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Massage Therapy
Continuing Education
HYDROTHERAPY
NCBTMB Provider #451897-12
www.nirvanamassagecenational.com
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HYDROTHERAPY
2 CEUs
Content copyright 2012, 2013 Nirvana Massage CE National, LLC
All rights reserved. All trademarks and/or copyrights are in effect.
This course is for informational and continuing education purposes
only.
All information in this course has been thoroughly researched and
referenced. It is accepted as factual at the time of publication. Nirvana
Massage CE National, LLC disclaims responsibility for any contradictory
information.
It is the responsibility of the massage therapist and/or medical professional to
determine what precautions to take in the particular field and to abide by
their scope of practice.
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COURSE OUTLINE
Chapter One: What is Hydrotherapy?
Chapter Two: Modalities
Chapter Three: Hydrotherapy in the Massage Practice
Chapter Four: Cautions and Contraindications
References
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COURSE BEGINS NOW
Chapter One
What Is Hydrotherapy?
Definition
Generally speaking, hydrotherapy is the use of water to treat disease.i The
water can be in any form- liquid, vapor, or ice. Temperature often plays a
role in hydrotherapy, as does water pressure.ii
History
The roots of hydrotherapy practice (also known as hydropathy) reach far
back into history. The ancient civilizations of Rome, Greece, China and
Japan all used hydrotherapy.iii The ancient Celts dedicated a natural spring
to their goddess Sulis, and when the Romans conquered Britain in 43 A.D.
they built a hydrotherapy bath over the spring and named it Aquae Sulis.iv
The site is now known as Bath, and was made famous by the author Jane
Austen, who sent several of her characters there for water treatments.v
The Austrian farmer Vincenz Priessnitz helped make hydrotherapy a more
acceptable method of treating illness. vi While working on his father’s farm,
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Priessnitz witnessed a deer immerse its wounded leg in a stream until it was
healed.vii He then began using cold-water therapy to treat his own injuries
and illnesses.viii Priessnitz continued developing his practice with his
neighbors, until his fame spread to the royal Austrian house. In 1826, Priessnitz
healed Anton Victor, the Emperor’s brother.ix His friends in high places saved
him from arrest and ridicule from members of the medical establishment who
looked down on his treatments. x Priessnitz went on to establish a 30-room spa
where he treated several more members of various royal houses, as well as
the famous author Nickolai Gogol.xi
Father Sebastian Kneipp is another foundational character in the spread of
hydrotherapy. Kneipp was diagnosed with tuberculosis as a young man. He
treated himself by taking baths in the cold water of the Danube River.xii His
tuberculosis was cured, and Kneipp spent much of the rest of his life
experimenting with hydrotherapy and opening hydrotherapy clinics. His
book My Water Cure was published in 1886 and started a worldwide revival
in interest in the use of water as a medicinal treatment.xiii
Hydrotherapy continued to grow throughout Europe in the 19th century. Over
600 Turkish baths opened in the later half of the 1800’s. There were even
Turkish baths on the Titanic, though their use was limited to first-class
passengers.xiv The Titanic’s Turkish baths featured hot, mild, and cool
temperature rooms, steam saunas, and shampooing rooms.xv
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The first Turkish bath didn’t open in the United States until 1863; however,
other hydrotherapy institutions had been opening throughout the country
before then.xvi Joel Shaw is said to have opened the first hydrotherapy clinic
in 1843 in New York.xvii There were over 200 clinics in the United States by the
late 1860’s, most of which were located in the northeast. xviii The United States
was also home to the Water Cure Journal, a popular monthly founded in
1844 by David Campbell.xix
President Theodore Roosevelt would eventually purchase a resort in Warm
Springs, Georgia, in pursuit of a hydrotherapy treatment for polio. Roosevelt
valued how much easier it was to move his paralyzed legs underwater, and
he went on to develop hydrotherapy-based exercises for polio patients.xx His
enthusiasm for hydrotherapy led to the foundation of the Roosevelt Warm
Springs Institute for Rehabilitation. xxi
Medical Uses
Since its most ancient inceptions, hydrotherapy has been used to treat minor
aches and pains, especially of the joints. xxii In 1891, the famous American
author Mark Twain began frequenting the springs of Aix-les-Bains in order to
treat his rheumatism. He found the springs, “so enjoyable that if I hadn’t had
a disease I would have borrowed one just to have a pretext for going on.”xxiii
It is still used today to ease the pain of arthritis.
