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Table 8–1 . Comparison of modern water-based therapeutic modalities (continued)
Flotation
restricted
environmental
stimulation
technique
Cold water
exposure or
immersion
Aquarium therapy
Water- bas ed
exercises
162 NATURE THERAPY
Balneotherapy
Proposed
therapeutic
mechanism
(continued)
Decreased functional
connectivity between somatomotor
and default mode
networks (Al Zoubi
et al. 2021)
Cold shock may im-
prove mood through
activation of the hypothalamic-pituitaryadrenal axis (Kelly
and Bird 2021).
Decreased
inflammation and
pain may
contribute to
general wellbeing.
Decreased inflam-
mation and pain
may contribute to
general well-being.
Whole-body heating
and patient expectations may also
contribute to shortterm therapeutic
effects.
Natural environ-
ment may confer
restorative benefits, as in aquarium
therapy.
Table 8–1 . Comparison of modern water-based therapeutic modalities (continued)
Flotation
restricted
environmental
stimulation
technique
Cold water
exposure or
immersion
Aquarium therapy
Water- bas ed
exercises
The Wet Outdoors 163
Balneotherapy
Frequency and
duration
12 sessions (45 min
twice a week) have
been proposed
(Bood et al. 2007).
Duration of ~7 weeks
is common (Kjellgren et al. 2020).
Ideal frequency and
duration are
unknown.
Acute improvement in
mood is seen after
≤20 min of immersion
in cold seawater
(Kelly and Bird 2021).
For reduction of ex-
treme emotions, can
be done as needed for
15–30 s (Linehan
2015).
Ideal frequency and
duration are unknown.
Va ri es
2–3 weekly
sessions of
40–60 min for
8–14 weeks have
been used (Jackson et al. 2022;
Silva et al. 2019).
Va ri es
In published re-
search, several
protocols use 20- to
30-min sessions for
~15–20 sessions
over 3–4 weeks
(Bender et al. 2014).
Table 8–1 . Comparison of modern water-based therapeutic modalities (continued)
Flotation
restricted
environmental
stimulation
technique
Cold water
exposure or
immersion
Aquarium therapy
Water- bas ed
exercises
164 NATURE THERAPY
Balneotherapy
Barriers and
contraindications
Active suicidality
with plan or intent
History of neurologi-
cal condition that
may interfere with
protocol
Skin condition or
open wound that
causes pain with
exposure
Discomfort or fear of
water
Acute intoxication
Caution use for those
with
• Hypertension
• Previous cerebrovascular disease
(McKee et al. 2015)
• Anorexia or heart
disease (Kelly and
Bird 2021)
• Concurrent use of
β-blockers or other
heart-slowing
medications
• Cold urticaria
Barriers include mon-
etary costs (e.g.,
price of admission
for public aquarium
or cost to purchase,
install, and maintain
a home aquarium).
Severe cardiac dis-
ease
Active suicidality
with plan or
intent
Severe epilepsy
Skin condition or
open wound that
causes pain with
exposure
Discomfort or fear
of water
Acute intoxication
Allergy to pool ad-
ditive
Cold urticaria
Allergy to minerals
or water content
Impaired thermal
regulation
Intoxication
Water p hobia
Table 8–1 . Comparison of modern water-based therapeutic modalities (continued)
Flotation
restricted
environmental
stimulation
technique
Cold water
exposure or
immersion
Aquarium therapy
Water- bas ed
exercises
The Wet Outdoors 165
Balneotherapy
Possible beneficial
effects
Stress reduction
Alleviation of chronic
pain
Anxiolysis (Jonsson
and Kjellgren 2017)
Improved mood and
subjective wellbeing (Kjellgren et
al. 2020)
Improved sleep (Kjell-
gren et al. 2020)
Bradycardia
Anxiolysis
Decrease in panic
symptoms (Kyriakoulis et al. 2021)
Acute mood improve-
ment (Kelly and Bird
2021)
Reduced extreme emo-
tions (Linehan 2015)
Positive emotions
Connectedness to nat-
ural environments
and other beings
(Cracknell et al.
