Cuesta-Vargas (2013) Hydrotherapy as a recovery strategy after excercise A pragmatic trial

Background: Our aim was to evaluate the recovery effects of hydrotherapy after aerobic exercise in cardiovascular,performance and perceived fatigue.

Methods: A pragmatic controlled repeated measures; single-blind trial was conducted. Thirty-four recreationalsportspeople visited a Sport-Centre and were assigned to a Hydrotherapy group (experimental) or rest in a bed(control) after completing a spinning session. Main outcomes measures including blood pressure, heart rate,handgrip strength, vertical jump, self-perceived fatigue, and body temperature were assessed at baseline,immediately post-exercise and post-recovery. The hypothesis of interest was the session*time interaction.

Results: The analysis revealed significant session*time interactions for diastolic blood pressure (P=0.031), heart rate(P=0.041), self perceived fatigue (P=0.046), and body temperature (P=0.001); but not for vertical jump (P=0.437),handgrip (P=0.845) or systolic blood pressure (P=0.266). Post-hoc analysis revealed that hydrotherapy resulted inrecovered heart rate and diastolic blood pressure similar to baseline values after the spinning session. Further,hydrotherapy resulted in decreased self-perceived fatigue after the spinning session.

Conclusions: Our results support that hydrotherapy is an adequate strategy to facilitate cardiovascular recovers andperceived fatigue, but not strength, after spinning exercise.

 

R E S E A R C H A R T I C L E Open Access
Hydrotherapy as a recovery strategy after
exercise: a pragmatic controlled trial
Antonio I Cuesta-Vargas1*, Alvaro Trav-Mesa2, Alberto Vera-Cabrera2, Dario Cruz-Terrn3,
Adelaida M Castro-Snchez4, Cesar Fernndez-de-las-Peas5and Manuel Arroyo-Morales2
Abstract
Background:Our aim was to evaluate the recovery effects of hydrotherapy after aerobic exercise in cardiovascular,
performance and perceived fatigue.
Methods:A pragmatic controlled repeated measures; single-blind trial was conducted. Thirty-four recreational
sportspeople visited a Sport-Centre and were assigned to a Hydrotherapy group (experimental) or rest in a bed
(control) after completing a spinning session. Main outcomes measures including blood pressure, heart rate,
handgrip strength, vertical jump, self-perceived fatigue, and body temperature were assessed at baseline,
immediately post-exercise and post-recovery. The hypothesis of interest was the session*time interaction.
Results:The analysis revealed significant session*time interactions for diastolic blood pressure (P=0.031), heart rate
(P=0.041), self perceived fatigue (P=0.046), and body temperature (P=0.001); but not for vertical jump (P=0.437),
handgrip (P=0.845) or systolic blood pressure (P=0.266). Post-hoc analysis revealed that hydrotherapy resulted in
recovered heart rate and diastolic blood pressure similar to baseline values after the spinning session. Further,
hydrotherapy resulted in decreased self-perceived fatigue after the spinning session.
Conclusions:Our results support that hydrotherapy is an adequate strategy to facilitate cardiovascular recovers and
perceived fatigue, but not strength, after spinning exercise.
Trial registration:ClinicalTrials.gov Identifier: NCT01765387
Keywords:Hydrotherapy, Heart rate, Fatigue, Strength, Blood pressure, Body temperature
Background
The translation ofSalus per aquato a metropolitan envir-
onment is a Club Spa facility where the primary purpose
is fitness by offering a variety of professionally adminis-
tered hydrotherapy services on a day-use basis. Different
strategies including massage 1, compression garments
2, cryotherapy 3, contrast baths 4, and electromyos-
timulation 5 are effective for enhancing recovery after
exercise, but their effects remain to be fully elucidated.
Hydrotherapy could be a strategy that may be effective for
assisting in recovery after exercise. Several exercises
modalities are offered in Spa Club centers for improving
aerobic capacity. Spinning is considered a high intensity
interval exercise modality 6 which leads to improve bonemineral density as a health benefit 7. Furthermore, high-
intensity interval exercise may improve health status 8.
