In Greek mythology, Zeus is king of the gods. In ancient Greece, however, the most important and powerful deity might have been his brother, Poseidon, God of the Sea. After all, ancient Greece had a maritime economy. A nation of mariners and fishermen, it needed water to sustain both its population and its economy. The sea was its most important asset.
Thousands of years later, water remains essential—not only to wealth, but also to health. Drinking it nourishes the body. Bathing in it protects the body from disease. And as massage therapists around the world can attest, using it in massage therapy can rejuvenate and restore the body.
So impactful is water on wellness that there is a long tradition of hydrotherapy in cultures around the world.
“In Turkey, there’s loads of people sitting around at the baths. And in Germany, there’s a sauna in everyone’s back garden,” observes Rachel Fairweather, LMT, who, along with colleague Meghan Mari, LMT, serves as co-founder and co-director of Jing Advanced Massage Training in Brighton, England. “Being in water is primal. It’s cleansing and it’s healing.”
It might also help you build client loyalty and grow your client base. Although hydrotherapy isn’t as pervasive in the United States as it is in Europe, American massage therapists and massage consumers are embracing hydrotherapy—and there is plenty of room for growth.
Hydrotherapy Basics and Benefits
Brian Utting, LMT, is a longtime fan of hydrotherapy. When he began practicing and teaching massage some 40 years ago, it was a “no-brainer” to add it to his repertoire, he says.
“Hydrotherapy improves vascular, lymphatic and interstitial circulation, and affects cellular activity,” explains Utting, an instructor at the Pacific Northwest School of Massage in Seattle, where students explore hydrotherapy during an annual continuing-education retreat to Oregon’s Breitenbush Hot Springs. “It also has a major impact on the integumentary, nervous, digestive and muscular systems.”1
But what is hydrotherapy, exactly? When he’s teaching courses on the subject, Utting describes it as “the use of water in all its forms for the maintenance and improvement of health.” That includes liquid water, water vapor and ice. In practice, however, Utting says hydrotherapy is more about temperature than it is about elements. It just so happens that water is an especially effective medium through which to transfer heat and cold.
“Water is 24 times more conductive than air,” Utting says. “So you can heat the air or cool the air, but the effect won’t be as dramatic.”
Heat and cold offer different benefits. “Heat is very soothing and induces a relaxation response,” says Marybetts Sinclair, LMT, author of Hydrotherapy for Bodyworkers. “As mammals … we simply cannot survive unless we are warm. Thus, the application of heat satisfies our innate craving for warmth. So if I’m doing any kind of mind-body treatment, I’m going to use heat for basic relaxation; whatever kind of massage I’m doing, it’s going to work better, and feel better to the client, if he or she has already started to let go of tension and stress.”
A relaxed client is going to have a better outcome, both physically and mentally, while reducing the likelihood of strain and injury for client and therapist alike. “Heat also makes tissues softer and more malleable,” Sinclair continues. “If I’m working on somebody’s neck and shoulders, and they’re really tight, it’s going to be a lot easier for me to treat layers of tension if I’ve warmed the tissue first.”
Fairweather agrees and says heat induces both psychological and physiological responses. The latter is especially apparent in clients with chronic pain. A 2020 study in the Journal of Back and Musculoskeletal Rehabilitation, for example, found that the local application of heat to trigger points reduces neck and foot pain by increasing muscle relaxation and tissue blood flow.2
“Heat increases the viscoelasticity of fascia and reduces trigger-point firing,” Fairweather says. Indeed, a 2018 study in the journal Evidence-Based Complementary and Alternative Medicine confirmed that bathing in warm water induces vasodilation and increases blood flow, which delivers more oxygen and nutrients; as a result, bathers reported less fatigue, stress and pain.3
The nervous system reacts to heat as well as the circulatory system, points out Carla Moodie, LMT, owner of Intuitive Spirit Healing Arts in Bowie, Maryland. “Heat can relax you, and when you’re relaxed, your nervous system typically goes into parasympathetic mode, which is when your internal systems get to reset and recover,” she says.
