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Creating Optimal Healing Environments

WATSU for Children withSevere and Profound Disabilities

Effects of Aquatic Physiotherapyfor Children with a Disability:

Views of Parents and Therapists

Water Exercise for Individualswith Parkinson’s Disease: A Pilot Study

Creating Optimal Healing Environments

WATSU for Children withSevere and Profound Disabilities

Effects of Aquatic Physiotherapyfor Children with a Disability:

Views of Parents and Therapists

Water Exercise for Individualswith Parkinson’s Disease: A Pilot Study

The Aquatic Therapy Journal is published biannually by theAquatic Therapy & RehabInstitute, Inc. and the AquaticExercise Association. The AquaticTherapy Journal articles 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.

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

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

©2007 AEA/ATRI-Nokomis, FloridaVolume 9, Issue 2

Managing Editors: Sue GrosseRuth Sova

Graphic Design: Carolyn Mac Millan

Printing: Palm Printing

About Our Cover:Discover the benefits of WATSU for children for severe disabilities. Ann Wieser,PhD, on the faculty of Gateway Education Center, Greensboro, NC shows you howin an article in this issue.

1 Aquatic Therapy Journal • October 2007 • Volume 9 • 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 Articles Creating Optimal Healing Environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Sheralee Beebe, HBORRedwood City, CA

WATSU for Children with Severe and Profound Disabilities . . . . . . . . . . . . . . . 9Ann Wieser, PhD, NCLMBT#3150,Aquatic Therapist and Rehabilitation Specialist, WATSU PractitionerGateway Education Center, Greensboro, NC

Effects of Aquatic Physiotherapy for Children with a Disability: . . . . . . . . . . . 17Views of Parents and TherapistsMargarita Tsirios, BPhys, Senior Physiotherapist,Novita Children’s Services, Regency Park, South Australia

Water Exercise for Individuals with Parkinson’s Disease: A Pilot Study . . . . 22Alexander M. Crizzle, MPH., PhD Candidate, University of Waterloo, Waterloo, ON, CanadaIan J. Newhouse, PhD., Lakehead University, Thunder Bay, Ontario

Feature ColumnsAre You Prepared? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Sue Skaros, BA, BS, PA-C, Medical College of Wisconsin, Milwaukee

Around and About the Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13, 21

Pool Problems: Therapy Pool “Bathtub” Ring . . . . . . . . . . . . . . . . . . . . . . . . 14Alison Osinski, PhDAquatic Consulting Services, San Diego, CA

Interface: Aquatic Therapists Interact With… . . . . . . . . . . . . . . . . . . . . . . . . 16Editors and PublishersSusan J. Grosse, MSAquatic Consulting & Education Resource Services, Milwaukee, WI

New for Your Library . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

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

Research Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Table of Contents

October 2007 • Volume 9 • Issue 2 • Aquatic Therapy Journal 2

This is the last scheduled issue of the Aquatic Therapy Journal. Preparing these issues for you

has been a joyful adventure. We have had the pleasure of working with a marvelous group of

reviewers, all of whom we thank most heartily! We have also been inspired and stimulated

by our contributing authors. Whether writing a repeating column, as Alison Osinski has

done, several articles, as Sue Skaros and Kathryn Azevedo have done, or making just a single

literary contribution, each and every author has been as committed as we were to providing

you, our readers, with the best content we could prepare.

Our last four issues each contained CEC articles. The individual deadlines for completion of

home study for AEA and/or ATRI CEC credit will be honored by Aquatic Consulting &

Education Resource Services, as stated on each article.

Though ATJ will no longer be coming to you as it is, we hope you will continue your quest

for knowledge in the field of aquatic therapy. It is never possible to say “I have enough

knowledge.” Each individual with a disability or health challenge has unique needs and

goals. To provide quality aquatic services, each of us, as professionals in aquatics, must have as

many different solutions as there are unique problems and challenges. That takes knowledge.

Attend conferences and workshops. Read books.

Ask questions. Challenge suppositions. Share

information. Experiment. Swim upstream!

That’s what we will be doing.

Thank you for YOUR support. u

From the Editors

Hulls, V., Walker, L., & Powell, J.(2006). Clinician’s perceptions ofthe benefits of aquatic therapyfor young children with autism:a preliminary study. Phys OccupTher Pediatr. 26 (1-2),13-22. The purpose of this study was to identi-fy clinicians’ perceptions of benefits ofaquatic therapy for young children withautism. Eighteen aquatic occupationaltherapists treating young children withautism responded to a survey. Themajority reported a substantial increasein swim skills, attention, musclestrength, balance, tolerating touch, ini-tiating/maintaining eye contact, andwater safety. Given the impairments,activity limitations, and participationrestrictions seen in children withautism authors believe this information

could help narrow the field of likelyoutcomes as a first step toward studiesof effectiveness of aquatic therapy forchildren with autism.

Assis, M., Silva, L., Alves, A.,Pessanha, A., Valim, V.,Feldman, D., Neto, T., andNatour, J. (2006). A randomizedcontrolled trial of deep waterrunning: clinical effectiveness of aquatic exercise to treatfibromyalgia. Arthritis Care andResearch. 55(1), 57-65. February.The purpose of this study was to com-pare the clinical effectiveness of aero-bic exercise in the water with walk-ing/jogging for women with fibromyal-gia. Sixty sedentary women withfibromyalgia, ages 18-60, were ran-

domly assigned to either deep waterfunning or land-based exercises.Training was for 15 weeks at theiranaerobic threshold, following which avariety of measurements taken and sta-tistical analysis performed. Resultsdetermined deep water running to be asafe exercise shown to be as effectiveas land-based exercise regarding pain.However, deep water running has beenshown to bring more advantages relat-ed to emotional aspects. Aerobic gainwas similar for both groups, regardlessof symptom improvement. Deep waterrunning could be studies as an exerciseoption for patients with fibromyalgiawho have problems adapting to land-based exercise or who have lower limblimitations. u

zxx Feature Column: Research Review

CEC Credit AvailableBack issues of the Aquatic TherapyJournal are available from theAquatic Exercise Association.Issues published in 2006 and2007 each contain two CEC study articles. You can obtainAEA/ATRIC approved credits forcompleting a study assignmentrelated to these specially markedarticles. Contact the AEA ataeawave.com. u

Ruth Sova, Editor Sue Grosse, Editor

Clients with chronic illness often findtheir way to the aquatic medium.Many individuals use water activityand/or therapy as a long-term treat-ment that allows them a greatlyimproved quality of life. Yet the diseaseremains. Is there more that can bedone, then, to treat the physical body?Is it possible to empower clients indiscovering their own healer within? Isthere a lasting way to guide clients tobetter long-term health and well-being,despite limitations of time, and theinsuring body? Are we able to plant aseed of new attitudes within the mindsof clients that helps them make a per-sonal commitment to a journey in self-exploration, improved awareness, anda deeper level of healing? These ques-tions form the basis for exploring howaquatic staff teams can create optimalhealing environments (OHEs) forclients.

Review of literature for this article hasincluded a group of over 50 publishedpapers in the Journal of Alternative andComplimentary Medicine (Contactauthor for complete list). Most of thepapers have been presented at theSamueli Institute Symposium titled“Toward Optimal Healing Environ-ments in Health Care”. The SamueliInstitute believes an emphasis on heal-ing is a key to the future medical man-agement of chronic illness and estab-lishment of sustainable approaches inhealth care. The primary mission ofthe Samueli Institute is to supportbasic and clinical research in the sci-ence of healing; to support a collabora-tive research effort to develop, imple-ment, and evaluate the impact of anOHE in specifically identified healthcare settings.1

HealingIn the context of this article, healing isdefined as the dynamic process ofrecovery, repair, restoration, renewaland transformation that increasesresilience, coherence and wholeness.Healing is an emergent process of theperson’s whole system: physical, men-tal, social, spiritual and environmental.Healing is a unique, personal and com-munal process and an experience thatmay, or may not, involve curing.2

Healing is facilitated through develop-ment of proper attitudes and intentionswithin both the client and aquaticprovider. It includes the recipient’s useof personal self-care practices, creatinghealing relationships, applying theknowledge of health promotion andmaintenance, as well as appropriateintegration of complementary and con-ventional medicine practices.2

An optimal healing environment (OHE)is defined as one in which the social,psychological, spiritual, physical, andbehavioral components of health careare oriented toward support and stimu-lation of healing and achievement ofwholeness.3 According to the Samueliinstitute, the major characteristics of anoptimal healing environment include—• Developing awareness and healing

intention.• Experiencing personal wholeness.• Cultivating healing relationships.• Practicing healthy lifestyles • Applying integrative or collaborative

medicine.• Creating healing places and healing

spaces.

Developing Awareness andHealing IntentionBetter health depends upon conscious

development of intention, awareness,expectation and belief in the possibili-ties of improvement and wellbeing.There is much written on this topic ofhow we create our every experiencebased on how we think and act. Everythought we think is creating our futureand our health. Our being unconsciousor innocent of how we create health ordis-ease in our lives does not free usfrom our responsibility of living andcoping with what we have created.

It is so easy to blame our stress onsome external source; however it is ourreaction to external stressors that cre-ates the greatest personal suffering.The mind state creates the body state.Patients without knowledge of theirown powers for healing often expectthe medical system to be responsible fortheir health. Developing consciousawareness is all about taking responsi-bility for our health and our personaland powerful role in creation of illnessas well as wellness.

The point of power in creating illnessor well-being is always in the presentmoment. Long term patterns of think-ing and behavior that are motivated byresentment, criticism, punishment,resistance and guilt are the most dam-aging to our health.3 Releasing thoughtand behavior patterns can dissolvemany of our patterns of stress, tension,hopelessness and dis-ease in the body.Replace negative patterns with proac-tive, conscious, choices designed to cre-ate health and positive wellness.

We can be the victims of dis-ease andthe stress that is around us or we canbe creators of positive change in our lifeexperiences and health. A preoccupationwith illness and its ill effects focuses


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Creating Optimal Healing EnvironmentsSheralee Beebe, HBOR

Redwood City, CA


energy into more of what we don’twant. If we want health improvementswe must focus our thoughts and energyon wellness, pursuing health improve-ments as a positive focus vs. fightingpain and symptoms of disease process-es. If the mind focuses on wellnessinstead of illness, outcomes are moredesirable.

The immune system functions better inpositive thought versus negativethought. Kinesiology experiments per-formed by David R Hawkins, M.D.Ph.D. have exposed, for the first time,the intimate connections between mindand body, revealing that the mindthinks with the body itself. Hawkins’swork has provided an avenue for theexploration of the ways consciousnessreveals itself in the subtle mechanismsbehind the disease process.4

Hawkins in his book Power vs. Force:The Hidden Determinants of HumanBehavior reports the body has, in themoment, the ability to record and reactto every thought or statement. Thebody will be weakened or strengthenedby the stimulus or thought in themoment. Those living with negativelanguage and environments will experi-ence repetitive weakening of the humanspirit and immune system.5

Positive psychology is very helpful inthe healing process. It is necessary toconvert negative emotions into the abil-ity to express pro-social, positive emo-tions, such as tolerance, forgiveness,hope, altruism, and gratitude. Positivepsychology advocates have united tostudy and build upon human strengths,in contrast to the psychological andmedical communities where over-whelming attention is given to humanweakness and illness.6 Research,although sporadic, is slowly emergingto show these skills can be taught andwhen measured, demonstrate benefit.

The effect of gratitude on psychologicaland physical wellbeing was evaluated inthree studies.7 Increased wellbeing andpositive mood states were strong find-ings in the three studies. There is abody of research showing that peoplehigh in hope suffer less depression,have better pain tolerance, have better

psychological adjustment with a multi-plicity of measures, have better adher-ence to medication regimes, have betteracademic performance and find greatermeaning in difficult life events.8 In astudy where hopefulness was used as anintervention with depressed elderlypatients, it was found that participantsin the hope group showed significantdecreases in anxiety, hopelessness andfunctional disability, as well as improve-ment in social interaction.9

Dr. Seligman and colleagues study theuse of cognitive methods to train peo-ple to dispute pessimistic thinking, andteach positive methods simple enoughto work for both adults and children.This goal is development of strength,not remediation of weakness. Theirresearch shows that optimism trainingis successful, and once learned,becomes self-reinforcing. People usethe skills they have been taught to helpthemselves in life situations. Seligmanand colleagues have documented thatlearned optimism cuts in half the futureincidence of depression and anxiety inboth children and adults.10

Consider the emotional effects of theseopposing statements. Focus deeply onthe first statement in the pair. Thenclear your mind and do the same withthe second statement. Pay attention toyour body. Does anything change –your breath, a stirring or feeling, sensa-tions in the body? Notice how thoughtscause physical sensations and notewhere you feel thoughts in the body, aswell as what you feel. The first state-ment; is spoken by a person victimizedby his or her situation, the secondstatement represents proactive and posi-tive choice.

My life is a mess and I am out ofcontrol. Vs. I am willing to let goof the behaviors that create stressin my life.

Nobody loves me and I feel alonein life. Vs. I am in the process ofpositive changes and buildinghealing relationships.

I hate my job and it is making mesick. Vs. I am going to focus on thegood aspects of my job, and devel-op positive relationships with my

workmates, while I search for ful-filling work and create opportuni-ties for myself.

I am so unorganized my life ischaotic. Vs. I will take action eachday to bring order and calm intomy life, I will ask for help when Ineed it. I see a positive clutter freelife now.

Teach your clients to positively affirm their own progress and goals in advance, to help improve outcomes.Encourage the practice of stating posi-tive affirmations at the start and end ofeach session. Encourage client initiatedpositive affirmations throughout thetherapeutic process. Involve familymembers is supporting positive affirmations.

Developing PersonalWholenessWhat actions and practices might benecessary for an aquatic health careprofessional to create self-awareness,personal wholeness, self-growth andimproved outward client awareness? To create a healing environment, practi-tioners should focus on practicing tech-niques that foster a palpable healingpresence. That presence should bebased in compassion, love, and aware-ness of interconnectivity.11

Practitioners interested in creating ahealing aquatic environment areencouraged to practice transformativeself-care behaviors that facilitate per-sonal integration and the experience ofwholeness and wellbeing. The HealerWithin, authored by Roger Jahnke,Doctor of Oriental Medicine, prescribestraditional Chinese techniques torelease your body’s own medicine,through movement, massage, medita-tion and breathing exercises.12 A corethesis is that every healing effort andintention starts within the health careprofessional. Thus, an accepting, mind-ful and warm-hearted relationship with the self is primary to any healingintention.13

To the Western mind a therapist mustdo some procedure or intervention toheal a client. The healer principle isabout being, aside from doing. Being

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completely present to our clients has asignificant healing effect; every healingintention starts from a healthy attitudetowards the self. Healing starts by heal-ing the healer.14 One of the basic quali-ties in a healing and holistic encounterwith a patient is unconditional accept-ance and positive regard. But this can-not be achieved without self-acceptanceand self-respect.

If present to a client we would not haveour head buried in note taking orreport reading when listening to theirconcerns and questions. The presenttherapist is listening to the client, mak-ing eye contact and exhibiting compas-sion. When present the healer gainsbetter insight, the client is listened too,and feels a bond with and trust for thehealer. The client, feeling accepted andhaving feelings of trust, will be morelikely to participate in the healing regi-men prescribed, and communicate con-cerns more effectively.

Cultivating PersonalRelationships A good personal relationship betweenpractitioner and client is based ondevelopment of listening and communi-cation skills that foster trust and estab-lish a bond. Further the practitioner hascompassion, empathy, and a desire toserve, exhibiting altruistic behaviorsthat cultivate social support and trust.15

The aquatic health care professionalmust stimulate an interest within theclient to become more self-aware. Thetwo develop a relationship in-order tofoster wholeness and personal growthfor the purpose of healing in general.

Empirically, health psychologyresearch literature indicates goodprovider-patient communication leads

to better patient satisfaction with theprovider and improved adherence totreatment,16 but only sometimes tobetter outcomes.17 Patient expectan-cies of treatment effectiveness and thequality of the therapeutic alliance tendto predict clinical improvement, withoutcomes mediated by patients’ contri-bution to the alliance.18 The thera-pist’s use of every day language, ratherthan technical medical language and amore affective, rather than cognitivestyle of communication, in both verbaland nonverbal behavior, favor higherpatient satisfaction and better qualityof life.19

The preference is for medical issues tobe discussed with affective quality20

and unconditional positive regard.21

At a biopsychosocial level, studies haveshown more effective communicationwithin the therapeutic relationshipincludes skill at exhibiting empathy andfocused attention.22 A major source ofsuffering for people is the experience ofisolation, a sense of being cut off fromconnection. In an empathic model ofcare, the primary role of the caregiver isto bring people back to healing connec-tions where they begin to reconnectwith themselves and bring themselvesmore fully into relationship withothers.23

Practicing Healthy Lifestyles Unhealthy lifestyle is the primary con-tributor to the six leading causes ofdeath in the United States: Heart dis-ease, cancer, stroke, respiratory dis-eases, accidents and diabetes, collective-ly account for 75% of all deaths.Almost two thirds of American adultsare overweight or obese, more then60% do not get enough physical activi-ty, 25% are completely inactive, and

only 23% eat recommended amounts offruits and vegetables. People withhealthier lifestyles live an average of 6to 9 years longer postpone disability by9 years and compress disability intofewer years at the end of life.24

Practicing Healthy Lifestyles requiresinstruction and practice. Lifestylehealth behaviors that support self-heal-ing are proper diet, exercise, leisure andwork balance, and addiction manage-ment.25 Health promotion and diseaseprevention involves behavioral andlifestyle activities targeted toward estab-lishing habitual behaviors that supportwell being, facilitate healing and pre-vent or treat illness.

A healthy lifestyle also requires man-agement of negative addictions such assmoking, alcohol, drugs and violence,and fostering positive habits such as,relaxation methods, self-appreciationand acceptance, establishment of sup-portive social and health networks.Studies have found that despite healthpromotion in schools, medical centersand the community, segments of ourpopulation remain unaffected byhealth education information. Studiesshow that longer-term education andcontact with clients is beneficial,26

which supports the continuum of caremodel common in an aquatic healingenvironment.

There are other aspects to healthy liv-ing, according to Dr. Frederic Luskin,in the Forgive for Good workshop andclass series Dr. Luskin,27 (www.learningtoforgive.com), presents forgiveness-training methodology validated throughsix successful research studies conduct-ed through the Stanford UniversityForgiveness Projects. Prior to the cur-rent surge of research interest, theimportance of practicing forgivenesswas extolled in both religious and psy-chological traditions. Recently, researchof Dr. Luskin and others has confirmedits virtues in the promotion of psycho-logical, relationship and physicalhealth. Forgiveness has been shown toreduce anger, hurt, depression andstress and lead to greater feelings ofoptimism, hope, compassion and self-confidence, which are all factors in thehealing process.28


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Optimal health is the balance of physical, emotional,

social, spiritual, and intellectual health. Lifestyle change

can be facilitated through a combination of efforts to

enhance awareness, change behavior, and create

environments that support good health services and

practices.

October 2007 • Volume 9 • Issue 2 • Aquatic Therapy Journal 6ä

Applying Integrative orCollaborative Medicine Creating a healing environmentincludes responsible application of inte-grative medicine via the collaborativeapplication of conventional and com-plementary practices in a manner sup-portive of healing processes. TheUnited States has the most expensivehealth care system in the world, butpeople of America are not as healthy aspeople in other countries who spend farless on medical care, in-fact Americanshold 26th place in world health.29 Thekey to improved medical outcomes isfocus on healing care, in contrast tofocus on curing disease. The aquaticenvironment has long welcomed inclu-siveness of disciplines, as the waterattracts every discipline, from doctorsto fitness professionals. Many differenttechniques from many professions havebeen integrated into our water prac-tices, examples might include, but arenot limited to Watsu and other aquaticmassage techniques, meditation, andguided meditations, Osteopathy, Yoga,Reiki, Lyu Ki Dou, Ai Chi, Qi gong,Cranial Sacral, Feldenkrais, Palates,healing sounds and music therapy.

Creating Healing Spaces and Places The physical space in which healingis practiced can affect an OHE. Thismay include characteristics of light,music, architecture, and color, as wellas other elements. Qualities of a heal-ing environment include trees, flow-ers, and other outdoor environmentelements.30

Seeking a safe shelter to heal is a natu-ral tendency. Wild animals would findhealing from injury in natural hotsprings, for instance. A healing placeoptimizes physical, mental emotionaland spiritual healing. Surroundpatients with nature, music, and art tocreate harmony.

Some healing places are spa like. Spa isan acronym for “Salus per aqua” orhealth through water. Spas are becom-ing more medical, and medical facilitiesare being more spa like.31

To become a healing place, changes in

facility characteristics may be necessary.Healing places should consider provid-ing space for family to offer supportand observe their family member in thetherapeutic process. Wide doors arenecessary for assisting the less ambula-tory clients through without difficulty.A home like environment where thepatient is treated like a guest, or a veryimportant person, facilitates creating anOHE. Space for social engagement andconnecting with others adds an addi-tional healing dimension. Reducingunpleasant noises and smells, as well asemploying decorative variation ratherthan sameness, is part of facilitychange.

Having fresh air, a small garden areaoutdoors, a warm place, and a placewhere windows open all support heal-ing. A quiet place to meditate is part ofan OHE, maybe with healing soundssuch as running water or chimes, alongwith crystal bowls, and guided healingmeditations.32

Assessment of the OptimalHealing EnvironmentCharacteristics of an optimal healingenvironment involve empathy, compas-sion, caring, love, reassurance, comfort,warmth, trust, confidence, credibility,honesty, courtesy, respect, harmony, chal-lenge, and communication. Cultivatingthese characteristics requires skills in lis-tening and communication, and can befostered by engaging in social service,and through family and communityactivities. An optimal healing environ-ment should incorporate training inthese characteristics and develop oppor-tunities for such activities in educationaland group programs. Variables impor-tant to consider when developing orassessing a healing environment includepresence, absence, or level of —• Administrative and/or supervisory

awareness of importance of a healing environment in patient care.

