Hydrotherapeutic Heat Application as Support in Febrile Patients: A Scoping Review

Abstract

Background:

Most often, fever is still treated by lowering body temperature with medication. In complementary and integrative health care, patients are supported during illness to use the positive effects of fever. Accompanying applications from the field of hydrotherapy are often used for gentle cooling, but there are references that warming in fever can also be used as a support. The aim of this scoping review was to identify available evidence on how, when, and why patients with fever are treated with heat application.

Methods:

The MEDLINE, CINAHL, EMBASE, COCHRANE, Google, and Google Scholar databases as well as references of identified literature were searched. As sources of evidence, publications studying patients who received heat application or were kept warm in febrile condition, regardless of medical situation, type of health care setting, and geographical background, were taken into consideration.

Results:

The literature search identified 1698 publications, of which only 7 were included. Methods of applying heat were the use of electric warming blankets, hot packs, hot-water bottles, or hot water footbaths. Most of the studies on heat application used temperatures of about 40°C and reported significantly lower body temperature after heat application.

Conclusions:

The literature suggests that hydrotherapeutic heat application is a common and well-appreciated method in Middle Eastern and Asian regions to support febrile patients. Using heat to support the energy-intensive and uncomfortable phase of rising fever may improve comfort, prevent unnecessarily high fever, and save biological energy. Therefore, high-quality studies on the role of heat application in fever are expected to be of high relevance for future fever management guidelines and integrative health care in general.

Introduction

Rationale

Fever is of great importance in integrative medicine and patient-centered care,¹ and there are numerous clinical studies in humans supporting the benefits of fever.^2
–4 The evolutionarily adapted febrile system helps organisms fight off infections and its benefits are large enough to outweigh energetic costs.⁵ The increase in temperature during fever is a potent biological response modifier with manifold effects on elements of the immune response. Fever has important consequences for survival⁶ as it appears to improve outcomes regarding viral replication and improve host defense mechanisms against pathogens.⁷

Fever in general is characterized by three dynamic phases: the first phase is the stage of temperature rise when the body decreases heat loss through vasoconstriction and increases heat production through shivering; the second phase is the temperature stabilization stage when the body's core temperature has reached the new thermoregulatory set point and heat production and heat loss are balanced; and the third phase of falling temperature occurs by lysis or by crisis.⁸

Although adverse events in the setting of febrile illness are more likely to be related to the underlying illness than to the increase in temperature,⁹ fear of fever has led to a literal “fever phobia,”^10,11 which tends to increase with the rise of temperature, rapid onset, and duration of fever.¹²

In most settings, the usual treatment for fever is still antipyresis from the very first moment, pharmacologically as well as by physical cooling.¹³ In the neurological or cardiological setting, induced hypothermia can have beneficial clinical effects on a wide range of body functions,¹⁴ but a recent meta-analysis confirms that pharmaceutical antipyresis does not impact mortality or other important clinical outcomes in critically ill patients.¹⁵

It has not been conclusively established that the benefits of antipyretic therapy outweigh its risks,¹⁶ and there is no uniform threshold for administration of antipyretics.¹⁷ Febrile seizures cannot be prevented by pharmacological antipyresis,^18,19 and there is growing consensus that the actual goal of antipyretic therapy is not to normalize core body temperature, but to reduce discomfort.^20
–22 The staff in intensive care units have also reached this consensus,^15,23 and some authors even call for providing febrile patients in the intensive ward with a blanket if they are cold.^24,25

Integrative health care focuses on whole person care²⁶ and emphasizes supporting the patient rather than treatment of a disease.²⁷ Supportive physical treatments for fever are widely used in integrative health care and go back a long way historically.^16,28 Early forms of hydrotherapy are known since ancient times²⁹ and have been reported from Egypt, Asia, and Europe.³⁰

Hydrotherapy belongs to the established naturopathy methods. It is defined as application of water in liquid form or as steam for medical purposes, with the water usually serving as a heat transfer medium.³¹ In literature of traditional European medicine, sources of evidence can be found on cold water treatments such as calf compression and other forms of physical cooling.³²

Beside cooling practices, warm water application is also a part of hydrotherapy. Application of heat leads to local and general vasodilatation. Sweat secretion increases, which leads to blood thickening and purification of the intercellular space by suction effect.³³ In addition, intestinal peristalsis is activated³⁴ and there is a vegetative balance with general relaxation.³³

For the support of febrile patients, cold hydrotherapeutic applications for gentle fever reduction are widely known,^32,35 but there are also references on the application of heat³⁶ with a referral to the cultural belief in “sweating out” fever.³⁷ Since there is a lack of literature, the authors of this study have taken a broad approach to investigate whether there is evidence to suggest that heat application can support patients with fever.