Cold may have the opposite effect, according to Moodie, who says cold typically activates the sympathetic nervous system, which floods the body with endorphins that can improve mood,4 glycogen that can increase energy5 and adrenaline that can blunt pain.6
“If you’ve ever taken a cold shower, you know that cold has a more stimulating effect,” explains Sinclair, who says the cardiovascular response to cold also is opposite. “What happens when cold is applied to a body part is a constriction of the blood vessels. This shunts blood away from the area, which in turn reduces inflammation.”
That makes cold an ideal remedy for fresh soft-tissue injuries, swelling and pain, which can be treated by reducing inflammation. But cold should be used sparingly, as recent evidence suggests using too much cold, or for too long, can actually decrease blood flow too much, which slows the healing process.7
“Inflammation is our friend. Anything that inhibits it is going to prolong healing,” says Susan Salvo, EdD, BCTMB, LMT, author of Mosby’s Pathology for Massage Professionals. “Ice is great for pain control, but you shouldn’t use it for more than 10 minutes at a time or else it might interrupt the inflammatory cascade.”
Increasingly, many massage therapists are using hot and cold together through a process known as contrast bathing, or contrast therapy.
“When you’re hot, your blood vessels dilate. When you’re cold, they contract. When you alternate between them, you’re expanding your blood vessels, then squishing them. It’s vascular exercise,” explains Utting, who says the effect is a pumping action that increases the flow of blood and immune-critical lymph. “Lymphatic drainage is a big benefit. The lymphatic system is more swampy and passive than most people realize, so you need to help it along.”
Localized vs. Immersive Treatments
Massage therapists can integrate hydrotherapy into their practices by way of either localized or immersive treatments. Unless they work in a spa environment that’s already outfitted with whole-body hydrotherapy amenities, the former typically are more practical. Here are a few that promise maximal effect with minimal space, equipment and investment:
Topical heat/cold: Topical hydrotherapy treatments are probably the most accessible, according to Utting, who uses hot and cold packs in his home-based practice because they’re simple and effective.
For cold, he says, practitioners can use reusable gel-filled cold packs, sometimes with a rolled-up hand towel underneath to conform to the neck. For heat, practitioners can use hot packs—the best are designed to be soaked in a hydrocollator. For those on a budget, hot water bottles also work well.
For many people, one of the simplest and best hydrotherapy practices is following a hot bath or shower with a 30-second cold rinse. “You find out just how long 30 seconds can be,” Utting says.
Hot/cold stones: Fairweather and Mari say their favorite hydrotherapy technique is hot stone massage. Like towels, they remark, stones can be covered with water and heated in a hot stone warmer. The water bath ensures a moist instead of dry heat.
“Wet heat is the most beneficial heat because it penetrates deeper,” Mari says.
Although basalt stones are most common, Mattie Hartley, LMT, owner of Radiant Wellness Studio in Arundel, Maine, likes to use pink Himalayan salt stones, which gently exfoliate the skin and are said to infuse it with essential minerals. For cold therapy, you can even use cold stones—polished marble stones that are cooled in ice water.
Wraps: Body wraps are another low-tech and soothing opportunity, according to Sinclair, who says wrapping warm towels around the body creates sensations of swaddling or compression. “It’s like a mummy wrap or a cocoon,” she says. “For some people, that can have a real anti-anxiety effect.”
Instead of towels, you can use body wrap cloth, sheets or even clothing items. Mari, for example, treats carpal tunnel syndrome by turning clean cotton gym socks into cold-therapy mittens. Simply cut the toes off, cut a hole for the thumb, wet the sock, then freeze it. “It’s great self-care for massage therapists, and it’s also great for people who have edema during pregnancy,” she says.
Ice massage: When she wants to utilize cold, Christina Suarez, LMT, often turns to ice therapy, wherein you integrate the use of ice into a massage. In order to reduce inflammation and pain, she often uses ice therapy with modalities like sports massage and deep tissue.
“I use it often for conditions like tendonitis,” says Suarez, owner of Luminous Massage in Coral Gables, Florida. “It’s a great way to spot-treat local inflammation—especially on the joints—in a controlled way.”
