Hydrotherapy in Your Practice

Enhance the Effects of Massage with H2O

By Marybetts Sinclair

Hydrotherapy is an important, time-tested adjunct to hands-on modalities. This use of water to heat, cool, stimulate, relax, and detoxify the human body has been used for thousands of years and by many cultures throughout the world. Native-American sweat lodges, Indian ayurvedic steam treatments, Greek and Roman hot and cold baths, Finnish saunas, and Japanese hot springs are just a few examples.

Few massage therapists are aware that many hydrotherapy treatments can be performed in the office or work space without investing in large and expensive equipment. Simple treatments that involve ice massage, hot packs, friction treatments, contrast applications, and compresses are inexpensive, effective, require little time, and are often loved by clients.

Many hydrotherapy treatments can 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; friction treatments stimulate the skin, increase localized blood flow, and reduce muscle tension; warm baths relieve stress and warm the entire body before a session; and paraffin dips warm and soothe arthritic joints. Hydrotherapy self-care can also be introduced by massage therapists as a “take home” after the session to encourage client follow-up, thus enhance the effects of the bodywork.

Varied Resources

My first exposure to hydrotherapy in a therapeutic setting was during treatment for a serious musculoskeletal injury in my early 20s. I was treated by a wonderful physical therapist who combined a relaxing soak in a warm whirlpool bath with massage and therapeutic exercises.

Later, once I became a practitioner, I gave massages at a health club that had a sauna and swimming pool, and I saw how both could prolong the relaxing effects of massage. I was also able to observe a physical therapist who used hot packs to relieve his clients’ aches and pains.

From my experiences, I developed a special interest in combining massage with water therapies. Following are a few clients in my general massage practice with whom I used hydrotherapy in just the last year:

• A developmentally disabled teenager who loves different sensations on her skin.

• A man with scalp pain after a traumatic head injury.

• A wheelchair-bound teenage girl with chronic tightness in her iliopsoas muscles.

• A woman whose emotional stress was so extreme that she was unable to remain still for her massage session.

• A woman with a severe contusion of the femur and tibia from an enormous rock striking her leg.

• A woman who was unable to lie prone due to severe sinus congestion from allergies.

• A young man with scar tissue from an old injury that was so tight it could barely be massaged.

• An 11-year-old boy who was receiving his first massage as a birthday present.

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

Benefits of Hydrotherapy in Your Practice

Like massage, hydrotherapy can relieve discomfort and pain, stimulate the flow of blood and lymph, and make connective tissue easier to stretch. If clients are too hot or too cold, hydrotherapy treatments can make them more comfortable before or during a massage session. Hydrotherapy treatments can also stimulate the skin in different ways—from the body-hugging sensation of being surrounded by water, the thermal sensations of warm or cool, or the scratchy feeling of friction treatment.

Hydrotherapy can reduce stress on the massage therapist’s hands, as well. Many localized hydrotherapy treatments can replace the massage strokes needed to relax superficial muscles and increase local circulation, hence the client’s tissues may be prepared for deeper work with less practitioner effort.

And finally, hydrotherapy is an excellent adjunct to rehabilitative bodywork. Cold treatments such as local baths, ice packs, and ice massage stimulate circulation and reduce inflammation, spasm, and pain. Heat treatments soften scar tissue and make muscle tissues easier to stretch.


Before giving your clients any hydrotherapy treatments, take a careful health history to alert you to any contraindications. Then, ask clients how they feel about any specific treatment you may have selected. A client who is claustrophobic will not enjoy a body wrap, and someone with a serious aversion to cold will not benefit from ice massage.

Below are general guidelines used to determine when clients can or cannot receive hydrotherapy treatments. Because there are many types of treatments, the resourceful massage therapist can usually substitute one treatment for another if contraindications are present. For example, although hot baths are helpful for insomnia, neutral temperature baths or a combination treatment (see below) can also be very effective.

A quick reminder: hydrotherapy treatments are not used on skin that is infected or has rashes. And use of some medications will preclude the use of some treatments (for more information, see Jean M. Wible’s Pharmacology for Massage Therapy (Lippincott Williams & Wilkins, 2004).

Localized Heat Treatments

Since they can encourage edema, heat applications, such as hot packs, 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, and over any part of the body that is known to be atherosclerotic, any area that is numb, and over the feet of anyone with diabetes.

Localized Cold Treatments

Local cold treatments, such as ice water handbaths or footbaths, are contraindicated for Raynaud’s syndrome (a vasoconstriction disorder of the extremities), because cold may cause a spasm of the smallest arteries of the hands or feet. They are also contraindicated for any area that is numb. (Many conditions can cause the loss of normal sensation, including arteriosclerosis, nerve injury, exposure to toxic substances, diabetes, and neuromuscular conditions like spinal cord injury and multiple sclerosis).

