Aquatic Therapy Journal Aug 2005 Vol 7

7/28/2019 Aquatic Therapy Journal Aug 2005 Vol 7

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AnAquatic

Therapy&RehabInstitut

e,

Inc.

Publication

August2005

Volume7Issue2

Aquatic Rehabilitationfor Medically Fragile and

Terminally Ill Children:A Case Study

Effects of Water Exerciseon Muscle Strength

and Endurance

Aquatic RehabilitationFor Orthopedic Trauma:

Part One


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The Aquatic Therapy Journalispublished biannually by theAquatic Therapy & RehabInstitute, Inc. and the AquaticExercise Association. The AquaticTherapy Journalarticles are peerreviewed to insure the highestquality information.

ATRI prohibits discrimination onthe basis of race, color, religion,creed, sex, age, marital status,sexual orientation, national origin,disability, or veteran status in thetreatment of participants in,access to, or content of its pro-grams and activities.

Articles may be submitted as acontribution to the profession;no remuneration can be made.Submissions should be directed toManaging Editor Susan J. Grosse,[email protected].

For permission to reprint foracademic course packets, pleasesend a written request [email protected].

For Subscription and Membershipinformation, please contactAEA, [email protected],phone: 941.486.8600

Opinions of contributing authorsdo not necessarily reflect theopinions of AEA and ATRI.

2005 AEA/ATRI-Nokomis, FloridaVolume 7, Issue 2

Managing Editors: Sue GrosseRuth Sova

Graphic Design: Carolyn Mac MillanPrinting: Palm Printing

On the Cover:From the Powerpoint presentation Fun and Functional Assessments for Childrenprovided at the Aquatic Therapy and Rehab Institutes Specialty Institute, Chicago, ILJune, 2005. Courtesy ofAquatic Consulting & Education Resource Services.

1 Aquatic Therapy Journal August 2005 Volume 7 Issue 2

US $17.00

The Aquatic Therapy & Rehab Institute, Inc. (ATRI) is a non-profit, educational corpo-ration dedicated to the professional development of health care providers in the area ofaquatic therapy. Offering educational courses, ATRI provides opportunities to advancethe competencies, knowledge and skills of the aquatic therapist.

ATRI Mission Statement

The Aquatic Exercise Association is a not-for-profit educational organization dedicated tothe growth and development of the aquatic fitness industry and the public served.

AEA Mission Statement

Feature ArticlesAquatic Rehabilitation for Medically FragileandTerminally Ill Children: A Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Kathryn Azevedo, Ph.D., ATRIC, Vladimir Choubabko

and Karen Herzog, Founder and Executive Director

Effects of Water Exercise on Muscle Strength and Endurance . . . . . . . . . . . . 12Diane J. Marra, MA

Aquatic Rehabilitation For Orthopedic Trauma: Part One . . . . . . . . . . . . . . . 21Piero Pigliapoco, Piero Benelli and Lorena Cesaretti

Feature ColumnsPool Problems: Cloudy Pool Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Alison Osinski, Ph.D., Aquatic Consulting Services, San Diego, CA

Interface: Aquatic Professionals Interact withPhysicians . . . . . . . . . . . . . . . 11Gary Glassman, M.D., Emergency Physician, St. Mary Medical Center, Langhorne, PA

Research Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

New for Your Library . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Around and About the Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Web Waves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

OthersFrom the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Aquatic Therapy JournalForm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Table of Contents


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Welcome to the first subscription issue

of theAquatic Therapy Journal! Some

of you are receiving this publication as

part of your membership benefits from

the Aquatic Therapy and Rehab

Institute (ATRI) or the Aquatic Exercise

Association (AEA). Others are brandnew subscribers. By the end of the

year, as part of the reorganization of

ATRI, everyone will need to be a sub-

scriber to continue to receive what we

feel is the finest publication in the

aquatic therapy industry. We hope this

subscriber group will include YOU.

As you read in our last issue, ATRI has

completed reorganization and reaffirma-

tion of its commitment to providing

quality professional education opportu-nities in therapeutic aquatics. Part of

that reorganization has included the

involvement of the Aquatic Exercise

Association as our new publisher, along

with redesign of our publication.

As usual, you will find detailed infor-

mation on educational opportunities

available through ATRI. We have also

addedAround and About, to keep you

updated on news in our field. We will

continue to bring you announcementsfrom the International Council for

Aquatic Therapy and Rehabilitation

Certifications (ICATRIC).

Each issue we will be including more

substantive articles for your reading.

This month we are proud to present the

topics of orthopedic rehab protocols

and effects of aquatic exercise on

strength development. Of interest to

individuals working in pediatrics is our

presentation on aquatic therapy for

medically fragile/terminally ill children.

Alison Osinski kicks off her recurring

Pool Problems column with a major

article on cloudy pool water.

Our Web Waves column continues,

along with four additional new column

offerings. Interface will be written

by a different professional each issue,

highlighting practical suggestions for

communication and interaction with

professionals in disciplines closely related

to therapeutic aquatics. Dr. Gary

Glassman is our column kick-off author

for this issues interface with the med-

ical profession. The very knowledge-

able Alison Osinski is the on-going

author of our new Pool Problems col-umn. Noted for practical problem solv-

ing, Dr. Osinski will address many of

the pool problems you, our readers,

face daily. Interested in research? You

will be able to find short, to the point,

research summaries inResearch Review.

Last, but not least, new publications in

the field will be reviewed in For Your

Library.

If you are reading someone elses

copy ofATJ, its time to subscribe!Yes, library and business subscriptions

are available also. Access http://www.aea

wave.com/press.release.htm.

Interested in authoring an article? Have

industry news to share? ContactATJat

[email protected]. We would be

pleased to receive your announcements

and/or send you Author Guidelines.

Were excited to be providing you

with the best the only peer-reviewed publication for aquatic

therapy. We encourage you to keep

moving forward with us. As Will

Rogers said, Even if you are on the

right track, you will get run over if

you just sit there. Ride the wave

with us and youll never get run

over! N

From the Editors

Ruth Sova, Editor

Sue Grosse, Editor

Highlights February 2006

Dont miss the next issue of theAquatic Therapy Journal, or youwill miss out on the following:

Aquatic Rehabilitation forOrthopedic Trauma, Part 2 byPiero Pigliapoco, Peiro Benelli,and Lorena Cesaretti.Discussion continues withconditions of the Shoulder &Elbow, Knee & Ankle and Pelvis& Hip. Guidelines for Phase Aand Phase B of Treatment arediscussed and specific exercisesuggestions provided.

A Questionnaire to Measure

Use of Aquatic Physiotherapy inSouth Australia: Research andDevelopment by Gisela M. vanKessel, Joshua J Stewart, andAuburn McIntyre. The aim ofthis study was to develop avalid and reliable questionnaireto measure current use ofaquatic physiotherapy byaquatic physiotherapists.

Ethics in the Aquatic TherapyProfession.

Interfacecolumn targetingEducators.

Pool Problemswith AlisonOskiski Alison Osinski, Ph.D.,Aquatic Consulting Services

Research Review

Beginning in the February 2006issue, readers can earn ICATRICapproved CECs and AEA CECs!

Aquatic Therapy Journal August 2005 Volume 7 Issue 2 2


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The decision to bring into a pool amedically fragile child or a child havinga life threatening illness requires carefulconsideration. Parents need to beenthusiastic and dedicated to the valuesof aquatic activity. Pool managementmust cooperate in the endeavor.Aquatic specialists accepting medicallyfragile and/or terminally ill childreninto their practices need to be highlyskilled, aware of disease progression,and able to adapt handling skills to thechilds specific needs.

The goal of aquatic therapy for medical-ly fragile children and/or children withlife threatening illness is to, as much aspossible maintain and improve qualityof life. For some children this meansproviding palliative care. For other chil-dren this becomes end of life care.

The Decision to Proceedwith Aquatic Rehabilitation

Warm water aquatic therapy can play a

vital role in habilitation/rehabilitationof children with cerebral palsy, sensoryprocessing disorders, arthritis, spinabifida, cancer, Down syndrome, ortho-pedic disorders, rare diseases such asTay-Sachs and Niemann-Pick, as well asother syndromes where motion andbreathing need improved synchrony.

Children who have diseases severelylimiting activities of daily living oftencan benefit the most from aquatic reha-bilitation. These children, however, are

the most challenging cases. Recently,there has been an increased effort forimproving palliative and end of lifecare to our rapidly aging elderly popu-lation. In the United States, however,very few facilities and practitioners,skilled at providing care for childrenand their families as they confront life-threatening illness, exist. The Initiativefor Pediatric Palliative Care (IPPC,2004) has outlined three segments ofthe pediatric population who would

benefit from enhanced palliative careservices: those who are born without an

expectation of survival to adulthoodbut who live a long time with sub-stantial suffering,

those who acquire illnesses such ascancer, and

those who suffer a relatively suddendeath due to trauma.

A great deal of preparation and plan-ning is needed before the child enters

the water. Following is a case study ofa child with Niemann-Pick Disease,Type A (NPA) illustrating how closecooperation and collaboration amongparents, practitioners, service agencies,and pool management can lead to apositive delivery of pediatric palliativecare in the aquatic environment.