Objectives

The aim of this scoping review is to identify available evidence on how, when, and why patients with fever are treated with heat application.

Methods

The value of scoping reviews lies in examining a broad scope to identify gaps in the body of knowledge, clarify key concepts, and report on the types of evidence that are relevant to practice.³⁸ This scoping review was conducted in accordance with the PRISMA extension for scoping reviews Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA-ScR).³⁹ The PRISMA-ScR checklist is provided in Supplementary File S1.

Eligibility criteria

Types of participants

This scoping review considered publications that studied febrile children and adults of all ages who received heat application regardless of their medical condition.

Concept

The key concepts examined by this scoping review were all methods of how, when, and why people receive heat application treatment for fever and what effects this had on the course of the disease in general or on the response of the immune system in particular. Fever here is defined as an equivalent rectal temperature of ≥38°C or an axillary temperature of ≥37.5°C,^40,41 although in many countries, fever is defined as any temperature ≥38.5°C. Conditions where this temperature has not yet been reached, or has been determined by other, nonapparatus measurement methods, have also been considered.

As many traditional hydrotherapeutic measures with hot water have been replaced over the years due to safety concerns (e.g., hot-water bottles) or technical advancements (e.g., electric heating blankets), for this review, heat applications were defined as all measures with the goal of supporting the body to increase temperature. This includes methods of preventing heat loss (e.g., insulating clothing/blankets, isothermal ambient temperature) or providing additional heat to the body surface (e.g., electric blankets, microwave heating packs, hyperthermic baths, or hyperthermic ambient temperature).

Context

This scoping review considered publications on studies that were conducted in any type of health care setting, including inpatient and outpatient treatment or home care. Sources of evidence from any geographic background were eligible for inclusion.

Sources of evidence

Publications on any type of research, such as method comparison studies, quasi-experimental studies, and diagnostic studies, as well as surveys, reviews, and meta-analyses, were considered as sources of evidence. Exclusion criteria were (1) publications on afebrile or unnatural conditions, such as the treatment of hypothermia due to extreme cold, hyperthermia through extreme heat exposure, and artificially induced fever; (2) publications on applications that are warm, but below body temperature, and assumed to be methods of cooling; and (3) publications where the full text was not available in the English language or when publications were inaccessible.

Information sources and search

The search strategy of this scoping review aimed to find published and gray literature in the English language. An initial limited search of MEDLINE and CINAHL was conducted to identify articles on this topic, with the intention to gather relevant keywords from titles and abstracts. The keywords used were “fever OR febrile in Title AND heat, warmth, warming, compress, heat bag, hot water bottle, warm pack, heating pack, heating pad, blanket, hydrotherapy, physical treatment, nursing, bath in title or abstract.” Results were limited to humans. This search strategy was adapted to the specifications of each database.

Databases included were MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials (CENTRAL). Due to the few matches expected, this scoping review included evidence without restriction on the year of publication, and all articles indexed until October 2021 were considered for inclusion. The complete electronic search strategy for the MEDLINE database, including any limits used, is provided in Supplementary File S2.

Comparable search strategies were used for the other databases. Sources for the search for unpublished gray literature were Google Scholar and Google. The reference lists of all identified articles were screened for additional sources of evidence.

Selection of sources of evidence and data charting process

The search results were independently considered for eligibility by two reviewers. From all sources included, the following data were charted using a data extraction form, which is provided in Table 1: author, year, country, design, sample size, participants, age, setting, intervention, temperature, duration, outcome, and results.

Table 1.