Whole-Body Heat Treatments

High temperature can create extra demands on the circulatory system, including significant changes in how fast the heart beats, how much blood the heart pumps with each beat, blood pressure, the size of different blood vessels, and where the blood is being shifted to in the body. In general, much more of the person’s blood supply than usual will be shifted to the vessels of the skin. Therefore, unless approved by the client’s doctor, whole-body heat treatments, such as saunas or hot tubs, are contraindicated for patients with high or low blood pressure, lymphedema, heart disease (such as coronary artery disease or congestive heart failure), and during pregnancy. Diabetes can lead to cardiovascular disease, so hot baths are contraindicated. (However, warm and neutral-temperature baths are a good choice for diabetics, as are whole-body salt glows). Clients with multiple sclerosis or who are prone to seizures should only have heat treatments with their doctor’s permission.

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.

Adapting Hydrotherapy to Different Settings

Many hydrotherapy treatments can be readily incorporated into your massage practice, even if you do not have running water in the room where your massage table is located, and even if you do not have money for expensive equipment. Local heat treatments include hot compresses, hot packs, hot water bottles, hot towels from a heated towel cabinet, paraffin dips, and hot handbaths or footbaths. Local cold treatments include ice packs, ice massage, cold compresses, and ice water handbaths or footbaths. Friction treatments such as salt glows and cold mitten frictions can also be given with little muss. And finally, body wraps are a simple, inexpensive way to give clients a whole-body heating treatment on your table.

By thinking ahead and assembling a few basic items, any massage therapist can perform some hydrotherapy treatments in almost any setting. For example, a massage practitioner working outdoors at a sports massage event can bring bags of ice and bottled water in a cooler, along with extra towels and washcloths, Epsom salts, and plastic tubs. With just these few tools, you 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.

A massage practitioner practicing in a hospital setting may see patients who have access to a whirlpool. Some hospitals that offer Jacuzzis for women during labor may have them available after the birth to help with perineal and low-back discomfort.

If you practice in a chiropractic office or physical therapy clinic, you may have access to hot packs. Hot packs 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. In this setting, where many clients are experiencing severe musculoskeletal pain, ice massage is also easy and useful.

Clients in assisted living facilities generally receive massage in their rooms, which contain a small kitchenette. Most likely this allows access to running water and ice. For larger quantities of ice, the facility’s kitchen may provide you with more from their ice machine. You may only wish to bring containers for water, such as plastic tubs or buckets. A much-loved treatment in this setting is a warm footbath that incorporates a salt glow of the feet and lower legs. Place a large towel on the floor and a chair on top of it; then have the client sit in the chair. Sitting on the ground in front of the client, work on each lower leg and foot. One foot may be taken out of the footbath and an Epsom salts glow performed with the foot resting on the edge of the tub or bucket. Then, put that foot back and repeat with the other foot and lower leg. Rinse off with clean water (cooler water if possible), dry the feet, and finish with hands-on massage techniques.

At nursing homes, clients are generally given massages in their rooms. With no kitchenette, you can still get hot and cold water from the tap in their bathroom and give simple treatments such as the footbath with local salt glows. You may wish to bring a container for water or obtain one from the nursing staff.

Typically, 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 their clients use those facilities before or after massage sessions. Health clubs that offer hydrotherapy treatments tend to inform clients about contraindications.

Basic Hydrotherapy Equipment

With simple equipment and a modest investment you can easily give your clients a variety of localized hydrotherapy treatments. If you can perform one type of local heat and one type of local cold, you can give hot, cold, and contrast treatments, as well as cold mitten frictions and local salt glows. Although having running water in the therapy room is not absolutely necessary, you will need to have a sink close at hand. Below is a list of basic equipment.

• A water thermometer, essential for safety.

• Extra linens, including about 20 washcloths, four small hand towels, and four large bath towels.

• Counter space or cart for hydrotherapy equipment.

• A large tray to carry materials to and from the therapy room, such as hot-water bottles, pitchers of water, bowls, and used linens or other items that need to be cleaned. Heavy cookie sheets, which are both sturdy and washable, work well for this purpose.

• Quart-sized metal or plastic bowls are useful for hot or cold water, ice cubes, salt for local salt glows, and other items.

• Pitchers: one that holds 4 cups and another that holds 8 cups.

• Plastic tubs that can go underneath the table to hold used towels and can also double as containers for local water baths.

• One form of local heat. Choose between a slow cooker pot or turkey roaster to heat water (useful for salt glows, hot compresses, silica gel packs, and hot water to pour into hot water bottles and handbaths and footbaths), a microwave oven (useful for heating fomentations—a large cloth pad that is first soaked in water and then heated—and some types of hot gel packs), a hot towel cabinet (holds many moist washcloths), or a moist heating pad.

