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Hydrotherapy

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Hydrotherapy may be defined as the use of water, in any of its forms, for the maintenance of health or the treatment of disease. although one of the oldest known therapies, it has received little attention from the research community, particularly recently. As one fo the ancient methods of treatment, hydrotherapy has been used to treat disease and injury by many different peoples, including the Egyptians, Assyrians, Persians, Greeks, Hebrews, Hindus, and Chinese. In the Rig veda, written about 1500 BC, we read that "water cures the fever's glow." Hippocrates used hydrotherapy extensively around 400 BC. In his writings concerning baths are some of the earliest dictums on the therapeutic uses of water.

Properties of Water

Water has several unique properties which contribute to its effectiveness as a therapeutic agent. It has an ability to store and transmit heat, which renders it most appropriate for treatment purposes. Water absorbs more heat for a given weight than any other substance--almost twice as much as alcohol or paraffin, 10 times more than copper or iron, and 30 times more than lead or gold. Water is also a good conductor of heat.

The solvent properties of water account for its usefulness in the most common of all hydrotherapy procedures, baths and showers. Water is commonly considered the universal solvent. Water's non-toxicity allows for its use both internally and externally, even in individuals who are extremely sensitive to their surroundings. Water also has the ability to change states within a narrow, easily obtainable temperature range. As ice, it is an effective cooling agent. In the liquid state, water may be applied as packs, baths, sprays, compresses, and douches at any desired pressure and temperature. As a vapor, it may be employed in vapor or steam baths or by inhalation.

Since the density of water is near that of the human body, it can be used as an exercise medium for patients with paralysis, inflammations, or atrophy. Upon immersion of the body in water, hydrostatic pressure is exerted upon the body surface, which has the effect of increasing venous and lymph flow from the periphery and increasing urine output. Water is also unique in that it is universally available, readily accessible, and applied with relatively simple and inexpensive equipment.

Physiological Effects

The physiological effects of hydrotherapy may be classified as thermal, mechanical, and chemical. Thermal effects are produced by the application of water at temperatures above or below that of the body. The greater the variation from body temperature, the greater the effect produced, other factors being equal. The mechanical effects are produced by the impact of water upon the surface of the body in the form of sprays, douches, frictions, whirlpools, etc. The chemical effects are produced when it is taken by mouth or used to irrigate a body cavity, such as the large colon. The most commonly utilized effect, therapeutically, is the thermal one.

Heat may be transferred from one object to another in several different ways, including conduction, convection, or conversion. In hydrotherapy, the heating and cooling effects are produced by conduction of heat from the water to the body. The contact of water with the body is accomplished by means of baths, showers, sprays, packs, compresses, etc.

The primary variable of concern is temperature, both of the water and of the patient. The temperature of the human body in a state of health is considered to be normal at 98.6° F orally, although it varies throughout the day from a low of near 97° F between 3 and 6 a.m. to a high of over 99° F around 6 p.m. These variations are important to consider when evaluating, an individual prior to a hydrotherapy application. There is also a wide range of temperature variation within the healthy human body.

Body temperature is also a reflection of other factors, such as exercise, fasting, ovulation, etc. In an infant, the temperature may be elevated by 1-3° F during a prolonged crying spell.

During a fever, the temperature is elevated due to any of several factors, including:

· infection

· tissue destruction

· malignancy

· foreign proteins in the blood

· dehydration

· hormonal imbalances

· muscular or chemical activity

Proper evaluation of the degree and cause of a fever is necessary prior to hydrotherapy treatments.

When we consider water temperature, the terms "hot" and "cold" are related to body temperature. The range of temperatures useful in hydrotherapy applications varies from very cold to very hot. Deep well water is near 53° F. Cold tap water varies in temperature throughout the year depending on location and the depth of the pipes and other exposures to the environment. During the winter it may be as low as 40° F and in the summer as high as 60° F. This temperature variation may be a significant factor in hydrotherapy treatments; therefore, it is advisable to be aware of your water temperature when using hydrotherapy techniques.

Effects of Cold Applications

Cold applications may be made by means of ice, cold water, or cold air, or by the evaporation of water or other liquids from the surface of the body. Although the applications may vary, the principles and effects remain consistent. The primary or direct effect of cold applications is depressant in nature, leading to a decrease in function, either locally or systemically, depending on the application. The longer and colder the application, the longer and more intense will be the depressant effect. However, as the body responds to the cold application, there is a return to normal function which may lead to a state of increased activity. This is known as the secondary, or indirect, effect of cold, also termed the "reaction." If the cold application is a short one, the reaction follows quickly, its intensity reflecting the intensity (i.e. coldness) of the application. The secondary effect, or reaction, occurs only when the body has the vitality to respond to the cold, either following its removal from the body, in such applications as showers, sprays, baths, etc., or after the body has warmed the application, in such cases as cold compresses or packs. In general, the colder the application, the greater the reaction. Many hydrotherapy techniques are directed at producing the reaction to the cold application.