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Hydrotherapy was also used throughout the 1800’s to treat a variety of minor
physical injuries by increasing circulation to the area, removing toxins and
preventing infection.xxiv Between 1860 and 1870, hydrotherapy was used to
treat abdominal typhus. xxv The treatment has also been used to treat
alcoholism; in fact, Alcoholics Anonymous co-founder Bill Wilson underwent
hydrotherapy for the condition in the ‘30’s.xxvi
More recently, the medical community has used hydrotherapy to treat
chemical burns, spinal injuries, psychiatric conditions, and localized pain in
the hips or back.xxvii It also has uses in physical therapy, where the water’s
ability to be a vehicle for hot or cold can be used to treat injuries.xxviii There
has been ongoing study on the effect of hydrotherapy in treating balance
issues and falls in the elderly, with patients who have undergone the
treatment showing a marked improvement in their balance.xxix
Modern Benefits
Hydrotherapy can have many benefits when used in conjunction with
massage therapy. For example, warm water hydrotherapy causes
relaxation, which eases waste removal and elimination. It also decreases
inflammation. Warm water baths can also be paired with aromatherapy
treatments.xxx
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Hydrotherapy can also assist in the following: improving digestive health,
boosting the immune system, easing of tight muscles and controlling the
production of stress hormones.xxxi It increases the body’s production of
endogenous opioid peptides such as endorphins, which increases a feeling
of well being.xxxii
The combination of stress relief and increased blood circulation associated
with hydrotherapy can also be used as an alternative treatment for infertility
in both men and women.xxxiii Dry hydrotherapy, which utilizes a high-pressure,
warm water massage table, can increase range of motion by combining
warming water with pressure-point therapy and kneading massage.xxxiv
Why Hydrotherapy Works
The main vehicle of hydrotherapy’s efficacy is its ability to hold a stable
temperature. The therapist can use either hot or cold water to achieve the
desired therapy. For example, warm water relaxes the blood vessels and
increases circulation. This leads to increased removal of waste from the
bloodstream, as well as an increased supply of oxygen to injured or sore
areas.xxxv
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The hydrostatic effect of immersion water therapy also has a calming effect
that can quiet nerves and release tight muscles.xxxvi The application of water
pressure can also be used to help release tight muscles. Cold-water therapy
is invigorating and causes the constriction of outer blood vessels, so blood is
directed toward the internal organs.xxxvii This can help treat inflammation.xxxviii
Scope of Practice
Massage therapists not trained in hydrotherapy should not add it to their
practice’s menu. In compliance with the NCBTMB Code of Ethics IV, always
acknowledge the limits of your practice and refer patients to the
appropriate medical professional, if necessary. Do not allow patients to
believe that your certification included training in hydrotherapy if it did not.
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Chapter Two: Modalities
Packings
A packing consists of a wet linen sheet wrapped around the area on which
you want to work (or the whole body). Dry linen or cotton sheets are then
wrapped over the wet one, with the additional, optional use of a
mackintosh. A looser packing will have a cooling effect as the water from
the wet sheet evaporates. The packing is left on for one hour or less, or you
can re-wet the sheet and continue the therapy for a longer duration.xxxix
Packs can be made warm by soaking the sheet in a warm herbal infusion
before wrapping the affected area. For increased coolness in cold packs,
place ice packs between the wet sheet and the outer wrappings.xl
Hot Air and Steam Baths
Saunas or Turkish baths utilize steam and heat to increase circulation and the
elimination of toxins through the skin through sweating.xli They are also used
to increase respiratory health.xlii
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Steam baths also stimulate the immune system and can assist in weight loss.
Sessions in a sauna or steam bath may be useful in massage therapy by
helping the client relax, though sessions should be limited to 20 minutes. Do
not let clients with heart conditions use the sauna or steam bath.xliii The
sauna is generally kept at 50 to 100 degrees C to induce these effects.