• One type of local cold. Choose between very cold water (useful for cold mitten frictions, cold compresses, and cold local baths), iced compresses, ice packs, and ice cups. A miniature refrigerator can hold all of these items comfortably. A small ice chest may also be used for ice packs and ice cups that will be used during a session.

• Zipper closure bags of various sizes. These are useful for making ice packs and iced compresses, as well as heating fomentations in a microwave.

• Local friction treatment options. Choose Epsom salts and two washcloths for salt glows; cold water and two washcloths for cold mitten frictions; a loofah glove or mitt and two washcloths for loofah scrubs; or a soft, natural bristle brush and two washcloths for dry brushing.

• Plastic sheets. Place these underneath cloth sheets to keep the table dry. 

• Towels to protect the sheets the client is lying on during a salt glow, footbath  or handbath, and to mop up spills.

Combination Treatment

The following whole-body treatment consists of a contrast treatment to the chest, using a hot fomentation and ice rub, combined with a hot fomentation to the back and a hot footbath. At the end of the treatment, clients generally feel soothed, warmed, and can breathe easier. This treatment is also excellent for relief of musculoskeletal discomfort such as soreness in the chest muscles from prolonged coughing, deep tension in the chest muscles, or arthritic pain in the back. Because this treatment is performed on a massage table, it is well suited for a client who would benefit from a warm bath but cannot get in and out of a tub, such as someone with severe arthritis or Parkinson’s disease. The entire procedure can be done without expensive hydrotherapy equipment.


• Habitual patterns of tightness in the chest muscles.

• Insomnia.

• Nervous tension.

• Musculoskeletal pain, including arthritis pain, muscular pain, and rigidity of Parkinson’s disease.

• Sore or tight scalene, intercostals, or pectoralis major muscles.


• Any condition that specifically contraindicates whole-body heating, such as cardiovascular problems, diabetes, hepatitis, lymphedema, multiple sclerosis, seizure disorders, and hypothyroid conditions.

• Great obesity.

• Inability to tolerate heat.

• Ingestion of alcohol or drugs.

• Lack of sensation in the feet.

• Pregnancy.

Time Needed

30 minutes

Equipment Needed

Water thermometer, kitchen timer, table or counter space to hold equipment, rubber gloves to protect your hands when handling fomentation, plastic bed sheet or thick towels to cover the massage table, cotton sheets, one blanket, footbath tub (a rectangular plastic dishpan works well), two pitchers, one drinking glass with straw, about six towels, three fomentations with fabric covers, two washcloths for cold applications to the forehead, basin for ice cubes, and hot and cold water.


1. Heat the fomentations in a microwave in a resealable plastic bag.

2. While the fomentations are heating, prepare the surface of a massage table with a blanket, plastic sheet, and one cotton sheet.

3. Using rubber gloves, wrap the first hot fomentation in its cover. Lay it down on the sheet where the client’s back will be, and cover it with one or two towels (Image 1).

4. Have the client get on the table and lie supine, making sure the pack is warming the entire back from sacrum to shoulders (Image 2). Be sure to ask the client for feedback frequently, and if it feels too hot, add another layer of towel.

5. Fill the dishpan with hot water (110°F) and place the client’s feet in it. Check with the client to make sure the water temperature is tolerable (Image 3).

6. Cover the second fomentation with towels, place over the chest, and monitor it frequently so it does not burn the skin (Image 4).

7. Cover the client. Then, during the next five minutes, you may perform a brief facial massage.

8. After five minutes, rub the entire chest briskly for 30 seconds with a washcloth wrung from iced water (Image 5). Do not apply this friction over a woman’s breasts.

9. Place another hot fomentation on the chest. Set a timer for five minutes.

10. Add more hot water to the footbath if needed so that the water remains at 105–110°F.

11. Provide water to drink as needed, and place a washcloth wrung out in ice water on the forehead.

12. Repeat steps 8–11.

13. After five more minutes, remove the chest fomentation, rub the chest with ice water, then dry the chest.

14. Have the client sit up. Remove the back fomentation and rub the entire back briefly with ice water. Dry the back. Do not let the client become chilled at this point.

15. Take the client’s feet out of the hot water, pour ice water over the feet, and dry them off (Image 6).

16. Remove the towel underneath the client, cover him or her with a dry sheet, and begin hands-on massage.


Hydrotherapy treatments complement your work as a massage therapist and expand your options when it comes to treating clients.


Marybetts Sinclair, LMT, has been a massage therapist in Oregon for 34 years. She is the author of Modern Hydrotherapy for the Massage Therapist (Lippincott Williams & Wilkins, 2004). Marybetts Sinclair has taught massage in special programs for disabled children in the United States, Mexico, and Ecuador. For more information, visit www.marybettssinclair.com.