Aquatic Therapy Journal Oct 2007 Vol 9

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Creating Optimal Healing Environments
WATSU for Children with
Severe and Profound Disabilities
Effects of Aquatic Physiotherapy
for Children with a Disability:
Views of Parents and Therapists
Water Exercise for Individuals
with Parkinsons Disease: A Pilot Study
WATSU for Children with
Severe and Profound Disabilities
Effects of Aquatic Physiotherapy
for Children with a Disability:
Water Exercise for Individuals
with Parkinsons Disease: A Pilot Study

The Aquatic Therapy Journal is
published biannually by the
Aquatic Therapy & Rehab
Institute, Inc. and the Aquatic
Exercise Association. The Aquatic
Therapy Journal articles are peer
reviewed to insure the highest
quality information.
ATRI prohibits discrimination on
the basis of race, color, religion,
creed, sex, age, marital status,
sexual orientation, national origin,
disability, or veteran status in the
treatment of participants in,
access to, or content of its pro-
grams and activities.
For permission to reprint for
academic course packets, please
send a written request to
info@aeawave.com.
Opinions of contributing authors
do not necessarily reflect the
opinions of AEA and ATRI.
2007 AEA/ATRI-Nokomis, Florida
Volume 9, Issue 2
Managing Editors: Sue Grosse
Ruth 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 how
in 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 of
aquatic therapy. Offering educational courses, ATRI provides opportunities to advance
the competencies, knowledge and skills of the aquatic therapist.
ATRI Mission Statement
The Aquatic Exercise Association is a not-for-profit educational organization dedicated to
the growth and development of the aquatic fitness industry and the public served.
AEA Mission Statement
Feature Articles
Creating Optimal Healing Environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Sheralee Beebe, HBOR
Redwood City, CA
WATSU for Children with Severe and Profound Disabilities . . . . . . . . . . . . . . . 9
Ann Wieser, PhD, NCLMBT#3150,
Aquatic Therapist and Rehabilitation Specialist, WATSU Practitioner
Gateway Education Center, Greensboro, NC
Effects of Aquatic Physiotherapy for Children with a Disability: . . . . . . . . . . . 17
Margarita Tsirios, BPhys, Senior Physiotherapist,
Novita Childrens Services, Regency Park, South Australia
Water Exercise for Individuals with Parkinsons Disease: A Pilot Study . . . . 22
Alexander M. Crizzle, MPH., PhD Candidate, University of Waterloo, Waterloo, ON, Canada
Ian J. Newhouse, PhD., Lakehead University, Thunder Bay, Ontario
Feature Columns
Are You Prepared? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Sue Skaros, BA, BS, PA-C, Medical College of Wisconsin, Milwaukee
Around and About the Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13, 21
Pool Problems: Therapy Pool Bathtub Ring . . . . . . . . . . . . . . . . . . . . . . . . 14
Alison Osinski, PhD
Aquatic Consulting Services, San Diego, CA
Interface: Aquatic Therapists Interact With . . . . . . . . . . . . . . . . . . . . . . . . 16
Editors and Publishers
Susan J. Grosse, MS
Aquatic Consulting & Education Resource Services, Milwaukee, WI
New for Your Library . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Others
From 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!
Thats what we will be doing.
Thank you for YOUR support. N
From the Editors
Hulls, V., Walker, L., & Powell, J.
(2006). Clinicians perceptions of
the benefits of aquatic therapy
for young children with autism:
a preliminary study. Phys Occup
Ther Pediatr. 26 (1-2),13-22.
The purpose of this study was to identi-
fy clinicians perceptions of benefits of
aquatic therapy for young children with
autism. Eighteen aquatic occupational
therapists treating young children with
autism responded to a survey. The
majority reported a substantial increase
in swim skills, attention, muscle
strength, balance, tolerating touch, ini-
tiating/maintaining eye contact, and
water safety. Given the impairments,
activity limitations, and participation
restrictions seen in children with
autism authors believe this information
could help narrow the field of likely
outcomes as a first step toward studies
of effectiveness of aquatic therapy for
children with autism.
Assis, M., Silva, L., Alves, A.,
Pessanha, A., Valim, V.,
Feldman, D., Neto, T., and
Natour, J. (2006). A randomized
controlled trial of deep water
running: clinical effectiveness
of aquatic exercise to treat
fibromyalgia. Arthritis Care and
Research. 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 with
fibromyalgia, ages 18-60, were ran-
domly assigned to either deep water
funning or land-based exercises.
Training was for 15 weeks at their
anaerobic threshold, following which a
variety of measurements taken and sta-
tistical analysis performed. Results
determined deep water running to be a
safe exercise shown to be as effective
as land-based exercise regarding pain.
However, deep water running has been
shown to bring more advantages relat-
ed to emotional aspects. Aerobic gain
was similar for both groups, regardless
of symptom improvement. Deep water
running could be studies as an exercise
option for patients with fibromyalgia
who have problems adapting to land-
based exercise or who have lower limb
limitations. N
TRR
Feature Column: Research Review
CEC Credit Available
Back issues of the Aquatic Therapy
Journal are available from the
Aquatic Exercise Association.
Issues published in 2006 and
2007 each contain two CEC
study articles. You can obtain
AEA/ATRIC approved credits for
completing a study assignment
related to these specially marked
articles. Contact the AEA at
aeawave.com. N
Ruth Sova, Editor Sue Grosse, Editor
Clients with chronic illness often find
their way to the aquatic medium.
Many individuals use water activity
and/or therapy as a long-term treat-
ment that allows them a greatly
improved quality of life. Yet the disease
remains. Is there more that can be
done, then, to treat the physical body?
Is it possible to empower clients in
discovering their own healer within? Is
there a lasting way to guide clients to
better long-term health and well-being,
despite limitations of time, and the
insuring body? Are we able to plant a
seed of new attitudes within the minds
of clients that helps them make a per-
sonal commitment to a journey in self-
exploration, improved awareness, and
a deeper level of healing? These ques-
tions form the basis for exploring how
aquatic staff teams can create optimal
healing environments (OHEs) for
clients.
Review of literature for this article has
included a group of over 50 published
papers in the Journal of Alternative and
Complimentary Medicine (Contact
author for complete list). Most of the
papers have been presented at the
Samueli Institute Symposium titled
Toward Optimal Healing Environ-
ments in Health Care. The Samueli
Institute believes an emphasis on heal-
ing is a key to the future medical man-
agement of chronic illness and estab-
lishment of sustainable approaches in
health care. The primary mission of
the Samueli Institute is to support
basic 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 an
OHE in specifically identified health
care settings.
1
Healing
In the context of this article, healing is
defined as the dynamic process of
recovery, repair, restoration, renewal
and transformation that increases
resilience, coherence and wholeness.
Healing is an emergent process of the
persons whole system: physical, men-
tal, social, spiritual and environmental.
Healing is a unique, personal and com-
munal process and an experience that
may, or may not, involve curing.
2
Healing is facilitated through develop-
ment of proper attitudes and intentions
within both the client and aquatic
provider. It includes the recipients use
of personal self-care practices, creating
healing relationships, applying the
knowledge of health promotion and
maintenance, as well as appropriate
integration of complementary and con-
ventional medicine practices.