• Facility staff, including front desk personnel/receptionist, awareness of the importance of a healing environment in patient care.

• Staff willingness to facilitate change.• Institutional support of personal

growth and mastery.• Presence of a cohesive staff.• Availability of alternative therapies

such as Yoga, Qigong, meditation,

MBSR, acupuncture. • A physical environment that supports

healing, including, but not limited to, providing a physical sense of safety while present in the facility, clean, quiet/low decibel sound level, pleas-ing décor, cheerfulness, sense of nur-turing while in the facility, and fresh air free of strong odors.

• Patient-centered relationships.• A respectful manner of treating

patients.• Access for privacy in patient-health

care provider interactions.• Continuity of care between the

provider and patient.• Methods for following patients

sequentially over an extended period of time

• Adequate interpreter services, if needed.

• Flexibility in accommodating treat-ment assessments and requirements for patients with varied needs

• Minimal waiting time to see practi-tioner.

• Behavioral interventions or referrals to community organizations with resources for diet, smoking cessation, exercise, and environmental alterations.

• Educational materials with menu of options such as motivational, educa-tional, maintenance interventions

• Personal counseling for high-risk groups.

• Availability of a wellness counselor/educator.

• Individual goal setting and acknowl-edgement for goal achievement.

• Support groups available.• Cognitive behavioral therapy/dialecti-

cal behavioral therapy available. • Availability of a nutritionist available

for referrals.(This entire list is an excerpt.33)

ConclusionMany qualities of the optimal healingenvironment occur naturally within theaquatic therapy environment. Waterhas many therapeutic qualities; water isbeautiful in how it interacts with light,creating dancing patterns of shadowand light about the room. The sound ofgently running water is calming andslows the heart rate. Water provides awarm and tactile input, while takingaway weight and pain, encouraging


relaxation, which deepens the breath,and freeing the body to gently movewith grace and ease. Aquatic practi-tioners tend to develop relationshipswith clients more quickly, perhaps dueto the warmth and closeness encour-aged by the water and our dresseddown profession. Many aquatic profes-sionals are drawn to the work from ahistory of love of the water and theinherent healing potential of the water.To generalize, they are naturally caringand passionate about their work. Whilethere are exceptions, of course, mostaquatic practitioners seek the water andinvest personal funds into their ongoing education.

The aquatic environment lends itselfwell to the continuum of care model, aswater is accessible within the medicalenvironment and within the communi-ty. The practitioners within each servicelevel are more willing to work togetherand refer to each other. Given longercontact time with the clients, aquatic

practitioners are able to impart layers ofdepth to the physical exercise by teach-ing and modeling personal experiencewith healing, mindfulness, awareness,hopefulness, positive language in lifeand in creating a vision around goodhealth goals.

Promoting healthful behaviors togreater depth of personal empowermentfor patients may be a needed additionwithin the common format for healtheducation, both within the communityresource network and in the health caresystem. Health promotion has beendefined as the science and art of help-ing people change their lifestyle tomove towards a state of optimal health.Optimal health is the balance of physi-cal, emotional, social, spiritual, andintellectual health. Lifestyle change canbe facilitated through a combination ofefforts to enhance awareness, changebehavior, and create environments thatsupport good health services and prac-tices. Supportive environments, when

fully observed, will probably have thegreatest impact on healing.34 u

AuthorSheralee Beebe, HonorsBachelor in Recreation, is a Post-Rehab AquaticSpecialist who has been

practicing since 1991. She has devel-oped three full service aquatic rehabprograms in Canada and now in PaloAlto, CA. Beebe is the co-author of theATRI Rheumatology Certification andan aquatics veteran of many currentand non-current certifications. She hasbeen a presenter for ATRI for 10 yearsand is owner of For Your Health InHome and Aquatic Therapies. ContactBeebe at [email protected].

Your reading and study of Creating Optimal Healing Environments by Sheralee Beebe can result in 2 ICATRIC/AEA approved CECs. First, study the article. Then complete the study guide assignments asdescribed below. Send your completed assignment and the course fee to Aquatic Consulting & EducationResource Services, 7252 W. Wabash Avenue, Milwaukee, WI 53223. Study of this article must be completed

no later than March, 2009. Please allow 4-6 weeks for processing, and your receipt of completion verification.Course fees depend on CEC verification requested. Fees are non-refundable.

ICATRIC = $30 AEA = $20 ICATRIC and AEA = $45AEA Member discount 20% ICATRIC = $24 AEA = $16 ICATRIC and AEA = $36

Creating Optimal Healing Environments ACERS #ATJ508/AEA # 7123 H

S. Beebe CEC Study Guide

Assignment Preparation – All assignments must be typed. Handwritten material will not be accepted. Start with a coversheet including your name, mailing address, phone, e-mail address, and CEC article title. Then, begin another sheet of paperand answer the following questions/complete the following applications. If answering a question, state the question prior tosupplying the answer. If documenting an application, state the application requirement and then provide your response.

Comprehension –1. Within the context of this article, how is healing defined?2. According to the Samueli institute, what are the 6 major characteristics of an optimal healing environment?3. How does thought affect the immune system?4. List 4 lifestyle health behaviors that support self-healing.5. A good personal relationship between practitioner and client is based on what?

Application –1. How can you implement optimism training in your therapy sessions?2. Describe the aspects of your work setting that make it a healing environment for your clients.3. Describe areas of improvement needed at your work setting to improve environmental aspects of healing.

All references for this articlecan be found on the HomePage of AEA’s website at

www.aeawave.com,click on Fit Pro News/Articles.


Fred is a fun guy, always sharing news ofhis grandchildren, cheerful, sometimes abit confused about right and left, but easyto work with and regular in attendance,arriving on time today in spite of reallybad weather. He completes his activitiesbut seems a bit sluggish, which youattribute to his having to shovel out hiscar before coming to the pool. You feelmuch the same way! As he leaves thepool, you see him look around quite a bit,prior to moving toward the stair/rampside. Then you notice he starts movingaway from the steps, rather than towardthem, but he catches his mistake andturns back before you say anything.When you next see Fred, he is walkinghesitatingly toward the deep end of thepool. Strange, because the men’s lockerroom is at the shallow end.

Are you prepared to handle this situa-tion? To see just how prepared you are,review the possibilities for action, ana-lyze the situation, and apply your safetyknowledge and experience.

Possibilities—a. You call out “Hey Fred – locker

room is that way” and point in thecorrect direction. Fred gives you ahalf-hearted wave, turns and headson his way. You recognize somethingisn’t right, and watch Fred take afew more steps. Yes, his gait isn’twhat it usually is. He seems to bedragging one foot. You climb out ofthe water and activate yourEmergency Action Plan, asking yourin-water people to move to the sideof the pool. You approach Fred, say-ing “Fred, wait up a minute. I needto check a few things for you.” Youthen perform a F.A.S.T. assessment.

b. You call out “Hey Fred – lockerroom is that way” and point in thecorrect direction. Fred gives you ahalf-hearted wave, turns and headson his way while you resume youractivities.

c. You call out “Hey Fred – lockerroom is that way” and point in thecorrect direction. Fred gives you ahalf-hearted wave, turns and heads

on his way while you resume youractivities. However, you recognizesomething isn’t right. Fred can usu-ally find the locker room. You haveanother individual leaving at thesame time and say to him, “Can youkeep on eye on Fred for me? Helooks a bit confused today.”

Were you prepared?Possibility b – Any change in behavioras indicated by Fred’s apparent, albeitbrief, confusion, along with a change innormal movement patterns should setoff warning bells in your mind. Anyone,but especially our older clients, is atrisk for a neurological event such as astroke. Add to that his having to do sig-nificant exertion with shoveling out hiscar, and you have the potential for adevastating injury. Time is of theessence. Early intervention can limitthe extent of damage, but ignoringFred’s changes may have devastatingresults. Ignoring, or failing to recognize,an emergent situation can also be negli-gence. Remember, Fred may be embar-rassed by what is happening and vigor-ously deny anything is wrong. YOU arethe key to his having a chance for agood outcome by recognizing thechanges you see and identifying themas possible signs of a medical problem,quickly evaluating him, and seekingadvanced medical intervention as soonas possible. You were not prepared!

Possibility c – You have recognizedsomething is wrong with Fred. That is astart, but without rapid and appropriateintervention, Fred is at risk for severeneurological impairment and possiblydeath. He is experiencing both a changein behavior AND a change in his mobil-ity. However, once you have recognizeda possible problem, you cannot delegateyour professional responsibility to apatron. You know he has the knownrisk factors of advanced age and recentvigorous exertion (shoveling out hiscar), plus the stress of driving in badweather conditions. All of these makehim a prime candidate for a stroke. Youare legally responsible. You have the

training and skills. You must continueto evaluate and monitor Fred, quicklyobtaining advanced medical care asneeded. This is not something one ofyour other clients should be doing forFred. This is your job. You were notprepared!

Possibility a – You recognize Fred’sbehavior and movement have changed.You take appropriate action. Even asyou respond to Fred, recognizing hemay be having a serious health prob-lem, you also have to provide properprotection for your remaining clients byactivating your Emergency Action Planand having your in-water people moveto a safe position. You provide Fredtimely and appropriate assessmentusing F.A.S.T.1 By checking Fred’s face(F) for asymmetry (you find one sidedrooping), his arms (A) for parallelmovement (his right arm does not riseas well as his left), and his speech (S)for slurring or difficulty forming words(he has difficulty saying a simple sen-tence), you have done a quick assess-ment for a possible stroke. You nowknow he needs timely (T) initiation ofcare—with calling 9-1-1—to provideFred with the best chance for a goodoutcome. You were prepared!

Were you prepared? If not, now is thetime to take or update your safety train-ing. Professionals in aquatic therapyare prepared!

1 American Red Cross (2006). First Aid/CPR/AED for the Workplace Participant’s Manual. Yardley, PA: Staywell. p. 48.

Content of Are You Prepared? isdesigned to bring to the attention of the reader situations and circumstancesrequiring knowledge and expertise inrisk management, first aid, and safety.Are You Prepared? Is not designed toprovide a legal opinion and/or docu-ment specific first aid proceduresand/or treatment. Commentary in Are You Prepared? is not a substitute for training. u

Sue Skaros, BA, BS, PA-C, Medical College of Wisconsin, Milwaukee.

zxx Feature Column: Are You Prepared?

9 Aquatic Therapy Journal • October 2007 • Volume 9 • Issue 2ää

WATSU, water shiatsu, uses floatingand a sequence of slow gentle continu-ous movements, stretching and acupres-sure to encourage relaxation, enhancestrength, and promote flexibility.WATSU, developed by Harold Dull atHarbin Hot Springs in the 1980’s, is anextension of his work with Zen Shiatsu.The stretches of Zen Shiatsu releaseblockages along the meridians or chan-nels that carry life force; the applicationof these stretches strengthens muscles,and increases flexibility and range ofmotion (Dull 1997a, Dull 1997b,Morris 1997). Dull found that floatingthe participant while doing stretches inwarm water enhanced the effect of thestretches (Dull 1997a).

Working in warm water is effectivebecause pain generally decreases inwarm water enabling a person to expe-rience a greater range of movement(Giesecke 1997; Vargas 2004).Resistance to movement or to stretch-ing decreases when the person is sup-ported, moved and rocked while beingstretched (Morris 1997). With a con-tinuous flow of movement through asequence of positions, the person losesthe ability to anticipate the next move-ment, which, in turn, decreases boththe fear of movement pain and theresistance to movement (Dull 1997a).

From experience, I found WATSU idealfor working with adults with disabili-ties. The warm water and continuousmovement encouraged relaxation andincreased flexibility. I expectedWATSU would be equally beneficial forchildren with disabilities, yet when Ifirst tried to use WATSU with the stu-dents, they were very uncomfortableand became even more anxious. As aresult, three questions became the focus

of this project – • How can I effectively connect with

the children throughout the WATSU? • What WATSU movements, transi-

tions, and positions are more comfortable and acceptable for the children?

• Following a WATSU session, what changes in the children could be identified?

In order to investigate these questions, I decided to organize the project aroundthree WATSU principles – • Being with the person.• Not doing TO the person.• Safety.

WATSU PrinciplesThe deep and profound relaxationobtained from WATSU develops fromapplication of several principles thatconstruct the WATSU sequence. Duringthis work I chose to focus on threeprinciples, being with the person, notdoing to the person, and safety.

The first principle of WATSU is that ofbeing with the person, (Dull 1997a,Dull 1997b). Being with the personmeans making a deep connection withthe person. It requires a deep listeningwith all senses, not only with eyes andears, to the person’s response. It meansaccepting the person’s response andadjusting our expectations and plans tothat response. By listening carefullyand following the response of the per-son, we enhance the connection, pre-vent any disruption of relaxation, andstrengthen the trust between the giverand the receiver.

Not doing to the person (Dull, 1997a),the second principle applied in this proj-ect, is an extension of the first

principle. In other words, we providesupport for the person in the water, andencourage and facilitate his or her move-ment. We become aware of the responseof his or her body in the water, and weadjust our movements to support andextend his or her movement explorationwithin his or her comfort zone. Theslow continuous flowing movementsease pain and encourage relaxation(Vargas, 2004). Both of these principles work on controlissues for both the receiver and giver of aWATSU. The person doing the WATSUmust give up control of the interaction,and allow the water and the response ofthe receiver in the water to dictate thesequence of moves. The person receiv-ing the WATSU must give up control ofhim or herself and surrender to the sup-port of water and continuous flowingmovements of the WATSU.

Safety awareness is the third principle Ifocused on. The primary safety con-cern is to maintain the receiver’s faceout of water in order to deepen trustand relaxation. Since many of our stu-dents have breathing and swallowingissues, maintaining the face out ofwater is particularly important with our

Keeping the student's ears out of water can bean important comfort and health concern.

WATSU for Children with Severe and Profound DisabilitiesAnn Wieser, PhD, NCLMBT#3150,

Aquatic Therapist and Rehabilitation Specialist, WATSU PractitionerGateway Education Center, Greensboro, NC


student population. In addition to theface, it is important for most of our stu-dents to have their ears out of water aswell since many of our children areprone to ear infections.

Another safety concern is to protect andsupport the neck and lower back in aneutral position. Proper support of theneck assists with maintaining the faceout of water, as well as initiating trustand relaxation. Similarly, maintaining aneutral back position relaxes back mus-cles and decreases overall pain.

Student PopulationGateway Education Center is a publicseparate school in Greensboro, NC.Gateway serves students ranging in agefrom birth to twenty-one years of agewho have severe and profound disabili-ties. Children with severe and pro-found disabilities require pervasive,ongoing supports in one or more majorlife activities. These supports providethe greatest degree of independence forthe functioning of the individual in spe-cific contexts and consider intellectualabilities, adaptive behaviors, and health,as well as interaction, participation, andsocial roles. Specifically, supports atGateway focus on improving opportuni-ties for student communication, mobili-ty, self-care, and academic skills.

Many of the students at Gateway are cat-egorized as MU/SPH; multiple severeand profound handicapped. Primarydisabilities of children who are served byGateway include cerebral palsy, autisticspectrum, and medical and healthimpairments. Many children also havedevelopmental delays, vision and hear-ing impairments, or seizure disorders.

Of the 59 potential students (withparental permission to participate in thetherapeutic pool) in my student load, Ihad 19 students with additionalparental permission to participate inthis project. Of those 19 participants, 9students were classified as autistic; theother 10 students were classified assevere and profound multiple handicap.Ages of the 19 project participantsranged from 6 to 21 years of age.

The nine students classified as autistichad excellent physical and motor abili-

ties; however, only one student demon-strated appropriate speech, 4 studentsdemonstrated echoalic speech, and fourwere non-verbal. The functional abilityof two of the student participants withautism was estimated between 2 and 3years; functional ability of the remain-ing seven student participants withautism was estimated between 15 and24 months.

The ten students classified as severeand profound/multiple handicap hadlimited physical and motor abilities; sixout of the ten students demonstratedhead control and could sit unsupported.Eight of the ten students used wheel-chairs; two students were ambulatory.Five students had good flexibility andrange of motion; however, only threeout of the ten students had any degreeof independent upper body motor con-trol. One student demonstrated adegree of appropriate speech, one stu-dent used echolalic speech; the othereight students were non-verbal. Theestimated functional ability of the tensevere and profound multiple handicapstudents ranged from 6 months to 15years. Educational goals for each of ourstudents are based on the standardizedNorth Carolina curriculum. Our stu-dents who do “regular” school workrequire such extensive medical, com-munication, and physical supports thatGateway is the best least restrictiveenvironment (LRE) for these student.Three students had estimated function-al abilities over 3 years (4 years, 7years, and 15 years). The other sevenstudents demonstrated functional abili-ties between 6 to 18 months.

Medical and safety concerns for ourchildren are considerable. Head con-trol, maintaining ears out of water, andbowel and bladder control are basicissues. Major medical and safety con-cerns exist because many of our chil-dren are medically fragile, have shunts,G-tubes, impaired breathing, andimpaired swallowing or cough reflexes.We also need to be mindful of variousbehavioral issues, such as limitedawareness, limited responsiveness,excessive drinking of pool water, selfstimulating behaviors, and personalspace issues, as well as tactile concernssuch as tactile defensiveness and sensi-tivity to touch pressure.

To insure safety of students we main-tain a one to one student to teacherratio in the pool. In addition to poolstaff, the classroom teacher or assistantis always on deck or in the pool whilestudents are in the pool. EmergencyCall buttons located on the deck, inthe locker room, and immediately out-side the pool doors connect directly tothe administrative office. EmergencyAction Response Procedures vary depend-ing on the situation, and include arapid response of the nursing andadministrative staff, as well as a crashcart and/or Behavioral InterventionTeam, if necessary. Rapid EMSresponse (within 3 minutes) is availableif more medical assistance is needed.

Why WATSU?WATSU is ideally suited for this popu-lation. The profound relaxation andstretching helps improve flexibility,range of motion, and muscularstrength in the children who have mul-tiple handicaps (Styer-Acevedo 1997).For our children with autism, relax-ation, support and stretching in warmwater assists each child to make con-nections and interact with the persongiving the WATSU and the environ-ment. In addition, many of our stu-dents have issues with anxiety, controland trust which should be helped withWATSU.

Considering my first project questionregarding the most effective ways tomake connections with the students, Ihad already experienced that themethod of making a connectiontaught in WATSU training (by center-ing in, connecting through the breathand slow movement sequences) wasnot effective with our children. Infact, making connections using tech-niques from the WATSU training agi-tated many of our children ratherthan calmed them. Many of our chil-dren struggle with developing controlover their bodies, emotions and com-munication. In the beginning of aWATSU session, the trust required toaccept a close physical connectionappeared to be problematic for manyof the children. However, the samephysical closeness during the middleor end of the session was usuallyaccepted.


Considering which WATSU positionsand movement sequences were themost effective and best tolerated by ourchildren, I noticed many of our chil-dren were uncomfortable and did notaccept being in some of the WATSUpositions in the movements.

Many of our students are accustomed tomoving their bodies in specific habitualways. Some demonstrated emotionaldiscomfort with unfamiliar movementsor unusual (for them) placement ofarms and legs. Rather than insist on astudent doing a particular movement orstretch in which he or she was uncom-fortable, I found modifying a movementor substituting another position ormovement was more effective and lessstressful for the student.

Finally, regarding changes in the chil-dren following WATSU that could bedocumented, both classroom teachersand I noticed some differences in thechildren after a WATSU session. I need-ed to devise a way to record thesechanges that we thought we were seeing.

MethodologyI work with the students in my studentload twice a week, once in the gym andonce in the pool, for 30 minutes. Inthe gym I work with the whole class.In the pool, I work with volunteers sothat a one on one relationship is main-tained with the children. I also tried toschedule a second 30 minute sessioneach week with the students who wereparticipating in this project in order togenerate as much information as possi-ble. All parents of the students I

worked with signed an informed con-sent and permission slip before thisproject started. I used the form inAppendix A to document each sessionwith each child. Teachers used theform in Appendix B after each sessionto document any changes he or shenoticed in the children.

Making ConnectionsI began each child’s session by makingsure I was focused on that child, onbeing with that child and not on what Iwas going to do to that child. In orderto make a profound connection withthe student, it was necessary for me togive up my expectations and supportand respond to the movements of thechild. Our children have minimum con-trol over their lives and they are reluc-tant to “let go” of control and relax.

Trust is another major issue for ourchildren that I had to consider. Achild’s trust level could vary from dayto day, and I needed to be alert to andwork within the student’s comfort zone.

Since many of our students lack a swal-low reflex and basic strength, as well ashead, neck and body control, I was ableto strengthen trust and ultimately theconnection with the child by makingsure the face, nose and ears were out of water.

In a WATSU the connection betweenthe giver and the receiver is developedthrough a supported, nurturing positionin the water, a quiet stillness, slowmovement, and breathing (Dull 1997b).Before any connection can be made, itis necessary for a person to feel safe andsecure in the water.

In WATSU, the sense of security isdeveloped through the support andnurturing closeness of the first position.Using the traditional WATSU first posi-tion, I would stand to the side of theperson, cradle his or her head and neckin the crook of my elbow, and supporthis or her sacrum with the back of myhand. Some students could tolerateand welcomed the closeness and nur-turing of the first position; however,many of the students were uncomfort-able with the closeness of this position.

In order to make the connection with anuncomfortable student, I would substi-tute other positions to increase studentcomfort and enhance a sense of security.Some children who were uncomfortablein the first position were more comfort-able starting in a vertical position, mostoften held facing me so I could also con-nect through the eyes. For those chil-dren who were uncomfortable with mak-ing connection through eye contact, Iwould start the session holding themfrom the back either in a vertical or horizontal position.