2018)
Relaxation, stress re-
duction (Clements et
al. 2019)
Anxiolysis (Barker et
al. 2003; Clements et
al. 2019)
Anxiolysis
Improved mood
Higher self-esteem
Higher sense of
well-being (Jackson et al. 2022)
Decrease in physi-
cal pain
Improved sleep
Reduced stress
Anxiolysis
Improved mood
(Clark-Kennedy et
al. 2021)
Reduced chronic
pain symptoms
General sense of
well-being (Bender
et al. 2014; Cheles-
chi et al. 2020)
Table 8–1 . Comparison of modern water-based therapeutic modalities (continued)
Flotation
restricted
environmental
stimulation
technique
Cold water
exposure or
immersion
Aquarium therapy
Water- bas ed
exercises
166 NATURE THERAPY
Balneotherapy
Possible adverse
effects
Currently being as-
sessed in clinical trials (NCT03899090)
“Intensification
phase,” in which
chronic pain symptoms or psychological problems, in the
absence of usual
stimuli, become
more apparent; may
occur early in treatment (Jonsson and
Kjellgren 2017).
Hypertensive crisis,
stroke (McKee et al.
2015)
Arrhythmias and myo-
cardial infarction
(Kelly and Bird 2021)
Hypothermia (with
colder water or more
prolonged exposures)
Small risk of aquar-
ium-associated bacterial infection (may
be minimized with
hygienic practices)
(Clements et al.
2019)
Small risk of injury
while installing or
maintaining aquarium (if patient is responsible for this)
Rarely, short-term
fatigue after treatment; potential
for increased pain
(Reger et al. 2022)
Allergic reaction to
pool additives
Risk of drowning
or falls (minimized with nonslip mats,
supervision)
Rarely, mild and
transient skin irri-
tation or exacerba-
tion of psoriasis
(Clark-Kennedy et
al. 2021)
Risk of drowning or
falls (minimized
with nonslip mats,
supervision)
Table 8–1 . Comparison of modern water-based therapeutic modalities (continued)
Flotation
restricted
environmental
stimulation
technique
Cold water
exposure or
immersion
Aquarium therapy
Water- bas ed
exercises
The Wet Outdoors 167
Balneotherapy
Advantages Effects of treatment
may be realized with
minimal effort or
specific instructions.
Minimal equipment
needed, quick technique
Few contraindications
or adverse effects
May be available to
clients for long periods of time and at
their convenience
Physical activity
confers other
(nonpsychiatric)
health benefits.
Effects of treatment
may be realized
with minimal effort
or specific instruc-
tions.
168 NATURE THERAPY
In patients with congestive heart failure, warm water baths and lowtemperature sauna bathing at 140°F for 15 minutes was found to improve cardiac function, increase 6-minute walking distance, and reduce
plasma levels of brain natriuretic peptide (Iiyama et al. 2008; Mooventhan and Nivethitha 2014).
Cold water immersion has been shown to increase heart rate, blood
pressure, metabolism, and peripheral catecholamine concentration and
to decrease cerebral blood flow (Bleakley and Davison 2010; Mooventhan and Nivethitha 2014). Acute immersion in warm water similarly
increases blood pressure but generally reduces heart rate (Mooventhan
and Nivethitha 2014).
Nervous System
The human nervous system is also sensitive to water in its various forms.
Applying water in cold modalities, such as ice massage, ice packs, or cold
water immersion, on the calf for 10 minutes reduces the skin’s temperature, thus reducing the amplitude of action potentials and in turn increasing their latency and duration. Cold water immersion is the most effective
way to produce therapeutic effects associated with reducing motor nerve
conduction (Herrera et al. 2010; Mooventhan and Nivethitha 2014).