General Baths and Local Baths
A general bath is the immersion of the entire body in a tub of water. The tub
can be a whirlpool tub, a jetted tub, or a traditional hot tub. Therapists can
use water pressure in hot tubs to direct up to 22 pounds per square inch to
aching muscles in order to relieve tension. For arthritis sufferers, jetted hot
tubs may be especially helpful to relieve pain during the winter.xliv The New
England Journal of Medicine has found that daily immersion in a hot tub can
help stabilize blood sugar in diabetics.xlv Immersion in a warm bath can also
help those who have trouble sleeping, according to the National Sleep
Foundation. xlvi
Therapists can add various items to the water to increase the efficacy of the
therapy. For example, Epsom salts can help remove toxins, relax the
muscles, and reduce swelling when added to a warm bath.xlvii Sea salts
added to warm baths exfoliate the skin and can ease irritation.xlviii Carbon
dioxide bubbles added to a bath can reduce blood pressure and improve
circulation.xlix You can also add aromatic essential oils, herbs, or essences.l
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Always clean a bath according to the manufacturer’s instructions between
clients, or after using any additive.
A local bath involves immersion of just one part of the body, using the same
principles of water temperature you would use for a general bath. Therapists
can also alternate hot and cold water to stimulate blood flow and reduce
inflammation.li When the water used is warm or hot, the treatment is also
known as hydrothermal therapy.
Dry Hydrotherapy
Dry hydrotherapy is the use of a massage table or chair that has contained
and pressurized warm water. The therapy is also known as aqua-massage or
hydro-massage.lii The patient is separated from the water source by a
waterproof barrier, such as vinyl. The warm water can produce a kneading
or pumping sensation that stimulates circulation, relieves stress, increases
lymphatic drainage, and lowers blood pressure.liii
Dry hydrotherapy offers the benefits of traditional hydrotherapy without the
maintenance required by tubs or the risk of falls.liv Always check with your
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state and local licensing authority before allowing an unlicensed employee
to operate a dry massage table or chair.
Aquatic Bodywork
Aquatic bodywork combines hydrotherapy and massage. One variation of
aquatic bodywork is known as “watsu.” This therapy is performed in warm
water (around 35 degrees C) and includes a combination of shiatsu and
meridian/pressure point work, stretching, and gentle movement. lv The warm
water used in aquatic bodywork facilitates muscle relaxation and supports
the weight of the client. The feeling of weightlessness also contributes to
relaxation.lvi
During aquatic bodywork, the therapist supports the weight of the client in
various poses. Unlike traditional massage therapy, aquatic bodywork
requires the therapist to be touching the client at all times. This may make
those who are new to massage uncomfortable, so be sure to explain the
process thoroughly to clients who express interest.lvii Offer earplugs to clients
who may be uncomfortable with having water in their ears. Some aquatic
bodywork therapists attach floats to the knees of their clients.lviii Require that
clients wear a bathing suit in order to stay compliant with NCBTMB draping
requirements.
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Traction
Hydrotherapy traction gently stretches the spine and connective tissues. The
client is immersed in warm water and held in place by the neck, chest, or
hips. As the client breaths, the up-and-down motion of the body weight
stretches the muscles and spine.lix This can relieve pain or pressure in the
back.lx
Chapter Three: Hydrotherapy in the Massage Practice
Hydrotherapy shares some of the same goals as massage therapy. Both
practices assist in stress relief, pain relief, recovery from injury, relaxation and
improved feelings of general well-being. Hydrotherapy can mesh well with
your existing massage therapy practice.
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Cleanliness
It is of the utmost importance that you maintain cleanliness in your
hydrotherapy practice, especially if you are using hot tubs. Texas A&M
University has reported that hot tubs can be a breeding ground for E.coli,
pseudomonas and staph infections.lxi Unclean hydrotherapy equipment can
also spread Athlete’s foot and parasites.lxii Keeping your hydrotherapy
equipment clean can prevent the spread of infectious diseases. Do not
allow clients with cuts or open sores to use hydrotherapy equipment.