Effects of Hot Applications

Heat may be applied to the body in a variety of ways, including hot packs, fomentations, steam, hot air, baths, showers, etc. All hot applications produce definite physiological responses which are attempts of the body to eliminate heat in order to prevent a rise in local and systemic temperatures. The effects produced by hot applications depend on the mode, temperature, and duration of the application and the condition of the patient. Water at 98° F or above is generally perceived as hot and over 104° F it is considered to be very hot. At 120° F, an immersion bath becomes unendurable, although small areas of the body, such as the hand, may be conditioned to endure a temperature 10-15° higher for short periods. The mucous membranes, unlike the skin may endure temperatures as high as 135° F, which accounts for our ability to drink very hot liquids, such as tea or coffee. Hot air may be tolerated by many individuals for fairly long periods, such as in a sauna, in which the temperature may reach as high as 200° F. Although exposure to the high temperatures of hot tubs and saunas has become quite popular in recent years, repeated and prolonged use may act to weaken the individual, unless counteracted by frequent cold applications, such as showers or ablutions.

Blood Movement with Hydrotherapy

In order to promote healing, either locally or systemically, it is important to maximize circulation of well-oxygenated, nutrient-rich, toxin-low blood. Hydrotherapy techniques are one of the most effective means of accomplishing this, if used in conjunction with proper levels of activity, optimal nutritional intake, and adequate detoxification.

There are four basic modifications of blood movement within the body:

* increased rate of blood flow through an organ or area of the body

* decreased rate of blood flow through an organ or area of the body

* increased volume of blood in an anemic area

* decreased volume of blood in a congested area.

In order to accomplish these modifications, there are five relevant physiological principles:

* revulsive effect

* derivative effect

* spinal cord reflex

* collateral circulation

* arterial trunk reflex.

Revulsive Effect

The revulsive effect provides a means of increasing the rate of blood flow through an organ or other body part, such as an extremity. The most effective means of accomplishing this is by using alternating hot/cold either as compresses, baths, showers, sprays, etc. Local, alternating, hot and cold applications produce marked stimulation of local circulation. It has been shown that a 30 minute contrast bath produces a 95% increase in local blood flow when the lower extremities alone are immersed. When all four extremities are immersed at the same time, there is a 100% increase in blood flow in the upper extremities and a 70% increase in the lower extremities.

Several studies have researched the optimal treatment times for revulsive effects. It was generally found that either 6 minutes of hot application and 4 of cold, or 4 minutes of hot and 1 minute of cold to be optimal. Another study found that 3 minutes of hot followed by 30-60 seconds of cold, provides satisfactory clinical results. Due to the variations in procedures and locales, it is best for practitioners to determine their own ideals, based on their observations of clinical results. Basically, the cold application need only be long enough to produce vasoconstriction, and this can be shown to occur in as short a period as 20 seconds.

Repetition of applications is another important variable to be considered when applying revulsive treatments. A series of three hot/cold applications seems to be practical. Most individuals show a decreasing secondary reaction to repeated applications of cold. Due to the increased blood flow within an area, the revulsive effect is ideal for treating situations presenting primarily as congestion. An example of this effect is the use of alternating hot/cold compresses over the face for sinus congestion. As a powerful decongestant, the revulsive effect also acts as an analgesic for pain resulting from congestion. Because of its marked stimulation of local circulation, the revulsive treatment is an exceptionally effective hydrotherapeutic procedure.

Derivative Effect

The derivative effect may be considered the opposite of the revulsive effect. Its primary intent is to alter the volume of blood in an organ or area of the body. This effect is best obtained by the prolonged use of either cold or heat depending on whether one wants to draw blood into an area (hot application) or to drive blood out of an area (cold application). An example of the derivative effect would be the prolonged application of heat to the feet, as with a hot foot bath, in order to decrease congestion in the head. This form of treatment may be quite successful for certain forms of congestive headaches. In general, the greater the area of the body exposed to the application, the more extreme the temperature, and the longer the application, the greater will be the effect.

