Motion-based treatment

Related Terms

Aqua lymphatic therapy, aquatic physical therapy, balneopelotherapy, balneoradonokinesitherapy, balneotherapy, bath, climatotherapy, cold therapy, cold water cure, colonic hydrotherapy, colonic irrigation, constitutional hydrotherapy, crenotherapy, Dead Sea bath, douche, dry-air radon bath, external hydrotherapy, fomentation, footbath, home spa, hot springs, hot therapy, hot tub, hot tub therapy, ice water immersion, immersion bath, internal hydrotherapy, Jacuzzi?, jet spray, local hydrotherapy, motion-based treatment, mud bath, pack, poultice, purifying bath, radon and iodine-bromine baths, radon bath, salt bath, saltwater baths, sauna, sauna bathing, shower, siliceous baths, sitz bath, soaked towel, spa treatment, specialized bathing systems, Stanger bath therapy, sulfide mud, temperature-based treatment, therapeutic bath in mineral water, thermal spring water, thermal therapy, Turkish bath, warm saltwater immersion, warm sulfur water immersion, warm tap water immersion, water bath, water birth, water immersion, water mineral bath, Watsu?, whirlpool, whirlpool bath.
Note: This review does not include in-depth discussions of therapies that may include the use of water as a part of the technique, such as colonic irrigation, enemas, nasal irrigation, physical therapy in pools, steam inhalation, humidifiers, drinking of mineral water or "enriched" water, coffee infusions, aquatic yoga, aquatic massage (including Watsu?), or aromatherapy or baths with added essential oils.