2
An optimal healing environment (OHE)
is defined as one in which the social,
psychological, spiritual, physical, and
behavioral components of health care
are oriented toward support and stimu-
lation of healing and achievement of
wholeness.
3
According to the Samueli
institute, the major characteristics of an
optimal 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 and
Healing Intention
Better 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 of
how we create our every experience
based on how we think and act. Every
thought we think is creating our future
and our health. Our being unconscious
or innocent of how we create health or
dis-ease in our lives does not free us
from our responsibility of living and
coping with what we have created.
It is so easy to blame our stress on
some external source; however it is our
reaction to external stressors that cre-
ates the greatest personal suffering.
The mind state creates the body state.
Patients without knowledge of their
own powers for healing often expect
the medical system to be responsible for
their health. Developing conscious
awareness is all about taking responsi-
bility for our health and our personal
and powerful role in creation of illness
as well as wellness.
The point of power in creating illness
or well-being is always in the present
moment. Long term patterns of think-
ing and behavior that are motivated by
resentment, criticism, punishment,
resistance and guilt are the most dam-
aging to our health.
3
Releasing thought
and behavior patterns can dissolve
many 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 and
the stress that is around us or we can
be creators of positive change in our life
experiences and health. A preoccupation
with illness and its ill effects focuses

Sheralee Beebe, HBOR
Redwood City, CA
energy into more of what we dont
want. If we want health improvements
we must focus our thoughts and energy
on wellness, pursuing health improve-
ments as a positive focus vs. fighting
pain and symptoms of disease process-
es. If the mind focuses on wellness
instead of illness, outcomes are more
desirable.
The immune system functions better in
positive thought versus negative
thought. Kinesiology experiments per-
formed by David R Hawkins, M.D.
Ph.D. have exposed, for the first time,
the intimate connections between mind
and body, revealing that the mind
thinks with the body itself. Hawkinss
work has provided an avenue for the
exploration of the ways consciousness
reveals itself in the subtle mechanisms
behind the disease process.
4
Hawkins in his book Power vs. Force:
The Hidden Determinants of Human
Behavior reports the body has, in the
moment, the ability to record and react
to every thought or statement. The
body will be weakened or strengthened
by the stimulus or thought in the
moment. Those living with negative
language and environments will experi-
ence repetitive weakening of the human
spirit and immune system.
5
Positive psychology is very helpful in
the healing process. It is necessary to
convert negative emotions into the abil-
ity to express pro-social, positive emo-
tions, such as tolerance, forgiveness,
hope, altruism, and gratitude. Positive
psychology advocates have united to
study and build upon human strengths,
in contrast to the psychological and
medical communities where over-
whelming attention is given to human
weakness and illness.
6
Research,
although sporadic, is slowly emerging
to show these skills can be taught and
when measured, demonstrate benefit.
The effect of gratitude on psychological
and physical wellbeing was evaluated in
three studies.
7
Increased wellbeing and
positive mood states were strong find-
ings in the three studies. There is a
body of research showing that people
high 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 better
academic performance and find greater
meaning in difficult life events.
8
In a
study where hopefulness was used as an
intervention with depressed elderly
patients, it was found that participants
in the hope group showed significant
decreases in anxiety, hopelessness and
functional disability, as well as improve-
ment in social interaction.
9
Dr. Seligman and colleagues study the
use of cognitive methods to train peo-
ple to dispute pessimistic thinking, and
teach positive methods simple enough
to work for both adults and children.
This goal is development of strength,
not remediation of weakness. Their
research shows that optimism training
is successful, and once learned,
becomes self-reinforcing. People use
the skills they have been taught to help
themselves in life situations. Seligman
and colleagues have documented that
learned optimism cuts in half the future
incidence of depression and anxiety in
both children and adults.
10
Consider the emotional effects of these
opposing statements. Focus deeply on
the first statement in the pair. Then
clear your mind and do the same with
the second statement. Pay attention to
your body. Does anything change
your breath, a stirring or feeling, sensa-
tions in the body? Notice how thoughts
cause physical sensations and note
where you feel thoughts in the body, as
well as what you feel. The first state-
ment; is spoken by a person victimized
by his or her situation, the second
statement represents proactive and posi-
tive choice.
My life is a mess and I am out of
control. Vs. I am willing to let go
of the behaviors that create stress
in my life.
Nobody loves me and I feel alone
in life. Vs. I am in the process of
positive changes and building
healing relationships.
I hate my job and it is making me
sick. Vs. I am going to focus on the
good 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 is
chaotic. Vs. I will take action each
day to bring order and calm into
my life, I will ask for help when I
need it. I see a positive clutter free
life 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 of
each session. Encourage client initiated
positive affirmations throughout the
therapeutic process. Involve family
members is supporting positive
affirmations.
Developing Personal
Wholeness
What actions and practices might be
necessary for an aquatic health care
professional to create self-awareness,
personal wholeness, self-growth and
improved outward client awareness?
To create a healing environment, practi-
tioners should focus on practicing tech-
niques that foster a palpable healing
presence. That presence should be
based in compassion, love, and aware-
ness of interconnectivity.
11
Practitioners interested in creating a
healing aquatic environment are
encouraged to practice transformative
self-care behaviors that facilitate per-
sonal integration and the experience of
wholeness and wellbeing. The Healer
Within, authored by Roger Jahnke,
Doctor of Oriental Medicine, prescribes
traditional Chinese techniques to
release your bodys own medicine,
through movement, massage, medita-
tion and breathing exercises.
12
A core
thesis is that every healing effort and
intention starts within the health care
professional. Thus, an accepting, mind-
ful and warm-hearted relationship
with the self is primary to any healing
intention.
13
To the Western mind a therapist must
do some procedure or intervention to
heal a client. The healer principle is
about being, aside from doing. Being
completely present to our clients has a

significant healing effect; every healing
intention starts from a healthy attitude
towards the self. Healing starts by heal-
ing the healer.
14
One of the basic quali-
ties in a healing and holistic encounter
with a patient is unconditional accept-
ance and positive regard. But this can-
not be achieved without self-acceptance
and self-respect.
If present to a client we would not have
our head buried in note taking or
report reading when listening to their
concerns and questions. The present
therapist is listening to the client, mak-
ing eye contact and exhibiting compas-
sion. When present the healer gains
better insight, the client is listened too,
and feels a bond with and trust for the
healer. The client, feeling accepted and
having feelings of trust, will be more
likely to participate in the healing regi-
men prescribed, and communicate con-
cerns more effectively.
Cultivating Personal
Relationships
A good personal relationship between
practitioner and client is based on
development of listening and communi-
cation skills that foster trust and estab-
lish a bond. Further the practitioner has
compassion, empathy, and a desire to
serve, exhibiting altruistic behaviors
that cultivate social support and trust.
15
The aquatic health care professional
must stimulate an interest within the
client to become more self-aware. The
two develop a relationship in-order to
foster wholeness and personal growth
for the purpose of healing in general.
Empirically, health psychology
research literature indicates good
provider-patient communication leads
to better patient satisfaction with the
provider and improved adherence to
treatment,
16
but only sometimes to
better outcomes.