CASE STUDY: AQUATIC THERAPYFOR A CHILD WITH NIEMANN-PICK DISEASE TYPE A

Children with lysosomal storage disor-ders, such as Niemann-Pick DiseaseType A (NPA), are born without theexpectation of a life expectancy beyonda few years. Children born with NPAare missing the enzyme acid sphin-gomyelinase (ASM), responsible formetabolizing and breaking down sphin-gomyelin, a special lipid component ofcell membranes. If ASM is absent or notfunctioning properly, sphingomyelinabnormally builds up, leaving fattydeposits called foam cells in manybody tissues and organs, primarily thebrain, liver, spleen, lungs, and bonemarrow. The sphingomyelin pairs withcholesterol and leaves the affectedorgan with a swollen, foamy appearance(Bank, 2002).

Impact of this enzyme deficiency isenormous on the central nervous sys-tem, resulting in progressive neurologi-cal impairment, profound developmen-tal delay, progressive spasticity, epilepsy,

enlarged liver/spleen, and a character-istic cherry red spot in the eye.Children with NPA exhibit a variety ofsymptoms including muscular weak-ness manifested by feeding difficulties,loss of early motor skills, abdominaldistention, hepatosplenomegaly, hypo-tonia, hypersensitivity and skin with ayellowish brownish discoloration.Death usually occurs between 2-4 yearsof age.

Baby SophiaIn summer, 2002, we began caring forBaby Sophia in the aquatic environ-ment. She was 14 months of age. Ouraquatic program was initiated as partof Sophias Circle of Healing, a holisticmodel of care her parents had devel-oped to increase the quality of Sophiaslife and search for a cure for NPA. Atthis time, Sophia required the assis-tance of one aquatic practitioner.Despite her small size, she demonstratedgood head support. Sophia was flexible

and able to perform supported kickingon her back. She was also able to sup-port herself in an inner tube for a fewminutes and her arm movementsresembled a dog paddle. We werecareful to keep her ears out ofthe water. The maximum enduranceshe had for an aquatic session was25 minutes.

At 16 months, Sophia began losingweight, her tactile sensitivity increased,and her tolerance for environmentalnoise in the pool environmentdecreased. However, Sophia was stillable to achieve assisted flexion andextension of her legs in the water. Byfall 2002, Sophia had frequent respira-tory and fungal infections and was inneurological decline. In February 2002,two choking and apenic episodes led toa hospitalization and her return homeon hospice. As a result, we temporarilysuspended aquatic therapy throughwinter 2003.


Aquatic Rehabilitation for Medically FragileandTerminally Ill Children: A Case Study

Kathryn Azevedo, Ph.D., ATRIC

Vladimir Choubabko

Karen Herzog


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In spring 2003, we reconnected withSophia at home, providing land-basedwork. As Sophia continued to grow, shelost postural strength and cognitivefunction, but her health stabilized.When she was 2 years, 6 months old(30 months), Sophias parents decidedto have Sophia return for aquatic reha-bilitation. We worked closely with her

parents to reassess how we would pro-ceed with Sophia in the aquatic envi-ronment. Vladimir Choubabko andKathryn Azevedo worked together toprovide aquatic rehabilitation forSophia once a week.

At this time, Sophia is very faciallyexpressive and communicates non-ver-bally, though her global developmentaldelay is apparent. Sophia does not bearweight on her legs and both her feetand ankles are externally rotated.Sophia is hypersensitive to movementand must be positioned carefully. She

tolerates some massage, but joint move-ment is painful and Sophia does notlike to have her limbs stroked. Insteadshe likes to have a hand gently placedon her, in one place. Sophia cries withpain when Choubabko lifts Sophia fromher stroller to carry her into the pool.Due to her lack of head and neck con-trol and the requirement of a continu-ous indwelling nasal gastric tube,Sophia now requires 2 experiencedaquatic practitioners to achieve aneffective 30-minute aquatic session.

Despite the warm water temperature of93 degrees, Sophia chills easily so weare careful to keep her close to our bod-ies. Since bowel incontinence hasbecome a concern, she now uses 2swim diapers. We closely monitor herabdomen and we are able to detectchanges indicating whether or not shewould need to be quickly removed fromthe pool environment. Bowel move-ments are very painful for her so she

cries when this happens. Since Sophiahas very limited ability to swallow, greatcare is taken to make sure pool waterdoes not enter her mouth. Sophia aspi-rates on thin liquids and does not elicita protective cough. More specifically,Sophia has a difficult time swallowingher own saliva.

When her abdomen is more distendedthan usual and her face more jaundiced,Choubabko will place one hand overher liver while the other arm cradlesher head and upper torso. Meanwhile,Azevedo holds the disconnectedindwelling nasal gastric tube out of thewater with one hand, monitors herbreathing, and leads Sophia in gentlerange of motion and extension exercises.

Sophia responds best with some type ofsound. Together, Azevedo andChoubabko sing to Sophia in English,Russian, and Spanish, reflecting their

respective cultural heritages. They singthe songs in a certain order, so Sophiacan recognize transitions. Singing is animportant part of her therapy since itseems to soothe her, reduce her crying,and promote relaxation, harmony, andsynchronization between the 2 aquaticpractitioners. The rhythmic singing, ouraquatic handling, and Sophias suspend-ed movement through water allows forincreased sensory input and allows herbrain and body to work together.

As her disease advances, Sophia haslow-grade seizure activity while in thewater. One of her parents, along with anurse, brings Sophia to the pool andremains while she is in the water.Sophia experiences about 2 seizures perday and multiple arousals, a form ofmild seizure activity manifesting in eyerolling and jerky arm and leg move-ments. If her seizure activity wouldbecome severe, as evident by drooling,choking, and/or gagging, there is a

medical practitioner already presentwho could determine if emergencyservices should be called.

The aquatic environment providesSophia with opportunities to experi-ence weightlessness, muscle relaxationand temporary reduction in pain. Herparents see direct benefits from her

aquatic sessions. They report anincrease in flexibility, and this experi-ence has led to home-based bathtubaquatic therapy 2-3 times a week. Thecognitive, visual, and auditory stimula-tion from the therapists singing, thevoices of other clients and therapistsin the pool, and music piped throughthe centers audio system provide stim-ulation different from the home envi-ronment. Social interaction with thera-pists, caregivers, clients, and staff atthe Betty Wright Swim Center are also

seen as a benefit. Our goal is toimprove Sophias quality of life whileher parents pursue life saving treat-ment to prolong her life.

In May 2004, Sophia reached a mile-stone as the family and communitycame together to celebrate her 3rdbirthday. At 3 years old, she continuedto grow new teeth and increase inlength. She has gained 2 pounds, andhas a full head of beautiful brown hair.Sophia shows increased comfort andtolerance in the warm water environ-ment. Immediately following the ses-sion, results of the aquatic rehabilita-tion are apparent. Sophia takes a longnap after the session. She cries less andher parents report she is able to sleepmore fully and deeper for the next fewdays. Her mother reports that after anaquatic session, Sophia is able to bettertolerate painful medical procedures,such as blood draws. Since it takes agreat deal of effort for the parents andthe caregivers to prepare Sophia for anaquatic session, their consistency in


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attendance is a clear indicator of thepositive impact that aquatic rehabilita-tion has had on this child with NPA.

Programming Implications

When a parent approaches aquatic facil-ity staff about the possibility of aquatictherapy for their child with a life threat-ening illness, they frequently face resist-

ance since there are real risks to beaddressed. Children with severe, pro-gressive, life threatening illnesses oftenpresent with what most would callcontraindications to pool therapynasal gastric tubes, supplemental oxy-gen, seizures, urinary and bowel incon-tinence and high susceptibility to infec-tion. Moreover, pool management maybe concerned about scheduling,whether their facility is appropriate,issues of liability, cost of providinglabor intensive care, and the impact

providing care will have on other poolclients.

The first barrier to consider is appropri-ateness of the pool environment andtrained staff. Medically fragile childrencan be hypersensitive to sound, touch,water temperature, and water turbu-lence. So precision in pool schedulingwill take cooperation between all staffmembers, as well as pool clients. Howa child enters/exits the pool is another

consideration. Ideally, the pool wouldbe equipped with a pool ramp for easywheel chair access. If the child is verysmall or has no postural control, he orshe will need to be carried, whichrequires staff strength and skill. A par-ent or caregiver can be trained to assist.Appropriate aquatic clothing needs tobe discussed. Warm water clothingmade of Neoprene can be custommade to maintain thermoregulation.

A child who has bowel/urinary inconti-

nence should be double diapered withrubber pants over the diaper. Skilledaquatic practitioners with advancedhandling skills should be able to pal-pate the abdomen, and monitor forchanges that could indicate inconti-nence, being prepared to quickly evacu-ate the child if necessary. An additionalprecaution that can be taken to addressincontinence is to coordinate the childspool time around feedings and usualbowel movements.

If a child requires an indwelling nasalgastric tube or supplemental oxygen, 2aquatic practitioners are needed oneto carry the child and another respon-sible for making sure the tubing is notobstructed. A nasal gastric tube shouldbe disconnected from the feedingsource prior to pool entry. The exposedend can be covered with plastic wrap to

prevent water contamination.

Oxygen usually needs to be continuedwhile in the pool. Children who requirenasal gastric and oxygen tubing entailmore risk, but with the appropriatelength of tubing and an assistantresponsible for the tubing, these riskscan be managed and passive horizontalaquatic modalities can be performed onthe child.

If a child has a tendency to experience

seizures, close communication with par-ent and physician can help aquatic prac-titioners distinguish between seizingactivity that is serious or mild, in orderto decide whether to continue the aquat-ic session or seek medical attention.