Nevertheless, immediate deleterious effects with these
exercise modalities include an increase of cardiac bio-
markers 9, rhabdomyolysis 10, or apparition of side
effects in illness population 11.
It seems that water immersion induces cardiovascular
system response mediated by parasympathetic branches of
autonomic nervous system 12. This response induces a
cardio-protector effect characterized by bradycardia and
reduction of cardiac output 13. It is not known if a simi-
lar response is elicited during the recovery phase after
exercise.
Preliminary research has demonstrated that contrast
bath therapy, a commonly used modality in sports centers,
is associated with faster recovery of power production
during a jump squat test 14. However, when exercise in-
volves isometric performance the contrast bath therapy
* Correspondence:acuesta@uma.es1School of Clinical Science, Faculty of Health Science, Queensland University
Technology, Brisbane, Australia
Full list of author information is available at the end of the article
2013 Cuesta-Vargas et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http:creativecommons.orglicensesby2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Cuesta-Vargaset al. BMC Complementary and Alternative Medicine2013,13:180
http:www.biomedcentral.com1472-688213180

was associated in reduced performance 14. Although the
effects of hydrotherapy are controversial, the beneficial
effects on self-rated recovery may further support the use
of these recovery strategies 15. Research focusing on
therapeutic recovery approaches e.g., hydrotherapy on
physiological and performance parameters following exer-
cise is scare.
Better knowledge relative to the appropriate com-
bination of exercise and hydrotherapy as a therapeutic ap-
proach to generate wellness could improve upon the
effects of combined strategies frequently used in sports
centers. Therefore, the aim of this study was to evaluate
the effects of hydrotherapy on recovery following a spin-
ning session focusing on cardiovascular, muscle perform-
ance and self-perceived fatigue in group of recreational
sportspeople.
Methods
This was a pragmatic, controlled, simple-blind study in-
vestigating the immediate effects of hydrotherapy (expe-
rimental group) or rest in a supine position (control) after
a spinning exercise in recreational sportspeople. Both
groups performed the recovery session (hydrotherapy or
rest in supine position) after completing the exercise
protocol. Participants were allocated to the control or
intervention group based on their order of arrival. Because
special facilities were required (hydrotherapy and spinning
equipment), we contacted the Y010 Sport Club (Granada,
Spain) to carry out the study. We had an ethical obligation
with the Y010 Sport Centre to avoid modifying the prefer-
ences of the club users with respect to hydrotherapy,
which did not permit us randomization. During the first 2
months, we recruited the intervention group and in the
subsequent 3 months the control group.
Subjects
Potentially eligible participants were initially screened for
the inclusion criteria including: 510 hourswk of physical
activity, no pharmaceutical drug intake in the past 3
months, no use of tobacco or other addictive substances,
no signs or symptoms of medical disease, no pain symp-
toms in the previous 12 months, and no contraindication
for high-intensity exercise and participation in previous
studies about recovery after exercise 1. Exclusion criteria
including: practice sport in professional setting to be
affected by orthopaedic or general conditions as diabetes
or hypertension. After this initial session, participants ar-
rived at the sport-centre between 17:0021:00 hours on 2
separate occasions to avoid circadian rhythm-induced var-
iations There was a 1-week interval period between each
treatment session. Participants were requested to abstain
from caffeine, alcohol, food and exercise for 24 h prior to
starting the study to reduce the influence of these sub-
stances on outcomes. The exercise session was supervisedby a certified trainer with 10 year of experience in Spin-
ning. Informed consent was obtained from all subjects,
and study procedures were consistent with the Helsinki
declaration. The study was approved by University of
Granada Ethic Commmittee.
Exercise session
The spinning session was performed using the same
protocol for all participants after a 24 h physical rest as
suggested 16. Participants were asked to perform this
session as a regular spinning class. The session was car-
ried out in the afternoon (room temperature 223.5C)
on a modified spinning bike (Keiser, M3). They were
allowed to drink water during the session and completed
the spinning session while listening to a compilation of
music that lasted 50 min and was composed of 9 tracks.