17
Patient expectan-
cies of treatment effectiveness and the
quality of the therapeutic alliance tend
to predict clinical improvement, with
outcomes mediated by patients contri-
bution to the alliance.
18
The thera-
pists use of every day language, rather
than technical medical language and a
more affective, rather than cognitive
style of communication, in both verbal
and nonverbal behavior, favor higher
patient satisfaction and better quality
of life.
19
The preference is for medical issues to
be discussed with affective quality
20
and unconditional positive regard.
21
At a biopsychosocial level, studies have
shown more effective communication
within the therapeutic relationship
includes skill at exhibiting empathy and
focused attention.
22
A major source of
suffering for people is the experience of
isolation, a sense of being cut off from
connection. In an empathic model of
care, the primary role of the caregiver is
to bring people back to healing connec-
tions where they begin to reconnect
with themselves and bring themselves
more fully into relationship with
others.
23
Practicing Healthy Lifestyles
Unhealthy lifestyle is the primary con-
tributor to the six leading causes of
death 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 adults
are overweight or obese, more then
60% do not get enough physical activi-
ty, 25% are completely inactive, and
only 23% eat recommended amounts of
fruits and vegetables. People with
healthier lifestyles live an average of 6
to 9 years longer postpone disability by
9 years and compress disability into
fewer years at the end of life.
24
Practicing Healthy Lifestyles requires
instruction and practice. Lifestyle
health behaviors that support self-heal-
ing are proper diet, exercise, leisure and
work balance, and addiction manage-
ment.
25
Health promotion and disease
prevention involves behavioral and
lifestyle activities targeted toward estab-
lishing habitual behaviors that support
well being, facilitate healing and pre-
vent or treat illness.
A healthy lifestyle also requires man-
agement of negative addictions such as
smoking, alcohol, drugs and violence,
and fostering positive habits such as,
relaxation methods, self-appreciation
and acceptance, establishment of sup-
portive social and health networks.
Studies have found that despite health
promotion in schools, medical centers
and the community, segments of our
population remain unaffected by
health education information. Studies
show that longer-term education and
contact with clients is beneficial,
26
which supports the continuum of care
model common in an aquatic healing
environment.
There are other aspects to healthy liv-
ing, according to Dr. Frederic Luskin,
in the Forgive for Good workshop and
class series Dr. Luskin,
27
(www.learning
toforgive.com), presents forgiveness-
training methodology validated through
six successful research studies conduct-
ed through the Stanford University
Forgiveness Projects. Prior to the cur-
rent surge of research interest, the
importance of practicing forgiveness
was extolled in both religious and psy-
chological traditions. Recently, research
of Dr. Luskin and others has confirmed
its virtues in the promotion of psycho-
logical, relationship and physical
health. Forgiveness has been shown to
reduce anger, hurt, depression and
stress and lead to greater feelings of
optimism, hope, compassion and self-
confidence, which are all factors in the
healing process.
28
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.
Applying Integrative or
Collaborative Medicine
Creating a healing environment
includes responsible application of inte-
grative medicine via the collaborative
application of conventional and com-
plementary practices in a manner sup-
portive of healing processes. The
United States has the most expensive
health care system in the world, but
people of America are not as healthy as
people in other countries who spend far
less on medical care, in-fact Americans
hold 26th place in world health.
29
The
key to improved medical outcomes is
focus on healing care, in contrast to
focus on curing disease. The aquatic
environment has long welcomed inclu-
siveness of disciplines, as the water
attracts every discipline, from doctors
to fitness professionals. Many different
techniques from many professions have
been integrated into our water prac-
tices, examples might include, but are
not limited to Watsu and other aquatic
massage techniques, meditation, and
guided 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 healing
is practiced can affect an OHE. This
may include characteristics of light,
music, architecture, and color, as well
as other elements. Qualities of a heal-
ing environment include trees, flow-
ers, and other outdoor environment
elements.
30
Seeking a safe shelter to heal is a natu-
ral tendency. Wild animals would find
healing from injury in natural hot
springs, for instance. A healing place
optimizes physical, mental emotional
and spiritual healing. Surround
patients with nature, music, and art to
create harmony.
Some healing places are spa like. Spa is
an acronym for Salus per aqua or
health through water. Spas are becom-
ing more medical, and medical facilities
are 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 support
and observe their family member in the
therapeutic process. Wide doors are
necessary for assisting the less ambula-
tory clients through without difficulty.
A home like environment where the
patient is treated like a guest, or a very
important person, facilitates creating an
OHE. Space for social engagement and
connecting with others adds an addi-
tional healing dimension. Reducing
unpleasant noises and smells, as well as
employing decorative variation rather
than sameness, is part of facility
change.
Having fresh air, a small garden area
outdoors, a warm place, and a place
where windows open all support heal-
ing. A quiet place to meditate is part of
an OHE, maybe with healing sounds
such as running water or chimes, along
with crystal bowls, and guided healing
meditations.
32
Assessment of the Optimal
Healing Environment
Characteristics of an optimal healing
environment involve empathy, compas-
sion, caring, love, reassurance, comfort,
warmth, trust, confidence, credibility,
honesty, courtesy, respect, harmony, chal-
lenge, and communication. Cultivating
these characteristics requires skills in lis-
tening and communication, and can be
fostered by engaging in social service,
and through family and community
activities. An optimal healing environ-
ment should incorporate training in
these characteristics and develop oppor-
tunities for such activities in educational
and group programs. Variables impor-
tant to consider when developing or
assessing a healing environment include
presence, 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 environ
ment 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 dcor, 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
)
Conclusion
Many qualities of the optimal healing
environment occur naturally within the
aquatic therapy environment. Water
has many therapeutic qualities; water is
beautiful in how it interacts with light,
creating dancing patterns of shadow
and light about the room. The sound of
gently running water is calming and
slows the heart rate. Water provides a
warm and tactile input, while taking
away weight and pain, encouraging
relaxation, which deepens the breath,
and freeing the body to gently move
with grace and ease. Aquatic practi-
tioners tend to develop relationships
with clients more quickly, perhaps due
to the warmth and closeness encour-
aged by the water and our dressed
down profession. Many aquatic profes-
sionals are drawn to the work from a
history of love of the water and the
inherent healing potential of the water.
To generalize, they are naturally caring
and passionate about their work. While
there are exceptions, of course, most
aquatic practitioners seek the water and
invest personal funds into their on
going education.
The aquatic environment lends itself
well to the continuum of care model, as
water is accessible within the medical
environment and within the communi-
ty. The practitioners within each service
level are more willing to work together
and refer to each other. Given longer
contact time with the clients, aquatic
practitioners are able to impart layers of
depth to the physical exercise by teach-
ing and modeling personal experience
with healing, mindfulness, awareness,
hopefulness, positive language in life
and in creating a vision around good
health goals.
Promoting healthful behaviors to
greater depth of personal empowerment
for patients may be a needed addition
within the common format for health
education, both within the community
resource network and in the health care
system. Health promotion has been
defined as the science and art of help-
ing people change their lifestyle to
move towards a state of optimal health.
Optimal health is the balance of physi-
cal, 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 prac-
tices. Supportive environments, when
fully observed, will probably have the
greatest impact on healing.
