Hydrotherapy in Your Practice

Enhance Your Bodywork Using Water Therapies

By Marybetts Sinclair

Cultures all over the world have used water for eons to soothe aches and pains, stimulate and relax minds and bodies, and detoxify and rejuvenate. Today, bodyworkers continue to use hydrotherapy to enhance their hands-on techniques in new and creative ways, using both ancient and modern hydrotherapy treatments.

Water treatment and bodywork seek the same results. They are natural complements to each other, which is why we find the two combined so often. Together, they can truly make a massage therapist’s work easier. For example, ice applications reduce inflammation and help treat trigger points; heating treatments enhance the flexibility of scar tissue; paraffin dips warm and soothe arthritic joints; friction treatments stimulate the skin’s nerves and blood vessels and reduce muscle tension; and warm baths, saunas, and showers increase body heat and quiet the nervous system before a session. 

Simple Hydro and Massage Treatments

Many hydrotherapy treatments can be readily incorporated into your massage practice without expensive equipment. Local heat treatments include hot compresses, towels, and packs; hot water bottles; heating pads; heat lamps; paraffin dips; and hot hand or foot baths. Friction treatments, such as salt glows, can also be given but usually require a place for the client to shower afterward. Body wraps and steam canopies are a simple, inexpensive way to give clients a whole-body heating treatment right on your table. Following are examples of how I used these simple treatments to improve client outcomes in my general massage practice: 

• Woman with head pain from head injury: massage-
table scalp bath soothed discomfort and warmed tissue before massage. 

• Male athlete, in his 20s, with severe hamstring tear: Heating pad alternated with ice massage increased circulation and soothed discomfort before massage. 

• Elderly female with polymyalgia rheumatica (inflammatory disorder that causes pain and stiffness with vigorous massage): Gentle neck stretching using warm, moist towels increased circulation and eased tension without pressure.

• Young autistic woman who craved swaddling: A warming body wrap led to profound relaxation, while massage was performed on head and neck during and after the wrap. 

• Six-year-old twins’ first-ever massage: A warm foot bath with essential oils was a fun way to begin a session. 

• Men and women at homeless shelter: Hot, moist towels before, during, and after hands-on work brought increased relaxation and comfort.

• Middle-aged woman recovering from surgery for a shattered knee on one extremity and a shattered ankle on the other: A contrast treatment in her home bathtub using alternating hot and cold water increased blood flow and eased discomfort before massage. 

• Elderly gentleman whose C1–C2 spinal cord injury led to spasticity on one side of his body: Hydrocollator packs to spastic areas helped soften tissues and make myofascial release more effective.

• Obese, elderly woman with mobility problems: A steam canopy treatment on a massage table followed by massage helped her relax and feel rejuvenated.

In each case, the hydrotherapy treatment combined with hands-on techniques made a significant contribution to the success of the session. 

Spas that Combine Hydrotherapy and Massage

Many spas and health retreats employ massage therapists who combine hydrotherapy and massage to help improve client conditions. Here are a few examples:

Banya 5

Banya 5, in Seattle, bills itself as an “urban spa” that blends hydrotherapy, body treatments, and old-world wellness rituals. Unlike most spas, the atmosphere at Banya 5 is not oriented toward pampering but has a more therapeutic slant and features more extreme temperatures and deeper bodywork. Fifteen massage therapists specialize in deep-tissue massage and swear by hydrotherapy (saunas, steam baths, and cold plunges) as a way of softening more superficial muscle tension so their hands-on work can better release deeper tensions while balancing body and mind.

Uchee Pines Institute

The Uchee Pines Institute in Seale, Alabama, is part
of a network of health facilities operated by the American Seventh-Day Adventist Church. At this physician-supervised medical treatment center, patients are often very ill, so the program is oriented to bring about healing through natural means and learning to live a healthier lifestyle. Simple, natural therapies include herbs, exercise, nutrition, hydrotherapy, and massage. Patients are given a combination of hydrotherapy and massage five days a week during their stay, varying from hot baths, infrared saunas, and detoxifying baths to contrast treatments over specific areas. Water therapies are followed by relaxation-based massage. Patients are then taught how to practice self-care. Since patients are at the institute for musculoskeletal problems and may be medically fragile, therapists generally use light Swedish techniques unless a doctor prescribes special bodywork for scar tissue, contractures, or constipation. 