Adjusting the water temperature in hydrotherapy is theorized to
modulate pain. Temperature and pain are peripherally sensed through
thermal receptors and nociceptors, respectively. The sensory signals are
transmitted to the brain via the lateral spinothalamic tract. Stimulating
the thermal receptors through immersion in a temperature extreme
competes with the pain signal traveling along the same spinal tract,
thus reducing the experienced pain.
Hydrotherapy also relieves mechanical stress on muscles and joints
because of water’s buoyancy. In patients with multiple sclerosis, 40 sessions of an aquatic exercise program were found to improve fatigue,
spasms, pain, depression, disability, and overall functional autonomy
(Bender et al. 2005; Castro-Sánchez et al. 2012).
Adapted cold showers send an overwhelming amount of electrical
impulses from the peripheral nerve endings of the dense cold receptors
in the skin to the brain, effectively working as a mild electroshock therapy, and may result in antidepressive or antipsychotic effects, as well as
analgesic effects by suppressing neurotransmission in the mesolimbic
system (Shevchuk 2008).
Cold immersion can also activate parts of the reticular activating system, which is the system responsible for regulating sleep-wake transitions and arousal, thereby promoting wakefulness, mobility, and energy.
The Wet Outdoors 169
Respiratory System
Water-based therapies can exert substantial and quantifiable changes in
pulmonary functioning as a result of both temperature- and pressuremediated effects. When water temperature is greater than body temperature, oxygen transport is improved through a concordant increase
in cardiac output. Conversely, when water temperature is less than
body temperature, oxygen transport is interrupted (Mooventhan and
Nivethitha 2014). Water temperatures also affect breathing parameters.
For example, vital capacity (the volume of air exhaled after a maximal
inhalation) decreases as temperature decreases. Tidal volume (the volume
of air moved into or out of the lungs during quiet breathing) has a parabolic relationship with temperature, such that tidal volume increases
at temperatures above and below neutral temperature (Choukroun et
al. 1989; Mooventhan and Nivethitha 2014).
Cold water immersion has been found to increase the respiratory
minute volume and decrease end-tidal carbon dioxide partial pressure,
which are indicative of a more efficient respiratory effort (Bleakley and
Davison 2010). Repeated stimulation with cold water has been shown
to reduce infections, increase peak expiratory flow, and improve quality
of life in patients with chronic obstructive pulmonary disease (Goedsche
et al. 2007; Mooventhan and Nivethitha 2014).
Musculoskeletal System
Application of cold water can cause physiological reactions such as a
decrease in local metabolic function, local edema, nerve conduction velocity, and muscle spasms and an increase in local anesthetic effects. Immersion in water colder than 59°F has been shown to significantly delay
the onset of muscle soreness after exercise (Bleakley and Davison 2010;
Bleakley et al. 2012). Studies have found that immersing one’s legs into
warm water maintained at approximately 111°F for 45 minutes before repetitive flexion-extension exercise significantly reduced markers of muscle damage attributable to exercise, including creatine kinase levels in the
blood, muscle soreness, jump height, and maximum voluntary contraction force (Mooventhan and Nivethitha 2014; Skurvydas et al. 2008).
Aquatic exercise is a practical alternative for people with obesity who
have high risk of falling or have joint pain, because the buoyancy of the
water reduces the overall weight put on bones, joints, and muscles. The
warmth and the pressure of the water also may reduce swelling, leading to overall muscle relaxation (Mooventhan and Nivethitha 2014).
170 NATURE THERAPY
Gastrointestinal System
Water has been shown to have a significant effect on the human gastrointestinal system. After hot water compress treatment, bowel sounds
increased by 1.7 times, suggesting that this treatment can help those
with constipation by promoting gas release or defecation (Mooventhan
and Nivethitha 2014). Drinking warm water is also effective for the
treatment of colonic spasms and has no side effects (Church 2002).
Patients with hemorrhoids or anal fissures found a significant decrease in anal burning and pain after using sitz baths with warm water
between 59°F and 86°F (Mooventhan and Nivethitha 2014). In those
with anorectal disorders, pain relief was more significant and longer
lasting when sitz baths were done at higher temperatures (104°F, 113°F,
or 122°F) for 10 minutes at a time. This effect may be a result of anal
sphincter relaxation with increased bath temperature due to the thermosphincteric reflex, a reaction in which thermal signals decrease internal sphincter electromyographic activity (Shafik 1993).