Suarez uses reusable plastic CryoCups, a homemade version of which you can fashion by freezing water in a paper cup. When you peel back the paper, you can massage with the exposed ice and use the cup as a grip.
“Some people like to do ice massage with cross-fiber friction,” Sinclair adds. “Cross-fiber friction can be quite painful and the ice helps numb its effect.”
Foot and hand baths: Moodie is a big fan of hot foot baths. “There are a lot of pressure points in the feet, so soaking them in warm water can be really beneficial,” she says. “I soak the feet in Epsom salt or magnesium flakes, then scrub the feet with a washcloth.”
For a small investment (machines are inexpensive) you also can bathe hands and feet in paraffin wax. “I use paraffin wax as a warming tool,” Suarez says. “For example, if a client is recovering from a broken finger or ankle surgery, I’ll use paraffin to warm and soothe tight tissue before we work on mobility to regain flexibility and reduce adhesions.”
Although they typically require a significant amount of space, investment and maintenance, immersive treatments aren’t out of the question for therapists who want to go all-in on hydrotherapy. If your budget and space allow it—and you’re willing to learn and follow appropriate sanitation protocols—you could install a small steam shower, soaking tub or sauna for the cost of a residential bathroom remodel. You could even install something like a Vichy shower. Having even just a basic “wet room” with tile flooring, a floor drain and a hand shower would allow for treatments like salt glows. According to Hartley, such investments often can be financed into manageable monthly payments and may be tax-deductible as a business expense.
If you don’t want to make big investments, there are affordable alternatives. For example, Sinclair has used a modern version of the traditional Ayurvedic steam bath, or swedana. This is a special cover over a massage table that holds in steam and can create a portable steam bath that can be done with the client on the table.
“A true steam room is pricey to install. This can create a steam treatment without one,” says Sinclair, who notes that the device must be cleaned thoroughly between uses.
Risks and Opportunities
Before you dip your toes in the waters of hydrotherapy—literally and figuratively—it’s important to not only learn techniques, but also to learn when hydrotherapy may be contraindicated. For example, Hartley says that heat is ill-advised for people who have heat-intolerant conditions like multiple sclerosis, vascular diseases, diabetes and eczema, as well as any condition where sensing temperature accurately is impaired. Women who are pregnant or in menopause might also be heat-sensitive, according to Salvo, who says there are also cold-intolerant conditions like Raynaud’s syndrome, hypothyroidism and Hashimoto’s disease.
“You need to do a full medical history with each client, and you have to closely monitor the person you’re working with,” Sinclair says.
Even as you mind the risks, however, don’t forget to celebrate the opportunities, urges Salvo, who says it’s common practice to charge up to $20 for hot and cold packs, up to $30 for access to a sauna, steam room or hot tub—and up to $75 for access to a “thermal suite” that includes all three and can be rented out to one client while massaging another.
“Hydrotherapy services are add-on services,” she says. “You’re taking a massage client who would spend $60 for a massage, and you’re getting them to spend double that by providing extra services. And oh, by the way, some clients might come to you because you offer these added services.”
Stone Massage for Head and Neck Pain
1. Mooventhan A, and Nivethitha L. "Scientific evidence-based effects of hydrotherapy on various systems of the body." North American Journal of Medical Sciences. 2014.
2. Petrofsky J, Laymon M, Lee H. "Local heating of trigger points reduces neck and plantar fascia pain. Journal of Back and Musculoskelet Rehabilitation." 2020.
3. Goto Y, Hayasaka S, Kurihara S, Nakamura Y. "Physical and Mental Effects of Bathing: A Randomized Intervention Study. Evidence-Based Complementary and Alternative Medicine." 2018.
4. Shevchuk NA. "Adapted cold shower as a potential treatment for depression." Medical Hypotheses. 2008.
5. Karolinska Institutet. "How our nerves regulate insulin secretion." ScienceDaily. 2012.
6. Hormone Health Network. What is adrenaline? Endocrine Society. 2018.
7. Mirkin G. Why Ice Delays Recovery. DrMirkin.com. 2020.