Thermae Bath Spa

The Thermae Bath Spa of Bath, England, is billed as England’s first and only natural thermal spa, which has been famed for millennia for the curative powers of its waters. Thermae Bath Spa has taken various forms, such as an ancient Roman bath complete with separate massage rooms for each gender, a medieval refuge for sick and leprous locals, a full-scale hospital with patients from all over Europe, and a rehabilitation center for wounded English soldiers. Today, the entire town of Bath is a World Heritage site and tourist mecca, and the waters are used in a modern, multi-level spa facility. Along with steam rooms, specialty showers, an infrared sauna, an ice chamber, and large swimming pools (with colored lights, special jets, and artificial currents) are 24 treatment rooms. At least 800 patrons use the spa each day in the summer. 

Thermae has a team of 50 massage therapists who are ready to add bodywork to the spa’s water experiences. Thermae generally hires massage therapists who have trained in “beauty massage,” which in England means pampering and beauty treatments rather than medical or therapeutic ones. Thermae then trains massage therapists in its specific treatments, including facials, body wraps, and various styles of massage. Watsu holds pride of place as Thermae’s signature treatment and is performed in the natural thermal waters. 

Breitenbush Hot Springs

Deep in the Oregon woods, Breitenbush Hot Springs bills itself as a remote nature-based sanctuary—a place to get away from it all. Patrons are drawn by natural hot pools deep in a fir forest with one pool especially reserved for silent contemplation. Other hydrotherapy facilities include a rustic wooden steam bath over a hot creek and cold plunges. A basic team of four massage therapists offer primarily Swedish relaxation massage, with more therapists added during the busy summer season. The combination of hydrotherapy, either before or after massage sessions, deepens the effectiveness of the bodywork and makes for a happier, more relaxed guest than if either modality was offered alone. 

New Creative Uses for Hydrotherapy

While most of the following hydrotherapy techniques are not new, many are updated. Creative therapists continue to come up with helpful ways to use hydrotherapy to ease client discomfort from common conditions such as traumatic injuries, chronic pain, depression, and the after-effects of cancer. 

No (or Limited) Ice, Baby!

In 1978, sports medicine doctor Gabe Mirkin, MD, began promoting ice applications for injuries such as sprains, strains, and bruises. He even coined the term RICE (rest, ice, compression, and elevation).1 Mirkin originally thought using ice immediately after an injury would delay swelling and reduce pain, but the latest research shows that swelling is a sign of white blood cells rushing to a damaged area to heal it. 

In 2015, Mirkin backtracked his icing recommendation after finding that many scientific studies show no healing benefits. Instead, it was found that icing can injure tissue, which leads to the restriction of blood flow (by the contraction of blood vessels) and slows activity of white blood cells. Unfortunately, the word has not gotten to all athletic trainers, physical therapists, extreme athletes, or emergency room staff, so ice is often overused. 

Mirkin now recommends that an injured person skip ice unless pain is very severe, and then use ice packs only two or three times, for 15–20 minutes at a time. Mirkin also recommends over-the-counter nonsteroidal anti-inflammatory medications, but only for the first 24–48 hours after an injury, since they also slow down recovery by suppressing inflammation. Compression and elevation are still recommended, while gentle exercise is preferred over complete rest.2 

In the massage world, where we frequently see clients with musculoskeletal injuries, contrast treatments (e.g., contrast foot baths) are now thought to be far better because they alternate hot and cold, which stimulates circulation and relieves pain. We often see older clients with poorly healed sprains, which have predisposed them to arthritis. So, avoiding prolonged use of ice will help avoid this problem—and can really do some good. 

Float the Pain Away

Invented in the 1950s by neuroscientist John Lilly, MD, flotation tanks have only recently become affordable and are now recognized as a therapy to relieve tension, stress, fibromyalgia, and chronic pain.3 Flotation tanks are dark, soundproof tanks of warm saltwater where a person can float for long periods in sensory isolation, free from the force of gravity and outside stimulation. A float before a massage is said to relax client muscles, which enables the massage therapist to work deeper and with less effort. A float after a massage allows the client to relax into the float more quickly. Since the water contains Epsom salts, floating can also help reduce the level of muscle soreness after vigorous exercise or a deep massage treatment. 

Hot Yoga Saunas

Special saunas are now being built specifically for hot yoga classes. These hot yoga saunas are kept at about 105°F, with the idea that warm muscles are easier to stretch. Plus, heat promotes vigorous sweating, which leads to detoxification. In addition, this whole-body treatment may ease depression. 