If a child is highly susceptible to infec-tion due to a compromised immunesystem, careful attention to the poolfacility environment is required.Outside the water, parents should paycareful attention to where they dress

and change the child. Since mold,mildew, and fungus thrive in the humidenvironment of indoor pools, to mini-mize exposure to these organisms, par-ents should bring their own towels andsheets to cover the changing table.

Pool chemicals should be checked priorto the session and if chlorine orbromine levels are low, the childsaquatic session should be rescheduled.If the pool water is cloudy, most likelythe chemicals and filtration are out of

sync and parents should be wary toallow their child in the pool.

With careful planning, many so calledcontraindications to pool therapy canbe addressed. This labor-intensive workis costly and, ideally, public and privatefunding could subsidize pediatricaquatic rehabilitation sessions in orderto diminish access barriers. Absolutecontraindications to aquatic therapy,however, do exist and these include

active infections, diarrhea, fever, andrecent persistent seizure activity.

Impact on Pool Staffand Clients

When we first brought Sophia into ourfacility for aquatic therapy, there weresome challenges. Of prime importancewas finding a time when Sophia would

be awake, fed, diapered, and ready foractivity. She needed a quiet protectedspace away from the commotioncaused by our ambulatory clients. Wedecided on an 11:30 am timeslot sincethis was after our adapted aquaticsprogram and before our senior swim atnoon. This posed a slight delay forindividuals in our senior program.However, the mother and nursing staffeducated the pool clients on Sophiasfragile health and this has promotedmore cooperation and consideration ofpediatric rehabilitative needs in a poolenvironment now dominated by thera-peutic rehabilitation of our local elderlypopulation.

Many pool staff were concernedwhether Sophia would actually benefitfrom aquatic rehabilitation. Staff whoshared the pool during our session withSophia quickly learned to work aroundus. Our pool colleagues limit movemento keep splashing and water turbulence

to an absolute minimum. Eventually,other staff members learned to workwith Sophia, and this opportunityenhanced staff training and fulfillment.

PALLIATIVE CARE VERSUS END

OF LIFE CARE

When dealing with children having ter-minal illness, issues of liability are ofspecial concern to pool management.Aquatic therapy, by its very nature, isrelaxing and diminishes pain. By provid-

ing comfort care, palliative care seeks toprevent or relieve physical and emotion-al distress produced by chronic, life lim-iting or terminal illness. Pediatric pallia-tive care helps a child and his or herfamily live as normally as possible, for aslong as possible, by preserving the digni-ty and integrity of both the pediatricpatient and his or her family.

It is important to note palliative care isNOT limited to people thought to be




dying. Palliative care can be providedconcurrently with life-prolonging treat-ments (Institute of Medicine, 2003).For Sophia, we are providing palliativecare in the aquatic environments, carethat specifically addresses pain manage-ment, assistance in breathing and bowelfunctioning, and progressive musclerelaxation. We try to improve her quali-

ty of life by making her feel better,while her parents pursue potentially lifesaving experimental treatments.

As the childs medical condition fluctu-ates, however, the distinction betweenpalliative care and end-of-life care is notalways clear. End-of-life care focuses onmeasures preparing for an anticipateddeath and in the warm water aquaticenvironment that usually means reduc-ing pain. Those involved with pediatrichospice care understand death often

finally occurs when a child is able tolet go of pain. So there is a remote pos-sibility passive, horizontal aquaticmodalities that relieve pain and facili-tate muscle relaxation can facilitate thedying process in children with lifethreatening illness. Although aquaticpractitioners may want to relieve painand suffering, while providing palliativecare, it is not advisable to have thechild pass away in most pool facilities.

In the United States, most pools have

parents sign a detailed waiver of liabilitydirectly addressing these issues, releas-ing both the aquatic practitioners andthe facility from legal prosecution ifdeath occurs in the aquatic setting. Itis important to note, however, the firstpediatric hospice in the United States,the George Mark Childrens House(www.georgemark.org), recently openedin San Leandro, California. This facilitydoes provide aquatic therapy to chil-dren in their final days of life. Since thestaff at this center has extensive train-

ing in hospice caregiving, issues of lia-bility are of less concern to aquatic staffin this environment. Parents who wishto have aquatic therapy sessions fortheir child in the end stages of lifeshould seek out these hospice facilitieswith warm water therapy pools.

Conclusions

Bringing a medically fragile child intothe pool environment requires a great

deal of effortand coordina-tion. Providingpediatric pal-liative care inthe aquaticenvironment ispossible and is

not only a worthwhile endeavor, but a

medically beneficial, morally justified,community building enterprise, and animportant opportunity for staff learn-ing. It is our hope this case study willinspire other practitioners to provideaquatic therapy for children with lifethreatening illness.

AcknowledgementsThe authors wish to thank SophiaHerzog Sachs for the opportunity towitness her courage. We wish to thankthe staff and patrons at the Betty Wright

Swim Center for providing us the envi-ronment to care for Sophia. Black andwhite photos courtesy of KarenSchreiber, copyright 2004. We alsoacknowledge Sergey Loginowski in hiscolor photo of our work. N

References

Bank, Michael G., University ofPittsburgh, Department of HumanGenetics, Niemann Pick Disease(Type A) http: www.pitt.edu, 2002

The International Center for TypesA and B Niemann-Pick Disease,Mount Sinai School of Medicine,Department of Human Genetics, http:www.mssm.edu/niemann-pick, 2004

Field, Marilyn, and Richard Behrman,Editors, When Children Die,Improving Palliativeand End-of-Life Care for Childrenand Their Families, Institute ofMedicine, Washington DC, USA,

2003

The Initiative on PediatricPalliative Carehttp://www.iappcweb.org/about.asp

AuthorsKathryn Azevedo,Ph.D., ATRICStanford UniversityMedicalCenter, Stanford, CASpecial Needs Aquatic

Program, SNAP, Richmond, [email protected], [email protected]

Kathryn Azevedo, Ph.D., ATRIC, is a clinicalresearcher at Stanford University MedicalCenter where she runs clinical trials. In her 20

years in aquatics, Dr. Azevedo has attainednumerous aquatic and massage certificationsand is a Master Trainer for the ArthritisFoundation. She began her aquatic career as avolunteer in the community based aquatics

program designed by the late Betty Wright. Ingraduate school, she worked with ProjectPROJIMO a rural community based rehabilitation center for children in Sinaloa, Mexico.She wrote her masters thesis on community-based rehabilitation and helped to edit thenewer editions of Where There is No Doctorand Disabled Village Children. While atC.A.R, Dr. Azevedo won an ArthritisCommunity Grant to test a pilot pediatricarthritis program and developed assessmentand training materials for their former adapt-ed aquatics program. She now works with theSpecial Needs Aquatics Program (SNAP) asthey seek to expand community based aquatics

programs for children with special needsthroughout the San Francisco Bay Area.

Vladimir ChoubabkoWest Valley College,Saratoga, CABetty Wright Swim Centerat C.A.R., Palo Alto, CA

Vladimir Choubabko has achieved a broadbase of expertise in his 40+ years in the aquat-ics field. In Russia, he graduated from the

prestigious Institute of Physical Education andSport with a degree in physical education,

physical therapy, massage, and coaching. As acoach in Olympic swimming, he produced out-

standing results in coaching 9 Olympic goldmedalists. He is well known for his dedicationtowards his athletes and was also able toinspire hard work and commitment from hiscoaching staff. This success propelled him tothe national level of sports administration inthe former Soviet Union where he managed abudget of several million dollars. From 1980to 1988 he was responsible for training, organizing, and budgeting Russian Olympic swim-mers. Vladimir was awarded several medals ofexcellence for this work. In the United Stateshe has continued his education in aquatics andgeriatric physical education. Vladimir nowworks as a lead physical education instructor

at both West Valley College and MissionCollege. At C.A.R, he is the lead aquatic per-sonal trainer and massage therapist.

Karen HerzogFounder & Executive DirectorSophias Garden Foundation,Palo Alto, CAwww.sophiasgarden.org

Karen Herzog is the mother of Sophia Sachs,who is battling Niemann-Pick Disease, Type A(NPA). As an educator and advocate for chil-drens health, Ms. Herzog is a founding adviso-ry board member of the UCSF-Stanford Jewish


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Genetic Disease Center. Out of what shelearned from Sophias struggle for survival andher familys search for meaning in the midst ofuncertainty, she created Healing in Community, acompassionate and highly effective community-based approach to caring for children with life-threatening conditions and their families. She co-

founded Sophias Garden Foundation to share thisknowledge with the world.

ReviewerComments

Julie Meno Fettig

This article brings awareness of therole aquatic therapy can play inmanagement of pain and providingpalliative care. Sophias case studyis an excellent example of howcoordinated professional disci-plines, different services, and tim-

ing of treatment need to be for suc-cessful aquatic therapy with a med-ically fragile child. Warm wateraquatic therapy is an excellent painmanagement modality. Aquatictherapy for the treatment of painhas greatest benefit when water isclean, temperature correct forpatients condition, and environ-ment is calm. The therapist shouldbe knowledgeable about the specif-ic condition, adaptable, reassuring,empathetic, yet humorous. Thisthree dimensional supporting envi-ronment can be a great equalizeragainst pain. When suspended inwater, without fear, it allows us tofeel and sense ourselves from with-in. From within we can heal our-selves, feel strong, in control, andvery much alive. N

Reviewer Bios

Julie Meno Fettig, CTRS,ATRIC, is the founder/owner ofTherapeutic Aquatics, Inc. andaquaticcentral.com, specializing inconsulting, information, and reha-bilitation. She is the author andpublisher of The Bad Ragaz RingMethod Visual Instructional Manualand video and co-producer of thePNF in the Pool video. She receivedthe 2002 ATRI Tsunami SpiritAward. N


Aquatic professionals often notice that pool water becomes turbid graduallythroughout the day or immediately after lengthy periods of peak use. Cloudy waterconditions may also occur immediately after chemical adjustments are made. Watermay appear cloudy or milky. A fine white precipitate may settle out of the water.Water clarity frequently deteriorates to the point where it is not safe to continueoperation and classes or programs must be cancelled.