Spinal Reflex Effect

The spinal reflex effect provides a means of affecting a distant area of the body through a local application. A sufficiently intense local application of hot or cold not only affects the immediate skin area, but also causes remote physiological changes, mediated through spinal reflex arcs. These effects have been carefully observed over many years, and have led to a mapping which correlates each surface area with its corresponding internal area and/or organ. Most texts on hydrotherapy contain such a diagram.

Studies have found changes in blood flow in the opposite arm and hand when one arm and hand were placed in hot or cold water. Another observed that when cold was applied to the epigastrium, there was a decrease in tone of the stomach, with a quieting of the pylorus. Heat at 50° C applied to the epigastrium produced increased tone in a relaxed stomach and decreased tone in a contracted stomach. Another study demonstrated that esophageal function could be influenced by irritation of the skin over the sternum. Others have shown reflex relationships between the skin of the abdominal wall and the colon. There is a relationship between the lungs and the skin of the chest wall as well.

One study found externally applied heat not only decreased intestinal blood flow, but also diminished intestinal motility and decreased acid secretion in the stomach, while cold had the opposite effect. This is an example of a contrary effect in which the reflex effect is not the same as that observed in the local reflex skin area, i.e. local heat decreases, rather than increases, intestinal blood flow as one might expect. Prolonged cold has the opposite effect.

Collateral Circulation Effect

The collateral circulation effect may be considered as a special case of the derivative effect. In general use, the derivative effect involves blood volume changes form one area of the body to another, as previously discussed. The collateral circulation effect, on the other hand, more specifically considers the local circulatory effects on deep (rather than superficial) collateral branches of the same artery. If we consider the circulatory patterns of a large body part, such as the thigh, we see that both superficial and deep areas are supplied by the same artery. A hot application to this area will dilate the surface vessels, drawing blood to the superficial areas and concurrently decreasing the blood flow to the deep areas. A cold application will cause the opposite effect. Local compresses and fomentations are the most commonly used techniques to affect collateral circulatory changes.

Arterial Trunk Reflex

The arterial trunk reflex is a special case of general reflex effects. It has been observed that prolonged cold applied over the trunk of an artery produces contraction of the artery and its branches distal to the application. Prolonged hot applications have the opposite effect of producing dilation in the distal arterial bed. An example of this effect would be the application of prolonged cold to the area of the femoral artery in the groin in order to decrease blood flow in a foot or ankle that had sustained an acute injury which resulted in either internal or external hemorrhage. Following the acute phase, prolonged hot applications might be used in like manner in order to increase circulation and speed healing of the injured part.

Hydrotherapy Techniques

The variety and ways in which water may be applied to the human body therapeutically is only limited by the imagination of the practitioner. To successfully use hydrotherapy, one must be familiar enough with the procedure to use it in an efficient and competent manner. Although the equipment required for these techniques is quite simple, it is important that it be clean, easily available, and maintained properly. Care for the comfort and confidence of the patient will greatly increase the effectiveness of the treatments.

Compresses

There are three basic types of compresses: hot, cold, and alternating hot and cold. They are each applied using cloth, or other compress material, which is wrung out to the desired amount of moisture, and then applied to any surface of the body. A single compress consists only of layers of the wet material, whereas a double compress is one in which the wet cloth is completely covered by dry material, usually wool, which acts to prevent cooling by evaporation or heat loss. This allows the body, in the case of a cold double compress, to warm the area, thereby producing a secondary reaction to the cold. Compresses are commonly referred to by the area of the body they are applied to, such as the throat, head, joint, trunk, or limb.

Cold Compress

A cold compress consists of a cloth wrung from cold or ice water and then applied to the body. The water may contain solutes such as NaCl, baking soda, Epsom salts, boric acid, or cider vinegar. Herbs may also be used to create a more specific effect from the compress. ; Some commonly used herbs are hayflower, oatstraw, and fenugreek made as teas into which the compress cloths are dipped.

The cold single compress has primarily a vasoconstrictive effect, both locally and distally. Due to this effect, it may be used to prevent edema following injury, inhibit inflammation, and relieve pain due to congestion. It may also be used to reduce body temperature when applied over a large area of the body. These compresses are renewed frequently (every 1-5 minutes) in order to maintain the primary cold effect. The temperature of a cold compress will depend on the specific problem being treated, as well as the state of health of the patient. In general, the colder the application, the shorter the period of application. Cold compresses should not be used locally in a person who is chilly or who has pleurisy, sinusitis, or acute asthma, as these conditions may be seriously aggravated.