Sources of Evidence

Authors (year), country, design	Aim	Sample size of participants (age)	Setting	Warmth intervention	Temperature, duration	Outcome	Results
Ikematsu (2004), Japan, survey, validation study	To determine characteristics of fever and interventions to treat febrile patients under acute and critical care nurses	356	Seminar; participants were nurses undergoing the intensive care course; questionnaire tool “International Classification of Nursing Practice” was used	To provide extra warmth (e.g., electric warming blankets, hot packs/hot-water bottles)	N/A, N/A	Major and minor characteristics of fever	Increases in body temperature and chills were the major characteristics, most part of the intervention was cooling (88%), followed by warming (48%) and medical management
Saied El-Nagger and Mohamed (2020), Egypt, quasi-experimental pre/post study with control group	To evaluate warm water footbath effectiveness on temperature and fatigue in children	100 Children with fever (6–12 years)	Hospital	Immersion of feet and ankles in warm water vs. standard treatment (unspecified)	40°C −43°C, 20–30 min	Body temperature and fatigue	Significant differences in temperature and fatigue levels among children with fever between the study and control groups and between pre- and post-tests for the study group
Mandal et al (2014), India, quasi-experimental study with control group, (RCT)	To assess the effectiveness of the warm water footbath therapy on physiological parameters	30 Children with fever (6–12 years)	Hospital	Warm water footbath therapy vs. standard treatment (unspecified)	N/A, 10 min	Body temperature, pulse rate, respiration rate, and blood pressure	Average reduction of axillary temperature, pulse rate, respiration rate, and blood pressure in the intervention group
Pereira and Sebastian (2018), India, quasi-experimental study, (RCT)	To assess the effectiveness of the hot water footbath therapy in reduction of temperature among children	60 Children with fever (6–12 years)	Hospital	Hot water footbath plus antipyretics vs. only antipyretics	37°C −43°C, 15 min	Body temperature	Significant difference between pre- and post-test reduction in the intervention group; significant post-test difference between intervention and control groups
Sharma and Kumari (2019), India, quasi-experimental study, (RCT)	To assess the effectiveness of the impact of the hot water foot immersion therapy on regulation of body temperature	60 Patients with fever (N/A)	Hospital	Hot water footbath along with standard treatment (unspecified) vs. standard treatment (unspecified)	39°C −40°C, 15–20 min	Body temperature	Significant reduction of temperature in the intervention group
Sunar (2017), India, RCT	To assess the effect of a hot water footbath on temperature among patients with fever	60 Patients with fever (17–25 years)	Hospital	Hot water footbath vs. routine management (unspecified)	41°C −42°C, 10–15 min	Body temperature	Significant reduction of temperature in the intervention group
Wilbert (2018), India, quasi-experimental time series nonequivalent control group design, (RCT)	To assess the difference in temperature between experimental and control groups after the hot water footbath therapy	60 Patients with fever (18–50 years)	Medical college and hospital	Hot water footbath vs. standard treatment (unspecified)	32°C–43°C, 10–15 min	Body temperature	Significant decrease in the temperature level after application of the hot water footbath therapy

N/A, not available; RCT, randomized controlled trial.

The data extraction form was modified and revised as necessary during the process of extracting data from each included source. To request missing or additional data, authors of publications were contacted if required.

Results

Selection of sources of evidence

The electronic literature search identified 1698 publications, of which 1435 remained after exclusion of duplicates. In the title and abstract screening, 1320 publications were excluded as not relevant. After assessing the full texts of the remaining 115 publications for eligibility, another 108 publications were excluded. A total of seven publications^42

–48 were included in the qualitative synthesis.

A flow diagram of the review process is provided in Figure 1.

FIG. 1.

Flow diagram of the review process.

Results of individual sources of evidence

As part of a large, multinational validation study, a survey was conducted among 356 nurses in Japan to determine characteristics and treatments of fever. Nearly half of the nurses (48.31%) reported the use of warming as an intervention for febrile patients. The author describes that in Japan, the belief prevails among nurses that treating patients by warming at the onset of fever helps the temperature rise to the new thermoregulation set point.

Warming is assumed to accelerate this process and shortens the duration of the patient's suffering. The author criticized that most of the nurses did not specify details of the warming method other than “providing extra warmth,” but some nurses indicated the use of electric warming blankets, hot packs, or hot-water bottles.⁴²

In a quasi-experimental pre/post control group study, the effectiveness of a warm water footbath on temperature and fatigue level among 100 children, aged from 6 to 12 years, with fever was examined. The study was conducted in various departments of a children's hospital in Cairo, Egypt. The intervention was a warm water footbath applied for 20–30 minutes.

The control group received standard treatment, which was not further described and is of unknown extent. There were significant differences in the temperature and fatigue scores among children between the intervention and control groups and between the mean scores of temperature and fatigue in pre- and post-tests. The authors of the study concluded that warm water footbaths are effective in reducing temperature and fatigue and should be implemented as a complementary therapy in management protocols for children with fever.⁴³

Another quasi-experimental study with control group design was conducted on 30 children with fever in the pediatric unit at a hospital in Kolkata, India. The aim of the study was to determine the effectiveness of warm water footbath therapy versus no intervention in terms of differences in physiological parameters (axillary temperature, pulse rate, respiration rate, and blood pressure).