Although water clarity should exceed 0.25 NTUs (Nephelometric Turbidity Units),most public pool bathing codes permit swimming pools to be used until the claritydeteriorates to the point that either the main drains or a 6-inch diameter black diskcant be clearly seen from the surrounding deck at the deepest point in the pool, orthe black and red (or black and white) quarter panels on a 2-inch diameter, Secchidisk cannot be distinguished at a depth of 15 feet.

Aquatic professionals should insist water clarity be maintained within an acceptablerange. It should be understood that activities will be cancelled rather than endan-gering users. Written pool rental agreements should outline how the instructor ortherapists will be compensated for lost fees or wages if the pool is not able to beused. If cloudy water problems result in more than very infrequent pool closures,the cause of the problem should be identified and remedied.

Water clarity problems can usually be traced to one of two possible causes eitherphysical or chemical in nature. Physical problems are caused by the design of thecirculation system or mis sized equipment. Chemical problems usually result fromimproper application of chemicals, incorrect dosing, or from not correcting water

quality problems when they occur.

Chemical Problems

Sometimes chemicals are added to water in too great a quantity in too short a periodof time. With the exception of chlorine, pool chemicals should be added to the poogradually, and in small quantities over an extended period of time. Pre dissolvesolid, granulated or powdered chemicals prior to their addition. Try to limit chemi-cal additions to 10 ppm changes at a time.

Excessively high Total Dissolved Solids (TDS) can cause water to appear less thancrystal clear. Use a TDS meter to determine the level of total dissolved solids. Inpools with high bather load to water volume ratios, regular dilution is recommendedat a rate of 8 gallons per pool user per day. If TDS levels exceed 1,500 ppm and arecausing problems with taste, clarity, ability to maintain ORP levels, or galvanic cor-rosion, dilute significantly, or drain and refill the pool with fresh water.

High concentrations of cyanuric acid will interfere with oxidation of organic con-taminants in the water. Do not use cyanuric acid or chlorinated isocyanurates, suchas trichloro-s-triazinetrione or sodium dichloro-s-triazinetrione, in indoor pools, orin outdoor pools and spas with extremely high organic loading problems. If cyanu-rates are used to prevent loss of chlorine and dissipation into the air due to exposureto ultraviolet light, use them in moderation. Keep cyanuric acid levels in the 10ppm 20 ppm range since 95% of the staying power benefit is achieved in thatrange. Also, the negative effects on pathogenic organism kill time and depressionof ORP are still within an acceptable range.

Cloudy Pool Water

Alison Osinski, Ph.DAquatic Consulting Services, San Diego, CA

TRR Feature Column: Pool Problems



If water is difficult to balance due toextremely high calcium hardness levelsin the source water, use of sequesteringor chelating agents is recommended.Sequestering agents increase the abilityof water to hold dissolved minerals ormetals in solution. It is a preventativetreatment. Sequestering agents keepminerals from: oxidizing and staining,

causing scale build-up, precipitating(coming out of solution) calcium andmagnesium salts when pH and watertemperature rise, discoloring or cloud-ing the water, attaching to and discolor-ing bathers hair. Chelating agentsremove metals or dissolved mineralsfrom the water. They cure mineralstaining problems. Organic water solu-ble molecules bond and react with ionsto keep them from precipitating.

Oversaturated water is one of the most

frequent causes of cloudy pool water.Since water is the universal solvent, allthings will inevitably dissolve in wateruntil the water becomes saturated.Eventually, water will become unbal-anced or oversaturated and excessproducts will be lost by precipitation.Well balanced water will increasebather comfort and will dramaticallyextend the life expectancy of the pooland its components. Water tempera-ture, pH, total alkalinity, calcium hard-ness, and total dissolved solids act

together to cause corrosiveness or calci-fication qualities of water. TheLangelier Saturation Index formula andchart can be used to determine if poolwater is balanced that is, neitheraggressive nor oversaturated.

To calculate the saturation index, usethe formula: Saturation index equalspH plus the alkalinity factor, plus thecalcium hardness factor, plus the tem-perature factor, minus the TDS factor.

Use your test kit and testing instru-ments to find each of the five values.Write down the actual pH value found.Then for the remaining four values,find the corresponding factor on thechart. Add or subtract the factors to orfrom the pH value. If an actual value isnot found on the saturation indexchart, do not interpolate since there isno direct linear relationship betweenthe values. Rather, move to the nexthigher value and use its factor.

If the sum obtained is zero, the water isbalanced and chemical equilibrium hasbeen achieved. A tolerance of plus orminus 0.3 is allowable for commercialswimming pools. Negative values indi-cate aggressive water, while positive val-

ues indicate likely calcification andscale formation.

Undersaturated water is aggressive andwill cause circulation pipes, heater ele-ments, and other metal components ofthe pool to corrode. Pool wall surfacematerials will deteriorate. Plaster willsoften and etch, vinyl liners willbecome brittle, metal staining willincrease, and tiles will become looseand begin popping off the walls.

If water is oversaturated, calcium car-bonate will begin to settle out of thewater. Water will become cloudy andtake on a milky appearance. Scale willbuild up on solid surfaces, making sur-faces rough, and discoloring dark sur-faces. Calcium carbonate scale will alsobuild up on interior surfaces of the poolrecirculation pipes, restricting flow andincreasing water pressure. Sanitizereffectiveness will be reduced, and algaegrowth may increase.

If the saturation index formula indi-cates the pool water is not balanced,make the appropriate chemical correc-tions, starting with total alkalinity, thenfollowed by pH, temperature, calciumhardness, and TDS.

Algae blooms may cause pool water tobecome turbid, cloudy, or discolored.Algae is a waterborne plant introducedinto pools by swimmers, make-upwater, rain, wind and windborne debris.

Although algae in and of itself is notharmful to swimmers, it does causeproblems when allowed to grow in aswimming pool. Algae graduallyremoves carbon dioxide from the waterin order to manufacture food and may

cause a dramatic rise in pH. Pool sur-faces can become slippery from anoticeable algae growth on the poolbottom or walls. Algae is a higherorganism that may harbor pathogens ordisease causing bacteria. Chlorinedemand may be high, as chlorine isused in an attempt to kill or controlalgae growth. Pools filled with algaemay give off unpleasant odors.

To control algae growth, maintain ade-quate chlorine and oxidation reduction

potential (ORP) levels, keep the watercirculating continuously, make sure youhave a uniform circulation pattern andabsence of dead spots in the pool,superchlorinate regularly, and scrub orbrush pool walls to prevent algae fromadhering. If water is not continuouslycirculated, sanitized and oxidized, youmay need to use commercially preparedalgaecides or algaestats to keep algaegrowth under control. Some algaecidesare more effective against a particulartype of algae, and some are more appro

priate for use in pools or in spas.

If you continue to have serious algaeproblems, you may want to monitornitrate levels more closely, and try todetermine the source of contamination.Nitrates stimulate plant growth, andwhen high levels of nitrates (greaterthan 25 ppm) are present in pool wateruncontrolled algae growth often occurseven though unaccountably largeamounts of chlorine are being used.

SI = pH + alkalinity factor + calcium hardness factor+ temperature factor TDS factor

Temperature Calcium Hardness TDS Total Alkalinity

degrees factor ppm factor ppm factor ppm factor

66 0.5 75 1.5 1000 12.2 75 1.9

84 0.7 150 1.8 100 2.0

94 0.8 200 1.9 150 2.2

105 0.9 300 2.1 200 2.3

400 2.2 300 2.5

800 2.5 400 2.6

1000 2.6


10/28

Nitrates are introduced into pools from:fill water in areas where fertilizer hasworked its way down into the groundwater, contaminated reservoirs or wells,rain, fertilizers or grass blown into thepool from the adjoining landscaping,human or animal urine or fecal matter,and bird droppings. Pools located inagriculture areas, screened pools, and

pools that border large bodies of wateroften experience nitrate problems. Tolower pool nitrate levels, try shockingthe pool with chlorine to over 30 ppm,or partially drain and refill the poolwith water not contaminated withnitrates.

Physical Problems

Water clarity problems may be persist-ent if the pool circulation and filtrationsystem was not properly designed or ifthe components were incorrectly sized.

However, even the best designed systemwill not keep water sparkling clear ifcomponents are not properly main-tained, or programming and batherloads increase beyond expectation.

To maintain clarity, keep bather load tototal filtered water in gallons per dayratio at 1 bather : 1,400 gallons or less.The onset of turbidity is constant andrelated to the number of bathers, notjust turnover time. If debris is added tothe pool water faster than the filter canremove it, turbidity will increase.Debris is introduced into a poolthrough airborne dirt, dust, plant mat-ter, and pollen; rain water, and bathers.But the greatest amount of debris isbrought into the pool by bathers.

To determine maximum bather load:multiply flowrate (gpm) x 60 (min-utes/hour) x 24 (hours/day) to get thetotal filtered gallons per day. Then,divide total filtered gallons per day bythe constant 1,400 gallons to get themaximum number of bathers per daywho can enter the pool before waterclarity problems result.

