Hydrotherapy for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune condition with symptoms that include pain, stiffness, and swelling in the joints. While medications are the gold standard for RA treatment, many people also explore complementary therapies to help manage their symptoms, provide relaxation, and improve overall quality of life.

Hydrotherapy, which spans hot tubs and saunas to cold plunges to treat a variety of diseases, isn’t a cure for RA, and it shouldn’t replace medications prescribed by your doctor. But for some people, these water-based therapies can offer short-term symptom relief and provide a safe way to exercise, especially during flares or periods of stiffness.

It should be added to your treatment plan under the supervision of your rheumatologist; some people with RA should work with a personal trainer for gentle exercise in water.

It comes in the form of warm baths and hot tubs, cold showers and cold plunges, and physical therapy in heated pools, according to John Gallucci, DPT, a licensed physical therapist and CEO of JAG Physical Therapy with clinic locations across New York, New Jersey, and Pennsylvania.

Physical therapists also use hydrotherapy to help patients with rheumatoid arthritis move their bodies while decreasing joint pain, he says. “It’s not just the concept of a spa treatment in a hot tub or a sauna.”

The guidelines emphasize patient preferences for including hydrotherapy in their individual treatment plan, says Louise Thoma, DPT, PhD, a physical therapist and faculty member at UNC School of Medicine in Chapel Hill, North Carolina, where her research focuses on improving function and quality of life of adults with rheumatic disease, including rheumatoid arthritis. She’s also part of the team that reviewed the evidence for these guidelines.

“Anecdotally, people with RA share a wide variety of responses to these thermal interventions. I encourage people to try it if they are interested, and if it helps them feel better, then they have another tool to help them manage their day-to-day symptoms,” Dr. Thoma says.

Aquatic exercise is one of the most studied — and recommended forms — of hydrotherapy for people with RA. Exercising in water allows for strength training, aerobic exercise, and flexibility work with less stress on the joints than with land-based exercise, says Thoma.

“Doing exercise in the pool can have several benefits, including taking the load off of painful joints, providing a soothing sensation, warming joints in a warm rehabilitation pool, and providing pressure, which can help with inflammation and circulation,” she says.

For some people with RA, exercising on land may be harder because of the impact on their joints. “In this case, starting in the water can be a gentler approach to start moving,” Thoma says.

Exercises include water walking, leg lifts, sidesteps, and arm exercises, typically in a large pool that’s about 80 degrees F, Gallucci says. The warm water combined with the buoyancy of a pool allows patients to perform these low-impact movements safely while the water resistance strengthens muscles.

Gallucci says that physical therapists often supervise these exercises initially — in one-on-one sessions or in small group classes. “Once [patients] learn from a trained physical therapist and understand the exercises, there’s no reason why they wouldn’t be able to add one or two days on their own.”

Of the three, Gallucci recommends a sauna, which he uses four or five times a week for about 20 minutes each time. “It helps in boosting circulation, it’s a great endorphin release, which reduces stress, and, of course, just like any warmth, it’ll decrease symptoms of arthritis. It also works to detox your body and increase the immune system,” he says.

Research on the benefits of using a hot tub for rheumatoid arthritis is limited, but Gallucci suggests it may have similar benefits to sauna therapy in providing short-term symptom relief. The heated water can be relaxing, alleviating pain, and loosening up stiff joints and muscles.

He cautions that people interested in using a steam room should pay attention to facilities’ cleanliness. That’s because there may be a risk of respiratory infections from breathing in mold or other germs.

But even with this preliminary evidence, cold water therapy should be used with caution, especially for people with circulation issues, cardiovascular conditions, or sensory sensitivities. “It's always recommended that before you do any type of cold plunge, you are cleared by your physician or cardiologist,” Gallucci says.

Some people may find short-term relief, while others notice increased bone pain and joint stiffness, he warns. Because of this, cold water therapy isn’t often recommended by physical therapists to RA patients, he says.

And it isn’t popular among most RA patients, says Neal Birnbaum, MD, a rheumatologist and past president of the American College of Rheumatology who’s been practicing for 48 years in San Francisco. “Some people may like a cold plunge or what they call contrast baths, but I don't think that's a lot of them,” he says.

The key is personal preference: if it feels helpful for you, it can be another tool in managing day-to-day symptoms. Still, check in with your healthcare team first.

Not everyone has access to a pool, gym, or therapy facility. But at-home hydrotherapy can be helpful and is as simple as taking a warm bath or shower — or hopping into your backyard jacuzzi, Dr. Birnbaum says.

He uses the analogy of a baseball player — before the big game, he’s in the hot tub, loosening up his body before pitching on the field. “For the arthritis patients characterized by nighttime pain and morning stiffness, that warm shower or tub will get them moving better,” Birnbaum says. “I’m a big believer of a warm shower in the morning, doing your stretches and getting moving.”

Timing, temperature, and frequency should be guided by personal comfort and safety, Thoma notes. “Many people report a warm shower eases their pain and stiffness, others report benefit from a cold bath,” she says.

Pay attention to your safety when trying hydrotherapy at home. Install grab bars, consider a shower bench, and avoid unsupervised or risky entries and exits from tubs to reduce falls. You should have a family member spot you if you don’t have a walk-in shower for accessibility, Birnbaum says.

• Used alongside medication, hydrotherapy may help manage rheumatoid arthritis symptoms such as joint stiffness, pain, and limited mobility, offering relaxation and gentle exercise.
• Hot showers, saunas, and hot tubs can improve circulation, reduce short-term pain, and loosen joint stiffness, and physical therapy in heated pools also provides low-impact exercise.
• Always work with your rheumatologist, physical therapist, and healthcare team to ensure hydrotherapy is done safely, with proper supervision, appropriate temperatures, and precautions to prevent slips, falls, or other injuries.