Each track corresponded to a specific phase of the spin-
ning session. The phases were labeled as warm-up, sitting,
seated climbing, jumping, and running, based on the
official spinning program manual 17. Some phases were
repeated during the session, the compilation being
purposely designed for beginners in a spinning class. In
addition to the music protocol, participants were asked to
maintain a pedal stroke cadence that had previously been
established for each track. For the resistance applied to
the flywheel, they were free to adjust it according to their
sensation and interpretation of the spinning session.
Recovery procedures
Experimental group
A cycle of 3 Vichy shower and whirlpool baths were ap-
plied during 30-minutes period. Vichy sedative shower
was applied for 90120 sec to the sides of the trunk and
the abdomen, avoiding as much as possible the gall bla-
dder area, at a temperature of 36-38C. A short, partial
jet spray followed the shower. A whirlpool bath was ad-
ministered where subjects immersed the body until their
clavicle level for a 10min period with a water temperature
ranging 33.5-35.5C. Aromatherapy application using lav-
ender and chamomile oils was used in all hydrotherapy
sessions.
Control group
The control group performed a rest session in supine
position in a room with neutral temperature condition
with a same duration to hydrotherapy session. Participants
of both groups were encouraged to drink waterad
libitumto prevent dehydration.
Measurements
Outcomes were obtained at baseline, after each exercise
intervention, and at the end of the recovery session
(hydrotherapy, rest). Self-rated measurements, physio-
logical and performance parameters were included in
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this study with the intention to have a broad and prac-
tical view of different aspect of recovery after fatigue.
Blood pressureheart rate measurements
An Omron HEM-737 validated automatic oscillometric
device (Kyoto, Japan) was used for assessing blood pres-
sure and heart rate measurements. Measurements were
performed in triplicate and the average was used for data
analysis.
Upper body muscular strength
Handgrip strength was assessed bilaterally with a digital
dynamometer (TKK 5101 Grip-D; Takey, Tokyo, Japan)
as previously described 18. Subjects performed the test
twice, allowing a 3-minute rest period between mea-
sures. The mean value of 2 trials was scored. This test
has been shown to be valid and reliable 19.
Lower body muscular strength
Vertical jump performance was assessed with a squat
jump with infrared photocell mat (Ergo-jump Globus,
Codogne, Italy) 20. The jumps were performed with
hands held on the hips and attaining 90 knee flexion at
the start of the push-off phase. Participants performed 3
trials of each jump, and the best attempt was retained
for the analysis.
A Visual Analogue Fatigue Scale (VAFS)was used to
assess the intensity of fatigue. The visual analogue scale
is a 100 mm line anchored with 0 at one representing no
fatigue, and 100 at the other end representing the worst
fatigue imaginable. Subjects were asked to mark on the
line the point that they feel their perception of their
current fatigue state. The score was obtained by measur-
ing the line fromNo Fatigueto the point indicated by
the subject that represents their fatigue level: the higher
the VAFS score, the higher the fatigue.
Body temperature
We assessed body temperature using the OMRON
GentleTemp 510, an infrared thermometry device (MC-
510-E2, Kyoto, Japan). The temperature of the room ranged
between 23 and 26.
Sample size
According a pilot study, a priori sample size calculation
indicated 14 patients per group were required to detect
a significant difference of 20% in fatigue analogue scale
between the intervention and control group (Effect size
d =1, alpha=0.05, beta=0.08).