To find the needed turnover timerequired at a given maximum batherload: Multiple the actual number ofbathers using the pool per day by theconstant 1,400 to get total filtered gal-lons per day needed. Divide by 24(hours/day), then divide by 60(minutes/hour) to get the required

flowrate in gpm. Divide the volume ofthe pool in gallons by the requiredflowrate to get the needed turnovertime in minutes.

Interestingly, since there are 1,440 min-utes in a day, a short cut method ofdetermining the correct turnover timeis simply to equate bather load and flow

rate. The flowrate in gallons perminute and the maximum bather loadshould be similar. For example, a poolwith a maximum daily bather load of300 swimmers should have a flowrateof around 300 gallons per minute inorder to maintain good water clarity.

Know your pools baseline readings,and monitor turnover time. Read theflowmeter and pressure gauges dailyand record the results. Make sure thatthe normal flowrate is being maintained

and that an obstruction or pumpimpeller damage due to cavitation isnot restricting the amount of watermoving through the filters.

Make sure filters are properly sized.If water is allowed to flow through themedia at a rate higher than recom-mended by the manufacturer and NSFInternational, debris will pass rightthrough without being removed. Todetermine needed filter size, calculatesquare footage of each filter tank (or

look on the permanently affixed plateon the front of the filter). Take theflowrate in gallons per minute (gpm)and divide by the design flow rate forthe particular tank using the samemedia. The total media square footageshould exceed this number.

For example, a pool with a flowrate of1,000 gpm, is being filtered with a bankof 4 horizontal high rate sand filterseach with 13.5 square feet of #20 silicasand filter media for a total of 54 squarefeet of media. The design flow rate is aminimum 15 gpm/ft2. One thousandgpm divided by 15 gpm/ft2 equals 66.6ft2. The filters are considerably under-sized and water is likely to be cloudyduring periods of heavy use.

Assure that all valves are open or in thecorrect position to allow water to movethrough filters. Label all valves, andpost a diagram on the pump room wallshowing the correct position of valves

during normal operation and duringbackwash procedures.

Broken laterals inside of a filter tankcan allow debris to enter the pool andwill cause a loss of filter media availablefor filtering particles from the water.Check bottom of the swimming poolfirst thing in the morning before the

water has been agitated and look forregular deposits of filter media near thereturn inlets. Isolate individual filtertanks from the bank to try to determinewhich laterals have broken. Removethe filter media and inspect the lateralsat the bottom of the tank, replacingthose which have broken.

Iffilters are not backwashed properlyand for an adequate amount of time,fine particles start to work their waydown into the filter bed. Eventually

fines are carried into the laterals andback into the pool. On filter systemswith automatic backwash valves, makesure booster pumps are bringing thepressure up to 50 psi during the back-wash process.

Perform regular filter tank inspectionand maintenance on a monthly basis.Open the filter tank and make observa-tions, being careful not to damage thefilter tank or components. Dig or pokearound with a trowel and look for:

flatness of the media bed, channeling(holes), biofilms on the tank walls,media migration, and contaminationcaused by improper backwashing orimproper chemical balance.

While the tank is open for inspection,perform a settling test to determinemake-up of the filter bed. Take a largeglass jar (like a mayonnaise jar) and fillit with 2 cups of water. Add 1 cup ofmedia from your filter. Add 1 teaspoonof dishwasher detergent or Calgonwater softener. Replace jar lid andshake. Allow the solution to settleovernight. The sample should settleinto a layer of sand with water on top.If instead, it settles into layers withsand on the bottom, silty materialabove the sand layer, and an organiclayer on top, replace the filter media inthe tanks.

Clean the sand media inside the filtertank by adding a commercial sand




cleaning solution or sodium bisulfate.Mudballs and channels which forminside the sand should be destroyed.Mudball formation is caused by calciumscale, organic debris, detergents, oils,and bather waste products. These oilyproducts reduce sanitizer effectiveness,promote bacterial growth, and cloudwater. In addition to forming scum

lines at the water surface, they may alsoclog cartridge filters and diatomaceousearth filter elements, and contribute tomudball formation in sand filters caus-ing reduced filter effectiveness.

Use of enzymes or absorbent foamproducts is recommended to help pre-vent filter problems from occurring inthe first place. Enzymes are catalyststhat start or speed up chemical reac-tions. Enzymes are protein-like sub-stances that form naturally in animal

and plant cells, but today, syntheticenzymes have been developed.Enzymes slowly, over several days,digest and destroy oils in pool water byconverting them to carbon dioxide andwater. A similar process is used toclean up oil spills occuring in theocean. An initial dose of one to twoounces of enzyme per 1,000 gallons ofpool water is recommended, and thenmaintenance doses of about half thatamount should be added to the pool ona weekly basis.

Absorbent foam products can also beused to physically remove oils from thewater. Manufacturers of the products saythe patented molecular structure and celldesign of the foam allows it to absorbmany times its own weight in oil. Whenthe foam is saturated with oil, it turns adark color, becomes heavy and sinks.The foam can be replaced or, for a periodof time, can be cleaned and reused byremoving the absorbent foam from thepool skimmer, hair and lint strainer orfilter tank, squeezing out the oils andreplacing it in its hidden location.

Colloidal particles are particles smallerthan 1 micron in size, which are sus-pended in water. Colloids are smallenough to pass through pool filters,too light to settle on the bottom of thepool, and make water murky or cloudy.Flocculants and clarifiers make col-loidal particles stick together orcoagulate so that the particles become

large enough to be filtered out or heavyenough to settle so they can be vacu-umed out.

Although aluminum sulfate (alum) wasthe most common flocculant used inthe past, today cellulose fiber or polyaluminum chloride are more common.The products are added directly to the

filter bed and form a layer on top of orbetween the grains of sand media.

Clarifiers are biodegradable organicpolymers usually made up of the natu-ral polymer chitin often extracted fromsea organisms. Positively chargedrepeating polymer links attract nega-tively charged colloidal particles. Theelectric charge is neutralized, and thepolymer coils up into a large particle,which can be filtered.

Infrequent vacuuming of debris fromthe pool can contribute to cloudy waterconditions. Make sure the pool is rou-tinely being vacuumed on a daily basis,first thing in the morning, or after aperiod of quiescence of at least 2 hours,to allow debris which is heavier thanwater to settle on the bottom of thepool. Check that portable or roboticpool vacuum filters are being disinfec-ted and cleaned properly.

And finally, make sure the pool does

not have any circulation dead spots.Perform a dye test of pool circulationpatterns to make sure all inlets areoperating properly. Note the inlet pat-tern, any inlets that don't work, inletswhere the water stream is weak, inletspointed in the wrong direction, or inletsin need of adjustment. Look for circu-lation eddies or weak spots where waterdoes not change color and record. Iffiltered, heated, chemically treatedwater is not being uniformly distributedto all areas of the pool, it is likely algaewill become established in the pool,and other water quality problems willdevelop. N

TRR Pool Problems

Pool Problems is an on-going column.Does your pool have a persistentproblem? Submit your pool problemand/or pool operations question [email protected]. The purpose ofthis column is to help you, our readers,operate safe, healthful facilities.

Why Join the eListBulletin Board?

The eList is a free way to networkwith other aquatic professionals, toexchange ideas and gain the knowl-

edge necessary to best serve mypatients.Stacy Yagow, COTA/L, ATRIC

Networking is the key to havingthe latest information to provide thehighest level of care every day.Since so many of us are not part oflarge service delivery teams, partici-pating in the bulletin board givesimmediate access to co-workers ofdiverse experience enabling me todo a better job for each person inmy pool.

Barbara L. Batson

I read almost everything on thebulletin board and have a veryvaluable file of information. Also,it is nice to begin to get to knowother aquatic professionals as ques-tions and information comes fromthem and I am able to respondback. Thanks to all. I always lookforward to the mail.

Patti Crimer, COTA/LDowners Grove, IL

The ATRI eList has proven to be aplethora of useful aquatic informa-tion as well as a device to networkwith other aquatic specialists. As asmall business owner of an aquaticphysical therapy department, I con-tinue to stay informed with currentaquatic information and connectedwith aquatic specialists through the

ATRI eList.Julie Huber, Owner,

Mission BeachWater & Sports Physical Therapy

Join the ATRIBulletin BoardFREE

When you subscribe to theBulletin Board (its free), youll getthe Aquatic Therapy Bibliographyof Books free also. To subscribego to www.atri.org and click oneList Bulletin Board then follow

the directions.


12/2811 Aquatic Therapy Journal August 2005 Volume 7 Issue 2

INTERFACE is a column devotedto the interaction between aquatictherapy professionals and profes-sionals in other disciplines. Sincemany of your aquatic clients areunder care of a physician, effectivecommunication with their doctorsis important for your patientsultimate health and well being.What follows is a brief guide topromote this communication.

General PointsAs a general rule, remember a physicianstime is very limited, so whatever form ofcommunication you expect in return, tryto make it very simple. After discussionswith numerous colleagues of mine invarious sub-specialties, I have summa-rized what works well for them. A pre-printed form that asks specific ques-tions about what you need to know, ismost helpful. This will need to beadjusted for each patient, but havingseveral templates on your computer

would be a good place to start. Formswhere boxes can be checked will make iteven easier for the physician to fill out.Having the patient take the form withhim/her to their next appointment,directly hand it to the physician andhave the doctor fill it out immediately(and return it to the patient during thatoffice visit) will hasten the flow of infor-mation. Any other form of communica-tion just takes too long, and its too easyfor busy doctors to forget to fill out

non-revenue-generating forms. Next,lets deal with some of the specialistsyour patients may see.