34
N
Author
Sheralee Beebe, Honors
Bachelor in Recreation,
is a Post-Rehab Aquatic
Specialist who has been
practicing since 1991. She has devel-
oped three full service aquatic rehab
programs in Canada and now in Palo
Alto, CA. Beebe is the co-author of the
ATRI Rheumatology Certification and
an aquatics veteran of many current
and non-current certifications. She has
been a presenter for ATRI for 10 years
and is owner of For Your Health In
Home and Aquatic Therapies. Contact
Beebe at sheraleebeebe@comcast.net.
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 as
described below. Send your completed assignment and the course fee to Aquatic Consulting & 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 of completion verification.
Course fees depend on CEC verification requested. Fees are non-refundable.
ICATRIC = $30 AEA = $20 ICATRIC and AEA = $45
AEA 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 cover
sheet including your name, mailing address, phone, e-mail address, and CEC article title. Then, begin another sheet of paper
and answer the following questions/complete the following applications. If answering a question, state the question prior to
supplying 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 article
can be found on the Home
Page of AEAs website at
www.aeawave.com,
click on Fit Pro News/Articles.
Fred is a fun guy, always sharing news of
his grandchildren, cheerful, sometimes a
bit confused about right and left, but easy
to work with and regular in attendance,
arriving on time today in spite of really
bad weather. He completes his activities
but seems a bit sluggish, which you
attribute to his having to shovel out his
car before coming to the pool. You feel
much the same way! As he leaves the
pool, you see him look around quite a bit,
prior to moving toward the stair/ramp
side. Then you notice he starts moving
away from the steps, rather than toward
them, but he catches his mistake and
turns back before you say anything.
When you next see Fred, he is walking
hesitatingly toward the deep end of the
pool. Strange, because the mens locker
room 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 safety
knowledge and experience.
Possibilities
a. You call out Hey Fred locker
room is that way and point in the
correct direction. Fred gives you a
half-hearted wave, turns and heads
on his way. You recognize something
isnt right, and watch Fred take a
few more steps. Yes, his gait isnt
what it usually is. He seems to be
dragging one foot. You climb out of
the water and activate your
Emergency Action Plan, asking your
in-water people to move to the side
of the pool. You approach Fred, say-
ing Fred, wait up a minute. I need
to check a few things for you. You
then perform a F.A.S.T. assessment.
b. You call out Hey Fred locker
on his way while you resume your
activities.
c. You call out Hey Fred locker
on his way while you resume your
activities. However, you recognize
something isnt right. Fred can usu-
ally find the locker room. You have
another individual leaving at the
same time and say to him, Can you
keep on eye on Fred for me? He
looks a bit confused today.
Were you prepared?
Possibility b Any change in behavior
as indicated by Freds apparent, albeit
brief, confusion, along with a change in
normal movement patterns should set
off warning bells in your mind. Anyone,
but especially our older clients, is at
risk for a neurological event such as a
stroke. Add to that his having to do sig-
nificant exertion with shoveling out his
car, and you have the potential for a
devastating injury. Time is of the
essence. Early intervention can limit
the extent of damage, but ignoring
Freds changes may have devastating
results. 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 are
the key to his having a chance for a
good outcome by recognizing the
changes you see and identifying them
as possible signs of a medical problem,
quickly evaluating him, and seeking
advanced medical intervention as soon
as possible. You were not prepared!
Possibility c You have recognized
something is wrong with Fred. That is a
start, but without rapid and appropriate
intervention, Fred is at risk for severe
neurological impairment and possibly
death. He is experiencing both a change
in behavior AND a change in his mobil-
ity. However, once you have recognized
a possible problem, you cannot delegate
your professional responsibility to a
patron. You know he has the known
risk factors of advanced age and recent
vigorous exertion (shoveling out his
car), plus the stress of driving in bad
weather conditions. All of these make
him a prime candidate for a stroke. You
are legally responsible. You have the
training and skills. You must continue
to evaluate and monitor Fred, quickly
obtaining advanced medical care as
needed. This is not something one of
your other clients should be doing for
Fred. This is your job. You were not
prepared!
Possibility a You recognize Freds
behavior and movement have changed.
You take appropriate action. Even as
you respond to Fred, recognizing he
may be having a serious health prob-
lem, you also have to provide proper
protection for your remaining clients by
activating your Emergency Action Plan
and having your in-water people move
to a safe position. You provide Fred
timely and appropriate assessment
using F.A.S.T.
1
By checking Freds face
(F) for asymmetry (you find one side
drooping), his arms (A) for parallel
movement (his right arm does not rise
as 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 now
know he needs timely (T) initiation of
carewith calling 9-1-1to provide
Fred with the best chance for a good
outcome. You were prepared!
Were you prepared? If not, now is the
time to take or update your safety train-
ing. Professionals in aquatic therapy
are prepared!
1
American Red Cross (2006). First
Aid/CPR/AED for the Workplace
Participants Manual. Yardley, PA:
Staywell. p. 48.
Content of Are You Prepared? is
designed to bring to the attention of
the reader situations and circumstances
requiring knowledge and expertise in
risk management, first aid, and safety.
Are You Prepared? Is not designed to
provide a legal opinion and/or docu-
ment specific first aid procedures
and/or treatment. Commentary in
Are You Prepared? is not a substitute
for training. N
Sue Skaros, BA, BS, PA-C, Medical College of Wisconsin, Milwaukee.
TRR
Feature Column: Are You Prepared?
WATSU, water shiatsu, uses floating

and a sequence of slow gentle continu-
ous movements, stretching and acupres-
sure to encourage relaxation, enhance
strength, and promote flexibility.
WATSU, developed by Harold Dull at
Harbin Hot Springs in the 1980s, is an
extension of his work with Zen Shiatsu.
The stretches of Zen Shiatsu release
blockages along the meridians or chan-
nels that carry life force; the application
of these stretches strengthens muscles,
and increases flexibility and range of
motion (Dull 1997a, Dull 1997b,
Morris 1997). Dull found that floating
the participant while doing stretches in
warm water enhanced the effect of the
stretches (Dull 1997a).
Working in warm water is effective
because pain generally decreases in
warm 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 being
stretched (Morris 1997). With a con-
tinuous flow of movement through a
sequence of positions, the person loses
the ability to anticipate the next move-
ment, which, in turn, decreases both
the fear of movement pain and the
resistance to movement (Dull 1997a).
From experience, I found WATSU ideal
for working with adults with disabili-
ties. The warm water and continuous
movement encouraged relaxation and
increased flexibility. I expected
WATSU would be equally beneficial for
children with disabilities, yet when I
first tried to use WATSU with the stu-
dents, they were very uncomfortable
and became even more anxious. As a
result, 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 around
three WATSU principles
Being with the person.
Not doing TO the person.
Safety.
WATSU Principles
The deep and profound relaxation
obtained from WATSU develops from
application of several principles that
construct the WATSU sequence. During
this work I chose to focus on three
principles, being with the person, not
doing to the person, and safety.