Statistical analysis
Data were analyzed using the SPSS package (version
19.0). Mean and standard deviations or 95% confidence
intervals of the values were calculated for each variable.The Kolmogorov-Smirnov test showed a normal distribu-
tion of the data (P 0.05). Pre-intervention values prior to
each condition were compared using the independent t-
tests for continuous data. A 2x3 mixed model ANOVA
with session (hydrotherapy, control rest) as the between-
subjects variable and time (pre-; post-exercise; post-
recovery) as the within-subjects variable was used to
determine the potential effects of the recovery method on
each variable. Separate ANCOVAs were performed with
each dependent variable. The hypothesis of interest was
session * time interaction. The Bonferroni test was used
for post hoc analysis. A P-value 0.05 was considered sta-
tistically significant.
Results
Finally, 17 male and 17 female recreational sportspeople
(age: 29.4 8.4 years; weight: 68.4 11.7 kg; height: 172.5
8.2 cm; body mass index: 22.9 2.9) were included. Partici-
pants had engaged in physical activity for 4.22.7 hours
week (aerobic exercise: 3.11.9 hoursweek; strength exer-
cise: 1.21.4 hourweek). Pre-intervention scores for each
variable were not significantly different between each ses-
sion: systolic arterial pressure (P=0.079), diastolic arterial
pressure (P=0.120), heart rate (P=0.263), handgrip (domin-
ant side: P= 0.568; non-dominant side: P=0.734), jump test
(P=0.078), fatigue analogue scale (P=0.067) and body
temperature (P=0.311).
The ANCOVA revealed a significant session*time inter-
action for diastolic blood pressure (F=3.897; P=0.031) and
heart rate (F=3.549; P=0.041), but not for systolic blood
pressure (F=1.384; P=0.266) (Table 1). Pair-wise compari-
sons found significant decrease in diastolic blood pressure
(P0.05) and increase in heart rate (P0.001) after
spinning exercise. Diastolic blood pressure decreased
(P0.001) after rest in the control group as compared to
baseline, whereas no change was observed after hydro-
therapy (P=0.093). Heart rate increased (P=0.042) after
rest in the control group as compared to baseline,
whereas did not change in relation to baseline values
after hydrotherapy (P=0.142).
The ANCOVA did not reveal a significant session*time
interaction for vertical jump (F=0.851; P=0.437), and hand-
grip force (F=0.148; P=0.863) (Table 2).
The ANOVA revealed a significant session*time inter-
action for fatigue (F=3.386; P=0.046) and body temperature
(F=8.490; P=0.001). Pair-wise comparisons revealed that
both groups exhibited significant increases in fatigue
(P0.001) after Spinning. Fatigue was no different from
baseline values (P=0.436) after hydrotherapy, but was in-
creased with respect to baseline within the control group
(P=0.006) (Figure 1). A non-significant body temperature
change (P0.05) was found after spinning exercise in both
groups. After hydrotherapy, body temperature was similar
than baseline in control group (P=0.147), but increased in
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the spinning group (P=0.006) (Figure 2). Gender did not in-
fluence the results of these parameters.
Discussion
The integration of hydrotherapy services combined with
exercise is postulated to produce a healthier individual.
A comprehensive search through different databases did
not reveal any study investigating the effects of hydrother-
apy as a recovery method after the application of spinning
session. Our study confirms the ability of hydrotherapy to
facility perceived and cardiovascular recovery of fatigue
after a spinning session. However, there were no signifi-
cant effects in terms of strength performance compared to
rest as control strategy.
A better self-perceived recovery was obtained after the
spinning session, which was developed with moderate
intensity (close 70% of the maximum heart rate) elicitinga moderate perceived fatigue. These results confirm the
effects of hydrotherapy after a demanding exercise results
in improvements in self-perceived fatigue. The main effect
of buoyancy is a reduction of post-gravitational forces that
act on the musculoskeletal system allowing a greater con-
servation of energy that could potentially reduce perceived
fatigue 12. These results could be related to local muscle
damage elicited during the spinning session 10 which
may be buffered by muscle relaxation response during
water immersion 21.
A relevant finding of this study was the recovery of dia-
stolic blood pressure and heart rate to non-significant dif-
ferences after hydrotherapy with respect to baseline values.