Background

Water has been used medicinally for thousands of years, with traditions rooted in ancient China, Japan, India, Rome, Greece, the Americas, and the Middle East. There are references to the therapeutic use of mineral water in the Old Testament. During the Middle Ages, bathing fell out of favor due to health concerns, but by the 17th Century, "taking the waters" at hot springs and spas became popular across Europe (and later in the United States).
Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. These approaches have been used for the relief of various diseases and injuries, or for general well-being. There are other therapies that may include the use of water as a part of a technique, such as colonic irrigation, enemas, nasal irrigation, physical therapy in pools, steam inhalation, humidifiers, drinking of mineral water or "enriched" water, coffee infusions, aquatic yoga, aquatic massage (including Watsu?), or aromatherapy or baths with added essential oils, however, they are not discussed in-depth in this review.
Modern hydrotherapy originated in 19th Century Europe with the development of spas for "water cure" ailments, ranging from anxiety to pneumonia to back pain. Father Sebastian Kneipp, a 19th Century Bavarian monk, spurred a movement to recognize the benefits of hydrotherapy. His methods were later adopted by Benedict Lust, who immigrated to the United States from Germany in 1896 and founded an American school of naturopathic medicine. Lust claimed to have cured himself of tuberculosis with Kneipp's methods, and so hydrotherapy was included as a component of naturopathic medicine. In the present day, a wide variety of water-related therapies are used, some of which are described below.
Aquatic physical therapy/Watsu?: Physical therapy in pools is a well-established technique that takes advantage of buoyancy and resistance to movement in water. Watsu? is a Chinese form of bodywork conducted in pools.
Coffee infusions: The use of coffee infusions was developed by Dr. Max Gerson. It is thought to stimulate intestinal contractions and is used in cases of indigestible food and nausea.
Cold arm bath: For a cold arm bath, the arm is placed in a basin of cold water with the water level reaching just above the elbow.
Cold footbath: Cold footbaths involve placing the feet in a bath filled calf-deep with cold water. "Walking in water" involves stepping on a nonslip mat placed under water.
Cold rubbings: This technique may use linens or towels soaked in cold water then wrung out and vigorously rubbed on the upper and lower trunk or the entire body.
Cold water therapy (60 degrees Fahrenheit): Cold water therapy is used to stimulate blood flow in the skin and underlying muscles.
Colonic hydrotherapy: Colonic hydrotherapy uses water as a vehicle to eliminate toxins and wastes in the colon, which are either immobilized in pockets or glued to its sides. Colonic hydrotherapy frees the intestinal tract of organic wastes. During colonic irrigation, a therapist inserts a plastic tube into the person's rectum and pumps water or herbal solutions until the colon is full (called an enema). Once the colon is full, the therapist massages the abdomen area and then draws the fluid out. The procedure is repeated for up to an hour. Body-temperature water is used. Some experts in the field claim this treatment is unnecessary and possibly harmful.
Constitutional hydrotherapy: Constitutional hydrotherapy is hydrotherapy used on the whole person, usually by being wrapped in sheets and blankets of varying temperatures. Constitutional hydrotherapy is thought to reestablish normal brain function.
Dead Sea balneotherapy: There are numerous published articles regarding the use of therapeutic uses of water immersion in the Dead Sea (and other salt water bodies), particularly for chronic skin conditions. Because this therapy also involves prolonged exposure to sunlight, it is not clear to what extent possible benefits are due to the water, to minerals and high salt content in the water, to sun exposure, or to a combination of factors.
Douches: Douches may be carried out with a watering can or hose. Treatments may be applied to any area of the body, with the intention to relieve tension or pain, or to affect blood flow.
Hot fomentation: Hot fomentation involves application of warm liquid or moist heat to the surface of the body. Practitioners believe that this enhances the body's ability to fight cancer cells, viruses, and bacteria. This therapy is often used to relieve fever, because it raises the body temperature to 101-103 degrees Fahrenheit, which is suggested to reestablish the natural fever cycle, allowing the body to heal itself.
Hot water therapy: Hot water therapy (around 100 degrees Fahrenheit) is used to relax muscles and cause sweating. It is commonly used for arthritis, rheumatism, poor circulation, and sore muscles.
Internal hydrotherapy: Internal hydrotherapy consists of colonic irrigations and enemas. It also includes steam baths or inhalation of steam to relieve respiratory congestion, and drinking mineral water to restore electrolyte balance or cleanse the system.
Local hydrotherapy: Local hydrotherapy is hydrotherapy used on one part of the body.
Packs: Cold or warm packs are applied to treat certain muscular, joint, or psychiatric conditions.
Poultices: Poultices are used for health maintenance and treatment of disease.
Purifying baths: Purifying baths include bathing in solutions of chlorine bleach, sea salt, lemon juice, turmeric, Epsom salts, baking soda, or other substances in order to purify the body of radiation, toxins, or heavy metal deposits.
Rising-temperature arm bath: In the rising-temperature arm bath, arms are immersed in a bath with water at body temperature. Hot water is gradually added until the temperature reaches 103-104 degrees Fahrenheit. The whole process lasts for 10-15 minutes and may be done daily. Caution is warranted so as not to cause burns.
Rising-temperature footbath, warm footbath: In these baths, feet are immersed in water at body temperature. Hot water is gradually added until the temperature reaches 103-104 degrees Fahrenheit. The process lasts for 10-15 minutes and may be done daily. Caution is warranted so as not to cause burns.
Rising-temperature hip bath: These baths are administered in tubs initially filled with shallow, tepid water. Hot water is gradually added until levels reach the navel. A common temperature is 103-104 degrees Fahrenheit. Caution is warranted so as not to cause burns. The bather may then be wrapped in warm dressings.
Shower: Hot, cold, or alternating-temperature sprays are commonly used.
Sitz bath: A sitz bath is administered in a tub that allows the hips to be immersed in water. Sitz baths have been used in the management of back pain, sore muscles, muscle spasms, body aches, sprains, hemorrhoids, pruritus (itching), inflammation, rashes, and anxiety; for wound care and hygiene; and for relaxation. For various ailments, different temperatures may be used, and minerals or medications may be added to the water.
Spa/hot tub/whirlpool/motion-based hydrotherapy: These therapies are sometimes used in people with wounds, chronic musculoskeletal pain, or inflammation. Awareness of the risk of introducing infections into wounds and keeping wounds clean is important.
Steam bath/sauna: Heat may be used to cause sweating, and this technique is variably included in the definition of hydrotherapy. People should not spend more than 15-20 minutes in a steam bath or sauna, and individuals with medical conditions such as heart or lung disease should avoid prolonged heat exposure (as directed by a qualified healthcare provider).
Stanger bath therapy: Stanger bath therapy consists of application of a current through metal electrodes placed in a special water tub. It is most often used in the relief of pain.
Water birth: The potential benefits of giving birth in water have been explored. Water births may be as safe as vaginal births if they are conducted by experienced professionals with low-risk women.
Wraps: Hot or cold wet wraps may be used around various parts of the body. This technique is sometimes used with the intention to reduce fever or foster relaxation. Hot fomentation involves the application of warm liquid or moist heat with towels to the surface of the body.