The cold double compress, also known as the heating compress, consists of a cold compress covered completely by several layers of dry material such as flannel or wool. It is allowed to remain on until warmed by the body. The layers of dry material prevent heat loss by evaporation, thereby permitting accumulation of heat and creating a general heating effect. Cold double compresses are used most commonly in upper respiratory infections, such as sore throats, bronchitis, influenza, pneumonia, and swollen lymph glands in the neck. They may also be applied over the trunk or abdomen, genital area, joints, limbs or feet.

The primary effect of cold double compresses is to increase the local circulation, thereby providing for increased nutrition and oxygenation of the tissues, and increased elimination of metabolic waste from the area. As with cold single compresses, the temperature of the initial application depends on the state of the patient and the condition being treated. In general, the colder the application, the stronger will be the secondary reaction to the cold. As weak and debilitated patients are unable to generate a strong secondary reaction cool rather than cold application may be indicated. The same general precautions as for a cold single compress should be followed.

Hot Compress

The hot compress is a prolonged application of moist heat, generally to a local area of the body. The fomentation is a special case of a hot compress, which provides prolonged exposure at a higher temperature. Hot compresses and fomentations have several therapeutic effects. In many situations they may create an analgesic effect, thereby decreasing pain. They are generally more effective locally for pain resulting from spasm than for pain due to congestion. They also create a derivative effect, which may be used to increase blood flow to the periphery, thereby decreasing internal congestion. By applying short, intensely hot compresses, a stimulation effect may be obtained. This may be used to increase blood flow to a part, to stimulate certain organ functions, to decrease others, and to produce tissue warming and relaxation. Mildly hot compresses may be beneficial for their sedative effects in treating insomnia, nervous tension, and mild muscular spasms.

Fairly hot compresses may be applied directly to the skin surface, with care taken to not burn or startle the patient. As stated previously, hot applications are contraindicated on the extremities of diabetic individuals. When treating the elderly, or those with impaired neurological function, edema, or decreased circulation, special cautions must also be taken. Fomentations are commonly applied at temperatures which are not tolerated directly on the skin, and therefore must be applied over a bath towel placed on the area.

Baths

Baths are full or partial immersions of the body into water of various temperatures. Bath waters may contain additional substances such as salts, minerals, herbs, or medications and may be in an agitated state, as with a whirlpool.

Hot Full Immersion Baths

These are given within a temperature range of 100-106° F for up to 20 minutes. They are indicated as home treatment for rheumatoid arthritis, to aid in relief of muscular spasms, for cleansing the body, and to induce sweating. Given for brief periods, they may help to reduce fevers by creating peripheral vasodilation, thereby promoting an increased heat loss. In most instances they are best followed by a brief cool bath, shower, or spray. Prolonged hot tub baths are never appropriate in the very old or very young, weak or anemic persons, individuals with severe organic disease, or in anyone with a tendency to hemorrhage.

Neutral Bath

The neutral bath is a full immersion bath given at the average temperature of the skin, 92-95° F, in which the recipient has neither the sensation of being warmed nor that of being cooled. A minor variation in temperature of as little as 2° F may create a totally different therapeutic effect. As the ideal temperature is dependent on the patient's condition and reaction to the water, it is often better to use their sensation, rather than a thermometer, as a guide to adjusting the temperature. The duration of a neutral bath may vary from 15 minutes to 4 hours. If the bath lasts longer than 20 minutes, it will be necessary to add warm water to maintain the temperature.

The primary effect of a neutral bath is to create a state of decreased excitation. This sedative effect, similar to that produced in deprivation tanks, calms the nervous system. A second effect is activation of the kidneys, creating increased urinary output due to the absorption of water into the body during periods of prolonged immersion. It is aided by the neutral temperature, which provides no stimulus for water loss through sweating. Nephrotic patients display increased phosphate excretion following prolonged immersion; therefore, they warrant special care when given prolonged immersion baths. Lastly, the neutral bath causes a decrease in the surface temperature of the body due to the lack of the normal heat-producing stimulus of cool air on the skin. AS a result, the surface may be cooled as much as 6° F, creating a tendency to chilling following the bath. This effect necessitates special care in keeping the patient warm. When prescribed for home treatment, a neutral bath is best taken just before getting into bed, in order to avoid chilling.