In summary, water affects physiology in many ways. Therefore, various mechanisms likely underlie each of the modern water therapies,
which are described in the next section.
Hydrotherapy
Flotation Therapy
Flotation REST is one type of hydrotherapy. During flotation REST, participants float inside a dark, quiet tank filled with water saturated with
magnesium sulfate (Epsom salts). The water is usually heated to skin
temperature, about 93°F–95°F. Sensory signals from visual, auditory, olfactory, gustatory, thermal, tactile, vestibular, gravitational, and proprioceptive channels are minimized. Theoretically, this reduction in
physiological stress guides participants’ thoughts to the here and now,
promoting a state of relaxation (Kjellgren et al. 2008). Contrarily, this reduction in physiological stress may bring about a resurgence of chronic
pain or psychological issues, making it harder for some patients to relax, especially early in treatment (Jonsson and Kjellgren 2017). Default
mode networks (DMNs) are parts of the brain that are activated while
a person is awake but not engaged in any specific task and is focused
on internal mental state processes, such as self-referential processing;
DMNs are often related to difficulty in disengaging from self-centered
thoughts. Altered DMN activity has been implicated in depression and
anxiety (Coutinho et al. 2016). Decreased functional connectivity between somatomotor networks and DMNs brought about by flotation
The Wet Outdoors 171
REST (Al Zoubi et al. 2021) also may reduce anxiety. A typical flotation
REST regimen may include twelve 45-minute sessions over the course
of 6–7 weeks (Bood et al. 2007; Kjellgren et al. 2020).
Flotation REST may reduce stress and sleep difficulties, muscle tension, and pain, as well as anxiety and depression (Al Zoubi et al. 2021;
Jonsson and Kjellgren 2017). Related sleep improvements in patients
with insomnia may persist even 4–6 months after treatment cessation
(Kjellgren et al. 2020). Its use may result in mood improvements characterized by increases in relaxation, happiness, and well-being. Effects
tend to be more significant in participants who are most severely anxious. Therefore, indications for which flotation REST is being investigated include generalized anxiety disorder (GAD), major depressive
disorder (MDD), PTSD, panic disorder, chronic pain conditions, and insomnia. It may be used as an adjunct treatment along with pharmacotherapy or psychotherapy. Possible adverse effects of flotation REST are
being investigated in clinical trials.
Cold Water Exposure or Immersion
Cold water immersion or exposure is another type of hydrotherapy. It
can be done in various ways, including immersion in large ice or water
buckets, seas, ponds, oceans, or lakes in winter, or the application of ice
packs or wraps to the skin. Either partial-body (such as hands or face)
or whole-body exposure can be performed. Multiple theories have been
proposed for the positive effects of this hydrotherapy. The shocking
cold effect has been theorized to lead to positive changes in mood
through activation of the hypothalamic-pituitary-adrenal axis (Kelly
and Bird 2021). A mammalian diving reflex also may be activated with
either cold water exposure (especially on the face) or water immersion
(and related breath-holding) (McKee et al. 2015). The diving reflex actually consists of a predictable series of physiological reflexes, leading to
bradycardia, an increase in parasympathetic tone, a decline in arterial
blood pressure, and peripheral vasoconstriction (Panneton 2013). It
promotes the survival of all mammals in an oxygen-deprived state by
preferentially circulating blood to the brain and heart. In humans, it can
also be used as a means of emotional regulation, as part of dialectical
behavior therapy (DBT; Linehan 2015). The diving reflex can be used as
a means of managing extreme emotions in stressful situations, particularly for patients with borderline personality disorder. One technique
involves self-submersion of the face in icy, cold water for 30 seconds
while holding a deep breath (Linehan 2015). This technique theoretically allows its user to have immediate relief from overwhelming feel-
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