Physiological parameters were assessed before and 15 and 25 min after the intervention. Results showed an average reduction of physiological parameters in the intervention group after the warm water footbath therapy. The authors recommended the warm water footbath therapy as a complementary treatment by nurses and mothers of children with fever.⁴⁴

A quasi-experimental study with a pre-/post-test control group design examined 60 children (aged 6–12 years) who were medicated with antipyretics for fever and admitted in hospitals at Mangaluru, India. The pretest temperature was assessed in intervention and control groups. The intervention group received the hot water footbath therapy (immersion of feet and ankles in hot water) for a period of 15 min, with water at a temperature of 100°F–110°F. The control group received no intervention.

The study showed a significant difference between the pre- and post-test reduction in body temperature in the intervention group and significant post-test difference of body temperature between intervention and control groups. The authors concluded that because there was significant reduction in body temperature in the intervention group, the hot water footbath therapy is effective in reduction of body temperature. They suggested that the hot water footbath therapy is a complimentary, easy, cost-effective, and complication-free therapy for families and nurses.⁴⁵

An additional quasi-experimental study, with pretest and post-test control group design, examined 60 patients admitted with fever at a hospital in Greater Noida, India. The intervention group received the hot water footbath therapy along with standard treatment of unknown extent and the control group received only standard treatment.

There was a significant reduction in temperature after application of the hot water foot immersion therapy. The mean difference between the pretest and post-test temperature was 2.030°F. The authors concluded that the hot water foot immersion therapy was effective in patients with all types of fever and participants were highly satisfied with the therapy.⁴⁶

Using a pre-experimental design, another study examined the effectiveness of the hot water footbath therapy in 60 patients (aged 17–25 years) with fever admitted in selected hospitals in Pune, India. Participants were randomly allocated into two groups. The intervention group received the hot water footbath therapy (immersion of feet and ankles in hot water), with water at a temperature of 41°C–42°C for 10–15 min.

The control group received routine management of unknown extent. Mean temperature in the intervention group was 101.04°F (±0.04) at preintervention and 99.37°F (±0.58) at postintervention. A significant difference was found in the temperature after the intervention. In the control group, there was no major difference. The authors concluded that reduction of temperature in the intervention group proved that the hot water footbath is effective and can be advocated as a simple and safe therapy for reducing body temperature at home and in hospitals.⁴⁷

In another quasi-experimental study with a control group design, 60 adult patients (aged 18–50 years) with fever from a medical college and a hospital in Kanchipuram, India, were randomly assigned to intervention (n = 30) and control (n = 30) groups. The intervention group received the hot water footbath therapy for 10–15 min, with water at a temperature of 90°F–110°F.

The control group received standard treatment of unknown extent. The mean post-test temperature level after the intervention (100.267°F) was lower than the mean pretest temperature level before the intervention (101.120°F). The results showed a significant improvement in the temperature level after application of the hot water footbath therapy. The authors concluded that the hot water footbath therapy is an effective and cost-effective measure in reducing temperature.⁴⁸

Critical appraisal within sources of evidence

The quality of the included sources of evidence must be rated as low overall. With the exception of one survey,⁴² all included articles appear to be studies conducted as part of academic graduate theses at nursing schools.^43

–48 Due to this context, all of these studies used simple experimental designs that cannot meet the requirements of high-level assessment tools and were therefore only generally described with regard to their risk of bias.

The studies can be classified as quasi-experimental studies or quasi-experimental time series with nonequivalent control group design. No information on blinding is provided in the five studies and it can be assumed that there was none because blinding of personnel and patients is impossible due to the type of intervention. Although completeness of outcome data appeared to be present, some studies lacked demographic data or assessment of these.

In some cases, the control group data were missing altogether or the groups were not comparable and inclusion criteria were not met. There were no trial registrations or prepublished protocols. The highest risks of bias in the studies were the insufficiently described control groups and the unspecified standard treatment the groups received.

Synthesis of results

In summary, seven sources of evidence were identified, which relate to the review question and its objective of fever support by heat application: six clinical trials^43

–48 and one survey.⁴² Methods of applying heat include the use of electric warming blankets, hot packs, hot-water bottles, or hot water footbaths.^{42,43,45

–48} On average, the publications report a temperature of 40°C for the heat application.^43,45

–48

Five studies reported significantly lower body temperature between the intervention and control groups, and between pre- and post-tests.^43,45

–48 One study reported an improvement in fatigue⁴³ and another study reported a reduction in pulse rate, respiration rate, and blood pressure through warm footbaths.⁴⁴ The publications came from Middle Eastern and Asian regions, including Egypt, India, and Japan.^42

–48

One study showed that warming is a usual intervention for febrile patients among nearly half of the nurses surveyed.⁴² For an overview of all characteristics of the included sources of evidence, see Table 1.