In the traditional WATSU the connec-tion is deepened through the use ofstillness and slow, gentle movements(Dull 1997b). Students enjoyed contin-uous movement; however they werevery sensitive to the speed of move-ment. Many children would becomeagitated with slow movements. In fact,two thirds of the students classified asautistic, and a third of the students des-ignated as SPH/MU could not tolerateslow movements. It was necessary toincrease movement speed until a

The student is not comfortable in the traditionalWATSU first position; however, he was verycomfortable when held from the back in the

Head Cradle, Corner Spread movement.

Trust must be established before connections can be made.

In the middle of a sequence the student becameuncomfortable and stood up. I continued tomaintain a connection and reestablished the

WATSU sequence when the student was ready.


student felt comfortable, and then grad-ually slow the movement speed down.By alternating quick movements withslow movements, I was able to graduallylengthen the time an individual wouldtolerate the slower movements.

In the traditional WATSU, the givermatching the speed of the movement tothe breathing patterns of the receiverenhances the connection (Dull 1997b).The breathing in of our students isextremely subtle, and is often maskedby floatation equipment. In place ofbreathing, it was more effective for meto connect with the student througheye contact, soft speech, and support oftheir head, neck and back in the water.For a few children who were uncom-fortable with any close interaction, lightwater play with the child relaxed thechild and served to make a connection.

Although WATSU does not normallyuse equipment, because of the medicalconcerns or personal characteristics ofthe students a variety of floatationdevices were often used.

Children with poor head and body control and strength, shallow breathing,and lack of a swallow reflex wereplaced in a collar to insure against any

uncontrolled head movements.Children who experienced fear or anxi-ety in the water, and/or land wore afloatation belt until they became morecomfortable in the water.

Movement and SafetyOnce making the connection betweenmyself and the student, I began toincorporate WATSU movementsdesigned to loosen and stretch the hipsand spine. Next, I worked to furtherloosen the lower body and legs before Imoved to the upper body and arms. Iended each session with movementsdesigned to integrate the relaxation intothe person’s body while groundingthem into a vertical or weight bearingposture. After each session, I docu-mented the movement sequence, speed,ways of making connections, studentcomfort and response, and any otherobservations.It is necessary for a person to feel safeand secure in water before any relaxationcan be attained. Safety and securitystarted with keeping the students faceabove water, and using floatationdevices. In addition, position of the stu-dent in the water, movement sequenceand speed were also important for thestudents feeling of safety and security.Student needs and tolerance to positionsvaried from day to day.

Although a traditional WATSU sessiongenerally follows a suggested movementsequence (Dull, 1997b), I did not fol-low a specific sequence, but I alwaysbegan by loosening the hips and spine.During the session, I would attempt todetect and respond to the student’sbody movement, and then attempt tomatch that movement with a WATSUposition that was a close approxima-tion. The session became a continuousflow of movement into and out of posi-tions, which ultimately became a dance.

In a traditional WATSU, the receiverrarely, if ever, interrupts movement flowor the silence. However, students in thisproject often interrupted the movementthemselves by sitting up, rolling over,moving arms and legs, or stretching intofull extension. Students would oftentalk, giggle, laugh or vocalize during thesession. Rather than trying to preventtheir interruptive response, I accepted

their interruption of the movement andredirected or worked their response intoa dance by following their movements.In some cases, the student would standup, and we would break physical contactbriefly, while continuing to maintain aconnection.

By watching the student and maintain-ing eye contact, I could later reestablishphysical contact and introduce a flow-ing movement sequence comfortable forthe student. Talking in a soft quietvoice helped calm the student andmaintain a connection. WATSU posi-tions students were most comfortablewere: Under Head: Seaweed; FirstPosition: Accordion, Near and Far LegRotation; Head Cradle: Thigh and LegPress and Arm/Leg Rock.

DocumentationThe last focus of the project was to doc-ument the effects of the WATSU on thechildren. In addition to adapted physi-cal education, many of the children alsoreceive speech therapy, physical therapy,and occupational therapy. Our studentsalso have many opportunities for peerinteraction in their classrooms, media,art, and music. Classroom teachers,support staff and I would discuss eachchildren’s responses to the WATSU ses-sion. Classroom teachers and supportstaff used the form in Appendix B todocument any changes in the children,while I recorded my session observa-tions on the form in Appendix A.

Flexibility showed improvement.Children who had severe physical andmotor limitations became more flexibleafter a session and were easier to dress.

Making connections often included accepting the verbalizations of the students

during the WATSU.


Increased flexibility would often last forseveral hours. Two students main-tained increased flexibility over thesummer and into the next school year.

Fear while in water was reduced.Children extremely fearful in the waterbegan to relax into front and backfloats. One student, who had clung tostaff when in the pool, began to go tothe wall on her front and come off thewall on her back by the end of the proj-ect. She is now swimming. Anotherstudent, who would not let go of thewall or even walk in the water, sur-prised his parents on vacation by inde-pendently going into a back float.

Comfort during pool, as well as landactivity, increased. Children who werefearful doing gym activities, walking inthe hall, or doing some classroom activ-ities began trying and enjoying moreactivities in the gym and classroom. Astudent who fought going up the ladderin the pool and the gym, and going upand down the steps of the bus, began toexit the pool using the ladder and need-ed less assistance getting on and off thebus. A student who had not smiled inthe gym or pool since the beginning ofthe year, smiled and laughed during hisfirst WATSU session. After several ses-sions he also began to smile and enjoysome of the gym activities.

Behavior improved. Another student,who was usually non-compliant andimpulsive, was calm and focused duringmost of the day after a WATSU session.In general, all students were morerelaxed, calmer, and more patient aftertheir WATSU. All students were gener-ally more focused in the classroom;they listened and followed directions,and would try new activities better thanbefore the WATSU.

The changes lasted from several hours toall day, and in a few cases, for severaldays. The length of time that the changelasted varied with the child, and with theother activities in the classroom.

SummaryWATSU was very beneficial for the chil-dren at Gateway Education Center.Overall, the children became more flex-ible, and showed greater range ofmotion. The children appeared calmer,less aggressive, and demonstrated anincreased focus and willingness to trynew activities. Based on the responsesof the children, I made five basic modi-fications to the WATSU techniques overthe course of the project. I used floata-tion devices when necessary to main-tain head above water for those stu-dents who lacked head control or whomade sudden unpredictable head move-ments. I used quiet, soothing talk andeye contact to make a connection withthe student.

I usually began the session with theUnder Head, or Seaweed position; mostof the time the session started from avertical position rather than a horizon-tal position. Although I used continu-ous movement, speed of movement var-ied with responses of the child. Finally,I did not use a specified sequence ofWATSU movements. Rather, using var-ious WATSU positions and transitions Ideveloped an interactive “dance” witheach student. u

ReferencesDull,H. (1997a). WATSU: Freeing the

body in water. Harbin Springs, CA:Harbin Springs Publishing.

Dull,H. (1997b). WATSU. In Ruoti, R.G., Morris, D. M., and Cole, A.J.,Aquatic Rehabilitation. Philadelphia,PA: Lippincott.

Giesecke, C.L. (1997). Aquatic rehabili-tation of clients with spinal cordinjury. In Ruoti, R. G., Morris, D. M.,and Cole, A. J. Aquatic Rehabilitation.Philadelphia, PA: Lippincott.

Morris, D. M. (1997). Aquatic rehabili-tation for the treatment of neurologicdisorders. In Becker, B. E.Comprehensive Aquatic Therapy.Boston, MA: Butterworth-HeinemannPublications.

Styer-Acevedo, J. (1997). Aquatic rehabilitation of the pediatric client.In Ruoti, R. G., Morris, D. M., andCole, A. J. Aquatic Rehabilitation.Philadelphia, PA: Lippincott.

Vargas, L. G. (2004). Aquatic therapy:Interventions and Applications.Ravensdale, WA: Idyll Arbor, Inc.

AuthorAnn Wieser, PhD, is AquaticTherapist and RehabilitationSpecialist at GatewayEducation Center,Greensboro, NC. Active in

aquatics for over 40 years, formerly she origi-nated and developed the aquatic therapy pro-fessional preparation emphasis at Universityof North Carolina-Greensboro. She has servedAAHPERD as Treasurer of Aquatic Counciland is a Council Master Teacher in AdaptedAquatics. Dr. Wieser received the 2000 ATRIProfessional Award. She can be contacted [email protected].

Making a connection is impossiblewhen the student is uncomfortable.

Many times the best connections were madestanding and face to face.

Additional information for “New for Your Library” and“Around and About the Industry” can be found on the Home Page

of AEA’s website at www.aeawave.com, click on Fit Pro News/Articles.

Appendices for thisarticle can be foundon the Home Pageof AEA’s website atwww.aeawave.com,

click on Fit Pro News/Articles.


Your reading and study of WATSU for Children with Severe and Profound Disabilities by Wiesercan result in 2 ICATRIC/AEA approved CECs. First, study the article. Then complete the study guideassignments as described below. Send your completed assignment and the course fee to AquaticConsulting & Education Resource Services, 7252 W. Wabash Avenue, Milwaukee, WI 53223. Study of this

article must be completed no later than March, 2009. Please allow 4-6 weeks for processing, and your receipt ofcompletion verification. Course fees depend on CEC verification requested. Fees are non-refundable.

ICATRIC = $30 AEA = $20 ICATRIC and AEA = $45AEA Member discount 20% ICATRIC = $24 AEA = $16 ICATRIC and AEA = $36

WATSU for Children with Severe and Profound Disabilities ACERS #ATJ507/AEA # 7122 H

A. Wieser CEC Study Guide

Assignment Preparation – All assignments must be typed. Handwritten material will not be accepted. Start with a coversheet including your name, mailing address, phone, e-mail address, and CEC article title. Then, begin another sheet of paperand answer the following questions/complete the following applications. If answering a question, state the question prior tosupplying the answer. If documenting an application, state the application requirement and then provide your response.

Comprehension –1. WATSU stands for what two words?2. WATSU promotes relaxation, enhances strength, and improves flexibility through what two types of experiences?3. Why is working in warm water effective or beneficial? Give 3 reasons.4. What three principals are the focus of this study?5. Why is WATSU suitable for children with severe multiple disabilities? Give 3 reasons.

Application –List and explain the rationale behind 4 modifications in traditional WATSU as used with children in this study.

Therapy Pool “Bathtub” RingAlison Osinski, Ph.D.

Aquatic Consulting Services, San Diego, CA

Question: How do you prevent the“bathtub” ring from forming on thewalls around the edge of thepool? How do you remove it?

The “bathtub” scum ring that forms onthe pool walls at the waterline is usual-ly caused by a combination of twoproblems: oversaturated water and con-centrated oils at the water surface.

Scum rings form as organic debris,detergents, oils, and bather waste prod-ucts (including body fats and oils, sun-screen lotions, personal hygiene andhair care products) which are lighterthan water and float at or near thewater surface, come into contact withrough pool surfaces. In addition toforming scum lines at the water surface,

they contribute to the build-up of totaldissolved solids (TDS), reduce sanitizereffectiveness which promotes bacterialand algae growth, cloud water, clog car-tridge filters and diatomaceous earth fil-ter elements, and contribute to mudballformation in sand filters causingreduced filter effectiveness.

To prevent scum ring formation, con-sider using enzymes or absorbent foamproducts. Enzymes are catalysts thatstart or speed up chemical reactions.Enzymes are protein-like substancesthat form naturally in animal and plantcells, but synthetic enzymes have beendeveloped for pool use. Over severaldays, enzymes slowly digest and destroyoils in pool water by converting themto carbon dioxide and water. An initial

dose is added and then maintenancedoses are added to the pool on a weeklybasis.

Absorbent foam products can be usedin addition to, or instead of, enzymes tophysically remove oils from the waterand prevent scum lines from forming.Absorbent foam can be placed in thepool skimmer baskets, hair and lintstrainer, filter tank, or other locationwhich is inaccessible to pool patrons.Manufacturers of the products say thepatented 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 peri-od of time can be cleaned and reused.

zxx Feature Column: Pool Problems


When water is unbalanced and has ahigher than desirable mineral satura-tion, excess calcium will precipitate outof solution and leave calcium scaledeposits, visible as unsightly, rough,white stains on the interior pool walls.This is especially noticeable on thewaterline tiles of pools with perimeteroverflow systems designed with skim-mers rather than rimflow, or fully orpartially recessed gutters. If body fatsand oils, and other organic debris arealso present, they will readily adhere tothe rough surface.

In addition to aesthetic problem ofwaterline stains, the excess calciumdamages heater elements, pool circula-tion system equipment, and restrictswater flow though the recirculationlines. Calcium carbonate build-upinside pipes will cause an increase invelocity as water is forced through asmaller diameter opening. Friction loss-es will increase, pressure will increase,flow will be reduced, and energy con-sumption will increase. Water maybecome cloudy and take on a "milky"appearance, particularly if pH is alsohigh. Sanitizer effectiveness will bereduced, and algae growth mayincrease. This is particularly a problemin warm water therapy pools becauseunlike most elements, calcium is less,rather than more, soluble as tempera-ture increases.

To prevent the problems caused byexcess calcium, monitor the water bal-ance and calculate the LangelierSaturation Index regularly. The LSI isused to keep the pH, total alkalinity,calcium hardness, water temperature,and total dissolved solids in balance,preventing the water from becomingaggressive or oversaturated. Dr.Langelier , a professor at the

University of California, Berkeleydevised his formula and chart in the1930s to help prevent scale build-up inclosed systems like boilers, but the for-mula was adapted and has been usedsuccessfully by pool operators fordecades.

To find the LSI, use your test kit andtesting instruments to find each of thefive values (pH, total alkalinity, calci-um hardness, water temperature andTDS). Saturation index equals pH plusthe alkalinity factor, plus the calciumhardness factor plus the temperaturefactor minus the TDS factor. Writedown the actual pH value found. Thenfor the remaining four values, find thecorresponding factor on the chart. Addor subtract the factors to or from thepH value. If an actual value is notfound on the saturation index chart,do not interpolate since there is nodirect linear relationship between thevalues. Rather, move to the next high-er value and use its factor. If cyanuricacid has been added to stabilize thewater , divide the cyanuric acid levelby 3, then subtract this interferencefactor from the total alkalinity readingprior to calculating the saturationindex. (see chart below)

If the sum obtained is zero, the water isbalanced and chemical equilibrium hasbeen achieved. A tolerance of plus orminus 0.3 is allowable for commercialpools. Negative values indicate corro-sive water, while positive values indi-cate likely calcification and scale forma-tion. If the saturation index formulaindicates that the pool water is not bal-anced (not equal to zero, plus or minus0.3), make the appropriate chemicalcorrections, starting with total alkalini-ty, then followed by pH, temperature,calcium hardness, and TDS.

Example: pH 7.8Total Alkalinity 130Calcium Hardness 300Water Temperature 92° F

TDS 750SI = pH +af + cf + tf - TDSfSI = 7.8 + 2.2 + 2.1 + 0.8 - 12.1 = +.8

Water is oversaturated. The water couldbe balanced by adding sodium bisulfateto drop the total alkalinity to 100 ppm,and by reducing the pH level to 7.2using muriatic acid or carbon dioxide.Well balanced water will increasebather comfort, will help prevent theformation of “bathtub” ring, and willdramatically extend the life expectancyof the pool and its components.

If calcium carbonate deposits and scumrings still form on pool walls despiteyour attempts to remove oils and keepthe water balanced , they can beremoved by scrubbing with tri sodiumphosphate (TSP), or with a non abra-sive chlorine bleach based liquidcleanser, using a 3M Scotch Brite® pad.If that doesn!t work, try using a finegrit sandpaper or pumice stone. Do notuse muriatic acid to scrub off the stains,because over time, acid will damage thegrout, will remove the plaster surfaceand expose the gunite below, and mayetch the ceramic tile. Power grindingmay be the only way to remove the cal-cium build-up if you ignore it for anylength of time. u

Author Alison Osinski, Ph.D.Aquatic Consulting Services1220 Rosecrans St. #915, San Diego, CA 92106(619) 602-4435(619) 222-9941 (Fax)[email protected] (e-mail)http://www.AlisonOsinski.com (Web Site)

Langelier Saturation Index

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

Temperature Calcium Hardness TDS Total Alkalinitydegree factor ppm factor ppm factor ppm factor66 0.5 75 1.5 <1000 12.1 50 1.777 0.6 100 1.6 >1000 12.2 75 1.984 0.7 150 1.8 100 2.094 0.8 200 1.9 150 2.2105 0.9 300 2.1 200 2.3

400 2.2 300 2.5800 2.5 400 2.61000 2.6


Aquatic Therapists Interact With…Editors and PublishersSusan J. Grosse, MS

Aquatic Consulting & Education Resource Services, Milwaukee, WI

Legitimacy, over time, of any academicpursuit is established by its body of pub-lished literature in the field.

While some interactions are a requiredpart of professional endeavors, workingwith a supervisor, for example, otherin-teractions are optional. Interacting witheditors and publishers clearly falls notonly into the optional category, butprobably into a subset labeled “interac-tions to be avoided!” However, publica-tion validates practice. Practice foundvalid is more often medically recom-mended, and financially reimbursable.How to specifics of aquatic therapypractice become published? Throughinteraction with editors and publishers.

To develop positive interaction, it isnecessary to understand job roles. Thepublisher is a businessperson, focusedon staying in business by remainingfinancially solvent. Ideally, the pub-lisher wants to make a profit from hisor her publishing efforts. If no profitresults, the publisher will have to goout of business, and his or her publica-tion will cease to exist. Publishers sur-vive (or not) on individual issue salesand subscriptions. Even publisherswho publish periodicals of member-ship based subscription groups musthave members who like their publica-tion to survive. Publishers rarely inter-act with authors.

Editors work for publishers. It is thejob of the editor to secure and developcontent for the publisher’s periodical.The editor is the gatekeeper for thepublisher. The editor, in conjunctionwith other editors in the field, is alsothe gatekeeper for validity in the profes-sion. What the editor chooses to acceptfor publication must first meet theneeds of the publisher in publishing aperiodical of interest and attraction toreaders. If no one wants to read thepublication, no one will pay for it.What the editor chooses to accept must

also meet standards of content reliabili-ty and validity. If a publication publish-es inaccurate, unreliable, invalid, orillegal content a long list of negativeconsequences can result, the least ofwhich is loss of readership, the greatestof which is legal action resulting inbankruptcy for the publisher. Editorswork with authors.

What does this mean for professionals –potential authors – in the field? First, itmeans the editor wants your article tobe the very best article possible. Theeditor will be there to help you – notbecause they like you, but becausehelping you develop your article helpshim or her put good content into apublication that generates revenue forthe publisher.

Most articles submitted for publicationrequire some re-write. Be prepared forthis process. Re-write will be easier if –• Your topic is unique. Read before you

write. Submit an article on a topic NOT recently in print. Take a fresh viewpoint, explain a new technique, describe your specific results, report on the unusual.

• Your writing is clear and understand-able. Avoid jargon. Be specific. Give examples and applications.

• You carefully proofread your article before submission. Look for – 4 spelling errors (spell check will

not flag errors like using “too” for”to”),

4 grammar errors (easy to make if you are interrupted while writ-ing),

4 run-on sentences (more than 3 lines of type is too much),

4 poor paragraph style (a paragraph is 3-4 sentences including a topic sentence),

4 lack of headings and sub-headings (those section titles help the reader organize thoughts), and

4 appropriate citations (even web-

site material must be cited with author, title, publisher, place of publication, and date).

The publishing process takes time.Typically editors are working 2-4 issuesahead of the one currently in print (6months to a year ahead). Once submit-ted, your article will most likely be sentto reviewers (part of that professionalvalidity process). It may also undergopreliminary editing. Plan for time.

When you next see your article, be pre-pared to –• Read it carefully to make sure any

editing has not changed intent of the content.

• Answer any and all questions from your editor (even if your answer is saying “no” to a change, reply and explain. Never ignore).

• Add requested information.• Ask any additional questions you

might have.• Return material on the deadline

requested by the editor (successful publications appear on time).

Anyone can get his or her informationpublished. The key is making that ini-tial decision to write. The field ofaquatic therapy needs professionals todocument their experiences, successes,trials, populations, protocols, research,equipment, facilities, staff training, riskmanagement, legal issues, businesspractices, and even failures. The bodyof knowledge created today is the foun-dation of the aquatic therapy profes-sional of the future.

Once that decision is made, successfulinterface with an editor will ensure ahappy result to your efforts. The firstarticle is the most difficult. While notwo publications – or editors – are alike,the process varies little. Your second arti-cle will be easier, and your third one eas-ier than your second. Don’t avoid inter-face with editors – embrace it! u

zxx Feature Column: Interface


ä

While the physiological effects of aquaticphysiotherapy have been studied in theadult population (Hall, Bisson &O’Hare, 1990), there is a distinct lack of quality research on the outcomes ofaquatic physiotherapy (Geytenbeek,2002). This is particularly so for thepaediatric population. Despite thestrong emphasis by physiotherapists on evidence-based practice, the majorityof paediatric research consists of casereports or anecdotal evidence, (Dumas& Francesconi, 2001). Benefits attrib-uted to aquatic physiotherapy for chil-dren with disabilities include improve-ments in muscle tone, over-all strength,joint range of motion, oral-motor con-trol, intercostal muscle strength, cardio-vascular endurance, sensory-perceptualabilities, balance, head control andbreathing control (Campion, 1991;Ruoti et al., 1997). However, there islittle or no research evidence to sub-stantiate these claims for the paediatricpopulation.