Theory

There are numerous proposed mechanisms of action of hydrotherapy, depending on the specific technique used. Hydrotherapy practitioners and texts propose that immersion treatments and wraps may serve to detoxify the blood.
Alternating cold with hot temperatures is suggested to alter blood circulation, enhance the immune system, and improve digestion. Applying warmth to skin surfaces does cause vasodilation (expansion of blood vessels), which brings blood to the body's surface. Cold temperature has the contrary effect. Warmth also causes muscle relaxation. Some hydrotherapy techniques make use of these physiological changes, although the correlation to long-term health benefits is not clear.
Electrical stimulation is sometimes used and is suggested to stimulate muscles, digestion, and circulation (although caution is warranted due to the risks associated with using electricity while in water).
Physical therapy in water makes use of buoyancy (the ability to float) to reduce working against gravity, as well as making use of the resistance of motion through water.
It is difficult to design high-quality studies in this area due to the challenge of creating "placebo" hydrotherapy.

Evidence Table

These uses have been tested in humans or animals. Safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider. GRADE *
These uses have been tested in humans or animals. Safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider. GRADE *


Hydrotherapy has been used historically for the treatment of symptoms related to rheumatoid arthritis and osteoarthritis. Multiple studies have been published, largely based on therapy given at Dead Sea spa sites in Israel. Although most studies report benefits in pain, range of motion, or muscle strength, additional studies are needed in this important area.

 B


Hydrotherapy has been used historically for the treatment of symptoms related to rheumatoid arthritis and osteoarthritis. Multiple studies have been published, largely based on therapy given at Dead Sea spa sites in Israel. Although most studies report benefits in pain, range of motion, or muscle strength, additional studies are needed in this important area.

 B


Several small controlled trials report that regular use of hot whirlpool baths with massaging jets improves the duration and severity of back pain when added to standard therapy, compared to standard therapy alone. It is not clear if there is a reduced need for pain control drugs, or if benefits are long-standing. Because these studies are small, with flaws in design and reporting, better-quality research is necessary before a strong conclusion can be drawn.

 B


Several small controlled trials report that regular use of hot whirlpool baths with massaging jets improves the duration and severity of back pain when added to standard therapy, compared to standard therapy alone. It is not clear if there is a reduced need for pain control drugs, or if benefits are long-standing. Because these studies are small, with flaws in design and reporting, better-quality research is necessary before a strong conclusion can be drawn.

 B


There is preliminary evidence supporting the use of sitz baths in people with anorectal conditions, particularly for symptom relief. Sitz baths are offered to people in many hospitals. However, controlled studies are needed to determine the effectiveness and optimal use of sitz baths.

 C


There is preliminary evidence supporting the use of sitz baths in people with anorectal conditions, particularly for symptom relief. Sitz baths are offered to people in many hospitals. However, controlled studies are needed to determine the effectiveness and optimal use of sitz baths.

 C


Hydrotherapy is widely used in hospitals and rehabilitation centers in the management of burns. Various techniques are used, with variations in methods, lengths of time, frequency, and training levels of personnel administering treatments. There is limited research at this time, and no clear conclusions can be drawn.

 C


Hydrotherapy is widely used in hospitals and rehabilitation centers in the management of burns. Various techniques are used, with variations in methods, lengths of time, frequency, and training levels of personnel administering treatments. There is limited research at this time, and no clear conclusions can be drawn.

 C


There is preliminary evidence that daily breathing exercises in a warm pool may improve lung function measurements in people with COPD. It is not clear if this technique is superior to breathing exercises alone. Evidence from controlled trials is necessary before a clear conclusion can be drawn.

 C


There is preliminary evidence that daily breathing exercises in a warm pool may improve lung function measurements in people with COPD. It is not clear if this technique is superior to breathing exercises alone. Evidence from controlled trials is necessary before a clear conclusion can be drawn.