Require your clients to rinse in clean water before entering a hydrotherapy
tub or a warmed pool. This will remove any soap or oily lotions that could
contaminate your equipment.lxiii Drain and clean your equipment between
each client using an EPA registered product, in accordance with the
recommendations of the Centers for Disease Control and Prevention
(CDC).lxiv If you have no clients using the equipment, you should still clean it
daily. Dust and soil that gathers on the equipment can be an environment
for the growth of pathogens.lxv
Always follow the manufacturer’s instructions for cleaning the equipment. If
you are cleaning a jetted tub, you will need to drain it completely, then fill it
again with clean water. Add the manufacturer’s recommended cleaner
and let it soak according to the instructions on the package. You may be
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required to turn on the jets so the cleaner can enter the tub’s plumbing. You
will then need to scrub the walls and floor of the tub, drain the water and
refill it to rinse the surface.lxvi
You should also clean and disinfect any hydrotherapy tubs after the use and
removal of a tub liner.lxvii
Safety
You may need additional training before you can safely offer a
hydrotherapy treatment to clients. Always consult your state and local
licensing authorities before offering a hydrotherapy service.
Never allow the water in a hot tub to exceed 104 degrees F in temperature.
Immersion in water that is above that temperature can result in heart failure,
stroke, or death.lxviii
Always keep the floor around the equipment dry to prevent falls. Remove
clutter that could cause tripping. Do not wring out the client’s bathing suits
or towels near walkways.lxix Install handrails where appropriate. Always keep
a staff member present when a client is undergoing hydrotherapy. Never
leave the client alone. Do not allow anyone to operate the hydrotherapy
equipment without reading all the safety guidelines first.
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Pricing
The NCBTMB’s Standard of Practice IV requires practitioners to ensure the
client understands the fee schedule before you begin the session. The fees
must be displayed where the client can see them before the session begins,
or you must discuss them. In compliance with the NCBTMB Code of Ethics XI,
always stop a session if a client expresses a wish to discontinue it.lxx
A hydrotherapy best practice is to price each individual treatment
separately.lxxi On your services menu, list every treatment that will happen
during a session so a client can turn down any part of the therapy s/he does
not want. For example, instead of your menu reading “Water Massage for
$80,” have it read “Water Massage-45 minute Swedish massage and 45
minute aquatic bodywork- $80.”
Post your refund policy clearly in the foyer of your practice to avoid any
confusion.
Resting
The client may be sleepy or fatigued after hydrotherapy or aquatic
bodywork. As with all types of bodywork, it is important to give the client the
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option to rest for as long as they need to after the session.lxxii Encourage the
client to rest for the rest of the day, and to drink plenty of water.
Chapter Four: Cautions and Contraindications
When to Not Perform Hydrotherapy
Not all clients are appropriate candidates for hydrotherapy. Provide the
client with an intake survey before the session, or even when the client
makes the appointment, to ensure that they have no contraindications for
the therapy you offer.
The following conditions are general skin-related contraindications for
hydrotherapy: skin lesions, cuts, skin sensitivity, or loss of sensation in the legs
due to diabetes.lxxiii Other contraindications for hydrotherapy include the
following: fever, cancer, tuberculosis, anemia, heart disease, lung diseases,
and the implantation of pacemakers.lxxiv
Some clients may have contraindications related solely to the temperature
of the water used in the hydrotherapy. Contraindications for hot water
hydrotherapy include: age (the elderly and young children)lxxv, multiple
sclerosis, pregnancy, inflammation, peripheral vascular disease, alcoholism,
heart disease, and low or high blood pressure.lxxvi Contraindications for cold
water hydrotherapy include: bladder irritation, sciatica,
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rheumatism,lxxviiReynaud’s phenomenon,lxxviiikidney issues, and muscle
spasms.lxxix
If the client has no contraindications for the therapy, you should still be on
the look out for any signs of a health issue during the session. If the client
begins showing signs of dizziness, faintness, trouble breathing or stomach
upset, stop the therapy. As the saying goes, “ Always err on the side of
caution.”