The first principle of WATSU is that of
being with the person, (Dull 1997a,
Dull 1997b). Being with the person
means making a deep connection with
the person. It requires a deep listening
with all senses, not only with eyes and
ears, to the persons response. It means
accepting the persons response and
adjusting our expectations and plans to
that response. By listening carefully
and following the response of the per-
son, we enhance the connection, pre-
vent any disruption of relaxation, and
strengthen the trust between the giver
and 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 provide
support for the person in the water, and
encourage and facilitate his or her move-
ment. We become aware of the response
of his or her body in the water, and we
adjust our movements to support and
extend his or her movement exploration
within his or her comfort zone. The
slow continuous flowing movements
ease pain and encourage relaxation
(Vargas, 2004).
Both of these principles work on control
issues for both the receiver and giver of a
WATSU. The person doing the WATSU
must give up control of the interaction,
and allow the water and the response of
the receiver in the water to dictate the
sequence of moves. The person receiv-
ing the WATSU must give up control of
him or herself and surrender to the sup-
port of water and continuous flowing
movements of the WATSU.
Safety awareness is the third principle I
focused on. The primary safety con-
cern is to maintain the receivers face
out of water in order to deepen trust
and relaxation. Since many of our stu-
dents have breathing and swallowing
issues, maintaining the face out of
water is particularly important with our
Keeping the student's ears out of water can be
an important comfort and health concern.
WATSU for Children with Severe and Profound Disabilities
Ann Wieser, PhD, NCLMBT#3150,
Aquatic Therapist and Rehabilitation Specialist, WATSU Practitioner
Gateway Education Center, Greensboro, NC
student population. In addition to the

face, it is important for most of our stu-
dents to have their ears out of water as
well since many of our children are
prone to ear infections.
Another safety concern is to protect and
support the neck and lower back in a
neutral position. Proper support of the
neck assists with maintaining the face
out of water, as well as initiating trust
and relaxation. Similarly, maintaining a
neutral back position relaxes back mus-
cles and decreases overall pain.
Student Population
Gateway Education Center is a public
separate school in Greensboro, NC.
Gateway serves students ranging in age
from birth to twenty-one years of age
who have severe and profound disabili-
ties. Children with severe and pro-
found disabilities require pervasive,
ongoing supports in one or more major
life activities. These supports provide
the greatest degree of independence for
the functioning of the individual in spe-
cific contexts and consider intellectual
abilities, adaptive behaviors, and health,
as well as interaction, participation, and
social roles. Specifically, supports at
Gateway 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 severe
and profound handicapped. Primary
disabilities of children who are served by
Gateway include cerebral palsy, autistic
spectrum, and medical and health
impairments. Many children also have
developmental delays, vision and hear-
ing impairments, or seizure disorders.
Of the 59 potential students (with
parental permission to participate in the
therapeutic pool) in my student load, I
had 19 students with additional
parental permission to participate in
this project. Of those 19 participants, 9
students were classified as autistic; the
other 10 students were classified as
severe and profound multiple handicap.
Ages of the 19 project participants
ranged from 6 to 21 years of age.
The nine students classified as autistic
had excellent physical and motor abili-
ties; however, only one student demon-
strated appropriate speech, 4 students
demonstrated echoalic speech, and four
were non-verbal. The functional ability
of two of the student participants with
autism was estimated between 2 and 3
years; functional ability of the remain-
ing seven student participants with
autism was estimated between 15 and
24 months.
The ten students classified as severe
and profound/multiple handicap had
limited physical and motor abilities; six
out of the ten students demonstrated
head control and could sit unsupported.
Eight of the ten students used wheel-
chairs; two students were ambulatory.
Five students had good flexibility and
range of motion; however, only three
out of the ten students had any degree
of independent upper body motor con-
trol. One student demonstrated a
degree of appropriate speech, one stu-
dent used echolalic speech; the other
eight students were non-verbal. The
estimated functional ability of the ten
severe and profound multiple handicap
students ranged from 6 months to 15
years. Educational goals for each of our
students are based on the standardized
North Carolina curriculum. Our stu-
dents who do regular school work
require such extensive medical, com-
munication, and physical supports that
Gateway is the best least restrictive
environment (LRE) for these student.
Three students had estimated function-
al abilities over 3 years (4 years, 7
years, and 15 years). The other seven
students demonstrated functional abili-
ties between 6 to 18 months.
Medical and safety concerns for our
children are considerable. Head con-
trol, maintaining ears out of water, and
bowel and bladder control are basic
issues. Major medical and safety con-
cerns exist because many of our chil-
dren are medically fragile, have shunts,
G-tubes, impaired breathing, and
impaired swallowing or cough reflexes.
We also need to be mindful of various
behavioral issues, such as limited
awareness, limited responsiveness,
excessive drinking of pool water, self
stimulating behaviors, and personal
space issues, as well as tactile concerns
such as tactile defensiveness and sensi-
tivity to touch pressure.
To insure safety of students we main-
tain a one to one student to teacher
ratio in the pool. In addition to pool
staff, the classroom teacher or assistant
is always on deck or in the pool while
students are in the pool. Emergency
Call buttons located on the deck, in
the locker room, and immediately out-
side the pool doors connect directly to
the administrative office. Emergency
Action Response Procedures vary depend-
ing on the situation, and include a
rapid response of the nursing and
administrative staff, as well as a crash
cart and/or Behavioral Intervention
Team, if necessary. Rapid EMS
response (within 3 minutes) is available
if more medical assistance is needed.
Why WATSU?
WATSU is ideally suited for this popu-
lation. The profound relaxation and
stretching helps improve flexibility,
range of motion, and muscular
strength in the children who have mul-
tiple handicaps (Styer-Acevedo 1997).
For our children with autism, relax-
ation, support and stretching in warm
water assists each child to make con-
nections and interact with the person
giving the WATSU and the environ-
ment. In addition, many of our stu-
dents have issues with anxiety, control
and trust which should be helped with
WATSU.
Considering my first project question
regarding the most effective ways to
make connections with the students, I
had already experienced that the
method of making a connection
taught in WATSU training (by center-
ing in, connecting through the breath
and slow movement sequences) was
not effective with our children. In
fact, making connections using tech-
niques from the WATSU training agi-
tated many of our children rather
than calmed them. Many of our chil-
dren struggle with developing control
over their bodies, emotions and com-
munication. In the beginning of a
WATSU session, the trust required to
accept a close physical connection
appeared to be problematic for many
of the children. However, the same
physical closeness during the middle
or end of the session was usually
accepted.
Considering which WATSU positions
and movement sequences were the
most effective and best tolerated by our
children, I noticed many of our chil-
dren were uncomfortable and did not
accept being in some of the WATSU
positions in the movements.
Many of our students are accustomed to
moving their bodies in specific habitual
ways. Some demonstrated emotional
discomfort with unfamiliar movements
or unusual (for them) placement of
arms and legs. Rather than insist on a
student doing a particular movement or
stretch in which he or she was uncom-
fortable, I found modifying a movement
or substituting another position or
movement was more effective and less
stressful for the student.
Finally, regarding changes in the chil-
dren following WATSU that could be
documented, both classroom teachers
and I noticed some differences in the
children after a WATSU session. I need-
ed to devise a way to record these
changes that we thought we were seeing.