Hydrotherapy resulted in recovery of the physiological state
but was insufficient to reach similar cardiovascular values
to baseline because of the high cardiovascular demand in
the spinning session 1. Besides, the hypotension induced
Table 1 Comparison of blood pressure and heart rate between the groups at different time points
Variable Hydrotherapy (experimental group) n=17 Supine rest (control group) n=17
Systolic blood pressure (mm Hg)
Baseline 124.76 9.83 (95% CI 119.70129.82) 132.17 17.25 (95% CI 123.30141.04)
Post-spinning session 120.76 9.49 (95% CI 115.88125.64)* 123.41 18.67 (95% CI 113.80133.01)*
Post-recovery 118.82 13.31 (95% CI 111.97125.67) 128.17 18.30 (95% CI 118.76137.58)
Diastolic blood pressure (mm Hg)
Baseline 76.05 9.23 (95% CI 71.3180.80) 81.00 8.78 (95% CI 76.4885.51)
Post- spinning session 71.05 9.17(95% CI 66.3475.77)* 75.41 8.99 (95% CI 70.7880.03)*
Post-recovery 71.82 7.97 (95% CI 67.7275.92) 71.58 8.44 (95% CI 67.2475.92)#
Heart rate (beatmin)
Baseline 73.29 10.89 (95% CI 67.6978.89) 78.00 13.06 (95% CI 71.2884.71)
Post-spinning session 100.0 13.4 (95% CI 94.3105.7)* 97.29 15.16 (95% CI 89.49105.09)*
Post-recovery 80.35 16.60 (95% CI 74.086.3)# 85.94 14.91 (95% CI 78.1992.27)
Data are expressed as mean standard deviation (95% confidence interval).
* Bonferroni correction, P 0.05, post-exercise vs. baseline value # Bonferroni correction, P 0.05, post-Spa therapy vs. Post-exercise value.
Table 2 Comparison of force handgrip and vertical jump between the groups at different time points
Variable Hydrotherapy (experimental group) n=17 Supine rest (control group) n=17
Vertical jump test (cm)
Baseline 22.94 5.74 (95% CI 19.9825.89) 26.96 7.01 (95% CI 23.3530.57)
Post-spinning session 23.55 6.12 (95% CI 20.4026.70) 28.60 7.59 (95% CI 24.7030.52)
Post-recovery 23.06 5.6 (95% CI 20.1126.02) 27.88 7.13 (95%CI 24.2131.25)
Force handgrip dominant side (Kg)
Baseline 36.63 10.36 (95% CI 31.3040.96) 38.83 11.86 (95% CI 32.7344.93)
Post-spinning session 37.16 11.12 (95% CI 31.4442.88) 38.96 12.33 (95% CI 32.6245.30)
Post-recovery 36.83 12.08 (95% CI 30.6243.04) 38.44 12.89 (95% CI 31.8145.07)
Force handgrip non dominant side (Kg)
Baseline 34.32 9.73 (95% CI 29.7239.33) 35.54 10.84 (95% CI 29.9641.11)
Post-spinning session 34.72 9.40 (95% CI 29.8839.55) 35.81 11.28 (95% CI 30.0041.61)
Post-recovery 34.06 9.86 (95% CI 28.9939.14) 34.82 11.20 (95% CI 29.0640.58)
Data are expressed as mean standard deviation (95% confidence interval).
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by exercise 22 was buffered by the hydrotherapy session.
It is suggested that immersion in water to a xiphoid level at
similar water temperatures used in our study 23 produces
an 11-18% heart rate decrease 24 by inducing a parasym-
pathetic responses 1. It is possible a summation effect of
aromatherapy with lavender 25 and hydrotherapy, which
may assist in heart rate recovery by promoting relaxation
responses similar to other recovery strategies. These results
provide relevant information about hydrotherapy since
there no dangerous strain on the cardiovascular system in-
ducing hypotension or tachycardia was promoted by water
immersion 26.
