - A towel soaked in ice water will be a greater challenge to the body than a cool towel; - d/w: Additives can be used and will increase the stimulus 2. Place on area to be treated as a single layer and secure with pins if necessary  37 3. Some sources suggest placing a layer of plastic saran wrap or similar over the wet towel enhance the heating response 4. Cover completely with dry preferably wool flannel or synthetic material 5. Leave on for a minimum of 30 minutes or overnight 6. Check in with the patient to make sure compress is heating up.  38 HEAT REVIEW Warm: raises the target tissue temperature to 33 – 38 degrees C Hot: raises the target tissue temperature to above 38 degrees C Factors that influence heat’s effects: o Extent of rise in tissue temperature (temperature of application relative to temperature of treated tissue) o Size of treatment area o Duration of treatment o Amount of adipose in the treatment area – heat treatments used in hydrotherapy are superficial – tending to penetrate no more than 1cm. Passive derivation: Adding heat to the body causes the hypothalamus to trigger heat releasing mechanisms. These include increased superficial vasodilation which allows blood to move to the skin’s surface where heat escapes more easily. Superficial vasodilation will decrease the blood pressure in the warmed blood vessels. There is movement of blood from areas of higher hydrostatic pressure (congested areas or the core) towards the area of lower hydrostatic pressure in order to equalize pressure. The movement of blood from higher to lower pressure vessels is a passive process. Passive Hyperemia: An increased quantity of blood flowing through any part of the body (in response to heat) as shown by redness of the skin. INDICATIONS/USES of HEAT Chronic muscle spasms/ muscles with chronic elevated muscle resting tension Trigger points (use pre- and post-treatment) Chronic stages of healing, injury repair, inflammation e.g. chronic muscle strain, chronic tendonopathy, chronic dislocation, chronic scar tissue To warm a chilled patient, or before a very cold treatment Pre- or post-massage treatment Detoxification (full body treatments)/ to encourage sweating and increased circulation General stress and tension (full-body treatments are especially sedating and relaxing)  39 Please review the indications, uses, contraindications and physiological effects of: Hot foot bath, Hot arm bath, Hot alternating towels (hot compress) Fomentations (thermophore, hydrocollator, paraffin wax) FULL BODY HEAT TREATMENTS (Chapter 8 - pp 218 – 241) Physiological effects of heat (local, reflex and systemic effects) Vasodilation/ passive hyperemia (increased circulation) Increased metabolism, increased tissue temperature (increased local cellular activity) o Heat increases cellular metabolic rate and therefore the demand for oxygen and nutrients increases. As cells use up more oxygen and nutrients and release more CO2 tissue health and performance increases Heart rate increases: o Combination of increased tissue metabolism and increased peripheral blood flow (as a result of vasodilation) will increase demand on heart for oxygenated blood delivery to tissues. ▪ The heart has to work harder to provide the warmed tissues with more oxygen/nutrients ▪ This will increase systemic blood pressure/cardiac output initially which is of a concern for patients who have a compromised CV system ▪ Eventually, the application of heat will lead to the physiological effects of the relaxation response (decreased SNS firing) ▪ The relaxation response combined with continued peripheral vasodilation will counterbalance the initial rise in BP ▪ In patients with a healthy CV system and under normal circumstances prolonged full body heat treatments will eventually cause a decrease in systemic blood pressure FYI: Pulse rate rises 6 – 10 beats a minute for every 1 degree rise in core temperature.  40 Breathing rate increases (to eliminate more CO2 and increase uptake of O2) Increased sweat production leading to detoxification ▪ “Detoxification: decreased toxicity and increased function of organs of elimination” Sedation/relaxation with optimal temperatures Decreased muscle spasm, pain Direct effects on soft tissue structures: mediated through nervous system. Heat increases fascial excursion, decreases joint stiffness. Baths, whirlpool, steam cabinets (and saunas) procedures: 1. The PULSE RATE RULE should be used for every full body heat treatment 170 – age of patient is the SAFE MAXIMUM PULSE RATE o E.g. A 30 year old patient should not have a pulse rate above 140bpm (beats per minute) Pulse rate is recorded BEFORE, every 5 minutes during treatment (or more if there is a concern), AFTER treatment and 15 minutes AFTER treatment is complete. Pulse is recorded using CAROTID ARTERY 2. A COLD COMPRESS (cold alternating towels) MUST be used over the posterior neck or forehead to decrease the likelihood of a headache developing during the treatment. For some patients a cold compress over the heart may be used. 3. WATER is always provided, so that the patient can stay hydrated. SOP? 4. A salt glow/DRY brushing or cold