i “Hydrotherapy.” http://www.holisticonline.com/hydrotherapy.htm, January 1, 2004 ii Cathy Wong, “Hydrotherapy.” http://altmedicine.about.com/od/therapiesfrometol/a/hydrotherapy.htm, February 1, 2005 iii Richard Metcalfe, “Sanitas Sanitatum et Omnia Sanitas.” http://www.archive.org/stream/sanitassanitatu00metcgoog#page/n6/mode/2up, 1887 iv Max Marquardt, Dave Ryder, Sean Williams, Ian Macfarland, Brian Snodgrass, “Aquea Sulis” http://faculty.vassar.edu/jolott/old_courses/crosscurrents2001/aquae_sulis/index.html v Tamara Colloff-Bennett, “Jane Austen in the City of Bath, England,” http://quillcards.com/blog/index.php/articles/jane-austen-in-the-city-of-bath-england/, February 1, 2009 vi “Pioneers of Natural Medicine (An Historical Series): Vincenz Priessnitz,” http://www.optimumhealthvitamins.com/OptiBlog/tabid/105/entryid/206/Default.aspx vii Richard Metcalfe, “Life of Vincenz Priessnitz,” http://www.archive.org/stream/lifeofvincentpri00metciala#page/12/mode/2up, 1989 viii “The Central European Spa Tradition,” http://www.hiddeneurope.co.uk/the-central-european-spa-tradition ix “Malvern Water and Complementary Therapies,” http://www.beaconclinic.net/the_clinic/malvern_water_and_complementary_therapies.shtml x “Vincenz Priessnitz and Spa Grafenberk,” http://priessnitz.jeseniky.org/text/historie.htm xi “Vincenz Priessnitz Jeseniky and Springs,” http://www.rozhlas.cz/leonardo/historie/_zprava/364418, July 20, 2007 xii Nancy Griffin, “The Man and His Mission,” http://www.massagetoday.com/archives/2003/06/17.html xiii “Fr Sebastian Kneipp and Hydrotherapy,”
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http://www.amaluxherbal.com/amodality/sebastian_kneipp_hydrotherapy.html xiv “Titanic’s Turkish Baths,” http://www.titanic-titanic.com/titanic_turkish_bath.shtml xv Malcolm Shifrin, “Turkish Baths on Ocean Liners,” http://www.victorianturkishbath.org/6directory/AtoZEstab/Liners/TitanOlympicSF.htm, 1988 xvi “Turkish Bath,” http://en.wikipedia.org/wiki/Turkish_bath xvii John Grant Wilson, John Fiske, “Appleton’s Encyclopedia of American Biography,” http://www.archive.org/stream/appletoncyclo05wilsrich#page/n9/mode/2up, 1888 xviii The Hunter-Rice Health Sciences Library and Samaritan Medical Center Newsletter, “Stonewall Jackson and the Henderson Hydropath,” No. 42, September, 2008 xix William Horsell, “Hydropathy For the People,” http://www.archive.org/stream/hydropathyforpe00horsgoog#page/n6/mode/2up, 1850 xx Georgia State Parks, “Roosevelt’s Little White House State Historic Site,” http://gastateparks.org/item/129854 xxi “Warm Springs Historic District,” http://en.wikipedia.org/wiki/Roosevelt_Warm_Springs_Institute_for_Rehabilitation#cite_note-nrhpinv2-2 xxii Tieraona Low Dog, “What is Hydrotherapy, and How is it Used to Treat Pain Associated with Osteoarthritis?” http://abcnews.go.com/Health/PainArthritis/story?id=4566827 xxiii Time Magazine, “Medicine: Gurgle, Gargle, Guggle,” http://www.time.com/time/magazine/article/0,9171,825126,00.html, July 8, 1957 xxiv Living With Cerebral Palsy, “History of Hydrotherapy,” http://www.livingwithcerebralpalsy.com/hydrotherapy-history.php xxv Ibid.