Discussion

The review of existing sources of evidence shows that overall there is very little literature on the use of heat application to support patients with fever. Why there are so few sources of evidence on heat application, especially from Western cultural regions and medical research on this topic, remains an open question. Most of the included studies used warm water footbath as the heating method.^43,45

–48 This form of hydrotherapeutic heat application seems to be a usual fever treatment in patient care in some cultural regions.

Treating patients with electric warming blankets, hot packs, and hot-water bottles was the second most common way of managing fever—used, for example, by Japanese nurses.⁴² From the reported rationale, it can be assumed that the reason for this approach is the need for different interventions in different phases of fever to support the body³²: the warming process for increasing body temperature to meet the increased thermoregulation set point, and maintaining this temperature; and gentle cooling once the body signals through sweating that it is striving for a lower temperature.

One of the most striking results of this review is that heat application was followed by a lower core temperature in all six interventional studies. This may first be counterintuitive, yet it is in harmony with the intention of most caregivers to provide warmth (because the patient developed chills and shivering) and at the same time hope for the fever to not rise too high.

The findings prompt the authors to formulate the triple hypothesis that heat application at the onset and rising phase of fever could be beneficial in three different ways. First, it could relax the thermoregulatory pressure and mechanisms to increase the core temperature, such as centralization, chills, and shivering. This would in turn decrease the discomfort of these symptoms. Second, this relaxation could also mean that average body temperature does not rise above what is really needed for optimal immune function. This would also increase comfort since very high temperatures are likely related to higher levels of discomfort. Third, heat application could enable reaching the optimal global body temperature for immunological function in a faster and easier manner.

The findings also raise a number of questions for future research. Given the advantages of fever in fighting pathogens and upgrading the efficiency of the immune system, the question arises as to why all of the reported studies primarily assessed core body temperature. Concentration on lowering the temperature as an outcome may actually be more due to the fact that this is an outcome that is easy to measure, but may not reflect the original culturally embedded intentions of using heat application as a fever support.

Being an external application, it is necessary to understand how peripheral body temperature interacts with core temperature during hydrotherapy and how to determine the central–peripheral temperature in various febrile illnesses. Since existing literature lacks further details on the fever phases in which heat is applied, and none of the studies reported whether the course of the underlying disease was affected by the interventions, there is a need to determine the safety of heat application at specific fever stages or severity levels.

Should it become evident that heat application in fever is more beneficial than harmful, it could lead to a fundamental rethinking in management of fever. As hydrotherapy or other forms of heat application can be used in a variety of outpatient and inpatient settings as patient-centered treatments for fever, future research should focus on evaluating feasibility in various clinical settings and acceptability among patients and health care professionals.

Limitations

Every electronic literature search inherently contains limitations. A limited number of eight databases was searched with keywords in English, meaning that articles that are not indexed in those databases or are published in any other language were not included. Publications were excluded based on title and abstract and according to the a priori defined inclusion and exclusion criteria.

Disagreements between the reviewers were resolved through discussion or by a third reviewer. It is nevertheless possible that relevant publications were not considered due to this process.

Conclusions

The findings of this scoping review provide initial evidence that hydrotherapeutic and other forms of heat applications in fever are used successfully to support the body in developing an increase in body temperature as well as with the contrary intention of lowering temperature. Since there are still many questions about the use of heat application in fever, which this review cannot answer, high-quality studies are necessary to understand its influence on central–peripheral body temperature and on the course of underlying diseases and patient perception.

If heat application at fever onset and in the rising phase of fever turns out to be effective, safe, and acceptable, it will be of high importance for future fever management guidelines and integrative health care.

Availability of Data and Materials

Data are available on request from the authors.

Footnotes

Authors' Contributions

D.D.M. initiated the work. H.S.K. conceived the review and was the major contributor in writing the manuscript. Data collection, analysis, and interpretation were performed by H.S.K. and C.K.R. D.D.M. and C.K.R. critically revised the article. All authors read and approved the final manuscript.

Author Disclosure Statement

The authors have no conflicts of interest.

Funding Information

No funding was requested for this study.

Supplementary Material

Supplementary File S1

Supplementary File S2

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