mitten friction before the full body heat is recommended as it can help make the body more efficient in sweating during a full body treatment 5. Ideally the water level for a bath or whirlpool treatment is up to the neck but this can be adjusted if necessary to below the heart e.g. mild hypertension, pregnancy (with modifications for temp and depth, duration)  41 6. It is best to drain the water first before the patient gets out of the bath as this will gradually decrease the hydrostatic pressure on the body 7. Full body heat treatments should be followed by a COOL or COLD rinse (or an affusion). FYI: AFFUSIONS The affusion consists of single or multiple columns of water directed against a part of the body without any pressure. This was first introduced by Father Kneipp in his Hydrotherapy Institute. Affusions have a tonic effect and are applied with precise regulation of the direction of the water stream on the body Variables in affusions: o Mechanical: simple affusions are applied using a stream of water without pressure (water should be applied to the body so that it surrounds the body like a coat); affusions can be also applied to the body under pressure o Thermal: affusions can be applied at cold, warm or contrast temperatures (affusions after a full body heat treatment should be applied at a very cold temperature) o Area treated: affusions can be applied to a specific area of the body e.g. arm affusion, leg affusion, chest affusion or to the whole body. Full body cold affusion Cold water is applied to the body in a specific pattern without pressure using a hosepipe connected to a tap or a large mug. It is recommended that the water is wiped from the body with the patient’s hands rather than using a towel. Avoid using friction with a towel to dry the body. C/I’s: menstruation, bladder or kidney infection, over sensitivity to cold, unstable blood pressure, atherosclerosis, patient is chilled (plus refer to C/I list lecture 1) Procedure:  42 Posterior body: the patient comfortably stands and focuses on breathing as cold water is poured on the body: Begin at R foot: up lateral R leg to glutes, down medial R leg to foot Hose from L heel up L leg to glutes and then move to R hand; Hose from R hand up R arm to shoulder, move down spine on R side of back down to glutes and then over to L hand; Move up the L arm to L shoulder across back to R side and back to L side, hosing down L back along spine to gluteus and then down the L medial leg to foot. Anterior body R foot up lateral R leg to inguinal crease then down medial R leg to foot; R inguinal crease to R hand, up R arm to R shoulder then down the R side of the sternum to the R inguinal crease; Move to L hand, hosing up L arm to L shoulder, then across top of chest to R shoulder and back to L shoulder again; Move down the L side of the sternum. Hose the abdomen clockwise then down medial L leg to foot, finish with a circular affusion on the plantar surfaces of both feet. EPSOM SALTS BATH (p 232) Use of Epsom salts in a hot bath to increase circulation and promote detoxification through increased elimination Epsom salts -magnesium sulphate Temperature of an Epsom Salts bath should begin at 39 degrees C but is usually increased slowly to 44 degrees C Add 2 – 4 cups of Epsom Salts to a standard bath tub Ideal duration of treatment is 10 – 20 minutes  43 BATHS (p 232 – 234) Standard bath treatments: 36 - 38 degrees C Baths include arm baths, foot baths, sitz baths (term 4), half or partial baths and full baths. WHIRLPOOL (pp 240 – 241) Full or partial treatments using air jets in a tub of hot/warm, cold/cool or contrast water for 10 – 20 minutes STEAM CABINET (pp 226 – 228) Use of steam to increase core temperature of body, leading to profuse sweating, elimination and DETOXIFICATION The more saturated the air, the harder it is for the body to perspire initially. Detoxifies, increases circulation to skin, can help loosen mucus, decreases pain and muscle resting tension, increases core temperature Indications/uses: o Osteoarthritis o Rheumatoid arthritis (non-acute stages) o Kidney conditions (non-acute) o Detoxification to treat alcoholism, drug addiction, nicotine withdrawal o Colds FYI: A Turkish steam is a completely tiled room filled with steam; a Russian steam is set up so that the patient is lying supine in a room with their head out of the room  44 SAUNA (pronounced “sow-na) (pp 223 – 225) A wooden room heated with dry air to encourage an increase in sweating and elimination. The wooden sides of the sauna absorb the moisture from the heated air which results in easier sweating than the steam rooms. A sauna is ideally 2 hours in duration with only 30 minutes spent in the heat. Separate periods of heat-up, cool-down and rest intervals following the cold stimulus. Cold should intensify each time Types of sauna: o Wood burning o Electric o Infrared sauna Water is poured over the stones to increase the heat. The top bench is where the heat is the most intense. Beginners should take the lowest bench level or lie down. Cold compresses should be used. Sauna rule of etiquette: adapt the temperature to the “weakest” person