Heat Treatments for Depression 

Heating treatments have been used for centuries to help people feel more relaxed and more invigorated at the same time. Whole-body heating treatments can also help some depressed people. According to a 2018 Psychiatric News article, heat treatments, including hot yoga, hot baths, and saunas, have shown promise for depression.4 

One study evaluated patients in a bed with infrared heat lamps that raised their core temperature to 103°F. Blood tests found that the treatment boosted levels of interleukin-6, a signaling molecule of the immune system that has inflammatory and anti-inflammatory effects. (Intense exercise can also hike interleukin-6.) While some people got no benefit from the heat treatments, those who did continued to feel less depressed throughout the six weeks of the study.5 

How might heat treatments fit into your work with depressed clients? A massage combined with a heat treatment and a brief cold exposure might just double the effect of massage alone.

Exercise Baths for Preemies

Neonatal intensive care units are high-stress environments for babies who often receive painful interventions, such as heel pricks. Years ago, touch was avoided until two pediatric physical therapists tried gentle exercise in warm water to reduce harmful effects of pain and stress and promote comfort and pain relief on premature babies. Using a large plastic container, babies were immersed in body-temperature warm water up to their shoulders, while the therapist performed subtle movements, mobilization, and stretching for about 10 minutes. Afterward, the babies’ heart rates and levels of cortisol (a stress hormone) were reduced.6

Contraindications: Keeping Treatments Safe 

Fine-tune your hydrotherapy work with clients by selecting treatments that are suited to their situation. Always take a careful health history to alert you to any contraindications before beginning treatments. Then, make sure each treatment is a good fit by presenting it to the client. 

Keep in mind that client comfort is critical. A client who is claustrophobic will not enjoy a body wrap, and ice massage is likely to discourage someone with a serious aversion to cold. Also, hydrotherapy treatments should not be used over skin that is infected or has rashes.

Following are general contraindication guidelines for determining when clients should avoid hydrotherapy treatments.

Contraindications to Local Heat Treatments

Since heat treatments can encourage edema, applications are contraindicated when clients have acute local inflammation of any kind, from phlebitis to a fresh ankle sprain to lymphedema. Heat applications are also contraindicated over implants, pacemakers, defibrillators, medication pumps or other artificial devices, numb areas, and the feet of anyone with diabetes.

Contraindications to Local Cold Treatments

Local cold treatments are contraindicated for Raynaud’s syndrome, a simple vasoconstriction disorder of the extremities, because cold may cause a spasm of the smallest arteries that supply the hands or feet. Local cold treatments are also contraindicated for any area that is numb. 

Contraindications to Whole-Body Heat Treatments

High temperatures create extra demands on the circulatory system. There are changes in heart rate, how much blood the heart pumps per beat, blood pressure, and where the blood is distributed in the body. In heating treatments such as saunas, warming body wraps, steam baths, and hot showers, blood is shifted to the skin’s blood vessels so heat can be radiated off the skin to prevent overheating. Therefore, unless approved by the patient’s doctor, whole-body heat treatments are contraindicated for patients with high or low blood pressure, heart disease, and during pregnancy. Patients with multiple sclerosis or seizures should only have heat treatments with their doctor’s permission. Hot baths are also contraindicated for anyone with diabetes because they may have cardiac problems. However, warm and neutral-temperature baths are a good choice for diabetics, as are whole-body salt glows.

Contraindications to Whole-Body Cold Treatments

Short, cold plunges or showers are a traditional way to stimulate and invigorate; however, they are contraindicated for clients who are chilled, have an aversion to cold, or have cardiovascular or kidney disease.

Hydrotherapy Self-Treatments 

Hydrotherapy treatments your clients can perform at home will help increase the benefits of your massage, help them achieve faster and better results, and help them take charge of their own health. Following are a few self-treatments your clients can try at home.

Epsom Salts Footbath 

Epsom salts footbaths are recommended for bruises, sprains in the subacute stage, soreness after exercise, soreness after massage, chronically cold feet, edema of pregnancy, or arthritis pain. To perform this self-treatment, your client will need a water thermometer, a chair, a plastic tub, 2 cups of Epsom salts for an adult (or 1 cup for a child), a bath towel, and a bath mat.


• Place a bath mat on the floor in front of
the chair.

• Begin filling the plastic tub three-quarters full with warm (not hot) water, about 98–102°F. 

• Pour the Epsom salts directly under the spigot while the tub is filling to make sure they dissolve completely. 

• Optional: Add essential oils to the footbath after filling the tub.

• Place the tub on the towel, and then sit on the chair and put your feet in the water.