Not only is there a lack of evidence foroutcomes in the general aquatic physio-therapy literature, there is also a strongbiomedical focus on the research meth-ods and outcomes of aquatic physio-therapy. The International Classificationof Functioning, Disability and Health(ICF; WHO 2002) is based on thebiopsychosocial model, and provides aview of different perspectives of health:biological, individual and social. TheICF framework, therefore, also givesimportance to understanding patientexperiences as an essential factor indetermining health outcomes (Borrell-Carrio, Suchman & Epstein, 2004).

Experiences of children and their families with aquatic physiotherapyhave not been well considered. Parents,as primary carers, have an enormousinfluence on access to therapy, andtherefore have a role to play in support-ing therapists in evaluating effective-ness of physiotherapy interventions. Itis important to compare and contrastviews of parents with those of thera-pists as parents and professionals mayhave differing views.

This approach supports Family-Centered Practice (FCP:http//:www.novita.org.au) as the basicphilosophy of how Novita Children’sServices (Novita) provides services toits clients, and their families. Novitaprovides therapy, equipment and familysupport services to over 1000 childrenin South Australia with physical andsevere multiple disabilities. Services aredelivered in the clients’ homes, kinder-gartens, schools and in community set-tings by multidisciplinary teams of ther-apists who also visit country areas.

This study explores what parents ofchildren with disabilities, and theirtherapists think about aquatic physio-therapy. Specifically, the study aimswere to investigate: • What carers of children with a

disability perceive as benefits and downfalls of aquatic physiotherapy,

• What therapists view as benefits and downfalls of aquatic physiotherapy for children with a disability, and

• Whether there is a difference between the views of therapists and carers, and reasons for these differences.

MethodThis was a qualitative study utilizingfocus groups, allowing participants topresent and discuss their views inresponse to others (Krueger, 2000).Focus group methodology was usedbecause it is time efficient and costeffective in exploring a question thor-oughly prior to data collection. Ethicsapproval was obtained from theUniversity of South Australia Divisionof Health Sciences Ethics Committee.

To assist in the preparation for focusgroups, a short questionnaire was usedto establish demographics of EarlyIntervention (EI) aquatic physiotherapygroups offered at Novita. This question-naire included such questions as day,time and duration of the EI hydrothera-py group, how many children attendedthe group, how many therapists attend-ed the group, how the group was run,and attendance rates. This question-naire was distributed via email to allphysiotherapists employed by Novita.Information gained from the question-naire assisted in formulation of ques-tions to be used in focus groups aimedat exploring participant understandingof the definition of aquatic physiothera-py, perceived benefits and downfalls,potential barriers, structure of groups,and carryover effects.

An information package was sent toforty-one parents and fifteen therapystaff involved in EI aquatic physiotherapy.The information package included a letter explaining the project and invit-ing participation, a consent form, and a request to indicate a suitable focus

Effects of Aquatic Physiotherapy for Children with a Disability:Views of Parents and Therapists

Margarita Tsirios, BPhys, Senior Physiotherapist,Novita Children’s Services, Regency Park, South Australia

Gisela van Kessel, BA, MHSM, Lecturer, University of South Australia, Adelaide

Susan Gibson, M.App.Sc.Physio, Research Senior Physiotherapist,Adjunct Lecturer, Division of Health Sciences, University of South Australia

Parimala Raghavendra. Ph.D., Manager, Clinical Research, Novita Children’s ServicesAdjunct Lecturer, Division of Health Sciences, University of South Australia


group date. No payment or other bene-fits were provided to the participants.

There was a limited response to theinvitations, resulting in only two focusgroups being conducted. The firstgroup consisted of three parents/carersof Novita clients who were participatingin an EI aquatic physiotherapy group orhad participated in the previous 6months. The second group involvedthree therapists (two physiotherapistsand one speech pathologist) at Novitawho had participated in EI aquaticphysiotherapy groups at least 3 timesper term or had participated in the 6months prior.

During focus groups, parents and therapists were asked questions abouthydrotherapy including; their definitionof hydrotherapy, perceived benefits anddownfalls of hydrotherapy, potentialbarriers to access/attend, structure ofhydrotherapy groups, and any carryovereffects. Focus groups were facilitated bya research assistant, and proceedingswere audiotaped and transcribed verba-tim. Completed transcripts were sent toeach participant for verification that thetranscript was a true and accuratereflection of proceedings.

These transcripts were independentlyread by three of the researchers, andideas about content and themes werenoted. Once researchers had independ-ently completed their initial coding, theresearch team met to group the codesinto similar themes. Coding was refineduntil the main themes emerged. Themesincluded perceptions of benefits ofaquatic physiotherapy, outcomes, barriers and pool accessibility issues.

ResultsThemes around the perceived benefits,outcomes, and challenges of aquaticphysiotherapy emerged, and could beclassified into four main subgroupsrelating to – • Benefits for the child• Benefits for the parents • Benefits for the siblings, and • Barriers to participation.

Benefits for the ChildParents mentioned a whole range ofbenefits for their children, some ofwhich were similar to those highlighted

by therapists. These included—• Sensory experience.• Improved head control.• General positive effects on

movement.

For example, a parent commented that –…they get the sensory feeling of thewater…that’s a really big thing for kids.

And a therapist reported –It’s really good…for sensory kind of expe-riences as well, like pouring water overthe kids and swishing them through thewater.

However, parents produced a moreextensive list of benefits than therapists,and reported other gains such as – • Strengthening muscles through

resistance of the water.• Improved communication.• Development of choice making.• Establishment of routines.• Effects on tone.• Learning of swimming skills.• Improvements in land based gross

motor skills. • Increased interaction with their

environment.

One parent said – …her muscles built up. I definitely thinkshe’s come along quicker than if we hadn’tdone it (hydrotherapy)

And another parent said – He’s started using his hands, he never…he’s got very sensitive hands and for along time he would never use them, andnow he’s starting to use his hands to prophimself up cos we’ve put him on the matin the water and just the unevenness of itand… I dunno, for some reason he didn’tmind putting his hands in the water andnow he’s used to it so that’s good, verygood.

Additional benefits for the child asmentioned by therapists were anecdotalin nature and included –• Increased sensory stimulation.• Fun and social interaction.• Improved relaxation.• Increased ease of movement. • Assistance of movement, balance,

postural control.• Acquisition of group skills, turn

taking.

• Increased independence in the water.

This is reflected in the comments madeby therapists, including one therapistwho said – I think they really enjoy it, definitely. It’s really fun…

Another therapist said – With all the kids it’s a chance to be inwater, which is different and especially forthe less mobile kids that perhaps are inwheelchairs all the time or have limitedmovement or whatever…

Although therapists recognised oppor-tunities for implementation of goal set-ting and outcome measures, this wasnot reflected in their comments. Thiscould well be related back to the lack ofevidence in the literature to support useof aquatic physiotherapy in paediatrics,leading to the perception by therapiststhat aquatic physiotherapy is bit of“extra input” and is not seen to be as therapeutically valid as land basedtherapy. One therapist said –

Well, we’ve not actually done any meas-urements of sort of range of movementsbefore and after hydro (aquatic physio-therapy), which I suppose we could do toget some real conclusive evidence. Butcertainly we’ve seen them actively movingtheir limbs in the water which they’ve notbeen able to do on dry land and that isoften one of our goals. They often movetheir head a bit better in the water thanwhat they do on dry land but I don’t knowhow you prove that with your evidencebased practice.

In summary therapists appeared to viewaquatic physiotherapy as an adjunct toland based therapy, whereas parentsviewed water based therapy as an essen-tial stand alone component of theirchild’s program. This was reflected inthe complexities of definition responsesoffered by the 2 groups –

It’s using water for therapy, I suppose(therapist.) I say it’s physiotherapy in thewater … In the water it’s a totally differ-ent feel of freedom, the different move-ments and it strengthens their muscles orwhatever (parent).

Benefits for the Parent(s)When examining benefits for parents,

ä


therapists’ comments suggested thegreater benefits of aquatic physiothera-py were related to parent networkingand social support, rather than the ther-apeutic values of water for the child.They specifically mentioned – • Fun and social interaction.• Networking, families forming

friendships.• Parent training, handling.

This is reflected in therapist comments –Yeah, socially, you know, I reckon is thebiggest thing. They love coming alongand, you know, chatting to each other, and yeah it’s good.

and

I think that one of the things as mums isthat the child is accepted. All the childrenhave got disabilities whereas a couple ofthem said when we’ve been to the ordi-nary swimming pool they have a lot ofstares… In the hydro (aquatic physiother-apy) group, …They’re all very supportiveof each other and it’s just fantastic.

Unlike therapists, parents did notimmediately recognise any benefits forthemselves until specifically questioned.Then responses included –

It was the first real contact with othermothers or families that had children withdisabilities ….. you become quite friendlywith those people and we catch up out ofwork, we have a mum’s club and go out todinner every few months and it’s good,you don’t feel so alone, there’s other peopleout there that have problems.

Another parent said:…you get social interaction with otherparents and other children.. you get toswap ideas and chat…

Benefits for the SiblingsWhen examining benefits for siblings,views of therapists and parents differed.Therapists recognised sibling supportand involvement as an important com-ponent of the aquatic physiotherapyprogram and tried to include siblings inthe program. One therapist said –

Yeah, I think definitely… bonding withtheir sibling and seeing what they cando…I guess they feel a bit of self-worth inthat they’re being useful and that they can

do something…I guess we help to promotethat by telling the sibling what they cando and how they can help and they seemto really enjoy splashing around too…

Parents on the other hand, viewedaquatic physiotherapy as an importanttherapy time for their child, and pre-ferred, if possible, not to have the siblings around. Hence, they did notrecognise any specific benefits for siblings.

Barriers to ParticipationSimilar themes emerged from both ther-apists and parents regarding barriers toaquatic physiotherapy, pool accessibilityand service gaps. These included – • Medical contraindications, risk of

infections• Parental priorities – such as the day

or other commitments • Pool characteristics – including water

temperature and depth• Staff resources – including travel

time, pool location, cost of hiring• Attendance and group format – such

as having enough children to run a group or the age and ability spread of clients

Responses from therapists regardingpool accessibility highlight challengespresented when working in a communitybased model of service delivery –

Well we’ve got a choice of a couple of different pools that we could use…The problem there is the water temperatureand also that even at the shallow end it’sstill too deep for some of our 4-year-olds tostand on the bottom and practice walking.

Another therapist responded – And a lot of them hire out just a lane so…if you did happen to have 13 or 10 youcan’t fit in a circle in a lane, you’re kindof in a big long line which isn’t quite thesame. Also, I guess the storage of ourequipment at [the location], we can storea lot of stuff there…[and] there’s not oftenchange tables.

Some service delivery gaps were identi-fied by therapists: –We did a survey at the end of last yearand they’re all more than happy with it, alot of them would like it every week butunfortunately we don’t have the staffresources...

and

I guess the fact that parents want it twicea week and we can only provide it once aweek I think is probably a good indicatorthat there could be more services outthere.

In general, parents highlighted similarbarriers and challenges as outlined bytherapists. Interestingly, however, par-ents did not highlight travel as a barri-er. This reflects the importance parentsplace on aquatic physiotherapy as atherapy modality.

…I wouldn’t care how far I had to travel,if I had to come all the way here, I’d comehere because you do it for your childbecause your child needs that…

Even when the timing of the groupclashed with other commitments androutines, parents would rearrange theirschedules. This again reflects the valueparents place on aquatic physiotherapy.

Even the time… Like [child]… Even thelast time we were going, it really didn’tsuit because that was when she wanted tohave a sleep… but I wanted to go…, so Ijust sort of tried to drag her sleep timeout a bit or get her to have an early sleepif she would and if she wouldn’t I’d justkeep her awake and she’d just crashafter…

DiscussionParents perceived far greater benefits ofaquatic physiotherapy, and valued theirown and that of their child’s involve-ment, more than did the therapists.Parents perceived the benefits associat-ed with their child’s gross motor skills.In contrast, therapists talked about thesocial benefits for the child, siblingsand parents attending the group. Barriers identified by therapists werelocation and temperature of the pool,difficulties with travel, and parentsbeing unable to fit it into their day.While parents concurred with this,their focus was more on fitting it inwith other siblings, kindergarten/schoolcommitments, and sleep times, ratherthan on the issue of travel.

Understanding benefits and barriers arean important component of behaviourchange theory (Talbot and Verrinder

ä


2005). Patients need to perceive suscep-tibility and seriousness in their own sit-uation, and then perceive benefits asoutweighing costs or barriers (Talbotand Verrinder 2005). Therapists whoare focussed on encouraging all poten-tial clients to attend aquatic physiother-apy need to design their programme toreinforce benefits perceived to be ofgreatest importance to parents, whichare essentially the outcome of improv-ing gross motor skills. It may be thattherapists remain ambivalent about thisbenefit as there is still no research tosupport this claim.

In encouraging participation and deal-ing with the common problem of nonattendance the therapist needs to man-age barriers to attending faceing par-ents. This appears to be primarily anissue about timing of sessions for par-ents. To reduce a barrier for attendanceit is recommended sessions be sched-uled to allow, as far as possible, for traveltime and school and kindergarten dropoff and pick up.

Limitations of this study are the smallnumber of participants in each focusgroup, and the number of focus groups.This was despite several recruitmentattempts and offering a range of flexibletimes and venues for focus groups.Although there may have been otherparents who were enthusiastic to partic-ipate in the study, this may have beenoutweighed by high demands on theirtime as a result of just managing theirevery day life with a child with a disability.

Recruitment of therapists was also challenging as the therapists were pre-dominantly part time and were based ata number of different venues. It is alsopossible a therapist’s lack of time andresources were a barrier to their partici-pation in the focus groups. In thefuture, one alternative might be toarrange individual interviews, eitherface-to-face, or over the telephone.However, an advantage of a focus group over an interview method is itallows a dynamic discussion, whichmay be less likely to occur in an indi-vidual interview.

Smaller numbers did allow each partici-pant sufficient time to discuss his or

her viewpoint. Thus, small groups canbe more appropriate when the topic isintense (Krueger 2000). Ideally, focusgroups should be repeated until no newinformation is obtained, although itmay be appropriate to run fewer groupsif participants are in a congruent cate-gory with similar backgrounds andexposure, as in the case of the thera-pists (Krueger 2000).

In future, if a focus group is to be imple-mented, utilising a scheduled aquaticphysiotherapy group where the partici-pants are a captured audience may resultin larger participant numbers. An alter-native technique may be to use on linediscussions or email to collect informa-tion. Consideration may also be given tousing a triangulated approach, whereby acombination of interviews and focusgroups are utilised.

ConclusionThis exploratory study showed parentsand therapists have differing views onbenefits of aquatic physiotherapy. Somedifficulties and practical barriers toaquatic physiotherapy were identified.This study highlights the need to con-duct more rigorous clinical studies toexamine effects of aquatic physiothera-py for children with physical and/ormultiple disabilities so therapists can bemore confident and clear about promot-ing benefits to families. u

ReferencesBorrell-Carrio, F., Suchman, A., and

Epstein, R. (2004). The biopsychoso-cial model 25 years later: Principles,practice, and scientific inquiry, Annalsof Family Medicin,. www.ann-fammed.org 2, 576-582.

Campion, M. (1991). Hydrotherapyin Pediatrics,. 2nd ed, Oxford:Butterworth- Heinemann Ltd.

Dumas, H & Francesconi, S, (2001).Aquatic therapy in pediatrics: anno-tated bibliography, Physical &Occupational Therapy in Pediatrics,20, 63-78.

Geytenbeek, J. (2002). Evidence foreffective hydrotherapy, Physiotherapy,88, 514-529.

Hall, J,, Bisson, D., & O’Hare, P. (1990).The physiology of immersion,Physiotherapy. 76, 517-521.

Krueger, R. & Casey, M. (2000). Focus groups: A Practical Guide forApplied Research 3rd ed, ThousandOaks, CA: Sage Publications.

Ruoti, R., Morris, D. & Cole, A. (1997).Aquatic Rehabilitation, Philadelphia,PA: Lippincott-Raven.

Talbot, L. & Verrinder, G. (2005).Promoting Health: The Primary HealthCare Approach 3rd ed, Sydney,Australia: Elsevier.

World Health Organization (2002).Towards a Common Language forFunctioning, Disability and Health:The International Classification ofFunctioning, Disability and Health.Geneva, Switzerland: WHO.

Survey Questions

Therapist Focus Groups• What do you think are the benefits

of hydrotherapy for this group ofclients?

• Why do you think clients enjoy hydrotherapy?

• Why do you think the caregivers of clients enjoy hydrotherapy?

• Do you see any problems with the use of hydrotherapy for this group of clients?

• Would you suggest any better alternatives to group hydrotherapy for this group of clients?

• Why do you think there are differ-ences in the format of the hydro-therapy groups between the differ-ent regional offices?

• Do you have any suggestions for the changes to the format of the hydrotherapy groups?

Parents/Caregivers Focus Groups• What do you enjoy about

hydrotherapy groups?• What do you think your child

enjoys about hydrotherapy groups?• What would you do to improve

the hydrotherapy groups?• What benefits do you think

hydrotherapy has for your child?• Why do you think hydrotherapy is

beneficial for the children involved?• How has your child changed or

improved since attending hydrotherapy?


AuthorsMargarita Tsirios, B PhysMargarita Tsiros has a Bachelor of

Physiotherapy from the University of SouthAustralia, and a Graduate Certificate inResearch Methodologies, for which she wasawarded the Health Science Student of theYear. She is currently completing a Bachelor ofHealth Science (Honours). Margarita nowworks as a Senior Physiotherapist at NovitaChildren’s Services, and is also a VisitingResearcher at the University of SouthAustralia. She can be contacted [email protected].

Gisela van Kessel, MSGisela van Kessel gained a Bachelor of AppliedScience (physiotherapy) at the SouthAustralian Institute of Technology in 1983 andcompleted a Masters in Health ServiceManagement at Flinders University in 2001.She has many years of clinical experience inaquatic physiotherapy and now lectures andsupervisors honours research in aquatic phys-iotherapy at the University of South Australia.She can be contacted at [email protected].

Susan Gibson, M.App.Sc.Physio Susan graduated from the South AustralianInstitute of Technology with a Bachelor ofApplied Science (Physiotherapy) in 1978, aGraduate Diploma in Physiotherapy(Paediatrics) from the South AustralianInstitute of Technology in 1989, and completeda Masters of Applied Science in Physiotherapy(Paediatrics) at the University of SouthAustralia in 1993. Her areas of interest includethe promotion, and use of, research in clinicalpractice in paediatric rehabilitation. Susan iscurrently employed as the Research SeniorPhysiotherapist, and has a clinical caseload atNovita providing metropolitan and outreachservices for children with disabilities. She canbe contacted at [email protected].

Parimala Raghavendra. Ph.D.Dr. Raghavendra obtained her Ph.D. in speech-language pathology from Purdue University,USA and has extensive clinical, teaching andresearch experience in communication disor-ders and disability. Her current work focuseson making research become an integral part ofhigh quality services, answering importantclinical questions through research, and pro-moting evidence-based practice in paediatricdisability. She can be contacted [email protected]

The Aquatic Therapy & Rehab Institute (ATRI) had announced an online optionfor their Aquatic Therapeutic Exercise Certification. This online exam will be abenefit to practitioners who have limited travel options.

Anne Miller, Executive Director of ATRI, said, “Many educational institutions areoffering online education and degrees. ATRI is following that trend so certificationcan be attained more conveniently for people with busy lifestyles.”

Practitioners will have to study ahead and will have 3 one-hour time blocks tocomplete all three sections of the exam, consisting of 110 – 130 multiple choiceand matching questions. For more information, see below or call toll free 866-462-2874 or go to www.atri.org and click on “Certification Information”.

Why Take the Aquatic Therapeutic Exercise Certification Exam?ATRI’s Aquatic Therapeutic Exercise Certification is for competent, knowledgeableprofessionals in aquatic therapy, rehab and therapeutic exercise. The exam will testyour ability to meet the Aquatic Therapy and Rehabilitation Industry Standards topractice. The Standards are available on the ATRI web site and can be downloadedfree of charge at http://www.atri.org/stflyer.htm.

This Certification will allow you to use the term “ATRI Certified” or the initials“ATRIC” after your name. The certification will not make you a therapist if youaren’t already one.

Exam Fees: The fee to sit for the on-site exam is $255 (pre-registered). The fee totake the exam online is $195.

Prerequisite: The prerequisite for this exam is 15 hours of Aquatic Therapy, Rehaband/or Aquatic Therapeutic Exercise education. It is preferable this education behands-on, but online or correspondence courses also qualify.

On-site Exam Date in Chicago: Sunday, November 18, 2007

1:00 pm - Registration1:30 pm - Exam Begins

Transfer Information: If you have already taken an aquatic therapy certification exam through theInternational Council for Aquatic Therapy and Rehabilitation Certifications (ICA-TRIC), but have not received your test results, ATRI will let you take the onlineATRI exam free. You will get your results from ATRI within 15 days guaranteed.

If you have already received your exam notification from ICATRIC and you didn'tpass, you can still take the ATRI online exam free.

If you did pass, you can transfer your certification directly to ATRI at no cost.That will give you the backing of the Aquatic Therapy & Rehab Institute for yourcertification.

For More Information and To Register: Go to www.atri.org/ATRICertification.htmor call toll free 866-go2-atri (462-2874). u

ATRI Announces New Online Option for theAquatic Therapeutic Exercise Certification

zxx Feature Column: Around and About the Industry


Physical exercise plays an importantrole in reducing the physical and psy-chological symptoms for individualshaving Parkinson’s Disease (PD). Oneform of exercise, water exercise, is a rel-atively untested treatment method forthese individuals. In this pilot study,four participants, aged 71-89 years,with PD followed a six-week exerciseprogram in water, three days weekly fora duration of from 20 minutes up toone hour in an attempt to improvephysical and psychological functions.Testing was done prior to and after thewater exercise program. This studyshowed participants improved physicalstrength, endurance, and balance. Testsof perceived self-confidence showed nodifference between the beginning andend of the study. Focus groups conduct-ed with the participants and caregiversafter the completion of the water exer-cise program showed positive psycho-logical results from engaging in a waterexercise routine. Results suggest waterexercise is a beneficial medium for indi-viduals with PD, and can be useful inmaintaining and/or improving strength,endurance, and balance. Furtherresearch with a randomized controlledtrial and a larger sample size is neededto verify the beneficial effects of waterexercises for individuals with PD.