Orthopedic Surgeons

Be precise with what you need to know.Many times you are dealing with post-op patients or post-injury patients andyou need to know what limitations theyhaveso ask just that and gear yourpre-printed form to the specific joint(s)affected. Another, better alternative is

to state what you usually do with thesepost-op/post-injury patients and seeif the physician agrees with that plan.If not, allow spaces for changes to bemade. Again, be precise with yourvarious parameters including weight,duration, equipment, time, etc.

As things continue with the patient,plan on providing the physicial progressnotes with updated info. Once again,these can be given directly to thepatient to give to the doctor, so the

doctor can see the patients improve-ment through your skillful hands.

Neurologists/Rheumatologists

Patients with chronic conditions often-times are under the care of these spe-cialists. Some are early in their diseaseprocess, some very advanced.Examples include Parkinsons,Multiple Sclerosis, Lupus, RheumatoidArthritis, Fibromyalgia, ReflexSympathetic Dystrophy and Stroke.Forms will need to be individualizedto the specific patient, yet try to keepthe information simple. Once again,utilize forms that are easy to fill out. Ifthese are physicians that are unfamiliarwith your expertise and experience, Isuggest providing them with a coverletter introducing yourself, including abrief resume. Then indicate on yourform what you can provide to theirpatients. Im sure that many of youalready know that too many physi-cians dont understand the benefits

of aquatic therapy, so this can bean excellent source of education forthem and, if all works well, perhapsa source of patient referral for you. Ifthey agree with what you have brieflyproposed, have them sign the form andreturn it with the patient.

Cardiac orPulmonary Clearance

Brand new aquatic therapy clients hav-ing underlying cardiac or pulmonarydisease should be cleared for exerciseby their cardiologist or pulmonologist.These patients may have graduatedfrom cardiac or pulmonary rehab andare looking for some further exercise;before undertaking this endeavor, itsprudent to obtain medical clearancefirst. Once again, provide the cardiolo-gist or pulmonologist with your pro-gram parameters and goals, target heartrates, length of activity, etc., in a simpli-fied, pre-printed form and allow thepatient to deliver and return this form.

Finally, for patients without any knowncardiac activity or history of exertionalangina, and with only one known riskfactor (diabetes, high cholesterol,hypertension, smoking, family history,morbid obesity), some cardiologistsmight not recommend a pre-exercisestress test. But if two or more risk fac-tors exist, a pre-exercise stress test isdefinitely warranted. Either way, get-ting their written clearance for yourexercise program is still sensible.

Conclusion

Effective communication with busyphysicians needs to be concise.Providing doctors with easy-to-fill-outforms and having the patients be themailpersons will readily provide youwith updated info. In addition, this maynot only promote the aquatic industryas a whole to doctors, but also serve asa marketing tool for future referralsfrom physicians. N

Aquatic Professionals Interact withPhysicians

by Gary Glassman, M.D., Emergency Physician, St. Mary Medical Center, Langhorne, PA

TRR Feature Column: Interface



Busy people need time saving, compre-hensive workouts, balancing aerobicactivity with upper body, lower body,and trunk strength training. The pur-pose of this study was to contribute tothe limited body of literature on effectsof typical water aerobics classes onmuscular endurance and strength inworking age people. This researchexamines performance of muscularendurance and strength measures incommunity water fitness participantswho typically utilize class for an

aerobic workout.

Background

Physiological declines of an inactivelifestyle and benefits of exercise areclearly documented, yet 25% ofAmericans are completely sedentary,and another 53% are not active enoughto attain many health benefits (CDC,2003; US Surgeon General, 1996).Since modern technology has tiedmany to desk jobs and computer recre-

ation, estimates of obesity in Americanchildren, as well as adults, are at epi-demic levels (Giammattei, Blix,Marshak, Wollitzer, & Pettitt, 2003).Although the most common excuse fornot exercising is lack of time (Pate etal., 1995), Americans average morethan 4 hours of TV viewing daily(Nielsen Report, 1998).

Maintenance of good body mechanicsis at higher risk due to our trendstowards limited activity (Kendall,McCreary, & Provance, 1993).Repetitive, restricted motion and faultyposture over a period of time cancause discomfort, pain, or disability,depending on severity and duration ofmuscle weakness (Kendall, et al.,1993). Disability in performance ofactivities of daily living (ADLs) hasbeen strongly associated with depres-sion, arthritis, loss of mobility, loss ofphysical capacity and function, andincreased risk of mortality in older

adults (Judge, J. O., Schectman, K.,Cress, E., & the FICSIT group, 1996;Laukkanen, Heikkinen, & Kauppinen,1995). Losing lean body mass,strength, and flexibility, gaining fatmass, losing cardiovascular capacity,and developing glucose intolerancehave been associated with inactivity.These are not products of aging, aspreviously thought (Hu, Li, Colditz,Willett & Manson, 2003; DiPietro,2001; Nelson, 1997; Pate et al., 1995).

Age/ Population Specific DataPeople ofworking age also sufferdegrees of disability in performance ofADLs, most commonly from low backpain (LBP) (Sullivan, Dickinson, &Troup, 1994 ). Epidemiologists reportLBP affects one in three Americans byage forty-five, 80% of the populationexperiences LBP at least once (Jenkins& Borenstein, 1994). The least fit peo-ple examined in a study of 1652 fire-fighters, were found to have a substan-tially higher incidence of LBP than the

most fit. Patients with LBP oftenbecome further de-conditioned frominactivity, creating more risk for contin-ued pain and loss of income (Jenkins &Borenstein, 1994).

Prevention and rehabilitation programsmake sense for preserving functionalabilities, and have proven effective inavoiding long-term healthcare(Girouard & Hurley, 1995). Loss oflower extremity strength and balanceare primary risk factors for loss of phys-ical function (Nelson, 1997; Wolfson etal., 1996). Typically, there is a 40%decrease in strength from age 20 to age70 attributed to loss of lean tissue(Eckmann, 1997; Wolfson et al., 1996).Sanders et al. (1997) documented sig-nificant effects of 16 weeks of waterexercise on functional measures simu-lating ADLs among 44 exercisers (73.6+ 7 years). Winter & Burch (2000) alsomeasured significant improvement onthe Get up and Go test among her

small group (62 + 10 years) withpainful osteoarthritis (OA) after only 8weeks of exercise.

Vertical water exercise offers resistanceto increase muscle strength (Winters &Burch, 2000; Sanders et al., 1997) andimprove or maintain bone mass(Tsukahara, Toda, Goto, & Ezawa,1994) in postmenopausal women.Varied intensity levels are accommodat-ed in one class with proper instruction(Marra, 1998; Ruoti, Morris, & Cole,

1997; Sanders, 1993), allowing for abridge into more vigorous activity forthe sedentary or overweight. Water fit-ness research has also demonstrated thecardiovascular benefits of water exer-

cise programs for all ages (Bushman etal., 1997; Whitlach & Adema, 1996;Taunton et al., 1996; Ruoti et al., 1994;and Sanders, 1993). The literatureaddressing functional benefits for ADLsand strength measures, however, hasprimarily used senior adults as sub-jects. For todays busy working-age

adult it appeared important to assessthe possibility of achieving an aerobicworkout with overall resistance trainingat the same time, as life becomes moresedentary for everyone.

Activity Specific Data

Resistance training on machinesstrengthened each isolated muscle, butfunctional performance did not improvewithout integration of multiple jointmovements, utilizing several musclegroups concurrently (Cress, Conley,Balding, Hansen-Smith, & Konczak,1996). Specificity of training in a ver-tical posture similar to ADLs, whileoverloading several muscle groups,occurs within water fitness classes.Varied intensity levels are accommo-dated in one class with proper instruc-tion (Marra, 1998; Ruoti, Morris, &Cole, 1997; Sanders, 1993).

Water fitness increased the adaptationassociated with muscle strength

Effects of Water Exercise onMuscle Strength and Endurance Diane J. Marra, MA


14/28

(Winters & Burch, 2000; Marra, 1998;Whitlach & Adema, 1996; Ruoti et al.,1994; Sanders et al., 1993) and hasbeen linked to maintaining or increas-ing lean body mass. Wilber, Moffatt,Scott, Lee & Cucuzzo (1996) measuredblood lactate levels in land-trainedwater runners to be 31% higher thanthose performing submaximal treadmill

running at the same volume of oxygenconsumed (VO2) on land. Researchersconcluded the waters resistance elicitedthis anaerobic response, typically asso-ciated with strength training, notendurance training.

Absolute muscular endurance, theability to perform repeated dynamic orstatic muscle actions for extendedperiods, may be increased throughstrength training (Wilmore & Costill,1994). Researchers have used muscle

strength testing to assess the capabilityof muscle groups to provide support,stability, and function in locomotion(Kendall et al., 1993). Chest andshoulder muscle endurance measuresshowed significant gains in severalaquatic fitness studies. Whitlach andAdema (1996) measured a 25% anteri-or deltoid strength gain in older adults(mean age 71.5 years) after 12 weeksof hot water (94-96) exercise. In anunderwater test, 59-75 year old indi-viduals, after 12 weeks of water exer-

cise, achieved significant endurancegains (p < .05) when moving theshoulder through a 90 joint range inboth abduction/ adduction and hori-zontal flexion/extension to a one repe-tition per second tempo. (Ruoti etal.,1994).