 C


Studies report that hydrotherapy may improve blood flow to the legs and increase the pain-free walking distance of people with claudication due to peripheral vascular disease. Additional research is needed in this area before a clear conclusion can be drawn.

 C


Studies report that hydrotherapy may improve blood flow to the legs and increase the pain-free walking distance of people with claudication due to peripheral vascular disease. Additional research is needed in this area before a clear conclusion can be drawn.

 C


There is preliminary evidence that daily showers with warm water followed by cold water, or cold water alone, may reduce the duration and frequency of common cold symptoms. Additional research is needed in this area before a clear conclusion can be drawn.

 C


There is preliminary evidence that daily showers with warm water followed by cold water, or cold water alone, may reduce the duration and frequency of common cold symptoms. Additional research is needed in this area before a clear conclusion can be drawn.

 C


There preliminary evidence suggesting that hydrotherapy may positively affect blood chemistry in diabetes mellitus. However, there is insufficient evidence on which to base conclusions for its use or to determine realistic expectations of benefit.

 C


There preliminary evidence suggesting that hydrotherapy may positively affect blood chemistry in diabetes mellitus. However, there is insufficient evidence on which to base conclusions for its use or to determine realistic expectations of benefit.

 C


There is limited evidence in this area. One study has shown that treatment with thermal baths cures secretory otitis media (ear infection) and reduces number of infections of the primary airways. Further research is warranted before a conclusion can be made.

 C


There is limited evidence in this area. One study has shown that treatment with thermal baths cures secretory otitis media (ear infection) and reduces number of infections of the primary airways. Further research is warranted before a conclusion can be made.

 C


There is preliminary evidence suggesting that hydrotherapy may improve endurance performance. A single study found an improvement in endurance performance after a sauna bath. Further research is required before any definite conclusion can be drawn.

 C


There is preliminary evidence suggesting that hydrotherapy may improve endurance performance. A single study found an improvement in endurance performance after a sauna bath. Further research is required before any definite conclusion can be drawn.

 C


There is preliminary evidence supporting the use of hydrotherapy in hyperthermia (elevated body temperature). A single study concluded that cool water reduces heat strain and increases work performance in hot environments. Further studies are required before a definite conclusion can be drawn.

 C


There is preliminary evidence supporting the use of hydrotherapy in hyperthermia (elevated body temperature). A single study concluded that cool water reduces heat strain and increases work performance in hot environments. Further studies are required before a definite conclusion can be drawn.

 C


Research results are mixed. Further well-designed trials are needed before a conclusion can be made.

 C


Research results are mixed. Further well-designed trials are needed before a conclusion can be made.

 C


Research results are mixed in this area. One human study suggested that repeated sauna treatment may reduce the risk of arrhythmias, while another suggested that this therapy may improve heart failure-related symptoms and heart rate response to exercise. Further well-designed research is needed before firm conclusions can be drawn.

 C


Research results are mixed in this area. One human study suggested that repeated sauna treatment may reduce the risk of arrhythmias, while another suggested that this therapy may improve heart failure-related symptoms and heart rate response to exercise. Further well-designed research is needed before firm conclusions can be drawn.

 C


There is preliminary evidence supporting the use of hydrotherapy for high blood pressure. A study has found hydrotherapy useful in people with high or medium blood pressure. Further research is warranted in this area.

 C


There is preliminary evidence supporting the use of hydrotherapy for high blood pressure. A study has found hydrotherapy useful in people with high or medium blood pressure. Further research is warranted in this area.

 C


Preliminary research on hydrotherapy for insomnia shows inconclusive results. A single study has shown that sitting in baths of warm water had positive effects on sleep parameters. Further research in this area is warranted.

 C


Preliminary research on hydrotherapy for insomnia shows inconclusive results. A single study has shown that sitting in baths of warm water had positive effects on sleep parameters. Further research in this area is warranted.

 C


Preliminary evidence supports the use of hot water for bluebottle stings over ice packs. However, further research is necessary before conclusions can be made.

 C


Preliminary evidence supports the use of hot water for bluebottle stings over ice packs. However, further research is necessary before conclusions can be made.

 C


There is preliminary research on the effects of giving birth in water on labor pain, duration of labor, perineal damage to the mother, and birth complications. Further studies of effectiveness and safety are necessary before a conclusion can be drawn.