Parkinson’s DiseaseIn 1999 Parkinson's is the most com-mon neurodegenerative disease afterAlzheimer's Disease1. It is a chronic,progressive disorder with no identifi-able cause. It is estimated PD presentlyaffects 1.5 million people in NorthAmerica. As the population ages, theprediction is that 1% of people over theage of 60, and 2% of people over theage of 70 will be affected with PD2.

There is no cure for PD. The funda-mental defect in PD is a gradual loss ofbrain cells, producing the chemicaldopamine, a neurotransmitter. Thisresults in messages from the substantia

nigra to the corpus striatum (the area ofthe brain that produces smooth, con-trolled muscle actions for movementand balance) not being delivered orbeing delivered incorrectly.

Symptoms of PD begin to appear when60% to 80% of the dopamine has beendestroyed3. While not specificallycaused by the aging process, it’s rela-tionship to aging could be because bothdopamine concentration and the num-ber of cells in the substantia nigra thatproduce it fall steadily from birth, some60% or so having been lost in extremeold age.4 Clearly, the older the person,the smaller the additional deficit incerebral dopamine produced by whatev-er mechanism that is required to pro-duce Parkinsonian symptoms.4

Most people with PD find they havehad the disease for several years beforeinitial diagnosis. This is understand-able because many of the early symp-toms of PD are also signs of aging expe-rienced by everyone. Parkinson’sDisease exacerbates the normal agingprocess. It affects each person different-ly. In some it progresses quickly, whilein others progression is quite slow.Some people become severely disabledover time, while others experience onlyminor movement problems.

Often, seniors who suffer from PD willdegenerate over time until a point isreached where they can no longer takecare of themselves or where home careis no longer sufficient, and they needresidential care. This places extra costpressures on the individual, family, andfinally the health care system, as dis-cussed by Lesemann & Martin5 whobelieve if people remain well enough tobe able to be cared for in their ownhomes, the resulting savings can be upto 75% of the costs of equivalent care ina hospital setting. Long term care insti-tutions, such as nursing homes, aremore cost effective than hospital care6.

But home care is the most cost effectiveway to support people no longer able tofunction independently. The 2003Health Care Renewal Accord recognizedhome care as one of the priority areasto receive substantial funding.7

Additionally, PD carries many second-ary symptoms that may affect people,while passing unnoticed for severalyears, thus increasing probability latediagnosis. When diagnosis is made, twoor more cardinal signs are present.These cardinal signs include restingtremor (shaking – affects approximately75% of all sufferers and is usually moreevident on one side of the body), pos-tural instability (impaired balance andmuscle weakness), muscle rigidity(stiffness of the limbs and trunk) andbradykinesia (slowness in initiatingmovement and changes in the speedand size of movement). Muscle rigidityand bradykinesia affect almost all sufferers of PD. There are also manycommon secondary signs such as freez-ing or having dyskinesis (involuntarymovements) associated with anti-parkinsonian medications.8

Benefits of Exercise forIndividuals with PDUntil the debate about the pathophysio-logic cause of impaired movement inParkinsonism is settled, it will be diffi-cult to develop a specific exercise treat-ment for symptoms that includehypokinesia, tremor, and muscularrigidity.9 Regardless of presence of anydisease condition, positive effects ofphysical activity on a person’s healththroughout the life span have been welldocumented. Participation in a regularexercise program is an effective inter-vention to prevent or reduce functionaldeclines associated with the generalaging process. Endurance training canhelp maintain and improve variousaspects of cardiovascular function.Strength training helps offset loss ofmuscle mass and strength typically

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Water Exercise for Individuals with Parkinson’s Disease:A Pilot Study

Alexander M. Crizzle, MPH., PhD Candidate, University of Waterloo, Waterloo, ON, CanadaIan J. Newhouse, PhD., Lakehead University, Thunder Bay, Ontario


associated with normal aging. If exercis-es are performed in water, the resistanceof water can be used for strength train-ing. Regular exercise improves bonehealth and postural stability, increasesflexibility and range of motion.10

Evidence also suggests that regular exer-cise provides psychological benefits suchas an improvement in mood and subjec-tive well being.10 These general benefitscan also accrue to an individual with PD.

There is growing evidence supportingwater exercise as a treatment methodfor many other conditions, includingstroke, coronary rehabilitation andother neuromuscular disorders such asstroke or multiple sclerosis. This pilotstudy, using descriptive measures, testsof balance confidence and focus groupsattempted to show water exercise isbeneficial for individuals with PD tohelp them maintain, and potentiallyimprove their physical and psychologi-cal well-being. Individuals with PDshould benefit from water exercise ther-apy because multidirectional hydrostat-ic pressure of the water on the body vir-tually eliminates falls, to which peoplewith PD are prone. Many people withPD do not exercise because of the fearof falling. Rehabilitation through waterexercise can provide a means for indi-viduals with PD to maintain mobilitybecause they can exercise without thefear of falling. Increased mobility willenable them to remain independent fora longer period of time, and costs to thehealth care system could be reduced.

Symptoms of PD can be relievedthrough a regular exercise program tar-geted to increasing strength, flexibility,endurance, balance and mobility byusing simple functional movements.Research suggests physical exercise ofmoderate intensity leads to an increasein the level of dopamine, which sug-gests an exercise program for individu-als with PD would be beneficial.11,24 Aclinical trial conducted at the School ofPhysical and Occupational Therapy atMcGill University confirms the value oftherapy in maintaining functional inde-pendence and in improving physicaland motor symptoms for persons withPD. They perceived a significantimprovement in their psychologicalwellbeing.12 Other studies have obtainedsimilar results with improvements to

various degrees in mobility, dexterityand flexibility.10,13,14

There have been several studies relatedto individuals with PD and improvementof gait.15,16 The ability to generate a nor-mal stepping pattern is not lost in PD.Normal stride length can be elicited inindividuals with PD using attentionalstrategies and visual cues, possiblybecause both these methods focus atten-tion on the criterion of stride size.17

The first line of defence for treatingsymptoms of PD is often drug therapy.Exercise is not routinely added to thatregimen. However, chronic use ofdrugs may cause more motor complica-tions in those with PD.18 Formisano,et. Al., in 199219 found in a comparisonbetween individuals with PD treatedusing drug therapy only and individualswith PD treated with drug therapy andexercise, there was a significantly lowerlevel of disability in the latter group. DeGoede, et.al., in a 2001 research synthe-sis, concluded individuals withParkinson benefit from physical therapyadded to their standard medications.25

However, there is conflicting evidence.Pedersen, et.al. in 199020 reported adeterioration of stride length and gaitvelocity after physical therapy in tenindividuals with PD. Despite partici-pants' reported subjective impressionsthat the training was beneficial, therewas no statistically significant improve-ment in the motor tasks. These resultssuggest increased well-being con-tributes to the benefits of exercise ther-apy, but is not the only decisive param-eter. It is not obvious why this study'sresults disagree, because the trainingprogram did not differ from those ofmore successful group studies.

Research delineation between aquatictherapy and general exercise for indi-viduals with PD is sometimes unclear.The majority of studies were doneusing land-based exercise regimes, onlyone study included exercises in water.10

Water has rarely been tested as an exer-cise medium, especially for people withPD. One study showed hydrotherapyproduced greater benefits for peoplewith rheumatoid arthritis than exercis-ing on land, combined with a progres-sive relaxation program.21 So whywould water be a good exercise medi-

um for individuals with PD? WaterArtFitness International Inc. a companyspecializing in rehabilitation for neuro-muscular, joint and other physical dis-orders, in their manual for instructors,27

claim one of the best places for trainingposture and balance is in the water.Water offers freedom from canes, walk-ers and wheelchairs as these assistivedevices are replaced by a three-dimen-sional support medium surrounding thebody. Postural improvement is achievedas the body is stabilized in a verticalposition without the need for some-thing to lean or sit on. Buoyancy pro-vided by water allows participants topractice good posture and gait mechan-ics without fear of falling. Currents gen-erated by movement in the water pro-vide a constant challenge to balance.

Gait and balance problems are the mostdisabling symptoms of PD. If claims bywater exercise proponents were true,being able to work on these impair-ments on a regular basis would help tomaintain functionality and retard theprogression of the disease. Walkingthrough water can strengthen andlengthen muscles with every stride asmoving against resistance of water opti-mizes strength training. It is also sug-gested water provides a constant mas-sage, helping to combat muscle rigidity.WaterArt Fitness International Inc. con-ducted a research project with theParkinson’s Association of SW Floridaunder the direction of Marjorie Johnsonwith 11 participants aged 63 to 88 yearsin various stages of PD22 At the end ofthe 12 week project all participants hadexperienced improved levels of func-tionality through a water exercise pro-gram targeted to their needs.

Pilot StudyThe hypothesis of this pilot study wasthat water exercise would help alleviatesymptoms of Parkinson’s Disease. Theassumption was that water exercisewould have beneficial effects on thesymptoms of PD. The hypothesis wasgenerated from previous studies involv-ing exercise and other joint or neuro-muscular disorders such as arthritis,osteoarthritis and multiple sclerosis.

MethodsThis study took place at theScarborough Young Men’s Christian

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Association (YMCA) in Ontario,Canada, in the shallow-retractable endof their pool. Depth of the pool waterwas consistently four feet, mid chestlevel of a person of average height.Water temperature was between 87 Fºand 91 Fº (31 Cº and 33 Cº) which isfairly warm for water in a pool. Intentof the warm water was to warm themuscles and thus facilitate movement.All participants in the study had to beat stage two or below on the Hoehn andYahr scale28 and well enough to carefor themselves. Land use of walkers,canes and wheelchairs was acceptableand did not preclude participation.Individuals with PD who had not exer-cised during the last four weeks weregiven preference for this trial.

Participants were hard to recruit, espe-cially participants who were at Stage 2on the Hoehn and Yahr scale and hadnot exercised prior to the study. Also,defining Stage 2 was difficult as medicalpractitioners use different rating tools(UPDRS, Hoehn and Yahr, Schwab andEngland Activities of Daily Living).Finding participants willing to exercisewas an additional problem.Transportation to and from the exercisefacility also proved to be a limitation.Facilities with supervised, heated poolssuitable for this special population arescarce, so transportation to and fromthe facility was a problem for potentialparticipants, many of whom did notdrive any longer and were either afraidto use public transport or did not liveclose to public transport.

Because of these limitations, and becausethis was a pilot study, the relatively smallnumber of four participants was deemedacceptable for this trial. Of these four,two came from retirement homes. Oneparticipant was referred by his doctor,and one by a friend. This small samplesize does not necessarily accuratelydescribe the population of PD patients.The sample included one racial minority(Philippino), and both male and femaleparticipants. The age distribution wasfrom 71 – 89 years of age. Half of theparticipants had exercised previously, butnot during the exclusion period. Therewas no age restriction.

Activity ProgramThe first week involved an orientation

session and allotment of time slots forthe pre-test. The orientation sessiondescribed the study in detail and showedthe layout of the facility. At this orienta-tion, participants had the chance to askquestions pertaining to the study. Afterall questions were asked and answered,an informed consent form, and a med-ical history form were given out to theparticipants to complete. Also, partici-pants met all core researchers of thestudy and had a chance to talk to each ofthem. Familiarization with the facilitywas provided through a personalizedtour of all equipment, program andchange rooms.

At their appointed times participantscame to the YMCA for the pre-exercisetest. The pre-exercise tests consistedof ten different tests measuring balance(dynamic and static balance), cardio-respiratory endurance (two minute stepin place test), mobility (get up and gotest), flexibility (chair, sit and reachtest, back scratch test), muscular fitness(stride length and speed) and muscularstrength (bicep curl, sit to stand test).All physical tests were derived from theAmerican Council of Exercise.29 Theonly test that was modified was thestride length and speed test, which,because of the small size of the gym,was changed from a 50-foot walk to a32-foot walk. Testing was done on landin the studio room. These test servedas a baseline test to compare with thetest results at the end of the trial.

Participants were also given two sur-veys: the Activities-Specific BalanceConfidence Scale (ABC Scale)30, whichlooks at the level of self confidence atthe time of completion, and the VitalityPlus Scale30, which looks at how theparticipant is currently feeling.

Once participants completed all pre-tests, they were ready to start the waterexercise program the following week.For the next six weeks, participantsexercised in the water. Protocol for thesubjects was to wear a bathing suit forthe pool. To preserve warmth in thebody, all participants wore a swim vest.As movement is easier when the body iswarm, wearing a vest also facilitatedmovement. We asked that participantseat lunch prior to exercise and remainon their normal medication regime.

An instruction sheet with generalguidelines of things that participantsshould be aware of was given at thebeginning on the study.

Water exercises from the WaterArtFitness International, Inc., manual.27

were used for this program. Participantswould always start the water exercisesession with slow warm up exercises toloosen muscles. The first two weeksencompassed many walking, gait andbalance activities. No upper body exer-cises were performed until the thirdweek of classes. At the beginning ofthe third week of classes, many morecomplicated and challenging movementexercises were incorporated, and upperbody exercises were introduced.Progressions were then included toincrease lower body strength and bal-ance, and use of aqua steps was includ-ed in the water exercise classes until theend of the 6-week program.

Classes took place three times perweek: Monday, Wednesday and Fridayfrom 1 pm to 1:30-1:45 pm.Participants were encouraged to exer-cise as much as possible. After the six-week exercise period, all participantswere evaluated on their post physicaltests to see if any improvementsoccurred.

Data CollectionThe collection of data used to evaluatethe study was made at the end of thesix week program. Several methodswere used, including repeating thephysical tests given prior to the start ofthe project. Both surveys given at thebeginning of the trial were repeated,and results were compared using apaired t-test to see if any subjectiveimprovements took place.

A third method used to analyze resultsinvolved conducting a focus group at theend of the study. To eliminate the possi-bility of bias, an independent researchernot familiar with the study conductedthe focus group. Partici-pants’ commentsthus collected allowed the researcher toassess feelings and thoughts of partici-pants about the study.

Additional information was gainedthrough observation of participantsduring activities.

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A journal log of all water exercise classes was kept. This allowed theresearcher to make daily notes of allparticipants, exercises done, and theirfeelings at the time.

ResultsSix people started the study but twodropped out. One drop out was due toanxiety in the water, and the other dueto a change in medication. All four par-ticipants had PD.

The remaining four participants in thestudy attended 89.5 +/- 10.2 percent ofthe scheduled training sessions duringthe six-week period.

Results from the physical testing scoresshowed individual improvements on alltests except for flexibility, which exhibit-ed a slight decrease in upper and lowerbody flexibility in 2 participants. Threeof the participants improved in both thestatic and dynamic tests. One partici-pant was unable to complete both bal-ance tests and any improvement was dif-ficult to measure. All participantsimproved on strength tests, the bicepcurl test and the sit to stand test.Endurance improved for all participantsas all individuals demonstrated improve-ments in the 2-minute walk in place testand the get up and go test. All partici-pants improved on stride length, takingfewer steps to walk 32 feet, and the timeto complete the 32 -foot courseimproved in 3 of the 4 participants.

Even though no statistical tests of sig-nificance were performed due to thesmall sample size, such as in this pilotstudy, the trend of these results doesseem to show improvement in physicalfunctionality through the many exercisebattery tests completed after the waterexercise program. Some physical per-formance improvements occurred in allsubjects, and in all physical dimen-sions, with only two subjects losing a

small percentage of flexibility over theduration of the exercise trial.

The focus group session provided use-ful subjective feedback about partici-pants’ opinions of the water exerciseprogram. When asked if their confi-dence in doing daily activitiesimproved, three of the four participantsclaimed they were more confident.They felt more confident because theyfelt better, and they felt as though theyhad improved. Participants reporteddaily tasks were easier to perform, andthey were not as tired as before.

Increased confidence in doing activitiesof daily living after the water exercisetherapy program was expressed in thefocus discussion session by three out ofthe four participants. The one partici-pant who said “no” to having moreconfidence said that although she hadincreased ability to perform chores, shehad always been confident in her abilityto do chores. There were no significantdifferences between confidence scoreson the ABC Scale. Even though theABC scale showed no difference, partic-ipants three and four did improve ontheir self-confidence and abilities toperform activities. Also, three of thefour participants did improve on theirVitality Plus Scale score, although nostatistical significance was computed.

DiscussionA major limitation is the small samplesize. However, results of this study pro-vide some indication of what an exer-cise program can do for people withParkinson’s Disease. All four partici-pants improved on measures of physicalperformance, as well as assessment ofwellbeing. The strength of this study isit was one of the first in the field forindividuals with PD. There have beenfew studies involving water exercisesand their effect on individuals with PD.One very important finding of this

study is it suggests improvementachieved after water exercise is notrestricted because of age. Ratherimprovement might be based on theseverity of the disease. Although allfour participants were classified as atwo on the Hoehn and Yahr28 scale, therange of impairment along the two clas-sifications is large. The more severe thedisease, the more difficult it is for indi-viduals with PD to exercise. But evenat an old age, well into the 80’s, individ-uals with PD can improve their physicalcapabilities. This has implications forthe treatment of PD, in as much as itpoints to the need to encourage exer-cise early on after diagnosis of PD. As an added benefit, the participants,

regardless of their physical improve-ment in the study, found it beneficial tobe active and out of their homes. Thiswas especially true of the participantsliving in retirement homes.

There are many limitations to this pilotstudy. The temperature of the pool var-ied from 87o F to 91º F. The air temper-ature outside the water varied, and attimes it was cold enough to shiver. Thetime at which each participant beganthe exercise sessions varied somewhat.Also, exercises were not always per-formed simultaneously as a group forthe duration of the exercise session.Rather, participants would perform dif-ferent types of exercises during somepart of the exercise session. Anotherfactor was that some of the participantsneeded constant re-assuring that theywere doing well and improving overtime. They needed constant positivefeedback from the researcher, and thiscould have biased their opinion ofthemselves and the study. Other limita-tions are that some of the participantswere more active than others. Theyengaged in activities such as walking ortherapy, which prevented them frombeing sedentary and seeing the trueeffects of the water exercises.

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Subject Body Mass Hoehn & Yahr Exercise Time (min) Training Sessions Attended (%)Index Classification Average Minimum Maximum

1 24.5 2 41.5+/- 6 30 50 94

2 23.2 2 41.3+/- 9.5 20 55 88

3 19 2 41.2 +/- 7.6 25 50 100

4 30 2 29.2 +/- 7.9 15 40 76

Mean 24.2 38.3 +/- 7.8 22.5+/- 6.5 48.8 +/- 6.3 89.5 +/- 10.2

Another limitation of this study is thatone cannot indisputably specify thatexercise reduces symptoms of PD.Physical improvements did occurred inparticipants in this study. However,many participants had other diseases aswell. Three of the four participants hadsome form of arthritis. One participanthad both osteoarthritis and rheumatoidarthritis, and all participants experi-enced back and knee joint pain. Waterexercise can help improve all theseproblems and has been proven to allevi-ate pain and increase physical wellbeing in osteoarthritis22 and rheumatoidarthritis.23 It is hard to tell if the waterexercises did indeed alleviate the symp-toms of PD, or increased the strengthand range of motion in the joints ofparticipants with arthritis, although thefact that dynamic balance improvednoticeably seems to point to improve-ment in PD specific impairments.

As not many studies have been doneinvolving water exercise therapy and it’seffects on individuals with PD, notmuch literature exists for comparisonpurposes. The study involving

WaterArt Fitness International Inc27shows the positive effects of water exer-cise. Results from this study supportresults found in the WaterArt study.Muscular strength, endurance, gait andbalance all improved with this study.Flexibility was the only dimension notto improve from exercise in the water.In general, support for the assumptionwater exercise can improve physicalfunctioning for individuals with neuro-muscular disorders is increasing.Previous studies22,23 have outlined thebenefits of water exercise on joint disor-ders, stroke recovery and other physicalimpairments. This pilot study hasshown moderate exercise performed inwater over a 6 week period providesphysical and psychological benefits tothose with PD. Future studies involv-ing water exercise and PD shouldinclude a larger sample to justify thepreliminary results of this pilot study.

With the ageing of the baby-boomers,PD will become more prevalent, as PDis an age related disease. It is importantto take into consideration that effects ofsome forms of neuromuscular disorders

can be improved with exercise.Participating in an exercise programwith resulting improved physical func-tioning may reduce the amount of med-ication needed by the person with PD.Improved physical functioning mayallow the PD sufferer to remain inde-pendent for a longer period of time.The last two points would result inconsiderable savings in health carecosts. To substantiate the preliminaryfindings of the currently availableresearch, more funding is needed forresearch into rehabilitation, for design-ing specific exercises for conditionspeculiar to PD and for developing bestpractices. Hopefully this study willserve as a stepping-stone for futureresearch into water exercise programsfor sufferers with PD. u

Ed. Note: All forms referred to are available from the authors.

Baun, M. (2007). Fantastic WaterWorkouts. Champaign, IL:Human Kinetics. 240 pp. paper.ISBN 978-0-7360-6808-6.This book provides water exerciserswith an easy to follow duige toimproving fitness and physique.Contents include more than 90 photo-graph-guided water exercises and 25step-by-step workouts addressing arange of fitness objectives and interestgroups. Suitable for older adults, preg-nant women, people in physical reha-bilitation, and people with specialhealth considerations.

