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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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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