 C


There is preliminary research on the effects of giving birth in water on labor pain, duration of labor, perineal damage to the mother, and birth complications. Further studies of effectiveness and safety are necessary before a conclusion can be drawn.

 C


Preliminary research suggests that using ice water may not be effective in reducing symptoms of delayed-onset muscle soreness (DOMS). Further research is warranted in this area.

 C


Preliminary research suggests that using ice water may not be effective in reducing symptoms of delayed-onset muscle soreness (DOMS). Further research is warranted in this area.

 C


There is limited evidence supporting the use of hydrotherapy in chronic neck pain. A study concluded that pulsed electromagnetic field therapy was superior to spa therapy in the treatment of chronic neck pain, although both were more cost effective than routine care. Further research is warranted in this area.

 C


There is limited evidence supporting the use of hydrotherapy in chronic neck pain. A study concluded that pulsed electromagnetic field therapy was superior to spa therapy in the treatment of chronic neck pain, although both were more cost effective than routine care. Further research is warranted in this area.

 C


There is insufficient research in this area to make a conclusion. Pelvic inflammatory disease is a potentially serious medical condition that should be evaluated by a qualified, licensed healthcare provider.

 C


There is insufficient research in this area to make a conclusion. Pelvic inflammatory disease is a potentially serious medical condition that should be evaluated by a qualified, licensed healthcare provider.

 C


There is preliminary evidence suggesting that aquatic exercises, like other forms of weight-bearing exercises, may help increase bone mass.

 C


There is preliminary evidence suggesting that aquatic exercises, like other forms of weight-bearing exercises, may help increase bone mass.

 C


Hydrotherapy has been used in people with pressure ulcers, and preliminary research suggests that daily whirlpool baths may reduce the time for wound healing. Better research is necessary in this area before a firm conclusion can be drawn. There is a risk of infection from contaminated water if sanitary conditions are not maintained.

 C


Hydrotherapy has been used in people with pressure ulcers, and preliminary research suggests that daily whirlpool baths may reduce the time for wound healing. Better research is necessary in this area before a firm conclusion can be drawn. There is a risk of infection from contaminated water if sanitary conditions are not maintained.

 C


There is preliminary evidence from two case series studies suggesting that hydrotherapy may be beneficial in psoriasis. However, there is insufficient research in this area to make a firm conclusion.

 C


There is preliminary evidence from two case series studies suggesting that hydrotherapy may be beneficial in psoriasis. However, there is insufficient research in this area to make a firm conclusion.

 C


Limited evidence suggests that hydrotherapy may improve Rett's syndrome. Larger trials are required before any firm conclusion is drawn.

 C


Limited evidence suggests that hydrotherapy may improve Rett's syndrome. Larger trials are required before any firm conclusion is drawn.

 C


There is preliminary evidence that hydrotherapy in an acidic hot spring bath may reduce the severity of symptoms in atopic dermatitis. Evidence from controlled trials is necessary before a clear conclusion can be drawn.

 C


There is preliminary evidence that hydrotherapy in an acidic hot spring bath may reduce the severity of symptoms in atopic dermatitis. Evidence from controlled trials is necessary before a clear conclusion can be drawn.

 C


Some evidence suggests that hydrotherapy, when added to routine physiotherapy, may be of benefit in spinal muscular atrophy. However, there is insufficient research in this area to make a conclusion. More studies are needed.

 C


Some evidence suggests that hydrotherapy, when added to routine physiotherapy, may be of benefit in spinal muscular atrophy. However, there is insufficient research in this area to make a conclusion. More studies are needed.

 C


There is insufficient evidence supporting the use of aquatic exercises in people with brain injury to enhance health-promoting behavior. More research is warranted in this area.

 C


There is insufficient evidence supporting the use of aquatic exercises in people with brain injury to enhance health-promoting behavior. More research is warranted in this area.

 C


There is insufficient evidence to support the use of balneotherapy in chronic vaginitis. A single study has found balneotherapy to be effective in chronic vaginitis in groups of childbearing age. Further research is required before any definite conclusion can be drawn.