Methodology
I work with the students in my student
load twice a week, once in the gym and
once in the pool, for 30 minutes. In
the gym I work with the whole class.
In the pool, I work with volunteers so
that a one on one relationship is main-
tained with the children. I also tried to
schedule a second 30 minute session
each week with the students who were
participating in this project in order to
generate as much information as possi-
ble. All parents of the students I
worked with signed an informed con-
sent and permission slip before this
project started. I used the form in
Appendix A to document each session
with each child. Teachers used the
form in Appendix B after each session
to document any changes he or she
noticed in the children.
Making Connections
I began each childs session by making
sure I was focused on that child, on
being with that child and not on what I
was going to do to that child. In order
to make a profound connection with
the student, it was necessary for me to
give up my expectations and support
and respond to the movements of the
child. 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 our
children that I had to consider. A
childs trust level could vary from day
to day, and I needed to be alert to and
work within the students comfort zone.
Since many of our students lack a swal-
low reflex and basic strength, as well as
head, neck and body control, I was able
to strengthen trust and ultimately the
connection with the child by making
sure the face, nose and ears were out
of water.
In a WATSU the connection between
the giver and the receiver is developed
through a supported, nurturing position
in the water, a quiet stillness, slow
movement, and breathing (Dull 1997b).
Before any connection can be made, it
is necessary for a person to feel safe and
secure in the water.
In WATSU, the sense of security is
developed through the support and
nurturing closeness of the first position.
Using the traditional WATSU first posi-
tion, I would stand to the side of the
person, cradle his or her head and neck
in the crook of my elbow, and support
his or her sacrum with the back of my
hand. Some students could tolerate
and 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 an
uncomfortable student, I would substi-
tute other positions to increase student
comfort and enhance a sense of security.
Some children who were uncomfortable
in the first position were more comfort-
able starting in a vertical position, most
often 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, I
would start the session holding them
from the back either in a vertical or
horizontal position.
In the traditional WATSU the connec-
tion is deepened through the use of
stillness and slow, gentle movements
(Dull 1997b). Students enjoyed contin-
uous movement; however they were
very sensitive to the speed of move-
ment. Many children would become
agitated with slow movements. In fact,
two thirds of the students classified as
autistic, and a third of the students des-
ignated as SPH/MU could not tolerate
slow movements. It was necessary to
increase movement speed until a
The student is not comfortable in the traditional
WATSU first position; however, he was very
comfortable 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 became
uncomfortable and stood up. I continued to
maintain 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 with
slow movements, I was able to gradually
lengthen the time an individual would
tolerate the slower movements.
In the traditional WATSU, the giver
matching the speed of the movement to
the breathing patterns of the receiver
enhances the connection (Dull 1997b).
The breathing in of our students is
extremely subtle, and is often masked
by floatation equipment. In place of
breathing, it was more effective for me
to connect with the student through
eye contact, soft speech, and support of
their head, neck and back in the water.
For a few children who were uncom-
fortable with any close interaction, light
water play with the child relaxed the
child and served to make a connection.
Although WATSU does not normally
use equipment, because of the medical
concerns or personal characteristics of
the students a variety of floatation
devices were often used.
Children with poor head and body
control and strength, shallow breathing,
and lack of a swallow reflex were
placed in a collar to insure against any
uncontrolled head movements.
Children who experienced fear or anxi-
ety in the water, and/or land wore a
floatation belt until they became more
comfortable in the water.
Movement and Safety
Once making the connection between
myself and the student, I began to
incorporate WATSU movements
designed to loosen and stretch the hips
and spine. Next, I worked to further
loosen the lower body and legs before I
moved to the upper body and arms. I
ended each session with movements
designed to integrate the relaxation into
the persons body while grounding
them into a vertical or weight bearing
posture. After each session, I docu-
mented the movement sequence, speed,
ways of making connections, student
comfort and response, and any other
observations.
It is necessary for a person to feel safe
and secure in water before any relaxation
can be attained. Safety and security
started with keeping the students face
above water, and using floatation
devices. In addition, position of the stu-
dent in the water, movement sequence
and speed were also important for the
students feeling of safety and security.
Student needs and tolerance to positions
varied from day to day.
Although a traditional WATSU session
generally follows a suggested movement
sequence (Dull, 1997b), I did not fol-
low a specific sequence, but I always
began by loosening the hips and spine.
During the session, I would attempt to
detect and respond to the students
body movement, and then attempt to
match that movement with a WATSU
position that was a close approxima-
tion. The session became a continuous
flow of movement into and out of posi-
tions, which ultimately became a dance.
In a traditional WATSU, the receiver
rarely, if ever, interrupts movement flow
or the silence. However, students in this
project often interrupted the movement
themselves by sitting up, rolling over,
moving arms and legs, or stretching into
full extension. Students would often
talk, giggle, laugh or vocalize during the
session. Rather than trying to prevent
their interruptive response, I accepted
their interruption of the movement and
redirected or worked their response into
a dance by following their movements.
In some cases, the student would stand
up, and we would break physical contact
briefly, while continuing to maintain a
connection.
By watching the student and maintain-
ing eye contact, I could later reestablish
physical contact and introduce a flow-
ing movement sequence comfortable for
the student. Talking in a soft quiet
voice helped calm the student and
maintain a connection. WATSU posi-
tions students were most comfortable
were: Under Head: Seaweed; First
Position: Accordion, Near and Far Leg
Rotation; Head Cradle: Thigh and Leg
Press and Arm/Leg Rock.
Documentation
The last focus of the project was to doc-
ument the effects of the WATSU on the
children. In addition to adapted physi-
cal education, many of the children also
receive speech therapy, physical therapy,
and occupational therapy. Our students
also have many opportunities for peer
interaction in their classrooms, media,
art, and music. Classroom teachers,
support staff and I would discuss each
childrens responses to the WATSU ses-
sion. Classroom teachers and support
staff used the form in Appendix B to
document 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 and
motor limitations became more flexible
after 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 for
several hours. Two students main-
tained increased flexibility over the
summer and into the next school year.
Fear while in water was reduced.
Children extremely fearful in the water
began to relax into front and back
floats. One student, who had clung to
staff when in the pool, began to go to
the wall on her front and come off the
wall on her back by the end of the proj-
ect. She is now swimming. Another
student, who would not let go of the
wall 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 land
activity, increased. Children who were
fearful doing gym activities, walking in
the hall, or doing some classroom activ-
ities began trying and enjoying more
activities in the gym and classroom. A
student who fought going up the ladder
in the pool and the gym, and going up
and down the steps of the bus, began to
exit the pool using the ladder and need-
ed less assistance getting on and off the
bus. A student who had not smiled in
the gym or pool since the beginning of
the year, smiled and laughed during his
first WATSU session. After several ses-
sions he also began to smile and enjoy
some of the gym activities.
Behavior improved. Another student,
who was usually non-compliant and
impulsive, was calm and focused during
most of the day after a WATSU session.
In general, all students were more
relaxed, calmer, and more patient after
their WATSU. All students were gener-
ally more focused in the classroom;
they listened and followed directions,
and would try new activities better than
before the WATSU.
The changes lasted from several hours to
all day, and in a few cases, for several
days. The length of time that the change
lasted varied with the child, and with the
other activities in the classroom.