xxvi Alcoholics Anonymous, Alcoholics Anonymous, New York City:
Alcoholics Anonymous World Services, Inc., 2001, p.7. xxvii Plastic and Reconstructive Surgery, “The Effect of Hydrotherapy on the Clinical Course and pH of Experimental Cutaneous Chemical Burns,” http://journals.lww.com/plasreconsurg/Citation/1975/02000/THE_EFFECT_OF_HYDROTHERAPY_ON_THE_CLINICAL_COURSE.11.aspx, February, 1975 xxviii The Encyclopedia Britannica, 11th Edition, http://www.archive.org/stream/encyclopdiabrit18chisgoog#page/n183/mode/1up xxix Resende, Rassi, Viana, “Effects of Hydrotherapy in Balance and Prevention of Falls Among Elderly Women,” https://docs.google.com/viewer?a=v&q=cache:OMCZuKahmXsJ:www.scielo.br/pdf/rbfis/v12n1/en_11.pdf+reduce+falls+hydrotherapy&hl=en&gl=us&pid=bl&srcid=ADGEESgP4zRd1hNPgMZWoCQiXoLd13pSCHg72wJtqmuzrckYpR-xYY2BhBZzQfBfrwsb1YOIWD1k41EjOOflZcYQijYczdSDEZtMa9yYqw-xKb6EqbVpULdaIhxBqjBC-aXEupB9invA&sig=AHIEtbSPQm73ewxIno8UrZxV-_R-VWBBqg, January 2008 xxx Wong xxxi Holistic Online, “Hydrotherapy” xxxii Elaine Moore, “Medicinal Benefits of Hydrotherapy,” http://elaine-moore.suite101.com/medicinal-benefits-of-hydrotherapy-a40905, January 9, 2008 xxxiii Getting Pregnant, “Hydrotherapy for Infertility,” http://www.gettingpregnant.co.uk/hydrotherapy.html xxxiv AETNA, “Clinical Policy Bulletin: Dry Hydrotherapy (Hydromassage, Aquamassage, Water
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Massage)” http://www.aetna.com/cpb/medical/data/600_699/0699.html xxxv Moore xxxvi “Hydrotherapy Information,” http://www.naturaltherapypages.com.au/article/hydrotherapy, September 20, 2008 xxxvii Nordic Hot Tubs, “What is Hydrotherapy,” http://www.nordichottubs.com/health-benefits-from-nordic-spas/134.html xxxviii Expert Village, “Massage Therapy: Hydrotherapy Treatments,” http://www.youtube.com/watch?v=yyOEoSJazbo, December 5, 2008 xxxix Living With Cerebral Palsy, “History of Hydrotherapy” xl Holistic Online, “Hydrotherapy” xli Discover Hydrotherapy, “Healing Waters,” http://www.perfect-balance-naturopathy.com/hydro.html xlii http://www.hydromassage.com/Hydro-Therapy-Massage.htm xliii Hydro Massage, “Resources,” http://www.weightlossforall.com/losing-weight-sauna-x.htm xliv Thermospas, “Health Benefits,” http://www.thermospas.com/spa/hot-tub-spa.html xlv Hot Tubs and Diabetes, “’Hot Tub Therapy’ Helps Diabetics,” http://www.rhtubs.com/diabetes.htm, September 15, 1999 xlvi National Sleep Foundation, “Healthy Sleep Tips,” http://www.sleepfoundation.org/article/sleep-topics/healthy-sleep-tips xlvii Annie B. Bond, Care2, “13 Wonderful Ways to Use Epsom Salts,” http://www.care2.com/greenliving/use-epsom-salts-13-wonderful-ways.html, December 11, 2010 xlviii Salt Works, “Dead Sea Salt Bathing,” http://www.saltworks.us/salt_info/si_DeadSeaSaltBathing.asp xlix Danubius Hotels Group, “Hydrotherapy,” http://www.danubiushotels.com/en/health_spa_and_wellness/medical_stays/hydrotherapy l Women’s Online Spa, “Hydrotherapy Baths,” http://www.womensonlinespa.com/hydrotherapy_baths.htm li Ibid. lii AETNA, “Clinical Policy Bulletin: Dry