 C


There is insufficient evidence to support the use of balneotherapy in chronic vaginitis. A single study has found balneotherapy to be effective in chronic vaginitis in groups of childbearing age. Further research is required before any definite conclusion can be drawn.

 C


Preliminary research reports improved symptoms and blood flow in people with varicose veins undergoing hydrotherapy with intermittent cold and hot water hydrotherapy. Additional research is needed in this area before a clear conclusion can be drawn.

 C


Preliminary research reports improved symptoms and blood flow in people with varicose veins undergoing hydrotherapy with intermittent cold and hot water hydrotherapy. Additional research is needed in this area before a clear conclusion can be drawn.

 C
* Key to grades

A: Strong scientific evidence for this use
B: Good scientific evidence for this use
C: Unclear scientific evidence for this use
D: Fair scientific evidence for this use (it may not work)
F: Strong scientific evidence against this use (it likley does not work)
* Key to grades

A: Strong scientific evidence for this use
B: Good scientific evidence for this use
C: Unclear scientific evidence for this use
D: Fair scientific evidence for this use (it may not work)
F: Strong scientific evidence against this use (it likley does not work)

Tradition / Theory

The below uses are based on tradition, scientific theories, or limited research. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider. There may be other proposed uses that are not listed below.

Safety

Many complementary techniques are practiced by healthcare professionals with formal training, in accordance with the standards of national organizations. However, this is not universally the case, and adverse effects are possible. Due to limited research, in some cases only limited safety information is available.

Attribution

This information is based on a systematic review of scientific literature edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Acikel C, Ulkur E, Guler MM. Prolonged intermittent hydrotherapy and early tangential excision in the treatment of an extensive strong alkali burn. Burns 2001;27(3):293-296.
Aderhold KJ, Perry L. Jet hydrotherapy for labor and postpartum pain relief. MCN Am J Matern Child Nurs 1991;16(2):97-99.
Ammer K, Melnizky P. [Medicinal baths for treatment of generalized fibromyalgia]. Forsch Komplementarmed 1999;6(2):80-85.
Beamon S, Falkenbach A, Jobst K. Hydrotherapy for asthma. Cochrane Database Syst Rev 2001;(2):CD001741.
Brock FE. [Additive effects of vein-typical hydrotherapy according to Kneipp and topic treatment with arnica-containing gel in patients with chronic venous insufficiency-synergism of naturopathic therapies]. Erfahrungsheilkunde 2001;6:357-363.
Constant F, Guillemin F, Collin JF, et al. Use of spa therapy to improve the quality of life of chronic low back pain patients. Med Care 1998;36(9):1309-1314.
Danesino V. [Balneotherapy with arsenical-ferruginous water in chronic cervico- vaginitis. A case-control study]. Minerva Ginecol 2001;53(1):63-69.
Ekmekcioglu C, Strauss-Blasche G, Feyertag J, et al. The effect of balneotherapy on ambulatory blood pressure. Altern Ther Health Med 2000;6(6):46-53.
Elkayam O, Ophir J, Brener S, et al. Immediate and delayed effects of treatment at the Dead Sea in patients with psoriatic arthritis. Rheumatol Int 2000;19(3):77-82.
Ernst E, Pittler MH. [How effective is spa treatment? A systematic review of randomized studies]. Dtsch Med Wochenschr 1998;123(10):273-277.
Franke A, Reiner L, Pratzel HG, et al. Long-term efficacy of radon spa therapy in rheumatoid arthritis--a randomized, sham-controlled study and follow-up. Rheumatology (Oxford) 2000;39(8):894-902.
Kurabayashi H, Machida I, Kubota K. Improvement in ejection fraction by hydrotherapy as rehabilitation in patients with chronic pulmonary emphysema. Physiother Res Int 1998;3(4):284-291.
Mcllveen B, Robertson VJ. A randomised controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain. Physiotherapy 1998;84(1):17-26.
Moore JE, Heaney N, Millar BC, et al. Incidence of Pseudomonas aeruginosa in recreational and hydrotherapy pools. Commun Dis Public Health 2002;5(1):23-6.
Robertson PA, Huang LJ, Croughan-Minihane MS, et al. Is there an association between water baths during labor and the development of chorioamnionitis or endometritis? Am J Obstet Gynecol 1998;178(6):1215-1221.