Summary
WATSU was very beneficial for the chil-
dren at Gateway Education Center.
Overall, the children became more flex-
ible, and showed greater range of
motion. The children appeared calmer,
less aggressive, and demonstrated an
increased focus and willingness to try
new activities. Based on the responses
of the children, I made five basic modi-
fications to the WATSU techniques over
the 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 who
made sudden unpredictable head move-
ments. I used quiet, soothing talk and
eye contact to make a connection with
the student.
I usually began the session with the
Under Head, or Seaweed position; most
of the time the session started from a
vertical 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 of
WATSU movements. Rather, using var-
ious WATSU positions and transitions I
developed an interactive dance with
each student. N
References
Dull,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 cord
injury. 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 neurologic
disorders. In Becker, B. E.
Comprehensive Aquatic Therapy.
Boston, MA: Butterworth-Heinemann
Publications.
Styer-Acevedo, J. (1997). Aquatic
rehabilitation of the pediatric client.
In Ruoti, R. G., Morris, D. M., and
Cole, A. J. Aquatic Rehabilitation.
Philadelphia, PA: Lippincott.
Vargas, L. G. (2004). Aquatic therapy:
Interventions and Applications.
Ravensdale, WA: Idyll Arbor, Inc.
Author
Ann Wieser, PhD, is Aquatic
Therapist and Rehabilitation
Specialist at Gateway
Education Center,
Greensboro, NC. Active in
aquatics for over 40 years, formerly she origi-
nated and developed the aquatic therapy pro-
fessional preparation emphasis at University
of North Carolina-Greensboro. She has served
AAHPERD as Treasurer of Aquatic Council
and is a Council Master Teacher in Adapted
Aquatics. Dr. Wieser received the 2000 ATRI
Professional Award. She can be contacted at
rawieser@worldnet.att.net.
Making a connection is impossible
when the student is uncomfortable.
Many times the best connections were made
standing 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 AEAs website at www.aeawave.com, click on Fit Pro News/Articles.
Appendices for this
article can be found
on the Home Page
of AEAs website at
www.aeawave.com,
Your reading and study of WATSU for Children with Severe and Profound Disabilities by Wieser
can result in 2 ICATRIC/AEA approved CECs. First, study the article. Then complete the study guide
assignments as described below. Send your completed assignment and the course fee to Aquatic
Consulting & 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 of
completion verification. Course fees depend on CEC verification requested. Fees are non-refundable.
ICATRIC = $30 AEA = $20 ICATRIC and AEA = $45
AEA 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 cover
sheet including your name, mailing address, phone, e-mail address, and CEC article title. Then, begin another sheet of paper
and answer the following questions/complete the following applications. If answering a question, state the question prior to
supplying 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 Ring
Alison Osinski, Ph.D.
Aquatic Consulting Services, San Diego, CA
Question: How do you prevent the
bathtub ring from forming on the
walls around the edge of the
pool? How do you remove it?
The bathtub scum ring that forms on
the pool walls at the waterline is usual-
ly caused by a combination of two
problems: 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 and
hair care products) which are lighter
than water and float at or near the
water surface, come into contact with
rough pool surfaces. In addition to
forming scum lines at the water surface,
they contribute to the build-up of total
dissolved solids (TDS), reduce sanitizer
effectiveness which promotes bacterial
and algae growth, cloud water, clog car-
tridge filters and diatomaceous earth fil-
ter elements, and contribute to mudball
formation in sand filters causing
reduced filter effectiveness.
To prevent scum ring formation, con-
sider using enzymes or absorbent foam
products. Enzymes are catalysts that
start or speed up chemical reactions.
Enzymes are protein-like substances
that form naturally in animal and plant
cells, but synthetic enzymes have been
developed for pool use. Over several
days, enzymes slowly digest and destroy
oils in pool water by converting them
to carbon dioxide and water. An initial
dose is added and then maintenance
doses are added to the pool on a weekly
basis.
Absorbent foam products can be used
in addition to, or instead of, enzymes to
physically remove oils from the water
and prevent scum lines from forming.
Absorbent foam can be placed in the
pool skimmer baskets, hair and lint
strainer, filter tank, or other location
which is inaccessible to pool patrons.
Manufacturers of the products say the
patented molecular structure and cell
design of the foam allows it to absorb
many times its own weight in oil. When
the foam is saturated with oil, it turns a
dark color, becomes heavy and sinks.
The foam can be replaced, or for a peri-
od of time can be cleaned and reused.
TRR
Feature Column: Pool Problems
When water is unbalanced and has a
higher than desirable mineral satura-
tion, excess calcium will precipitate out
of solution and leave calcium scale
deposits, visible as unsightly, rough,
white stains on the interior pool walls.
This is especially noticeable on the
waterline tiles of pools with perimeter
overflow systems designed with skim-
mers rather than rimflow, or fully or
partially recessed gutters. If body fats
and oils, and other organic debris are
also present, they will readily adhere to
the rough surface.
In addition to aesthetic problem of
waterline stains, the excess calcium
damages heater elements, pool circula-
tion system equipment, and restricts
water flow though the recirculation
lines. Calcium carbonate build-up
inside pipes will cause an increase in
velocity as water is forced through a
smaller diameter opening. Friction loss-
es will increase, pressure will increase,
flow will be reduced, and energy con-
sumption will increase. Water may
become cloudy and take on a "milky"
appearance, particularly if pH is also
high. Sanitizer effectiveness will be
reduced, and algae growth may
increase. This is particularly a problem
in warm water therapy pools because
unlike most elements, calcium is less,
rather than more, soluble as tempera-
ture increases.
To prevent the problems caused by
excess calcium, monitor the water bal-
ance and calculate the Langelier
Saturation Index regularly. The LSI is
used to keep the pH, total alkalinity,
calcium hardness, water temperature,
and total dissolved solids in balance,
preventing the water from becoming
aggressive or oversaturated. Dr.
Langelier , a professor at the
University of California, Berkeley
devised his formula and chart in the
1930s to help prevent scale build-up in
closed systems like boilers, but the for-
mula was adapted and has been used
successfully by pool operators for
decades.
To find the LSI, use your test kit and
testing instruments to find each of the
five values (pH, total alkalinity, calci-
um hardness, water temperature and
TDS). Saturation index equals pH plus
the alkalinity factor, plus the calcium
hardness factor plus the temperature
factor minus the TDS factor. Write
down the actual pH value found. Then
for the remaining four values, find the
corresponding factor on the chart. Add
or subtract the factors to or from the
pH value. If an actual value is not
found on the saturation index chart,
do not interpolate since there is no
direct linear relationship between the
values. Rather, move to the next high-
er value and use its factor. If cyanuric
acid has been added to stabilize the
water , divide the cyanuric acid level
by 3, then subtract this interference
factor from the total alkalinity reading
prior to calculating the saturation
index. (see chart below)
If the sum obtained is zero, the water is
balanced and chemical equilibrium has
been achieved. A tolerance of plus or
minus 0.3 is allowable for commercial
pools. Negative values indicate corro-
sive water, while positive values indi-
cate likely calcification and scale forma-
tion. If the saturation index formula
indicates that the pool water is not bal-
anced (not equal to zero, plus or minus
0.3), make the appropriate chemical
corrections, starting with total alkalini-
ty, then followed by pH, temperature,
calcium hardness, and TDS.