• Soak feet for 15–20 minutes, and then wash the saltwater off with clean water.

• Dry your feet, apply a moisturizing lotion, and then put on socks.

Neck-Limbering Exercises for the Shower

A hot shower that includes neck-limbering exercises is great for clients with chronically tight muscles, stress, injury, soreness after exercise, muscle spasms, or arthritis pain. This exercise may be performed as many as three times a day but should be avoided if the client has any of the following conditions: cardiovascular problems, diabetes, hepatitis, lymphedema, multiple sclerosis, seizure disorders, hypothyroid conditions, or loss of sensation (lack of feeling), or if they are unsteady on their feet, unable to tolerate heat, or they ingested alcohol or drugs. To perform this self-treatment, your client will need a water thermometer, bath towel, and bath mat. 


• Turn on the shower to hot and get in carefully. Use a grab bar if you feel unsteady. 

• Adjust the temperature to your tolerance (about 105–115°F).

• Let the water beat on your neck for at least 3 minutes. 

• Slowly continue to stand with the hot water beating on the neck muscles while you move your head as if you were drawing the letters of the alphabet with your nose. This will gently release muscle tension and make your neck more limber. Do all the letters of the alphabet.

• Stay in the shower until you have finished this neck-limbering exercise, but for no longer than 10 minutes.

• Get out of the shower carefully, and then dry off and put on a warm shirt, so your neck stays warm.

Handheld Sprayer Contrast Treatment 

A contrast shower over one part of the body with a handheld sprayer can be used for soreness after exercise, muscle spasm, muscle fatigue, arthritis pain, tendinitis, joint swelling from a sprain, after the removal of a cast, or simply to increase local circulation. This self-treatment should be avoided if you are cold or have any of the following conditions: peripheral vascular disease, such as diabetes, Buerger’s disease, or arteriosclerosis of the lower extremities; Raynaud’s syndrome; or loss of feeling. Never spray water over implanted devices, such as cardiac pacemakers, ports, defibrillators, or pumps. To perform this self-treatment, your client will need a handheld sprayer, a bath towel, and a bath mat. 


• Step carefully into the shower stall or bathtub. If you are going to spray the legs or feet, you may sit on the side of the bathtub.

• Spray the area with water as hot as you can comfortably tolerate for 2 minutes.

• Then, spray the area with water as cold as you can comfortably tolerate for 30 seconds.

• Repeat hot and cold sprays for three rounds.

• Get out of the shower carefully, dry off, and dress quickly to avoid chilling. 


Adapting Hydrotherapy to Different Settings

Because there are many types of hydrotherapy treatments, the resourceful massage therapist can usually substitute another treatment if one is contraindicated. For example, although hot baths are helpful for insomnia, many elderly clients are too stiff to get in and out of a tub, so an alternative such as hydrocollator packs on the back followed by back massage is a great substitute. By thinking ahead and assembling a few basic items, hydrotherapy treatments are doable in almost any setting you perform massage.

Outdoor Setting. A massage practitioner working outdoors at a sports massage event can perform ice massage to relieve sore and aching muscles; local salt glows of the back, legs, and feet to increase circulation and relax those areas; ice-cold foot soaks for aching and burning feet; and Epsom salt foot soaks for tired and aching feet. Simply bring ice and bottled water in a cooler, along with extra towels and washcloths, plastic dish tubs for foot soaks, and Epsom salts. 

Office Setting. If you practice in a chiropractic office or physical therapy clinic, you may have access to hot moist packs, and possibly ice for ice applications as well. These hot moist packs are easy to purchase and can be preheated before a session begins. They are highly effective in relieving muscle tension and increasing local circulation, and are easy to place on one part of the body while massage is being performed on another part. In any setting where you are helping clients with severe musculoskeletal pain, ice massage is also easy and useful.

Assisted Living/Nursing Home Settings. If your clients are in assisted living facilities, you will usually treat them in their apartments, where you can use their small kitchenette for access to hot and cold water and ice. You may wish to bring containers for water, such as plastic tubs or buckets, but you may also find them in the kitchenette.  At nursing homes, clients are generally given massages in their rooms. With no kitchenette, you can still get hot and cold water coming out of the tap in their bathroom, and give simple treatments. You may wish to bring a container for water, or obtain one from the nursing staff.

Health Club or Spa Setting. Generally, any health club or spa that offers massage will have at least one hot tub, shower, steam room, or sauna. After doing a health history, if there are no contraindications, you can suggest that your clients use those facilities before or after massage sessions. Generally, health clubs that offer hydrotherapy treatments inform clients about contraindications.