Grosse, S. (2007). WaterLearning. Champaign, IL: HumanKinetics. 190 pp, Paper $20.ISBN: 0736067663.Reinforce academic learning, applymulti-sensory techniques to therapeuticpractice, enhance perceptual-motordevelopment, fitness, and social interac-tion all through these fun water activi-ties. Use poly equipment, noodles, aqua

steps, wonderboards, and a variety ofreadily available home items to stimu-late creativity in the pool, as well astherapy setting or classroom. Over 100photos, an activity index, and assess-ment protocols make implementation ofwater learning easy.

Sova, R. (2007). Water FitnessAfter 40. Port Washington, WI:DSL. Paper, 208 pp. $23.95. ISBN1-889959-30-8. Looking for a safe and enjoyable wayto stay healthy and fit and slow theeffects of aging? In Water Fitness After40 Sova, explains how you can usewater exercise to stay healthy, active,and independent throughout your life.Learn a safe and effective way to exer-cise that will help you live a longer,more energetic and independent life.With 68 illustrations of water exercis-es, as well as goal charts and exerciselogs that you can use over and over,you can create a program tailor-madefor you or your clients. Part I intro-

duces the benefits of water exercise.Part II, includes exercises — 23 warm-up exercises, 30 calorie-burners, 9 ton-ing and strengthening activities, and17 cool-down exercises. You’ll evenfind 11 post-rehabilitation activities.Part III shows you how to create yourown program, as well as make modifi-cations for specific medical conditions.Goal charts create a path to personalfitness, and exercise logs assist in doc-umenting progress. Part IV features 69illustrations of the exercises from PartII, alphabetized for easy reference. The Appendix provides the names,addressees, and phone numbers of 36agencies and organizations that canhelp get you exercising in the pool.Available through www.aqua_gear.comor the Aquatic Exercise Association(888-AEA-WAVE or www.aeawave.com).

Additional information can be found on the Home Page of AEA’s website atwww.aeawave.com, click on Fit ProNews/Articles. u

zxx Feature Column: New for Your Library


All references and authors forthis article can be found on theHome Page of AEA’s website at

www.aeawave.com,click on Fit Pro News/Articles.

Topics Include: (Partial List)Intro to Aquatic Therapy and RehabATRI Rheumatology CertificationAi Chi Balance & Trunk StabilizationArthritis & RheumatologyBack RehabBad Ragaz Ring MethodBalance and Gait TrainingBalance Progressions for Orthopedic

Rehab – Fusions and Amputees

Chronic Neck PainClosed Chain Functional ProgrammingFunctional Therapeutic Training - ADLsInteractive Posture I & IILumbar Stabilization –

Burdenko MethodLumbar Stabilization for Spinal FusionsManual Techniques I & IIOrthopedics

PediatricsPNFRisk Awareness/Safety Training Cert.The Safe WayShoulder StabilizationSoft Tissue Injury RehabilitationTrunk StabilizationWatsu®

Intro to Aquatic Therap and Rehab 8 Credits / Full-Day Course Highly Recommended for those New to Aquatic Therapy! “Intro” is an entertaining and informative workshop for those health professionals who would like to expand skills into aquatic therapy andrehab. Aquatic therapy and rehabilitation is a growing market and pro-vides an excellent service to clients. As a health professional, here’s theopportunity to enhance your career with the most current essential infor-mation you need to get started. Experiment with the basic concepts ofAi Chi, Aquatic Feldenkrais®, Bad Ragaz, Pilates, PNF, Halliwick, theBurdenko Method, BackHab, Ai Chi Ne, Unpredictable CommandTechnique, and Watsu® in the pool, and analyze modifications and precautions, indications and contraindications of each aquatic protocolwith each client need.

Risk Awareness & Safety Training Certification8 Credits / Full-Day Course Highly Recommended for anyone involved in Aquatic Therapy! Preventing hazardous situations around and near the aquatic therapy environment will be a major focus of this course. Other components include standards of safety care, emergency responseplans, supervision, and techniques for responding to emergencieswithin a medical/therapeutic facility. Gain a safety perspective onwater temperature, principles and properties of water, use of equipment, and patient problems as they pertain to the therapeuticenvironment.

ATRI Rheumatology Certification8 Credits / Full-Day Course The ATRI Rheumatology Certification acknowledges your skills and edu-cation by providing advanced learning for rheumatological, autoimmuneand arthritis conditions. Gain better success with challenging conditionslike FMS, TKR, THR, etc. Know why you are doing the exercises (whyan exercise should or should not be performed) and plan for functionalcarry-overs to land activities. Create safe progressions with clients with-out causing flare-ups.

ATRI Certification OnlineThe Aquatic Therapy & Rehab Institute (ATRI) announces an onlineoption for the Aquatic Therapy Certification Exam. The online exam willbe a benefit to practitioners who have limited travel options. AnneMiller, Executive Director of ATRI, says, “Many educational institutionsare offering online education and degrees. ATRI is following that trendso certification can be attained more conveniently for people with hecticlifestyles.” Practitioners will have three hours to complete the 125 multi-ple choice and matching questions. For more information call 866-go2-ATRI (462-2874) or go to www.atri.org. For those who still want to takethe exam in person, the dates/locations are as follows:Thursday, August 9 – Palm Springs – La Quinta Resort & Club

(La Quinta, CA) – 1:30-5:00 pmSunday, September 9 – Washington, DC – Sheraton Premiere

(Vienna, VA) – 1:30-5:00 pmSunday, November 18 – Chicago, IL – Westin O’Hare

(Rosemont, IL) – 1:30-5:00 pm

Featured Courses

Register for ATRI Courses Anytime Online at www.atri.org ORCall Toll Free – 866-go2-ATRI (462-2874) • Fax ATRI – 561-828-8150

Mail ATRI – 13297 Temple Blvd, West Palm Beach, FL 33412

2007 Aquatic Therapy EducationThe Aquatic Therapy & Rehab Institute is proud to present several

opportunities for your continuing education experience:

2007 Specialty Institutes November 15-18 • Chicago, IL • Westin O’Hare

2007 Professional Development Days Saturday, October 6 • Tucson, AZ • Edith Ball Adaptive Recreation CenterSaturday, October 13 • Weston, WV • William R. Sharpe, Jr. HospitalSaturday, October 20 • Houston, TX • Texas Sports Medicine Center

2008 Aquatic Therapy Education 16th Aquatic Therapy Symposium • June 30-July 3Sanibel Harbour Resort & Spa • Fort Myers, FL

2008 Specialty Institutes February 21-24 • Washington, DC • Hyatt Fair Lakes (Fairfax, VA)April 10-13 • Chicago, IL • Westin O’Hare (Rosemont, IL)October 30-November 2 • Washington, DC • Hyatt Fair Lakes (Fairfax, VA)November 20-23 • Chicago, IL • Westin O’Hare (Rosemont, IL)

More information at www.atri.org or 866-go2-atri (462-2874)

An Aquatic Exercise Association Publication • October 2007• Volume 4 • Issue 2

Abstracts

Resisted training response in the water(Water Force) for professional futsal(soccer indoors) players.

The effect of water exercise on selectedaspects of overall health on afibromyalgia population.

Behavior of heart rate, at a constantspeed, in different positions of aquaticcycling in young overweight adults.

1 AEA Aquatic Fitness Research Journal • October 2007 • Volume 4 • Issue 2

An Aquatic Exercise AssociationPublicationOctober 2007 • Volume 4 Issue 2

Published by the Aquatic Exercise AssociationPO Box 1609Nokomis, FL 34275Phone: 941.486.8600Fax: 941.486.8820Toll-Free: 1.888.AEA.WaveWebsite: www.aeawave.comEmail: [email protected]

AEA Aquatic Fitness ResearchJournal StaffManaging Editor:

June M. Lindle Chewning, MA [email protected]

Peer Review Committee:Kimberly Huff, MS- chairpersonPaula Krist, PhDJodi Frank, PhDJudith E. Powers, MSMaria Sykorova-Pritz, MS

Please send all inquiries to theManaging Editor.

Aquatic Exercise AssociationResearch Council

Jodi Frank, PhDJack Wasserman, PhDPaula Krist, PhDJune Lindle Chewning, MAKimberly Huff, MSPaulo Poli De Figueiredo, MSFlavia Yazigi, MSMaria Sykorova- Pritz, MS

The AEA Aquatic Fitness Research Journalis a peer-reviewed journal. The journalserves the aquatic fitness professional’spersonal and professional interestsregarding research developments andpertinent information in the aquaticfitness industry. It is intended to stim-ulate, support, and disseminateresearch in the aquatic fitness industry,as well as educational and researchinstitutions.

The AEA Aquatic Fitness Research Journalmay not be reproduced without writtenpermission from the managing editor.

Opinions of contributing authors donot necessarily reflect the opinions ofthe Aquatic Exercise Association.

AbstractsA404 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2The effects of a 24-week deep wateraerobic training program on bone density.

A405 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Effects of an aquatic strength training program on certain cardiovascular risk factors inearly-postmenopausal women.

A406 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Effect of three months detraining on enduranceand maximum isometric force in elderly subjects.

ArticlesResisted training response in the water (Water Force) . . . . . . . . . . . . . . . . . . 3for professional futsal (soccer indoors) players.Fabrício Madureira, Mestre; Faculdade de Educação Física de Santos- FEFIS- UNIMES Santos-SPHenrique França, Especialista, Rodrigo Vilarinho, Especialista; Antônio Michel Aboarrage Jr., Mestre; Dilmar Pinto Guedes Jr, Doutorando

The effect of water exercise on selected aspects . . . . . . . . . . . . . . . . . . . . . . . 6of overall health on a fibromyalgia population.Maria Sykorova-Pritz M.S.

Behavior of heart rate, at a constant speed, . . . . . . . . . . . . . . . . . . . . . . . . . 13in different positions of aquatic cycling inyoung overweight adults.Ana Gouveia, Roxana Macedo Brasil, Ana Cristina Lopes Y. Glória Barreto, Andréa Cristiane Ferreira, Grace Barros de Sá

Table of Contents

October 2007 • Volume 4 • Issue 2 • AEA Aquatic Fitness Research Journal 2

A404 The effects of a 24-week deepwater aerobic training programon bone density.

E.Piotrowska-Calka,B.Wajszczyk2J.Charzewska3

Dept. of Swimming and Life Saving,Academy of Physical Education,Marymoncka 34, 01-813 Warszawa,Poland2National Food and Nutrition Institute,Epidemiology and Norms Department,Powsiska 61/63, 02-903 Warsaw, Poland3Dept. of Anthropology, Academy ofPhysical Education, National Food andNutrition Institute, Epidemiology andNorms Department

OBJECTIVE: The purpose of this studywas to determine the influence of pro-longed deep water aerobic training onbone mineral density (BMD). The fol-lowing questions were formulated:1.To what extent will deep water

aerobics have influence on bone

mineral density?2.Do any changes occur in the women

exercising with aqua aerobics in com-parison to the women not involved in any physical exercises?

PARTICIPANTS: Two groups ofwomen, between the ages of 30-62 par-ticipated in this research. Additionallythe groups were divided: beforemenopause (A2=6; 41.3±8,1yr; B2=10:42.2±4,5yr) and postmenopausal(A1=10; 54.6±4,5 yr; B1=9; 55.1±4,9yr).

METHODS: Group “A” participated ina 24-week deep water training program,exercising twice a week for 45 minutes.Control group B was asked to providenormal daily activity and not engage inany physical exercises. Subjects ingroup A were tested before and after the24-week program and compared withgroup B. Forearm bone mineral densityin the non-dominant arm was examinedusing OSTEOPLAN+ p-DXA in the mid distal and ultra distal section.Information on dietary intake was

obtained by three-day food records (twoworkdays and one weekend day).

RESULTS: The mean values of BMD inboth groups of postmenopausal women(exercisers and control group) werecontained in the range of changes rec-ognized as the progressive physiologicalprocess. The study showed in bothgroups many risk factors for osteoporo-sis. The most important of them wassmall in the relation to norms for con-sumption of calcium, magnesium, zinc,copper and vitamin D (except exercis-ing postmenopausal women - A1group) and excessive consumption ofprotein, phosphorus and sodium. The main irregularities are: insufficientintake of calcium, magnesium, zinc,copper and vitamin D (except groupA1) and excess in relation to RDA ofsafe level intake of protein, phosphorusand sodium.

KEY WORDS: Deep water aerobictraining-bone mineral density- nutritional intake-women. u

Abstracts

A405Effects of an aquatic strengthtraining program on certaincardiovascular risk factors inearly-postmenopausal women.

Juan C. Colado1, Pedro Saucedo2,Victor Tella1, Fernando Naclerio3,Iván Chulvi1, Jose Abellan2

1University of Valencia (Spain), 2CatholicUniversity of Murcia (Spain), 3EuropeanUniversity of Madrid (Spain)Supported by PMAFI-PI-01/1C/04 fromCatholic University of Murcia (Spain).

Despite it being known that local mus-cular endurance training has a positiveinfluence on the prevention of variousphysiological parameters associatedwith certain cardiovascular risk factorsamong early-postmenopausal women,there are still few scientific studies thathave shown the influence of said activi-ties when carried out in the aquaticmedium.

PURPOSE: To identify the effects of a

periodized aquatic program for strengthtraining (PAPST) on certain cardiovas-cular factors of early-postmenopausalwomen.

METHODS: 40 sedentary women vol-unteers without medical contraindica-tions were chosen: Seventeen (54.73 ±1.98 yrs) subjects trained in the aquaticmedium and twenty three (52.90 ± 1.85yrs) were the control group (CG). Theaquatic exercise group (AEG) trainedfor 24 weeks with a periodized programfor local muscular endurance based onOMNI-RES and with devices thatincreased drag force, carrying out ener-getic movements at all times and usingthe material that best allowed each sub-ject to adapt to the prescribed intensity.The program was: (a) 1st and 2ndmonth: 8 full-body exercises (F-B E), 2sets, 20 repetitions, 30 seconds restinterval (RI); (b) 3rd month: 8 F-B E, 3sets, 20 repetitions, 30 seconds RI; (c)4th and 5th month: 10 F-B E, 3 sets, 20repetitions, no RI; (d) 6th month: 8 F-BE using the pre-exhaustion method, 15repetitions, 30 seconds RI. They did not

change their eating habits.Cardiovascular risk factors wereassessed using some pre-post tests.

RESULTS: The PAPST reduces the riskof cardiovascular disease in the AEG vs.CG, respectively: Systolic BloodPressure (mm Hg) -9.14, p≤0.01, vs. -5.1, p>0.05. Diastolic Blood Pressure(mm Hg) -6.81, p<0.01, vs. +0.8,p>0.05. Total cholesterol (mg/dL) -6.2,p>0.05, vs. +19.2, p<0.05. Cholesterol-low density lipoprotein (mg/dL) +0.28,p>0.05, vs. +17.09, p<0.05. Basalglycemia (mg/dL) +0.04, p>0.05, vs.+6.74, p<0.05. Apolipoprotein B(mg/dL) -8.21, p≤0.05, vs. +3.92,p>0.05. Triglycerides (mg/dL) -7.65,p<0.01, vs. +2.11, p>0.05. Waistperimeter (cm) -3.667, p<0.01, vs.+2.35, p<0.05. Total fat mass (kg) -2.942, p≤0.01, vs. -0.611, p>0.05.

CONCLUSION: The PAPST is seen tobe effective in reducing cardiovascularrisk factors during the critical early-post menopause period. u


A406Effect of three months detrain-ing on endurance and maximumisometric force in elderly subjects. Author Block: Flávia G. Yázigi, Paulo A SArmada-da-Silva. Faculty of HumanKinetics, Oeiras, Portugal. Email: [email protected]

Compared to what is known about theeffect of exercise programs onendurance and strength capacities inthe elderly, the effect of detraining ismuch less documented.

PURPOSE: The purpose of this studywas to evaluate the effect of 3 monthsof discontinuation of participation in anexercise program in elders on generalendurance and maximum strength ofthe lower limbs.

METHODS: A total of 21 elderly sub-jects agreed to participate in this study.The subjects (12 females, age 72.5±4.9and 9 males, age 70.4±7.7 yrs) were

participants of a community exerciseprogram, composed of 1-hour sessionstwice a week designed to improveendurance, muscle strength and resist-ance, balance and coordination.Subjects were tested just before the 3-month summer holidays (BSH) andimmediately before resuming the exer-cise program after the summer holidays(ASH). Endurance was assessed by thesix-minute walk test (6MWT). Maximallower limb isometric force (MF) andmaximal rate of force development(RFD) were measured on the right sideduring static leg-press against a forceplatform. Total physical activity wasassessed by applying the Portugueseversion of the International PhysicalActivity Questionnaire (IPAQ). Resultsof BSH and ASH were compared bypaired t-tests. Relationships betweenvariables were explored by linear corre-lation.

RESULTS: MF and the outcome of the6MWT were significantly correlated

(p<0,000 and p<0.05 at BSH and ASH,respectively). The 6MWT resultsdeclined by around 6.5%, decreasingfrom 658.5±81.6m at BSH to615.9±9.0m at ASH (p<0.05) whereasbody mass and total daily physicalactivity declined by around 2.5 kg(p<0.05) and 879±755 METS(p<0.000), respectively. No differencesin MF and RFD existed between BSHand ASH.

CONCLUSIONS: A three month inter-ruption of physical exercise significant-ly decreases endurance. The decrease inbody mass registered after the 3-monthholiday might indicate loss of leanmass, but this change was not accompa-nied by decreased lower limb musclestrength. This study indicates thatendurance and walking ability are lostat higher rates with detraining than iso-metric muscle force generation capacityin elderly subjects. u

With the changes in the rules in futsalover the last decade, components suchas maximum strength, strength resist-ance and explosive strength havebecome pivotal skills in a player’s per-formance. With that principle as a start-ing a point, we analyzed the effects ofresisted training in the liquid environ-ment, particularly the Water Force(WF) program, on futsal professionalplayers. The study was performed withathletes of the Santos Team, with expe-rience of more than 10 years in thesport. Motor skills tests, as describedby Giannichi (1998), were used in thepre and post-tests as comparativeparameters. The program lasted 4months, with a 3 day per week sched-ule and 50 minutes for each session.The results of the study showed thatthe WF program can boost the increase

of the physical skills inherent to thegame, being thus a resource to corrobo-rate with specific futsal training.

Keywords: Futsal; Strength; Water aerobics.

Introduction: Over the last decade, futsal has undergone a number of evo-lutions in its technical, tactical andphysical aspects resulting from thechanges in the game’s rules. The newaspect of the game mainly modified thedeterminant physical characteristics foran athlete’s good performance. In thematches proposed by the InternationalFederation of Futsal (FIFUSA), thegame was considered to be slower; theofficial ball was heavier, of smaller cir-cumference and difficult conduction,causing the tactical standard to be slow-

er. In the 90s, after FIFUSA joinedforces with FIFA, those characteristicswere modified in order to make thegame more dynamic and attractive. Oneof the major changes happened withthe main instrument of the game, theball, which became bigger, with a sixty-four centimeter circumference, andlighter, with in the maximum weight offour hundred and thirty grams.According to Santos (1998) the changesin the ball allow it to be faster, whichrequires a better domain and controlfrom the athlete. The higher pace stan-dard for the matches required the pro-fessionals to focus on the physical con-dition of the players. According toWeineck (1998), for a good perform-ance during the game, the athleteshould give priority to the physical fac-tors of performance, leading us to

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Resisted training response in the water (Water Force) for professional futsal (soccer indoors) players.

Fabrício Madureira, Mestre; Faculdade de Educação Física de Santos- FEFIS- UNIMES Santos-SP, [email protected] França, Especialista, Rodrigo Vilarinho, Especialista; Antônio Michel Aboarrage Jr., Mestre; Dilmar Pinto Guedes Jr, Doutorando

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believe in the importance of highlight-ing the training of the physical capacitydeterminants of a game. The higherpace during the matches caused thestructure of the physical training of theplayers to be modified, as opposed to ahigher cardiovascular condition thatwas emphasized in the seventies as thebest way to increase resistance for thegame. Thus, the development of mus-cular strength should be prioritizedduring specific training as proposed byShinkarenco (1997). For Guedes Jr.(2003), strength is the capacity to exer-cise muscular tension against a deter-mined resistance, being able to boostthe speed as it increases, boosting twofundamental specific characteristics forthe futsal athletes: reaction power andchanges of direction in speed. Thesefactors enable a better tactical and tech-nical use of the player. Therefore,training programs that favor strengthdevelopment and hypertrophy willbecome indispensable strategies for futsal today.

The liquid environment seems to be aunique environment for the develop-ment of strength, due to the water’sresistance to the movements such as inwater aerobics. When trying to propela segment in fluid, an individual experi-ences a force known as drag(Maglischo, 2003). The nature of thisforce is explained by the physical char-acteristics of the water, such as theinternal pressure, density, and viscosity.The reaction of the water to bodymovement appears as: a) forces of per-pendicular pressure to its frontal area;and b) forces of friction acting alongthe body surface (Vorontsov &Rumyantsev, 2004). Thus, mechanicalwork performed by the water aerobicspractitioner is aimed to overcomehydrodynamic drag. This resistancecan be divided in two categories: pas-sive and active (Kolmogorov &Duplisheva, 1992). The magnitude ofthe reaction of the first results of thevortex produced behind the segmentbeing propelled (when we propel ourleg forward, the vortex producedbehind it pulls the segment backwards)may be influenced by the speed of dis-placement of the segment; by thestream of the water (laminate or turbu-lent); friction of the fluid with the skin(Sharp) and depth of immersion(Vorontsov & Rumyantsev, 2004). Theactive drag, on its turn, occurs when

the water aerobics practitioner movesmasses of water with his body seg-ments; therefore, this drag is considereda function of the movements, as well asthe anthropometry of the practitioner.Since it is an environment of great plas-ticity regarding the interaction withother organisms, one of the most fan-tastic characteristics of the water is thatit is unlimited when it comes to pro-ducing resistance loads. This meansthat as the practitioner gets stronger,the counter-resistance produced by thewater to this organism gets proportion-ally bigger, and what is extraordinary isthat this fact occurs automatically andin a specific way for each individual.