Therapeutically, neutral baths are most commonly used for their calmative effects in cases of insomnia, anxiety, nervous irritability, exhaustion, or chronic pain. By increasing kidney output, they may be appropriate in detoxification programs for substances such as alcohol, tobacco, or coffee, or as an adjunct treatment for peripheral edema. They also serve a valuable role in the control of fevers in individuals who would not be able to react to stronger measures. These patients would include the very young, very old, feeble, or exhausted. Start the baths at about 98° F and lower the temperature slowly over a period of 5-10 minutes to 92-93° F, until the desired body temperature is reached.

Sitz Bath

The sitz bath is a partial immersion bath of the pelvic region. It is more easily given in a specially constructed tub but may also be effectively done in a regular bath tub. Often it is taken with the feet immersed in a separate tub of hot water before or during the bath. A sitz bath may be taken hot, neutral, cold, or contrast hot and cold.

The hot sitz bath is generally taken for 3-10 minutes at 105-115° F. The primary effect is analgesic. It may be helpful in cramps of the uterus or ureters, pain from hemorrhoids, ovaries or testicles, sciatica, urinary retention, and after cystoscopy or hemorrhoidectomy. It is followed by cool sponging or effusion of the area. Hot sitz baths are not indicated in cases of acute inflammation, but may be appropriate for chronic PID. Hot applications to the pelvis are also contraindicated during menses in most instances. The hot sitz bath is best taken with a hot foot bath at 110-115° F.

Neutral sitz baths are more appropriate for situations of acute inflammation, such as cystitis and acute pelvic inflammatory disease (PID). They are given at 92-95° F for between 15 minutes and 2 hours. It is necessary to provide adequate coverings during this period to avoid chilling. Neutral sitz baths may also be very effective for pruritis of the anus or vulva. Appropriate herbs, salts or other medications may be added to the water to optimize the treatment.

The cold sitz bath is given immediately following a warm-to-hot sitz bath of 1-3 minutes, and lasts (at a temperature of 55-75° F) from 30 seconds to 8 minutes. It is important to ensure that the water level of the hot bath on the body is at least 1 inch above the level of the cold water. This insures adequate warming of the area, thereby preventing chilling. Friction rubs to the hips during the cold sitz bath promote an increased reaction. The cold sitz bath is used mainly for its tonifying effects. It may be used for subinvolution of the uterus, menorrhagia, atonic constipation, enuresis, atony of the bladder, and chronic prostatic congestion. Since it increases the tone of the smooth muscles of the uterus, bladder, and colon, it lessens the tendency to bleed from the uterus, the lower bowel and rectum.

Contrast sitz baths are given in groups of three, i.e. three alterations of hot to cold. Two separate tubs are necessary to facilitate this process. The hot is at 105-115° F, the cold at 55-85° F, with the temperatures again dependent on the condition being treated and the strength of the patient. A standard treatment would be 3 minutes hot and 30 seconds cold. The water level in the hot tub is set 1 inch higher than in the cold. Adequate draping is necessary to prevent chilling. As with all hydrotherapy treatments, one always finishes with the cold. The contrast sitz bath increases pelvic circulation and tone of the smooth muscles of the region. It is indicated in chronic PID, chronic prostatitis, atonic constipation, and other atonic conditions of the pelvis. The strong revulsive effect created increases the blood flow in the pelvic region dramatically.

Cold Friction Rubs and Ablutions

Cold friction rubs, or ablutions, consist of fractioning the body in a predetermined sequence with cold water. They differ from spongings in that they are more tonifying and are done more vigorously with rougher materials. A woolen bath mitt works well, but if this is not available, a coarse washcloth or loofa may also be used.

A whole body ablution is carried out with the patient lying supine, covered completely and not chilly. Using cool to cold water the therapist dips the mitt into the water and vigorously frictions a portion of the body. Depending on the cooling effect desired, the mitt may either be saturated or wrung dry prior to the fractioning. The body part is fractioned until reddening occurs. If the patient is weak, it is best to dry the areas as you proceed using a coarse dry towel. If the patient is strong and vigorous, one can wait and dry them at the end of the treatment. One sequence for an ablution treatment would be, with the patient supine, to proceed from the chest to the arms, and then the legs, then, turning the patient over, to do the back of the legs and feet, the buttocks, and finally the back. Only that part being fricitoned is exposed at any time. The primary effect of a cold ablution is tonic. Therefore, it may be used for any condition where a tonifying treatment is desired, such as fatigue following illness or surgery or after hot applications, such as saunas, whirlpools, or hot baths. It is an excellent prophylactic hydrotherapy technique when used regularly along with saunas, hot tubs, and massage.