Moist Air Discourages Transmission of Coronaviruses

Many researchers are finding that humidity is not the only factor in flu outbreaks, but it is an important one that should be considered during the winter season. Increasing water vapor in the air with humidifiers at home, school, work, and even hospital environments is a potential strategy to reduce flu symptoms and speed recovery. Therefore, many classic hydrotherapy treatments, such as long hot showers (which raise the core temperature) and local steam inhalations, are now recommended by some scientists in order to discourage transmission of the coronaviruses that cause the common cold, influenza, and COVID-19. Research has shown that more people get sick with influenza when the air in their houses is very dry (typically in the winter); this is because as the mucus droplets that carry them evaporate, more virus particles circulate high in the air where they are more likely to be inhaled rather than falling to the ground. At the same time, the mucus in our upper respiratory systems normally traps viruses before they contact skin cells, but dry air causes throat secretions to dry out, and then they don’t trap the organisms as well. Also, the cilia in the lungs do not function as efficiently in dry air and have more trouble getting rid of inhaled virus particles. Therefore, some scientists recommend inhaling very moist air, such as in long hot showers, steam baths, or local steam inhalations, as a preventive measure. A massage session that features hot moist towels, hot packs, steam inhalations, melting ice, foot baths, etc.—not to mention showers/saunas before a session—will lead to moister air.


Using hydrotherapy for stress relief

Here are simple hydrotherapy treatments for common physical manifestations of stress: 

• Insomnia—warm bath before bed 

• Low energy—whole-body contrast shower 

• Headaches—hot shower with cold on head 

• Tight neck and shoulders—neck-limbering exercises in hot shower 

• Aches and pains—stretching while in warm bath, followed
by ice pack, castor oil pack, or heat-trapping compress on painful area



Hydrotherapy treatments are great additions to your therapeutic tool kit. They complement your work as a massage therapist and expand your options when it comes to treating clients.


Kudo, Eriko et al. “Low Ambient Humidity Impairs Barrier Function and Innate Resistance Against Influenza Infection.” Proceedings of the National Academy of Sciences of the United States of America 116, no. 22 (May 28, 2019).

Iwasaki, A. “Why is Flu More Serious in the Winter?” YaleCampus, May 15, 2019. Accessed July 2020. www.youtube.com/watch?v=Rfb_TtlbuNM.

Noti, John et al., “High Humidity Leads to Loss of Infectious Influenza Virus from Simulated Coughs.” PLOS ONE (Feb 27, 2013). https://doi.org/10.1371/journal.pone.0057485.

Sajadi, Mohammad et al., “Temperature, Humidity and Latitude Analysis to Predict Potential Spread and Seasonality for COVID-19.” SSRN. Last modified April 6, 2020. www.ssrn.com/abstract=3550308.


1. Gabe Mirkin and Marshall Hoffman, The Sports Medicine Book (Boston: Little, Brown, 1978).

2. Consumer Reports, “Is RICE Still Nice?,” Consumer Reports on Health 27, no. 12 (December 2015): 97.

3. Sven A. Bood et al., “Effects of Flotation-Restricted Environmental Stimulation Technique on Stress-Related Muscle Pain: What Makes the Difference in Therapy—Attention-Placebo or the Relaxation Response?,” Pain Research and Management 10, no. 4 (Winter 2005): 201–9, https://doi.org/10.1155/2005/547467.

4. Richard Karel, “Treatments Involving Heat Show Promise for Alleviating Depression,” Psychiatric News 53, no. 10 (May 2018): 15–17.

5. C. Janssen et al., “Whole Body Hyperthermia for Treatment of Major Depressive Disorder: a Randomized Clinical Trial,” Journal of JAMA Psychiatry (August 2016).

6. Welcy Cassiano de Oliveira Tobinaga et al., “Short Term Effects of Hydrokinesiotherapy in Hospitalized Preterm Newborns,” Rehabilitation Research and Practice 2016, no. 1 (January 2016): 1–8, https://doi.org/10.1155/2016/9285056.

Marybetts Sinclair has been a massage therapist, teacher, and author since 1975. She is the author of Hydrotherapy for Bodyworkers (Handspring Press, 2020) and other massage textbooks and articles. Sinclair last reported on hydrotherapy for Massage & Bodywork in 2009. This update is based on current research into ancient and modern techniques, as well as an additional 10 years of using water therapies in her own practice.