Sanders (1993) measured the youngestwater exercise participants (39.9 +13.99 years), and found significantmuscle endurance gains in the YMCAtimed bench press performance (count-ing the greatest number of repetitions ata 60 bpm cadence) after 9 weeks of par-ticipation. In the same study, Sandersalso found significant performancegains in abdominal muscle endurancevia a bent-leg curl-up test. Since nocrunch training was utilized in thestudy, improvements were attributed todynamic, vertical, postural alignmenttraining within the water fitness classes.

Several researchers reported improve-

ment in muscle strength. Isometricquadriceps strength improved signifi-cantly and correlated highly withimprovements in the functional sit tostand time of 70- year old women in16 weeks of water aerobics (Sanders, etal., 1997). In 12 weeks of hot waterexercise, Whitlach and Adema (1996)measured 58% increase in quadriceps

strength on leg extension machineamong fifty-six older adults (mean age71.5 years). This group also increasedtheir walking speed by 40% on thetreadmill. Sanders, during her 1997study of older women, examinedchanges in knee flexor performance bymeasuring isokinetic strength, but onlyextensor strength changed significantly(p< .05). Hoeger (1994) also measuredknee flexion and extension isokinetical-ly in participants aged 15-35 years. Hefound improvements in both muscle

groups, but only hamstring perform-ance increased significantly (p < .05).Since pre-training strength of individu-als greatly affects relative gains from anexercise program (Kraemer, Deschenes,& Fleck, 1988), this discrepancy mayhave occurred because Sanders usedwomen in their seventies. Quadricepsstrength and size among this popula-tion tended to show greater declinesrelative to hamstrings strength and size(Sipila & Suominen, 1995), thereforedemonstrating more dramatic improve-

ments after training.

Cardiovascular benefit of water exercisehas been documented for all age groups(Bushman et al., 1997; Ruoti et al.,1994; Sanders, 1993; Taunton et al.,1996; Whitlatch & Adema, 1996).However, available information regard-ing strength gains and functional bene-fits for ADLs is limited. This projectaddresses this gap in the literature. Datain 9 muscular endurance and strengthmeasures were gathered from 22 work-ing age women (24-55 years), beforeand after 8 weeks of participation in acommunity water aerobics program.

Methods

Twenty-nine apparently healthy womenwere recruited from the communitythrough public service announcements,and gave informed consent to partici-pate in the study. Before beginning theprogram, each woman signed a consent

form approved by the Ethics Committeefor the Rights of Human Subjects atCalifornia (Sonoma) State University,Rohnert Park, CA. Twenty-two women(N=22) with a median age of 42.05 +8.3 years completed the programdesigned to address the questionregarding the effects of vertical waterexercise classes on muscular strength

and endurance. Data from 7 additionalvolunteers were excluded, due to lackof attendance. Subjects activity levelswere reported as exercising 0-2 days perweek for the previous 3 months, whileengaging in little or no forceful upperbody activity during daily job perform-ance. All indicated they felt comfort-able in water and agreed to exerciseonly within the designed water exerciseprogram for 9 weeks, until all testingwas completed. Participants attendedtheir choice of 3 one-hour water aero-

bics classes per week for an 8-weektraining period. Classes were a part ofpre-existing City Parks and RecreationDepartment program at a heated out-door pool with an average water tem-perature of 83F, where research partici-pants exercised alongside non-researchparticipants.

Subjects attended two testing sessionsbefore and two sessions after the 8-week exercise program. First appoint-ments were at a local athletic club for

baseline vital signs and 7 land-basedmuscular endurance and strength meas-ures, followed by two to three days ofrest, before 2 muscular endurancemeasures were performed in the waterat the city pool.

Exercise Testing

Land Evaluations: The Protocol beganwith 7-minute treadmill warm-up at3.0- 4.0 mph, followed by measures inseven categories. Shoulder adduction,knee extension, shoulder abduction,knee flexion, a one-repetition maxi-mum (1RM) leg press, isometricabdominal test, and back extensionmeasures were given, The session con-cluded with a 5 minute stretch (Marra,1998). The first four muscularendurance evaluations were modeledafter the YMCA bench press test(Golding, Myers, & Sinning, 1989).Quadriceps endurance was measuredon a seated CYBEX leg extensionmachine set at 10 lbs. Each subject




performed repeated non-preferred legextensions in the sagittal plane at60bpm. Hamstrings endurance tests onthe CYBEX prone leg-curl machine wereperformed with 10 lbs of resistance also(Marra, 1998). The one-repetition maxi-mum (1RM) (Baechle & Earle, 1995)was estimated using the CYBEX reclin-ing leg-press to observe performance of

gluteal muscles, hamstrings, and quadri-ceps. Two trunk measures were used, anisometric abdominal muscle test(Kendall et al., 1993), and second trunktest, from the Purdue Fitnessgram battery(Cooper, 1994).

Water Evaluations: Participants beganwater testing with a 5 minute joggingand arm-pumping warm-up. Then twotests were given. First, a modified ver-sion of an upper body water test usedby Ruoti (1994), where subjects began

in a standing position, water at the axil-la level, while wearing a weighted div-ing belt adjusted to 30lbs for increasedstability and Sprint Aqua Gloves forincreased surface area (Model Nos.725and No.780, Sprint RothhammerInternational, Inc., San Luis Obispo,CA). Beginning with palms touchingthe lateral part of the thighs, the testconsisted of a 90 abduction/adductionflapping movement, maintainingstraight wrists aligned with the arms,lifting until the top of the hands just

touched the surface of the water, andreturning to touch the palms to thighs(Marra, 1998).

The second and final water evaluationfor quadriceps endurance was adaptedfrom Sazaklidou (1994). It required a75 bpm cadence for appropriate diffi-culty as determined from pilot testing.Participants were positioned in waterapproximately waist deep,facing thewall, hands grasping the deck rail whilestanding on the preferred leg, on top ofa Speedo Aquatic Step (SPEEDO, Cityof Commerce, CA). The non-dominantleg was dangling off the side of the stepwith a Sprint Buoyancy Cuff. An addi-tional 3-piece Beltfloat was worn forresistance. Femurs remained parallel toeach other throughout the movement toavoid involvement of the hip flexors.Subjects flexed the working knee to a90 degree angle and then extended theleg to the original position, repeatedly(Marra, 1998).

Exercise Intervention Program

Subjects then participated in the 8-weekwater exercise program, as describedearlier. Each 1-hour exercise sessionconsisted of: a 10 minute warm-up, 20-minutes of shallow water activity wear-ing webbed gloves, followed by 25 min-utes of deep water activity using flota-tion bells with feet suspended off the

bottom of the pool, ending with a 5-minute stretch (Marra, 1998).

Data Analysis

Descriptive statistics were used to ana-lyze data. The Wilcoxon Matched-PairsSigned-Ranks test was used to deter-mine significance of changes, pretest toposttest. A nonparametric test wasselected because of lack of normal dis-tribution in the pretest data. TheWilcoxon test considers both t magni-tude of the differences in scores, and

direction of change. An alpha level of p= .05 was chosen a priori for criteria ofsignificance. Since most results weresignificant at the p = .005 level, it wasreported. Note, the Wilcoxon test chartused for this study (Pagano, 1986) indi-cates highly significant numbers at thep = .005 level, not at the more com-monly used p = .001 level. PearsonProduct Moment correlations were cal-culated to determine relationships

between water and land measures(Marra, 1998).

Results

Upper Body Muscular Endurance:

Both shoulder adduction and abductionmeasures on land showed increases ofstatistical significance (p < .005) follow-ing the exercise training. However, themean number of land adduction repeti-tions performed was nearly tripled fromthe baseline scores, while the meannumber of land abduction repetitionsimproved only about 20% (Marra,1998). The combined shoulder adduc-tion / abduction water test also revealedsignificant improvements (p < .005),with an average post-test score nearly 5times that of the pre-test (Marra, 1998)The descriptive results are shown inTable 1.

Lower Body Muscular Endurance:

Both hamstring and quadriceps per-formances on land increased signifi-cantly (p < .005). The mean number ofknee flexion repetitions improvedapproximately 51% from baseline(Marra, 1998). During posttest of theknee extension measure, participantsdemonstrated a mean increase ofaround 15% (Marra, 1998).

Upper Body Muscular Endurance MeasuresLand Water

Shoulder Adduction Shoulder Abduction Combination Shoulder Add/Abduction

M SD M SD M SD

Pretest 164.14 67.57 70.55 20.84 63.89 33.38

Posttest 466.05* 251.83 83.27* 25.01 293.27 228.62

Difference +301.91 +12.72 +229.38

repetitions repetitions repetitions

*Significant improvement at p


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Remarkably, the scores of quadricepsperformance in the water, after exercisetraining, were almost four times thepre-training scores (p < .005) (Marra,1998). Scores for lower body enduranceare displayed in Table 2.

Strength Measures of the Lower Bodyand Trunk: Participants significantlyimproved 1RM on the leg pressmachine by approximately 13% afterthe exercise intervention (p< .005)(Marra, 1998). Trunk extensionposttest scores also were improved bymore than 20% (p < .005) (Marra,1998). During abdominal testing, theaverage body angle to the floordecreased by 14%, which indicated animprovement, although not statisticallysignificant (Marra, 1998). See Table 3.