Our results did not support the ability of hydrotherapy
to recovery physical performance which is in agreement
with previous studies 27,28. However, there exists con-
troversy with other treatments 12 which have shownthe ability for improving physical performance. It has been
proposed that the large applications of cold water as a main
component of hydrotherapy can help to recover perform-
ance by inducing several cardiovascular mechanisms 12.
The current study did not support the previous reported
ability of hydrotherapy to reduce body temperature 29.
The increase of body temperature after spinning is ex-
plained by a sympathetic response 30. A thermotherapy
effect was found since an increase of body temperature after
hydrotherapy was observed. Thermotherapy has shown to
increase tissue temperature, increase local blood flow and
muscle elasticity, cause local vasodilatation, increases me-
tabolite production, and reduce muscle spasm 31. This
thermotherapy effect may plausibly be associated with bet-
ter self-perceived recovery after hydrotherapy in compari-
son to the control group.
30 31 32 33 34 35 36 37 38 39 40
BASELINE POST -EXERCISE POST -RECOVERY
CONTROL GROUP
HY DROTHE RA P Y GROUP*
Figure 2Body temperature at different moments of the study.*Significant change respect baseline value (P 0.05, Bonferroni correction).
0 1 2 3 4 5 6
7 8 9 10
BASELINE POST -EXERCISE POST -RECOVERY
CONTROL GROUP
HY DROTHE RA P Y GROUP
*
*
#
Figure 1Visual analogue scale-fatigue at different time moments of the study.*Significant change respect baseline value (P0.05,
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Since the purpose of hydrotherapy centers is to assist
people in the recovery of health 32, it is necessity to
develop studies similar to the current one to determine
the optimal strategies for preventing psychological and
physical drop off 31.
Finally some limitations need to be recognized in this
study. An immediate effect of hydrotherapy after exercise
does not guarantee that these changes will be maintained
during long-term follow-up periods. Therefore, more
studies are needed to clarify long-term effects of hydro-
therapy after different exercise modalities in an indoor
setting. Second, recreational sportspeople were included
in this study; it is possible that our findings would have
varied in different populations. Third the lack of rando-
mization and a small sample size warrant new studies to
confirm present results.
Conclusion
Literature about hydrotherapy used as a recovery strat-
egy often comes from textbooks or is based on anecdotal
information. Our study helps to reduce this gap in the
combination of exercise and hydrotherapy using a con-
trolled study. The findings of this study indicate that
hydrotherapy showed the ability to assist with recovery
of perceived fatigue and cardiovascular parameters after
a spinning session but no effects on strength recovery.
These improvements in the recovery profile support
hydrotherapy as a practical recovery strategy. Therefore,
hydrotherapy appears to be a recovery strategy that
could be adopted and integrated into recovery programs
for individuals participating in sport.
Competing interests
The authors declare that they have no competing interests.
Authorscontributions
All the authors have made contributions to conception of this study. MAM,
DCT, ATM and AVC participated in the acquisition of data. MAM, ACV, CFDLP,
ACS participated in the analysis and interpretation of data and were involved in
drafting the manuscript or revising it critically for important intellectual content.
All the authors have given final approval of the version to be published.
Acknowledgments
The authors are grateful to the volunteers for their participation and the
Sport & Spa Yo10 Club, Granada. This study received a grant from the
Research Office of the University of Granada.
Author details
1School of Clinical Science, Faculty of Health Science, Queensland University
Technology, Brisbane, Australia.2Department of Physical Therapy,
Universidad de Granada, Granada, Spain.3Sport Spa Club Yo10-Granada,
Granada, Spain.4Department of Physical Therapy, Universidad de Almeria,
Almeria, Spain.5Department of Physical Therapy, Occupational Therapy,
Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcn,
Spain.
Received: 3 January 2013 Accepted: 16 July 2013
Published: 18 July 2013References
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doi:10.11861472-6882-13-180
Cite this article as:Cuesta-Vargaset al.:Hydrotherapy as a recovery
strategy after exercise: a pragmatic controlled trial.BMC Complementary
and Alternative Medicine201313:180.
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