Based on the assumptions previouslydiscussed, professors of the SantosMetropolitan University – PhysicalEducation College, created a programof resisted training in the liquid envi-ronment called Water Force (WF). Theresults of the first studies of this pro-gram seemed quite promising, with uni-versity youths (Guedes Jr., et al. 2003;Vilarinho, et al, 2004; Rock et al, 2004).The facts found in these works causedus to ask the following question: if theprogram proved to be efficient withuniversity youths, what would be the

responses with professional futsal ath-letes? Thus, we tried to elaborate localexercises applied to the specificity ofthe motor gestures performed duringthe games, aiming to boost the determi-nant capacities of a match: maximumstrength, strength resistance, and explo-sive strength.

Equipment and Methods: 16 male athletes, with an average age between18 and 25 years, with average heightsof 1.77±0.06 meters and weight71.240±6.56 kg took part in this study.All of the individuals were professionalfutsal players from the Santos teamwith more than 10 years of practiceexperience. A point that must bestressed is that this group of playershad already trained for six monthsbefore the strength work in the liquidenvironment began, aimed at the sec-ond semester of the season. Before col-lecting the data, the athletes underwenta week of training tests in which theinformation about the procedures wasadministered. Each player performedthe tests experimentally, under the pro-fessor’s supervision in order to pointpossible errors in the performance ofthe procedures. The week of evaluationwas performed right after the experi-

Table 1. Description and comparison of the Total Body Weight (TBW),Height (H), Fat Percentage (FP) and Thin Mass (TM) between thepre-training, intermediate training and post-training periods.

Pre Inter PostTBW (kg) 69.73 (7.57) 71.07 (6.68) 71.24 (6.56)

[65.59; 73.87] [67.42; 74.72] [67.66; 74.83]H (cm) 176.18 (3.97) 176.36 (4.23) 176.55 (4.08)

[174.01; 178.35] [174.05; 178.67] [174.31; 178.78]FP(%) 14.67 (1.96) 14.34 (1.73) 11.80 (1.26)

[13.60; 15.74]a [13.40; 15.29]b [11.11; 12.49]TM (kg) 59.40 (5.42) 60.82 (5.02) 62.80 (5.45)

[56.43; 62.35]c [58.07; 63.57]d [59.83; 65.79]

The data is displayed in an average (standard deviation) format [confidenceinterval 90%]. a = significant difference related to post training for p =0.001. b = significant difference related to post training for p = 0.0001. c = significant difference related to post training for p = 0.035. d = significant difference related to post training for p = 0.005.

The results related to the neuromuscular tests (See Table 2) show that theplayers had positive modifications for all the tested variables: ABD (rep),APU (rep), MDLP (kg), FL (cm). These variables are extremely important forthe maintenance of the condition of the game, preventing injuries andstress by early fatigue.


mental testing week, with the followinganalyses: total body weight (TBW);height (H); fat percentage (FP); thinmass (TM); anaerobic power (ANAP),aerobic power (AEP); flexibility (FL);agility (AP); maximum dynamic leg

press (MDLP); abdominals (ABD); armpush ups (APU); and stand long jump(SLJ). All of the tests administered inthe week of evaluation are describedby Giannichi (1998).

Program Description: The athletes participated in training sessions of 50minutes each, three times per week.Exercise sets were performed for thefollowing muscle groups: chest anddorsal muscles through horizontaladduction and abduction of the shoul-der, front and back thigh muscles byflexing and extending the knee, bicepsand triceps brachii with vertical flexionand extension of the elbow, thighadductors and abductors through hipabduction and adduction. Three sets of 12, 14 and 16 repetitions were per-formed for each muscle group, with a45-second recovery interval betweensets. Between the muscle groupchanges, there was a 1 minute intervalof active recovery (stationary running).

All the athletes were instructed to usemaximum contractions during theseries. In order to better quantify thetraining loads, hints for amplitude andperformance acceleration were routinelypresented. During the training of themuscle groups chosen for the sets, thelower limb exercises approximated theexecution and use of, as specific as pos-sible, motor gestures used during thefutsal match. The objective was thepossible transference of strength gainfor the specific gestures involved in thegame, movement and changes in direc-tion. After three months of training,the athletes were submitted to re-evalu-ation aimed at analyzing the responseimposed by the training, observingpoints that might have possibly helpedin maintenance of the game condition.

Statistical Handling: After anexploratory analysis of the data and fur-ther corroboration of the normality ofthe characteristics evaluated, the aver-age (standard deviation) and the confi-dence interval were calculated, with aconfidence coefficient in 90% for thedescription of the studied sample. Theanalysis of variation for repeated meas-ures was applied to assess the statisticalsignificance of the effect of the trainingused. Whenever necessary, a post-hocLSD was used along with theBonferroni correction for multiple com-parisons in order to determine at whichpoints of the training the changes tookplace. The statistical significance levelwas established in 0.05 for all the statis-tical tests.

Table 2. Description and comparison of the set of abdominals(ABD) and arm push ups (APU), the maximum dynamic leg pressweight (MDLP) and flexibility (FL) between the pre-training,intermediate training and post-training periods.

Pre Inter PostABD (rep) 40.45 (5.72) 45.82 (8.95) 52.55 (11.49)

[37.33; 43.58] [40.93; 50.71] [46.27; 58.83]a

APU (rep) 20.09 (9.44) 32.45 (9.63) 34.18 (7.05)[14.93; 25.25] [27.19; 37.72]b [30.33; 38.04]c

MDLP (kg) 230.00 (21.33) 270.00 (23.13) 307.27 (26.49)[218.34; 241.66] [257.36; 282.64]c [292.80; 321.75]c, d

FL (cm) 28.36 (5.14) 32,82 (6.40) 34.36 (6.53)[25.55; 31.17] [29.32; 36.32]e [30.79; 37.93]f

The data is displayed in an average (standard deviation) format [confidence interval 90%] a = significant difference related to pre- trainingfor p = 0.015. b = significant difference related to pre- training for p = 0.002. c = significant difference related to pre- training for p = 0.0001.d = significant difference related to intermediate for p = 0.0001. e = signifi-cant difference related to pre- training for p = 0.023. f = significant differ-ence related to pre- training for p = 0.008.

The variables related to specificity of the game, such as SLJ (cm), AG (s),ANAP (s), AEP (m), showed positive alterations affirming that the WaterForce program was efficient enough to boost the performance of the inher-ent skills of the game (See Table 3).

Table 3. Description and comparison of standing long jump (SLJ),agility (AG), anaerobic power (ANAP) and aerobic power (AEP)between pre-training, intermediate training and post-trainingperiods.

Pre Inter PostSLJ (cm) 240.00 (19.07) 246.91 (17.58) 256.18 (17.76)

[229.58; 250.42] [237.30; 256.51] [246.48; 265.89]AG (s) 12.19 (0.70) 11.22 (0.42) 10.79 (0.28)

[11.81; 12.57] [10.99; 11.45]a [10.64; 10.95]b, c

ANAP (s) 7.01 (0.75) 6.47 (0.21) 6.38 (0.22)[6.60; 7.42] [6.35; 6.58] [6.26; 6.50]d

AEP (m) 2817.27 (238.14) 2905.45 (134.80) 2988.64 (176.89)[2687.13; 2947.41] [2831.79; 2979.12] [2891.97; 3085.30]e

The data is displayed in an average (standard deviation) format [confidenceinterval 90%]. a = significant difference related to pre- training for p =0.020. b = significant difference related to intermediate for p = 0.007. c = significant difference related to pre- training for p = 0.0001. d = signif-icant difference related to pre- training for p = 0.042. e = significant differ-ence related to pre-training for p = 0.003.

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Results: The anthropometry data (See Table 1) show that the Water Forceprogram was efficient for the reductionof (FP%) and an increase of musclemass, variables that are extremelyimportant for that game consideringthat predominant movement in thegame is intermittent (Turibio, 2005)requiring the athlete to be lighter inorder to boost speed and strength.

Conclusion: Training in the liquid envi-ronment has been largely used with thepurpose of helping the post-exerciserecovery process for players. In thisstudy, we were able to observe that thisenvironment can also be presented as aviable alternative to combine with thetraining of futsal players, enabling theimprovement of motor capacities inher-ent to the game, as well as positivealterations in body composition. Thus,water aerobics, specifically the WaterForce program, can be seen as anotherefficient training alternative for highlyskilled athletes. u

Bibliographical References:Ferreira, R,L. Futsal e a iniciação. Rio de Janeiro:

Sprint,1998. FIilho J, L,S. Manual de futsal. Rio de Janeiro: Sprint,

1998; Giannichi, R,S. Avaliação e prescrição de atividade físi-

ca. São Paulo: Shape, 2º edição, 1998. GuedesJr., D. P. Musculação: estética e saúde feminina.

São Paulo: Phorte, 2003Guedes Jr, D. P.; Rocha, A.; Guerardi, F.; Madureira, F.

Treinamento de Força no Meio Líquido. FIEP Bulletin, v.73, p.86, 2003

Kolmogorov, S. & Duplisheva, A. Active drag, useful mechanical power output and hydrodynamic force coefficient in different swimming strokes at maximal velocity. Journal of Biomechanics. v.25, p.311-18, 1992.

Maglischo, E.W. Swimming Fastest. Ed Human Kinetics, 2003

Ostonjic,S,M; Seasonal alterations in body composition and sprint performance fo elite soccer players. Jornal of Exercise Physioloy. v.6, v.3, 2003.

Rocha, A.; Guedes Jr, D. P.; Dubas, J.; Madureira, F. Comparação do treinamento abdominal dentro e fora da água. FIEP BULETIN. v. 74, p. 323-326, 2004.

Sharp, R. L., & Costill, D. L. Shaving a little time. Swimming Technique. v.1, p. 10-13, 1989.

Shikarenko,I; Golomasov,S. Futebol: preparação física.São Paulo: Shape, 1997.

Toussaint, H. M., & BEEK, P.J. Biomechanics of competi-tive front crawl swimming. Sports Medicine. v.13, n.1, p.8-24, 1992.

Vilarinho,R.; Rocha, A.; Gherardi, F.; Bulo, F.; Barboza, M.; Dubas, J.; Madureira, F.; Guedes Jr, D. P. Modific-ações morfológicas decorrentes do treinamento de força no meio líquido, Revista Científica JOPEF, v.1, n.1, p.27, 2004.

Vorontsov, A. R. & Rumyantsev, V. A. Forças resistivas na natação. In Zatsiorsky, V. M. (Ed.) Biomecânica do esporte: performance do desempenho e prevenção de lesão. Rio de Janeiro: Guanabara Koogan, 2004.

Weineck,J. Treinamento Ideal, 9º edição; Rio de Janeiro: Manole, 2000.

The effect of water exercise on selectedaspects of overall health on a fibromyalgiapopulation.

Abstract:This study had two aims: to confirm that subjects with Fibromyalgia Syndrome(FMS) have higher stress levels than healthy subjects; and to determine the effect ofa water exercise class on the overall health of a study group diagnosed withFibromyalgia Syndrome (FMS).

To achieve the first aim, 18 FMS subjects were compared with 18 healthy subjectsusing a questionnaire that measures life stress. To achieve the second aim, a sepa-rate study group of six women with FMS were treated at a community health-fitnessagency, using an aquatic group exercise program (Aquajoy) twice per week for 14weeks. Integrated within the group treatment were techniques such as somatic exer-cises, passive stretches, progressive muscular relaxation, visualization, biofeedbackand cranial-sacrum relief. The program was designated specifically to treat thephysiological and psychological symptoms of FMS. Proper use of the water environ-ment included both physiological elements (muscle relaxation, passive stretches,body positioning and biomechanics of movement) and psychological elements(body-mind connection using biofeedback, socializing and developing trust, security,and self-esteem).

To achieve the first aim, the Stress Analysis Questionnaire was used. To achieve thesecond aim, observations of overall health were collected based on self-reports fromthe participants using both quantitative and qualitative information. Quantitativemeasures observed participants’ perception of how they were feeling on severalaspects of health including sleep patterns, soreness, tiredness, overall pain, stiffness,energy and strength, mood and loneliness, and overall well-being. These were meas-ured on a six-point Likert-Type scale with a score of 5 meaning “feeling very good”and a score of 0 indicating “feeling very horrible”. Qualitative information includedresponse to three questions: 1) What did Aquajoy do for you, how did it make youfeel? 2) Why did you participate in Aquajoy? 3) Any other comments?

Data analysis for the first aim compared the 18 FMS subjects with the 18 healthysubjects – a between group comparison. Data analysis for the second aim was per-formed by comparing scores for each subject on different aspects of overall healthduring the course of the program – a within group program.

Results demonstrated: 1) subjects with FMS had higher life stress than healthy sub-jects during the between group comparisons; 2) FMS subjects who were treated withAquajoy maintained their level of pain, improved slightly in stiffness and soreness,and improved substantially in energy and strength, mood and loneliness and overallhealth during the within group comparisons.

Evidence from this study suggests that aquatic exercise can aid the FMS populationby improving overall health. This may contribute to increasing quality of life andimproving the ability to cope with the disease.

Maria Sykorova-Pritz M.S. [email protected]

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Background:TERMS: The term, FibromyalgiaSyndrome (FMS), is a combination ofthe Latin roots:

FIBRO-connective tissue fiber; MY-muscle; AL-pain; GIA-condition of;

SYNDROME-a group of signs andsymptoms that occur together whichcharacterize a particular abnormality.

Although the term, Fibromyalgia (FM),has appeared in literature for more than100 years, the disease is still a mysteryand the medical profession has called itmany different names: chronic rheuma-tism, myalgia, pressure point syndromeand fibrosis.

In 1987, The American MedicalAssociation (AMA) recognized FMS asa true illness and major cause of dis-ability. In 1993, the World HealthOrganization (WHO) established FMSas an officially recognized syndrome.Currently, FMS is described as a specif-ic, chronic, non-degenerative, non-pro-gressive, non-inflammatory, truly sys-temic painful state of muscles andfibrous tissue that causes widespreadfatigue, sleep disorders, stiffness, anxi-ety and chronic aching. FMS is referredto as a “syndrome” because it is a set ofsigns and symptoms that occurs togeth-er consistently (Mau, 1987). This doesnot mean that FMS is any less seriousor potentially disabling than an ordi-nary “disease”.

CAUSES: The causes of FMS areunknown, but current FMS researchershave uncovered a number of clues as towhat triggers FMS or causes a predispo-sition. A physical stressor, such as theflu, can lead to certain hormonal orchemical changes that promote painand disturb sleep. Emotional stress islinked to increasing rates of psychiatricdisorders like anxiety, depression anddistress which can trigger dysfunctionin the hypothalamus, pituitary andadrenal glands if the stress is persistent(McBeth, 2001).

In 2001, researchers discovered thatpeople with both the FMS and chronicfatigue syndrome (CFS) were more like-ly to have experienced physical, emo-

tional, or psychological abuse. Thesefindings support the belief that chronicstress plays a pivotal role in the devel-opment of FMS and CFS (VanHoundenhove, 2001).

SYMPTOMS: The basic symptoms ofFMS occur in approximately 2-4% ofpeople in industrialized societies(Littlejohn, 2001), of which 90% aremiddle-aged females slightly youngerthan 50 years old. The number of chil-dren with FMS is growing. It is referredto as “Juvenile Primary FibromyalgiaSyndrome” (JPFMS) and was recog-nized in the mid-eighties. In children,JPFMS affects more boys than girls(Yunus, 2001).

DIAGNOSIS: In diagnosing FMS, labo-ratory testing reveals very little, ornothing, and instead rules out other ill-nesses. This can be termed diagnosingFMS by “a diagnosis of exclusion”(Remington, 2001). After ruling outother illnesses, a diagnosis of FMS byhealth professionals is based on takinga careful personal and family historyand pinpointing tender areas in specificlocations of muscle throughout thebody called “tender points.” The crite-ria for FMS classification determined bythe American College of Rheumatologyin 1990 state that for the patient to bediagnosed as having the condition, shefirst must have “a history of widespreadpain”. The pain must be long termand ongoing, and it must be present inall four quadrants of the body lasting atleast three months. Pain must be pres-ent in at least 11 of 18 tender pointsthat are painful to the touch.

Goals and Hypotheses of Study:Goals of the study: The goals of thisstudy were to: 1) to establish that astudy population with FMS have higherlife stress than healthy subjects; and 2)to test a comprehensive water exerciseprogram called Aquajoy in a group setting.

Hypotheses of the study: 1) Subjectswho have FMS will have higher levelsof stress than healthy subjects as measured by the Stress AnalysisQuestionnaire; 2) Subjects who haveFMS will have improved health after

treatment with Aquajoy as measured by observing several aspects of overallhealth such as sleep, pain, stiffness,soreness, energy/strength, tiredness and mood/loneliness. .Materials and Methods of the Study:Subjects: 1) 36 subjects were recruitedto participate in the Stress AnalysisQuestionnaire: 18 subjects had FMS asdiagnosed by a physician, and 18 werehealthy; 2) a separate group of sixfemale subjects diagnosed with FMS bya physician were recruited to participatein the Aquajoy treatment.

Materials: To explore the first hypothe-sis, we used the Stress AnalysisQuestionnaire, which was speciallydesigned to assist with a stress statusevaluation. It measures three specificaspects of stress: level, causes and associations with personality types (A,B, Ab, and Ba). It is a self-administeredquestionnaire that requires minimaltraining to take and probes stress expe-riences during the previous year. Thevarious items across the level and caus-es of stress were weighted differentlyand then added to create a final score.A score of more than 100 is often asso-ciated with being more prone to devel-oping illness. Data were then compiledto represent the FMS subjects andhealthy subjects as separate groups for comparison.

To explore the second hypothesis, awater exercise treatment program wasdeveloped and executed as a groupprogram. The program was embeddedin concepts that supported aquaticexercise as therapeutic physiologicallyand psychologically. During thecourse of this study, we monitored anddocumented (by a self-rating method)the effect of the water exercise pro-gram by observing the level of severityof FMS symptoms across several spe-cific dimensions: sleeping habits, pain,stiffness, soreness, energy/ strength,tiredness, mood/ loneliness. Thesedimensions were selected for measure-ment because they are typical symp-toms of FMS and they represent broadaspects of overall health. Each dimen-sion was measured using a 6-pointLikert scale that was adapted from avisual analogue that measures painaccording the following progression:


0 = feeling very horrible; 1 = feelingvery poor; 2 = feeling poor; 3 = fellingfair; 4 = feeling good; 5 = feeling verygood (See Figure 1). In addition toquantifying these dimensions of FMSand the response to treatment, we alsoasked the subjects to answer threeopen ended questions that probed howthey subjectively responded to thetreatment (See Figure 1). Subjectswere treated twice weekly over 14weeks, and they were instructed to fillout the data collection sheet (SeeFigure 1).

First, we evaluated the stress score bycomparison of the two groups organ-ized by age, participants diagnosed withFMS (FSMP) and a healthy populationnot diagnosed with Fibromyalgia syndrome (HP)) and a stress score. All results were statistically proven withthe same method we evaluated the“Relationship of Stress Score toPersonality Type”.

Second, to see if the Aquajoy waterexercise class was beneficial for theimprovement of overall health to thesubjects of our study group, we evalu-ated progress of “Average Overall WellBeing/ Overall Heath”; “AverageOverall Sleep Patterns”; “AverageOverall Pain”; “Average OverallStiffness”; “Average Overall Soreness”;“Average Overall Tiredness”; and“Average Overall Mood/ Loneliness.”We compared a week-to-week rating of“Percentage of Improvement- OverallWell-Being/ Overall Health” for thefirst five weeks.

Results of Study andDiscussion:Results of the Stress AnalysisQuestionnaire were organized in fourtables (Table #1 and Table #2 for resultsof subjects with FMS (FSMP); Table #3and Table #4 for results of healthysubjects (HP). We documented

name (initials), age, gender (M- male,F- female), stress level number and typeof personality.

Results of Stress Analysis QuestionnaireSurvey:• The FMSP study group is under

greater stress than the study group (HP) with a healthy lifestyle and without FMS (statistically proven, See Chart #1).

• Cause of stress for the FMSP group is

health related. (statistically proven)• Having FMS is not affected by per-

sonality type, anyone may have it(See Chart #2).

• Based on our study group of 36 par-ticipants stress caused by finances is related to stress caused by family.

• Stress caused by health is related to stress caused by lifestyle changes.

• Females are more likely to have health related stress than males.

• Females are more likely to have stress caused by lifestyle change than males.

The self-rated results of the “AquajoyParticipant’s Feeling Journal” weregathered in Table #6. We established a weekly average feeling number for

Figure #1 – AQUAJOY PARTICIPANT’S FEELING JOURNAL

DATE: ________________________________________ WEEK: ______________

I, ____________________, give my consent to be part of this research project,knowing that this information will be compiled and results will be printed.

Name: ________________________________________ Age: _______________Female: _________ Male: _________

What days you participate in AQUAJOY?

Mon Tue Wed Thu Fri Sat SunAquajoy

How do you feel in the following areas: (5) feeling very good; (4) feelinggood; (3) feeling fair; (2) feeling poor; (1) feeling very poor; (0) feeling veryhorrible.

Total# Mon Tue Wed Thu Fri Sat SunSleepHabitsPainStiffnessSorenessEnergy/StrengthTirednessMood/LonelinessTotal #

Question 1 – What did Aquajoy do for you, how did it make you feel? ________________________________________________________________________________

Question 2 - Why do you participate in Aquajoy?____________________________________________________________________________________________________

Question 3 – Do you have any additional comments? __________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________


the group in each symptom for all 14 weeks. The weekly feeling averagenumber of the group based on symp-toms of FMS is calculated by the addi-tion of the weekly feeling average num-ber based on the symptoms of each participant, divided by the number ofparticipants.