Correlations of Changes in Land-Water Scores: There were very lowcorrelations between changes in scoreson land, and related muscle group testsin the water. The strongest relationshipwas only r = 0.30, between improve-ments in knee extension on land andknee extension in water. Correlationbetween improvements in the shoulderland adduction measure (the moreimproved land-shoulder measure) andthe shoulder water combination meas-ure yielded an r of only - 0.099. There

were no detectable patterns within orbetween individuals (Marra, 1998).

Discussion, Recommendations,and Conclusions

The purpose of this study was to con-tribute to the limited body of literatureon the effects of typical water aerobicsclasses on muscular endurance andstrength in working age people. Clearlythe quasi-experimental design and

small sample size limited the statisticalpower and interpretation of results.The direction of change was expected,however the magnitude of change wasunexpected. This study has providedevidence that after only 8 weeks ofwater aerobics, both muscularendurance and strength improved.

Upper Body: In the water, shoulderabduction/adduction final scores werealmost five times the pre-trainingscores. These results eclipsed even thegreatly improved shoulder adductiontest on land, which finished with num-bers nearly three times those of thepre-tests (Marra, 1998). The nearly20% improvements on the land shoul-der abduction test, while statisticallysignificant, seemed disproportionatelylow (Marra, 1998). These findings

supported an aspect of the specificityof training principle (Wilmore &Costill, 1994), demonstrating morenoticeable gains in tests duplicating theaquatic training environment (Marra,1998). This corroborates Ruotis(1994) findings of significant improve-ments in this same water measure per-formed without webbed gloves by indi-viduals aged 59 to 75 years after 12weeks of water training.

The dramatic difference in the isolated

land-based shoulder abduction scoresfrom the shoulder adduction results,demonstrated the focus on adductionactivities in vertical water exercise.Assuming an erect position in the pool,shoulder adduction is resisted by buoy-ancy and further challenged by use offlotation equipment, whereas shoulderabduction is assisted by buoyancy(Marra, 1998).

Order of testing may have also

contributed to weaker performancesin shoulder abduction through fatigueof stabilizing muscles. It is possiblethere was greater improvement inupper body relative to most lower bodymeasures, because upper body muscleswere weaker in pre-testing. It appearseven among inactive adult females,lower body muscles maintain greater

muscular strength and endurance dueto daily work against gravity, whereasthe upper body usually is not chal-lenged in this way.

Lower Body: Results of lower bodymuscle endurance tests in water indi-cated an almost five-fold increase innumber of knee extensions performedafter training. This substantial changein quadriceps endurance in waterseemed disproportionate to the 15%average improvement on land using

CYBEX equipment (Marra, 1998). Alsoworth noting, is the impressive under-water quadriceps scores recorded dur-ing post-testing are only an estimate ofparticipants actual abilities. The post-testing evaluations unexpectedly con-tinued for such long time periods, thatsome women quit, due to personal timeconstraints or impatience, before theyexperienced muscle failure. As noted inupper body measures, these dramaticfindings appear to demonstrate thespecificity of training principle (Marra,

1998; Wilmore & Costill, 1994).

The water measure originally intendedfor hamstrings endurance was eliminat-ed during pilot testing due to problemsin stabilizing subjects against buoyancy.However the land CYBEX knee-flexiontest was successfully completed, indi-cating a 51% average improvement(Marra, 1998). Sanders (1997), Hoeger(1994) and Winters & Burch (2000)report the only other available kneeflexion tests, following vertical waterexercise treatments. Winters & Burchused a 1RM hamstring strength meas-ure with their OA patients and reporteda mean increase of more than 20% afteronly 8 weeks. Using isokinetic strengthmeasures, Sanders (1997) and Hoegerboth reported improvements in ham-string performance with Hoeger notingsignificant changes at p



to quadriceps performances (Marra,1998). Hamstrings typically produce60% to 80% of isometric strength tothat of quadriceps muscles in healthyadults (Baechle, 1994; Fine & Weiss,1995). Therefore it makes sense thatparticipants in this study, like Hoegers,achieved more dramatic results in post-tests of hamstring strength over compa-

rable quadriceps strength, given averagepre-training age and status of thehealthy participants (Kraemer,Deschenes, & Fleck, 1988). On thecontrary, older adults tend to havedeclining quadriceps strength (Nelson,1997; Sipila & Suominen, 1995). Thiswould explain the dramatic gains inquadriceps measures compared to ham-strings, among Sanders (1997) septua-genarian female participants, given thetypical pre-training status of that popu-lation.

Increases in the 1RM leg press aver-aged 13%, indicating improvements instrength of the quadriceps, hamstringsand gluteal muscles (Marra, 1998).These findings corroborate significantimprovements in sit-to-stand, and get-up-and-go functional field tests(Winters & Burch, 2000; Sanders,1997). Improvements in strengthfrom water aerobics training is animportant finding because theseresults indicate participants can

achieve an aerobic workout (Brown,1991; Ruoti et al., 1994; Sanders et al.,1993), a muscle endurance workout,and a strength training session con-currently, during the same water class(Marra, 1998).

Trunk Measures: The more than 20%average improvement in the spinalextension evaluation indicates not justincreased strength, but likely animprovement in range of motion(Marra, 1998). Although these two fac-tors cannot be separately distinguishedin the given test, this is an importantfinding since spinal mobility decreaseswith age and extension shows the great-est decline (Einkauf, Gohdes, Jesnsen,& Jewell, 1987; Sullivan, Dickinson,& Troup, 1994).

Abdominal leg lowering measureproved difficult to administer. This testincluded only one tester and one spot-ter, but would have been more accurate

with two testers and a spotter due tothe poor body awareness demonstratedby subjects during pre-testing. Pretestscores may have been better than actualperformances had warranted from thispartially self-reported test. Since thewater aerobics program included train-ing in postural control, it became clearto the tester and participants at post-

testing, that participants awareness oftheir abdominal region had changedsubstantially through instruction.Individuals at post-testing were veryaware of the moment their low backsbegan to pull away from the floor andself-reported, cueing the spotter andconcluding each test. Many womenrecalled how inaccurately they mayhave self-reported body position duringpre-testing, so it is likely the 14% aver-age improvement is only a portion ofactual gains derived by participants

(Marra, 1998).

Although crunch exercises are notperformed in water, this improvementin abdominal strength may be attrib-uted to emphasis on maintaining pos-tural alignment throughout each class(Marra, 1998; Sanders et al., 1993).Thus, vertical water exercise allowscomprehensive trunk training, balanc-ing a strength workout of both spinalextensors and flexors in the safety ofimmersion in an upright position,

which simulates many ADLs (Marra,1998). Few workouts on land canduplicate this type of trunk workoutwith its low risk of injury. This ispromising, especially for de-condi-tioned or disabled populations withlimited body awareness.

Recommendations forFurther Research

Prior research indicates the possibilityof learning factors affecting the currentpost-testing performances (Kroll, 1972;Sale, 1988). Kroll (1972) noted learningeffects accounted for approximately 8%to 25% of improvements in repetitiveisometric strength and endurance activ-ities among college-age women. Thecurrent study included performances ofisometric, concentric, and eccentricmuscle activities with improvementsranging from 13% to over 400%, indi-cating much of the improvementoccurred as a result of training not sim-

ply learning factors (Marra, 1998).More water fitness training research isneeded to further investigate changesin muscle strength throughout the bodyperhaps with less focus on muscularendurance. Multiple pretests and theuse of already conditioned participantsto address learning factors may deter-mine more precisely, actual strength

gains.

This study also produced promisingevidence for improving trunk strength,during water aerobics (Marra, 1998).Due to overwhelming statistics of backproblems, including LBP and chronicpain syndromes, more research is need-ed to assess training effects on trunkperformance. Development of bettermeasures for testing performance ofback and abdominal muscles wouldimprove our ability to accurately exam-

ine the specificity of training verticallyin the water. To compare water aero-bics to swimming, as well as comparingland aerobics to water aerobics whileassessing trunk performances, wouldprovide valuable information on thistopic. Since it is becoming more com-mon practice for coaches to train veryfit athletes in water prior to injury,research designed to serve this popula-tion could open new doors for waterfitness programs to be taken more seri-ously, and shed the reputation they are

only for grandmothers.

Conclusions

Water aerobics provides an effectivemuscle strength and endurance work-out for a de-conditioned, healthy popu-lation (Marra, 1998). Although the 8-week program resulted in whole-bodyimprovements, there appeared to beparticular benefits for those weak inupper body and trunk strength. Waterexercise may be especially beneficial forpeople who have sedentary jobs, likemost of the participants in this study.Noting the large range of scores recordedindividuals with varying abilitiesimproved their personal fitness levelswhile attending the same classes together(Marra, 1998).

Properties of water offer advantagesover gravity-based land-exercises, forinstantly changing and controllingindividual workout intensities mid-


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movement. This concept agrees withtherapy professionals who use the waterenvironment as a gentle place for post-injury, older adult, and obese popula-tions who must control intensity andimpact while exercising.

Water aerobics is an excellent low-impact activity for beginning exercisers

and can be further adapted to any fitnesslevel, providing a unique whole-bodyworkout including a 3-dimensionalresistance-training environment.Although this study only measured sin-gle plane movements, strength-trainingexperts have noted such resistance work-outs, which utilize various angles, move-ments, and velocities, achieve optimumresults (Kraemer et al., 1988). Multiplejoint involvements in propelling thebody forward, backwards and laterallythrough water in a variety of ways, fo

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Aquatic Therapy Journal Aug 2005 Vol 7