Hydrotherapy” liii Cigna Medical Policy Coverage, “Dry Hydrotherapy,” https://docs.google.com/viewer?a=v&q=cache:nj3RCgAlgkEJ:www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0352_coveragepositioncriteria_dry_hydrotherapy.pdf+dry+hydrotherapy&hl=en&gl=us&pid=bl&srcid=ADGEESiQNGat2FOiWh8ql8OWOf7bSbqn3k9u9AOkmNZbpsGqSDweWwf7MwoynyO6rykj9ff3JLv_svnByy8WV6nHlKFuxqDPubnmM5SY3N0eWOpO7Sqk_WSWtp5ygwdN2zjciR6llSqp&sig=AHIEtbQpQyLF21VxsJFoVI1DP4-iVE_8LA liv AquaMed, “What is Dry Hydrotherapy?” http://www.aquamed.com/subpages/dry-hydrotherapy-treatments.asp lv Aqua Care For Me, “Pregnancy Watsu by Elina Root,” http://www.youtube.com/watch?v=3DFFRFC3U7M&feature=related lvi Aquatic Bodywork Association of New Zealand, “What is Watsu?” http://www.watsu.org.nz/ lvii Bloomberg Businessweek,”Diving Into Watsu Massage,” http://www.businessweek.com/magazine/content/05_36/b3949120_mz070.htm, September 5, 2005 lviii Splendor Spa, “Watsu Session,” http://www.youtube.com/watch?v=nGAhp43TWkk&feature=related
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lix Unbesheiden, “Underwater Traction,” http://www.unbescheiden.com/en/#/g/products/underwater-traction lx http://www.aquamed.com/subpages/physical-therapy-exercises.asp lxi Aqua Med, “What Are Physical Therapists?” http://blog.sanijet.com/2011/03/17/spa-bath-tubs-and-disinfection-how-clean-can-your-tub-get/ lxii “Onsen,” http://en.wikipedia.org/wiki/Onsen#cite_note-1 lxiii Ibid. lxiv Centers for Disease Control and Prevention, “Hydrotherapy Tank and Pool Operation,” http://www.cdc.gov/healthywater/swimming/pools/hydrotherapy-tank-pool-operation.html lxv Virox, “Cleaning and Disinfection Protocol for Hydrotherapy Tubs,” http://www.virox.com/msds/pdf/HydrotherapyProtocolCanada.pdf lxvi Ibid. lxvii Centers for Disease Control and Prevention, “Hydrotherapy Tank and Pool Operation.” lxviii Hot Tubs and Home Spas, “Not So Stupid Hot Tub Questions,” http://www.hottubsandhomespas.com/hot-tubs/not-so-stupid.aspx lxix Bolton Council, “Hydrotherapy Health and Safety Portfolio,” https://docs.google.com/viewer?a=v&q=cache:jSOaquhgxSoJ:www.bolton.nhs.uk/Library/policies/LDPT15.pdf+safety+hydrotherapy&hl=en&gl=us&pid=bl&srcid=ADGEESiA3aOpCyj6r9Zle4Ac7_xlYVtoN1RL9kDBd6S_hcgQe5J1UYYXVDxJSPvADFr76mNar1jKMtVbKA0CVPSXahjevdjLMrNmIZv2kgqXwmr3hTl5fkZ5Vsw3DOLIs7yuA3QWcevE&sig=AHIEtbRBBsi9eSRDoC1OVlf7Fl9Ek_8HXw lxx Ryan Hoyme, “350+ Swedish Massage Techniques and Others,” http://webcache.googleusercontent.com/search?q=cache:7S_iOXD73CQJ:www.massagenerd.com/pdf_massage_ebooks/Swedish_Massage_1_of_3_Ryan_Hoyme_.pdf+client+wants+to+stop+a+massage&cd=10&hl=en&ct=clnk&gl=us lxxi Larry Swanson, “Setting Massage Rates,” http://www.larryswanson.com/articles/setting-massage-rates/ lxxii Hoyme lxxiii The Bodyworker, “Hydrotherapy,” http://www.thebodyworker.com/hydrotherapycontraindications.htm lxxiv Moore lxxv Holistic Online, “Hydrotherapy” lxxvi The Bodyworker, “Hydrotherapy” lxxvii Holistic Online, “Hydrotherapy” lxxviii Moore lxxix The Bodyworker, “Hydrotherapy”
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