Sleep disorders are probably one of themost devastating symptoms associatedwith FMS. Sleep disruptions interferewith the production of growth hormoneneeded for healthy muscles and soft tissue. The combined effects of exercise(stimulates production of T-cells,growth hormone and increased produc-tion of endorphins) will help withsleep. Restful sleep is one of the keys to restoring health and returning to anactive lifestyle. Average Overall SleepPatterns of the study group did improveover the course of 14 weeks.

Pain is a logical side effect of perpetualmuscle contraction and insufficient,inadequate sleep. The participants ofAquajoy did not improve during thecourse of this study, but maintained

Chart #2 – Relationships of Stressto Personality Type

Chart #3 – Average OverallWell–Being/Overall Health

Chart #4 – Average OverallSleep Patterns

(The dark grey line is the beginningwell-being number, and the light greyline is the weekly updated averagewell-being number).

Table #1 – Results of Stress Analysis Questionnaire of FMSPInitial Age Gender Stress Score Personality

Type1. SVT 27 F 147 B2. DC 60 F 98 A3. DA 42 F 307 A4. BSU 37 F 147 A5. SFR 58 F 94 B with A

tendency6. BH 51 F 155 B with A

tendency7. SD 45 M 109 Strong A8. ENB 40 F 311 A9. BP 62 F 146 A with B

on way10. IM 54 F 165 B11. JLF 72 F 14 B12. CP 35 F 302 B with A

tendency13. RR 42 F 101 B14. BF 27 F 170 B15. MP 42 F 97 B16. BMC 54 F 318 B with A

tendency17. LC 40 F 206 B18. AF 67 F 78 B

Chart #1 – Average stress scores

Chart #5 – Average Overall Pain


Table #3 – Results of Stress Analysis Questionnaire of HP (healthy subjects, never diagnosed with Fibromyalgia Syndrome)Initial Age Gender Stress Score Personality

Type1. JH 26 F 61 B2. HH 26 M 136 B with A

tendency3. JF 30 F 100 A with B

tendency4. JW 19 F 180 B5. DC 20 M 44 B6. EB 24 M 98 A with B

on way7. JC 32 M 26 B with A

tendency8. PR 40 F 54 B9. MB 23 F 68 A with B

tendency10. MF 42 F 28 B11. AMC 23 F 47 A with B

tendency12. SM 26 F 72 B13. AK 23 M 120 A with B

tendency14. AO 22 F 217 B15. SL 42 M 47 B16. DSB 20 F 209 A with B

tendency17. SKR 18 F 116 B with A

tendency18. SM 22 M 56 B

Table #4 – Average stress score of HPAge Range # of Participants Average

& Gender stress score Total #18 – 29 13 (8F & 5M) 109.5430- 39 2 F 63 215.5449 - 49 3 (2F & 1M) 43

Table #2 – Average stress score of FMSPAge Range # of Participants Average

& Gender stress score Total #18 – 29 2 F 158.530 – 39 2 F 224.540 – 49 6 (5F & 1M) 188.5 875.550 – 59 4 F 18360 – 69 3 F 10770 - 79 1 F 14

their level of average overall pain (SeeChart #6). FMS is a chronic pain condi-tion and maintained levels of pain withincreasing physical activity means thatthe particular method used in this studyis a great advocate for pain control.

Stiffness is one of the major symptomsof FMS. When remaining in one posi-tion for any length of time, the bodystiffens in that position due to inflexi-ble myofascia, producing a low rangeof motion and affecting flexibility. Byexercising in water the participantsincreased blood flow to muscle tissue.This enhances the transport of oxygenand nutrients to the muscle fiber, help-ing restore and maintain the health ofmuscle tissue. When muscles, liga-ments and tendons become moreresilient, it means that stiffness will bereduced. We documented a slightimprovement of Average OverallStiffness of the study group, which alsoimproved overall muscle and jointfunction.

Soreness is a type of pain, created bytoxins and all the wastes from cellularprocessing, which must pass throughthe connective tissue to reach thelymph and blood vessels. When themyofascia sticks together, neurotrans-mitters can’t work properly. Musclesreceive insufficient fuel and oxygen.This can result in a sensation of sore-ness. Participants in the study slightlyimproved and maintained AverageOverall Soreness, which shows that the

Chart #6 – Average OverallStiffness

Aquajoy water exercise program servedas a good pain management program.This allowed better freedom of move-ment. Soreness is a major symptom for the FMS population.

The level of Average Overall Energy/Strength indicates the efficiency of theoverall physical and emotional responseof the participants’ bodies to the Aquajoyprogram. We can also see how well thebody and mind did connect due to thisexercise program. Average OverallEnergy/ Strength in the group didimprove greatly during the length of thestudy. Improvement of Average OverallEnergy/Strength was gradual as in everychronic pain and stress managementtreatment. We can also see a pattern of“Chronic Pain Cycle” and “Flare Ups”(the period of improvement is followedwith a period of slight regression ormaintenance). Generally the aspect ofOverall Well- Being/ Overall Health and in our case Average OverallEnergy/Strength, is improved.Tiredness is the body’s warning sign


Table #5 – Relationship of Stress Score to Personality TypeFibromyalgia Population (FMSP)Personality A Ab Ba BType# of 5 1 4 8participantsAverage 194 146 217.25 122.25Stress Score

Regular Healthy Population (HP)Personality A Ab Ba BType# of 0 5 4 9participantsAverage - 119 81.25 84.33Stress Score

Table #6 – Weekly feeling average number of study group basedon symptoms of FMSSymptoms:Week Sleeping Pain Stiffness Soreness Energy/ Tiredness Mood/

Habits Strength Loneliness

#1 23 26.2 19.5 21.2 21.4 25 25.6#2 23.8 19.2 22.3 21.2 21.6 21.25 28.2#3 24.6 19.2 20.5 21.4 20.6 20.8 27.6#4 27 20 18 21 21.5 21.25 22.25#5 26.5 22.5 20.75 23 23.7 28 28.25#6 21.5 19.2 20.25 22.5 25 22.5 28.5#7 28.5 20 22.5 18.5 22 21.5 30#8 28.5 27 28.75 24.5 25.5 26 33#9 27 22 23 23.5 24.5 23.5 30.5#10 35 19 18 26 26 27 35#11 35 20 19 23 24 24 35#12 32 24 21 21 27 26 35#13 31 26 33 24 28 28 35#14 34 20 21 21 28 28 35

Average level of Well-Being for the week is the addition of the weekly feel-ing average number of the study group based on symptoms of FMS.

Table #7 – Weekly average level of Well-Being/Overall Health of study group based on symptoms of FMS. Week #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14

Average 161.9 157.55 154.7 151 172.7 159.45 163 193.25 174 186 180 186 205 187level ofWell-Being

After 14 weeks of rating themselves, the participants of the Aquajoy Water Exercise Program did improve in AverageOverall Well-Being. See Chart #3 showing the results of the Aquajoy class for a FMSP.

Chart #7 – Average OverallSoreness

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that the organism is overwhelmed andneeds to be rested. It is also a sign ofhow efficiently the body can function.Having energy for endurance of the bodyand mind, without feeling tired, enablesyou to live a more functional and fulllife. Average Overall Tiredness of thestudy group did improve very gradually,which is an encouraging result.

Depression, isolation and feelings ofworthlessness are common feelingsamong the FMS population. A substan-tial improvement in Average OverallMood/Loneliness was noted in thestudy group. The results indicate thatthe Aquajoy program had a positiveeffect on the emotional health of thegroup, which is a significant part ofsuccess in fighting FMS. Aquajoy classes

also served as a support group reducingisolation that can lead to the feeling ofloneliness.

Discussion:Overall health and well-being is facili-tated by a balance of physiological,social, emotional, spiritual, and intellec-tual health. Using a self-rated methodof evaluation of six participants and by evaluating progression in severalaspects of overall health during the 14-week study, we did see an improvementin overall health. Exercise class wasdesigned not only as an activity of thephysical body, but also as an activity tobenefit emotions, intellect and spirit.The aspects of overall health screenedfor 1) emotional health by mood/ lone-liness which showed positive improve-ment; 2) physical health by pain, sore-ness, and stiffness which were main-tained and slightly improved; 3) body/mind connection by tiredness and ener-gy/strength levels which showed posi-tive improvements.

By stimulating the peripheral nervoussystem in the Aquajoy class using float-ing on water as a meditation/deep relax-ation technique and by focusing an sensations of the body (biofeedback)enhanced by hydrostatic pressure, participants did stimulate and influencethe function of the central nervous system and quality of the sensory-motor learning process.

It is recognized that physiologicalsymptoms can arise from psychologicalcauses such as stress. This is very char-acteristic for FMS patients and for ourgroup participants as well. This is asomatic viewpoint; namely that every-thing we experience in our lives is alearned adaptive response and can beunlearned. By adapting this behavior inlife it affected our subjects to feel lesstired and have more energy/ strength.This is exemplified in Participant # 3,J.E.M., who learned how to listen tosignals of her body (biofeedback) andultimately performed better.

Pain and continued injury can beavoided by reinforcing a participant’sgood postural alignment with threefunctions that water provides – assistance, resistance and support.Participants can exercise with little orno pain, perhaps for the first time inyears. This builds hope and breaks isolation/loneliness providing the moti-vation to continue water activity.Aquajoy did serve as a natural, gentleand safe tool to manage chronic pain,relive stress and restore freedom ofmovement.

Conclusion:Making a lifelong commitment to anexercise program is an important aspectof reduced medicinal treatment. Lowimpact or non impact exercises andactivities have been advocated toimprove symptoms and well-being,making an aquatic exercise environ-ment an excellent medium for reducingsymptoms of FMS. The emotional/mindcomponent of the class is to stabilizeemotions, stimulate the central nervoussystem and improve social participationand relationships. The socio-psycho-logical aspects of the class are to buildpositive behavioral changes in very gen-tle ways and to create positive expecta-tions, trust, respect and feelings of nor-malcy in an abnormal situation. Beingwith others who are suffering andworking together to find relief dispelsthe feeling of isolation. The physical/body component of the class has thegoal to improve general fitness,strength, endurance, increase circula-tion, oxygen consumption and preventinjuries by improving the biomechanicsof movement. Improving posture for


Chart #8 – Average OverallEnergy/Strength

Chart #9 – Average OverallTiredness

Chart #10 – Average OverallMood/Loneliness


Behavior of heart rate, at a constant speed, in different positions ofaquatic cycling in young overweight adults.

Introduction: Prospective studies show that accumu-lation of fat and physical ineptness arerisk factors for the development of sev-eral diseases (Machado; Sichieri, 2002,Maranhao Neto et al, 2005). The rise ofobesity is causing an increased need tocontrol and to measure some variablesduring the performance of exercises, forinstance the hemodynamic variables.

Recently, aquatic activities have beenincreasingly used for rehabilitation,therapies and general physical readiness(Fujishima; Shimizu, 2002). Amongaquatic activities, aquatic cycling is analternative for cardio-respiratory condi-tioning, applicable to all age groups anddifferent fitness levels (Ferreira et al,2005).

The particular physical properties ofwater such as flotation, density, viscosityand hydrostatic pressure among others,promote the individual's corporal phys-iologic adaptations when totally or par-tially immersed (AEA, 2006; Park et al1999), turning the aquatic environmentinto a pleasant atmosphere (Caromanoet al, 2003).

Ana Gouveia, Roxana Macedo Brasil, Ana Cristina Lopes Y. Glória Barreto, Andréa Cristiane Ferreira, Grace Barros de Sá

[email protected]

zxx Article

relief of pain involves a conscious con-trol over learned habits. This happensby applying the powerful neurologicalrule: less muscular effort produces moresensory motor learning and physicalimprovement.

The mind/ body connection componentworks via somatic exercises. The wateris slowing down the movement increas-ing reaction time. This enhances aware-ness for use of the senses (sight, hearing,balance and touch). Then, in conjunc-tion with movement, the sensory motorlearning process improves, which in turnimproves the biomechanics of move-ment. In this study we focused onscreening several aspects of overallhealth and improvement over 14 weeks,attending an Aquajoy class everyMonday and Thursday.

From results based on self-screening, weestablished that the structure andmethod of teaching the Aquajoy waterclass benefited the FMS populationthrough the method of relieving symp-toms. All participants in the study didimprove overall health. After 14 weeks,the participants experienced better sleep-ing habits, less pain, stiffness and sore-ness, as well as reporting moreenergy/strength. They reported feelingless tired and reported feeling more ful-filled at an emotional level of health.

The researchers believe this study indi-cates an improvement in the quality ofparticipant’s life as well as the capacityto cope with this health condition.

For more information contact Maria Sykorova Pritz M.S.; at [email protected] u

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In spite of some authors investigatingthe hemodynamic variations in theaquatic environment (Park et al, 1999;Perk et al, 1996; Masumoto et al,2007), few studies investigate the alter-ations of cardiovascular responses indifferent cycling positions possible inwater. Thus, the objective of this studywas to analyze the behavior of heartrate (HR) in different positions of thebody during aquatic cycling, at constantspeed, in overweight individuals.

Material and MethodsSample: The study was conducted with eightvolunteers, four males and four females,with ages ranging from twenty to thirty-three years, with Corporal MassIndexes (IMC) varying from 28.4 to29.6 Kg/m2. As criterion for inclusionin the study, the participants shouldhave a healthy appearance, with a mini-mum of three months of practice in thisspecific modality and characterized asoverweight according to the classifica-tion of the American College of SportsMedicine (ACSM, 2000).

Procedures for data collection:An analysis was performed and theRPar-q questionnaire was administered.Corporal mass and stature were meas-ured with the aid of a digital scale pro-vided with a stadiometer, with accuracyof 0.05 kg (Filizola, Brazil).

The positions of aquatic cycling in thestudy were seated or standing.Regarding the hands the following posi-tions were used: 1 (centralized, withrelaxed shoulders and elbows), 2(hands in line with the shoulders, atthe width of the handlebar), 3 (stand-ing up, with hands at the extremities ofthe handlebar), and 4 (simulating ahorizontal bicycle, the trunk will bebehind the saddle) (Torreao et al, 2003;Brasil; Dimasi, 2005).

The subjects remained immersed to theshoulder line (at a temperature of29ºC) for five minutes to check theirheart rate at rest. In sequence, an aquat-ic cycling protocol adapted by Torreãoet al (2003) was used, consisting ofpedaling for three minutes at a constantspeed of 144 RPM, controlled by ametronome (Wittne, Germany) in thefour positions. Heart rate was meas-ured with a heart rate monitor (Polar A-1, Finland) at each minute, for allpositions. Between the positions, thesubjects were submitted to a 5-minuterest in partial immersion.

Data Handling:The definition of the dataset profilerequired an estimate of the location’s cen-tral tendency measures. Initially, the vari-ables were evaluated in relation to theirproximity to the Normal Distribution,using the Shapiro-Wilk Test (Costa Neto,

2002). The confirmation of the normalityallowed evaluations of differences of thevariable HR in each one of the positionsduring the three minutes of the test (HRx position x minutes), and to analyzethese differences by applying a VarianceAnalysis Test of 3 x 4 (3 minutes x 4positions) with measures repeated for the2nd factor. The Bonferroni post hoc testwas used to identify possible differencesbetween the variables. The study admit-ted a significance level (α = 0.05), there-fore H0 rejection occurred with the valueof p < α.

Results:Figure 1 shows the results of the aver-age HR values in each one of the min-utes analyzed. It is speculated thathydrostatic pressure and the tendencyfor body flotation, caused by the waterproperties, facilitates blood displace-ment to the central area of the bodywhen submitted to immersion. Thismay increase systolic volume andreduce HR (Becker; Cole, 2000; Graef;Kruel, 2006). However, the hypothesisthat the positions with smaller immer-sion gradient would induce a larger CFresponse was confirmed.

In minute one, the higher average values of the variable HR were found in position three (155.13 bpm). In positions one (128.75 bpm) and two(130.37 bpm) the average values wereclose. Position four presented averagevalues of 137 bpm.

In minute two, position three demon-strated the highest average values(165.75 bpm). Position two showedvalues of 142.38 bpm for HR, while inposition four the subjects presentedaverage values of 146.00 bpm. In posi-tion one the smallest measures wererecorded (139.25 bpm).

The heart rates measured in minutethree were 145.25; 149.63; 172.00 and147.25 respectively for positions 1, 2, 3and 4.

The statistical test showed significantdifferences in minute one of positionthree for positions one and two (p =0.00). In minute two, differences were


Figure #1 – Relation between HR x Position x Time


verified between position three andposition one (p = 0.01) and two (p =0.04). In minute three differences werefound between position three and posi-tions one (p = 0.01) and four (p =0.03). These results corroborate, inpart, the findings by Torreão et al.(2003) who found significant differ-ences in position three in all minutes inrelation to the remaining positionswhen applying the same protocol. Itcan be suggested that the increasedhydrostatic pressure in the remainingpositions caused a redistribution of theblood volume in the central area of thebody when compared to position three.Possibly, immersion generates an incre-ment of the ejection volume; conse-quently, the pressure receivers of theaortic arch and carotid are stimulatedand cause a reflex reduction in HR(Avellini et al., 1983; Figueredo et al.,2005).

Torreão et al. (2003) also observed thatin position one there was no differencein relation to position four. HR in posi-tion two, diverging from the presentstudy, showed significant values in rela-tion to positions one and four. The factthat the group of volunteers in thisexperiment comprised overweight sub-jects may justify the similarity of posi-

tion four in relation to positions oneand two, because the accumulation ofcorporal fat reduces corporal density,favoring flotation, in other words, hin-dering the maintenance of the body inpartial immersion (AEA, 2006) (SeeFigure 1).

Conclusion:The society we live in has many diverseproblems, among them the issue ofoverweight and obesity. Nutritionhabits, inactivity, genetic and hormonalproblems are some of the most commoncauses for the rise in total corporalweight in individuals.

When associating aquatic cycling tooverweight individuals, posture adjust-ments and adaptation of the intensity ofthe class sessions are required for bettertraining adequacy and safety of thepractitioners.

Activities in the pool attract a heteroge-neous clientele to workout in an enter-taining and pleasant way, including aperception of less effort if compared toexercises on land. Therefore it becomesimportant to have control over thecharacteristics of the aquatic space aswell as its different modalities and theirapplicability. u

References:1. Avellinni B.A; Shapiro, Y.; Pandolf, K.B. Cardiores-

piratory physical training in water and on land. Eur. Journal Applied Physiol. v.50, n.1, p. 255 – 263, 1983.

2. Aquatic Exercise Assocition. Aquatic Fitness Professional Manual. 5Th Edition. Nokomis, Flórida, 2006.

3. American College of Sports Medicine. Manual do ACSM para teste de Esforço e Prescrição de Exercício. 5ed. Rio de Janeiro: Revinter, 2000.

4. Becker,B.E.; Cole, A.J. Terapia aquática moderna. São Paulo; Manole, 2000.

5. Brasil, R.M.; Di Masi, F. Manual de Aquaspin, Rio de Janeiro; Sprint, 2005.

6. Caromano, F.A.; Themudo Filho, M.R.F.; Candeloro, J.M. Efeitos fisiológicos da imersão e do exercício na água, Fisiologia Brasil, v.4, n.1, p. 61 – 66, 2003.

7. Costa Neto, PLO. Estatística. São Paulo: Edgard Blücher, 2002.

8. Ferreira A; Brasil R; De Sa BG; Barreto AC; Santos MA; Vale R; Novaes J. Comparação das respostas hemodinâmicas entre o ciclismo indoor e aquático. Arquivos em Movimento, V.1, N.2, p. 29-38, 2005.

9. Fujishima K; Shimizu T. Body temperature, oxygen uptake and heart rate during walking in water and land at exercise intensity based on RPE in elderly men. Journal Physiological Anthropology. V.22, N.2, P.83-88, 2003.

10. Figueiredo PAP, Coerjents M, Kruel LFM. Behavior of heart rate during vertical immer-sion in water and practical application. Aquatic Fitness Research Journal,v.2,n.1,p.3-6, 2005.

11. Graef FI; Kruel LFM. Freqüência cardíaca e percepção subjetiva de esforço no meio aquático: diferenças em relação ao meio ter-restre e aplicações na prescrição de exercícios – uma revisão. Revista Brasileira Medicina do Esporte, v. 12, n. 4, p. 221 – 228, 2006.

12. Machado PAN; Sichieri R. Relação Cintura-quadril e dieta em Adultos. Rev Saúde Pública v.36, n.2, p.198-204, 2002.

13. Masumoto K; Takasugi S; Hotta N; Fujishima K; Iwamoto Y. A comparison of muscle activityand heart rate response during backward and forward walking on an underwater treadmill. Gait & Posture V.25, P. 222–228, 2007.

14. Maranhao Neto GA; Polito MD; Lira VA. Fidedignidade entre peso

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16. em indivíduos que procuram a prática supervisionada de exercícios. Rev Bras Med Esporte. V.11, N. 2 – Mar/Abr, 2005.

17. Park KS; Choi JK; Park YS. Cardiovascular regulation during water immersion. Journal of Physiological Anthropology and applied human science. V 18, N.6, p. 233-241. 1999.

18. Perk J; Perk L; Boden C. Cardiorespiratory adaptation of COPD patients to physical train-ing on land and in water. European Respiratory Journal, v. 9, p. 248 – 252, 1996.

19. Torreao R; Brasil RM; Novaes J. Comportamento da freqüência cardíaca em diferentes posições para uma mesma veloci-dade no Aquaspin. XXVI Simpósio Internacional de Ciências do Esporte, 2003.

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