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Whirlpool

Information

Description of Intervention

The use of water as a therapeutic tool—currently referred to as hydrotherapy—dates back thousands of years, when it was originally used to alleviate pain in burn victims.1 Whirlpool, one type of hydrotherapy, is a modality frequently employed by physical therapists and hand therapists to treat for various conditions of the upper extremity. It involves submersing a portion of the upper extremity in a bath of heated water, often while the patient performs specific exercises.2

Whirlpool is typically indicated for patients with pain, swelling, or reduced range of motion (ROM) in the hand, wrist, or elbow from an injury, surgery, or some other musculoskeletal condition, including repetitive strain issues. Whirlpool baths may also be used for patients recovering from a burn or open wound in these regions,3 although this application of whirlpool is becoming less common due to the risk for infection.

The warm water in a whirlpool increases circulation because the heat helps to open small arteries, which brings fresh blood, oxygen, and cells to the affected area. This process can promote wound healing while also relaxing patients by relieving muscle tension. As a result, whirlpool therapy has been found to reduce pain, swelling, and muscle spasm, and improve wound healing, inflammation, and ROM. Collectively, this can lead to decreased use of analgesics, fewer complications, and faster discharge from therapy.4 When compared to hot packs, another common form of artificial heat application, whirlpool therapy has also been found to increase ROM to a greater degree. This advantage is likely related to patients’ ability to perform exercises while in the whirlpool bath.2

Indications for Intervention

Candidates for whirlpool therapy are patients that present with pain, swelling, stiffness, inflammation and/or reduced ROM in the upper extremity caused by a traumatic injury, burn, or musculoskeletal condition involving the hand, wrist, or elbow. Post-surgical patients may also be candidates for whirlpool therapy.

Diagnosis5

  1. Ask for the patient’s medical history, including any recent injuries to the hand/fingers, wrist, or elbow, and any recent surgeries performed in those areas.
  2. Ask if the patient has any comorbidities, including smoking, diabetes, or osteopenia.
  3. Perform a physical examination of the area of interest. If ROM is impaired, measure the ROM of any involved joints and compare these measurements with the contralateral side.
  4. Ask the patient to rate their pain on the visual analogue scale (VAS) or a similar outcome measure.
  5. If edema is present, assess and report the extent of the edema.
  6. If applicable, consider measuring fingertip-to-distal palm crease distance and evaluating hand grip and pinch strength using a hand dynamometer.
  7. For any open wounds or burns, ensure that proper bandaging has been applied.
  8. Assess muscle spasms, if present.
  9. If the patient presents with pain, swelling, inflammation, and/or impaired ROM in the upper extremity, consider utilizing whirlpool therapy.

Intervention Options2,5,6

Whirlpool therapy should be integrated into a comprehensive and individualized treatment program designed by the physical therapist or hand therapist. Depending on the patient’s specific presentation, the program is also likely to include strengthening exercises, stretching exercises, manual therapy, functional training, and/or other therapeutic modalities.

Most warm whirlpool baths should be heated to a temperature of 98–110°F (104°F is commonly used). The patient should then be instructed to remove any clothing on the involved arm and place their arm in the whirlpool bath. Other highlights of whirlpool therapy are summarized below:

  • The exact placement of the arm will vary, but most patients should submerse their arm to the mid-humerus, with the elbow flexed
    • The hands and wrist are often positioned at the surface of the water in the most comfortable resting position to maximize forearm rotation without compensation
  • If applicable, the patients should then be instructed to perform active wrist flexion, extension, radial deviation, ulnar deviation, pronation, and supination exercises while in the bath
    • Exercises may be repeated 10 times for each direction and each stretch held for 10 seconds with a one-minute rest in between
  • Most whirlpool baths should last for 15–30 minutes
  • After removing their arm from the whirlpool, patients should wash their hands in warm water

If a wound or incision is present, the therapist may need to debride it either before or during the whirlpool bath. After the patient has finished the whirlpool, consider conducting some of the same initial evaluations (eg, pain, ROM, swelling) to determine if any immediate improvements have occurred.

Diagnoses Where This Intervention May be Relevant
Comments and Pearls
  • Although the application of heat is generally accepted as a beneficial modality that improves joint ROM, its mechanism of action is not clearly understood and the optimal method of application has not yet been established, especially for the upper extremity.2
  • Whirlpools were traditionally used to treat open wounds and burns, but they are becoming decreasingly common for wound care due to a potential risk for infections and lack of strong supportive evidence. If a whirlpool is used, be sure to apply the correct dressing to ensure that appropriate healing continues.3
  • Be sure to ask the patient about their comfort level when setting and adjusting the temperature of the whirlpool to avoid a burn. Tell patients to report if the whirlpool feels too hot or becomes uncomfortable.
References
  1. Moufarrij S, Deghayli L, Raffoul W, Hirt-Burri N, Michetti M, et al. How important is hydrotherapy? Effects of dynamic action of hot spring water as a rehabilitative treatment for burn patients in Switzerland. Ann Burns Fire Disasters 2014;27(4):184-191. PMID: 26336365
  2. Szekeres M, MacDermid JC, Grewal R, Birmingham T. The short-term effects of hot packs vs therapeutic whirlpool on active wrist range of motion for patients with distal radius fracture: A randomized controlled trial. Journal of hand therapy : official journal of the American Society of Hand Therapists 2018;31(3):276-281. PMID: 28893496
  3. Howell JW. Management of the Acutely Burned Hand for the Nonspecialized Clinician. Physical Therapy 1989;69(12):1077–1090. PMID: 2685846
  4. Juve Meeker B. Whirlpool therapy on postoperative pain and surgical wound healing: an exploration. Patient Educ Couns 1998;33(1):39-48. PMID: 9481347
  5. Devrimsel G, Turkyilmaz AK, Yildirim M, Beyazal MS. The effects of whirlpool bath and neuromuscular electrical stimulation on complex regional pain syndrome. J Phys Ther Sci 2015;27(1):27-30. PMID: 25642030
  6. Szekeres M, MacDermid JC, Birmingham T, Grewal R, Lalone E. The Effect of Therapeutic Whirlpool and Hot Packs on Hand Volume During Rehabilitation After Distal Radius Fracture: A Blinded Randomized Controlled Trial. Hand (N Y) 2017;12(3):265-271. PMID: 28453348
  7. Al-Qubaeissy KY, Fatoye FA, Goodwin PC, Yohannes AM. The effectiveness of hydrotherapy in the management of rheumatoid arthritis: a systematic review. Musculoskeletal Care 2013;11(1):3-18. PMID: 22806987
  8. Horvath J, Balint Z, Szep E, Deiszinger A, Minier T, et al. Efficacy of intensive hand physical therapy in patients with systemic sclerosis. Clin Exp Rheumatol 2017;35 Suppl 106(4):159-166. PMID: 28869417
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