Wet Sheet Pack

The wet sheet pack is one of the most useful of all hydrotherapy procedures. It may be done either in the office or as a home treatment, if adequate direction is provided. It requires from 1-3 hours, depending on the condition of the patient. The technique is common to most schools of hydrotherapy. It is important to understand the process completely before using this treatment:

1. Using either a bed or treatment table, place two wool blankets lengthwise on the table with a small pillow at the head. The blankets must be large enough to cover the person being treated. If wool is not available, acrylic is the next best choice.

2. The patient must be warm before the pack is applied. If not, they may be warmed by a hot bath or shower, dry blanket pack, diathermy over the back, or any other appropriate technique.

3. Once the patient is ready, a clean white cotton sheet (equal in length to the height of the patient) is wrung as dry as possible after being soaked in cold water. It is much easier if two people are available to wring out the sheet. The sheet is opened and placed lengthwise along the table with equal amounts draped over each side of the table. The sheet should be 1-2 inches below the height of the blankets.

4. The patient now removes all clothing and lies on the wet sheet with shoulders 4 inches below the top of the sheet. Both arms are raised while the attendants quickly wrap one side of the sheet around the body, tucking it in on the opposite side, and carefully molding it to the body. Below the hips, the sheet is wrapped around the leg on the same side.

5. The arms are now lowered and the opposite side of the sheet is drawn over the body, covering both arms. It also wraps the opposite leg. The wet sheet is quickly smoothed over the body to ensure complete contact and is tucked in around the feet. As this is a shocking experience, it should be performed quickly and efficiently.

6. At this point, the blankets are quickly pulled over the body and tucked in firmly, ensuring there are no drafts around the neck or the feet. Additional blandest may be laid over the patient and tucked in as appropriate. A stoking cap may be pulled over the head to increase the heating effect.

While the patient is in the pack, it is necessary to have someone nearby at all times. Sudden attacks of claustrophobia in some individuals can create extreme anxiety. Should this occur, first remove the sheet from the feet, as this may allow enough movement to allay the attack. If this is unsuccessful, it may be necessary to stop the treatment. Providing hot teas is very helpful throughout the treatment. If the patient complains of chilliness, add blankets, place a hot water bottle to the feet, or provide warm drinks. The wet sheet pack proceeds through four stages: tonic or cooling, neutral, heating, and eliminative. Depending on the desired effect, the therapist may wish to prolong any one specific stage:

* Tonic stage. This stage may last from 2 to 15 minutes and is finished when the patient no longer perceives the sheet as being cold. This phase is intensely alterative to the body, due to the intense thermic reaction induced. The length of this stage is directly dependent on the amount of water left in the sheet. For weak or exhausted patients, the sheet should be wrung out as completely as possible. For young, strong individuals for whom a more tonifying treatment is desired, more water may be left in the sheet.

* Neutral stage. Once the sheet reaches body temperature, the person no longer feels cold. At this time, the neutral phase begins. It may last from 15 minutes, to an hour or longer, depending on the vitality of the patient. During this phase, there is a sense of calm which is similar to that experienced during a neutral bath. Very often the patient will fall asleep during this phase. This stage is indicated in cases of insomnia, anxiety, and delirium. In order to prolong the neutral phase, provide only adequate covering to prevent the patient feeling cool. Greater amounts of blankets will trap more heat and the neutral phase will finish sooner.

* Heating stage. As heat accumulates beneath the blankets, the patient will gradually sense the warming, and eventually begin to show light perspiration on the forehead. The time between the patient feeling warm and the beginning of perspiration is known as the heating phase. This may last from 15 minutes to 1 hour.

* Elimination stage. The final stage begins when body begins to perspire. In a febrile patient this stage will be reached sooner. This stage is especially beneficial for those patients in a detoxification process such as from alcohol, tobacco, coffee, or other toxins. It may also be used with acute infections, such as colds, flu or bronchitis. Certain skin conditions, such as jaundice, may also benefit from this stage, as well as acute inflammatory conditions, such as arthritis.

During the elimination phase, it is important to provide adequate fluid to the patient. Herb teas, used for either their diaphoretic or therapeutic effects, are most appropriate. This phase may last up to 1 hour. The treatment should be ended quickly if the patient begins to feel chilled or becomes uncomfortable. The treatment is ended quickly removing the patient from the pack, fractioning the skin briskly with a dry towel, and having the patient dress. As this is often an intensive treatment, it should be followed with rest or appropriate activity. Lying in a warm room for an hour is an ideal follow-up to this treatment. If done at home, it is best done in the evening, just prior to retiring.

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