Example: pH 7.8
Total Alkalinity 130
Calcium Hardness 300
Water Temperature 92 F
TDS 750
SI = pH +af + cf + tf - TDSf
SI = 7.8 + 2.2 + 2.1 + 0.8 - 12.1 = +.8
Water is oversaturated. The water could
be balanced by adding sodium bisulfate
to drop the total alkalinity to 100 ppm,
and by reducing the pH level to 7.2
using muriatic acid or carbon dioxide.
Well balanced water will increase
bather comfort, will help prevent the
formation of bathtub ring, and will
dramatically extend the life expectancy
of the pool and its components.
If calcium carbonate deposits and scum
rings still form on pool walls despite
your attempts to remove oils and keep
the water balanced , they can be
removed by scrubbing with tri sodium
phosphate (TSP), or with a non abra-
sive chlorine bleach based liquid
cleanser, using a 3M Scotch Brite pad.
If that doesn!t work, try using a fine
grit sandpaper or pumice stone. Do not
use muriatic acid to scrub off the stains,
because over time, acid will damage the
grout, will remove the plaster surface
and expose the gunite below, and may
etch the ceramic tile. Power grinding
may be the only way to remove the cal-
cium build-up if you ignore it for any
length of time. N
Author
Alison Osinski, Ph.D.
Aquatic Consulting Services
1220 Rosecrans St. #915, San Diego, CA 92106
(619) 602-4435
(619) 222-9941 (Fax)
alisonh2o@aol.com (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 Alkalinity
degree factor ppm factor ppm factor ppm factor
66 0.5 75 1.5 <1000 12.1 50 1.7
77 0.6 100 1.6 >1000 12.2 75 1.9
84 0.7 150 1.8 100 2.0
94 0.8 200 1.9 150 2.2
105 0.9 300 2.1 200 2.3
400 2.2 300 2.5
800 2.5 400 2.6
1000 2.6
Aquatic Therapists Interact WithEditors and Publishers
Susan J. Grosse, MS
Aquatic Consulting & Education Resource Services, Milwaukee, WI
Legitimacy, over time, of any academic
pursuit is established by its body of pub-
lished literature in the field.
While some interactions are a required
part of professional endeavors, working
with a supervisor, for example, otherin-
teractions are optional. Interacting with
editors and publishers clearly falls not
only into the optional category, but
probably into a subset labeled interac-
tions to be avoided! However, publica-
tion validates practice. Practice found
valid is more often medically recom-
mended, and financially reimbursable.
How to specifics of aquatic therapy
practice become published? Through
interaction with editors and publishers.
To develop positive interaction, it is
necessary to understand job roles. The
publisher is a businessperson, focused
on staying in business by remaining
financially solvent. Ideally, the pub-
lisher wants to make a profit from his
or her publishing efforts. If no profit
results, the publisher will have to go
out of business, and his or her publica-
tion will cease to exist. Publishers sur-
vive (or not) on individual issue sales
and subscriptions. Even publishers
who publish periodicals of member-
ship based subscription groups must
have members who like their publica-
tion to survive. Publishers rarely inter-
act with authors.
Editors work for publishers. It is the
job of the editor to secure and develop
content for the publishers periodical.
The editor is the gatekeeper for the
publisher. The editor, in conjunction
with other editors in the field, is also
the gatekeeper for validity in the profes-
sion. What the editor chooses to accept
for publication must first meet the
needs of the publisher in publishing a
periodical of interest and attraction to
readers. If no one wants to read the
publication, 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, or
illegal content a long list of negative
consequences can result, the least of
which is loss of readership, the greatest
of which is legal action resulting in
bankruptcy for the publisher. Editors
work with authors.
What does this mean for professionals
potential authors in the field? First, it
means the editor wants your article to
be the very best article possible. The
editor will be there to help you not
because they like you, but because
helping you develop your article helps
him or her put good content into a
publication that generates revenue for
the publisher.
Most articles submitted for publication
require some re-write. Be prepared for
this 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
spelling errors (spell check will
not flag errors like using too
forto),
grammar errors (easy to make if
you are interrupted while writ-
ing),
run-on sentences (more than 3
lines of type is too much),
poor paragraph style (a paragraph
is 3-4 sentences including a topic
sentence),
lack of headings and sub-headings
(those section titles help the
reader organize thoughts), and
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 issues
ahead of the one currently in print (6
months to a year ahead). Once submit-
ted, your article will most likely be sent
to reviewers (part of that professional
validity process). It may also undergo
preliminary 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 information
published. The key is making that ini-
tial decision to write. The field of
aquatic therapy needs professionals to
document their experiences, successes,
trials, populations, protocols, research,
equipment, facilities, staff training, risk
management, legal issues, business
practices, and even failures. The body
of knowledge created today is the foun-
dation of the aquatic therapy profes-
sional of the future.
Once that decision is made, successful
interface with an editor will ensure a
happy result to your efforts. The first
article is the most difficult. While no
two 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. Dont avoid inter-
face with editors embrace it! N
TRR
Feature Column: Interface
While the physiological effects of aquatic

physiotherapy have been studied in the
adult population (Hall, Bisson &
OHare, 1990), there is a distinct lack
of quality research on the outcomes of
aquatic physiotherapy (Geytenbeek,
2002). This is particularly so for the
paediatric population. Despite the
strong emphasis by physiotherapists
on evidence-based practice, the majority
of paediatric research consists of case
reports 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-perceptual
abilities, balance, head control and
breathing control (Campion, 1991;
Ruoti et al., 1997). However, there is
little or no research evidence to sub-
stantiate these claims for the paediatric
population.
Not only is there a lack of evidence for
outcomes in the general aquatic physio-
therapy literature, there is also a strong
biomedical focus on the research meth-
ods and outcomes of aquatic physio-
therapy. The International Classification
of Functioning, Disability and Health
(ICF; WHO 2002) is based on the
biopsychosocial model, and provides a
view of different perspectives of health:
biological, individual and social. The
ICF framework, therefore, also gives
importance to understanding patient
experiences as an essential factor in
determining health outcomes (Borrell-
Carrio, Suchman & Epstein, 2004).
Experiences of children and their
families with aquatic physiotherapy
have not been well considered. Parents,
as primary carers, have an enormous
influence on access to therapy, and
therefore have a role to play in support-
ing therapists in evaluating effective-
ness of physiotherapy interventions. It
is important to compare and contrast
views of parents with those of thera-
pists as parents and professionals may
have differing views.
This approach supports Family-
Centered Practice (FCP:
http//:www.novita.org.au) as the basic
philosophy of how Novita Childrens
Services (Novita) provides services to
its clients, and their families. Novita
provides therapy, equipment and family
support services to over 1000 children
in South Australia with physical and
severe multiple disabilities. Services are
delivered 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 of
children with disabilities, and their
therapists think about aquatic physio-
therapy. Specifically, the study aims
were 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.
Method
This was a qualitative study utilizing
focus groups, allowing participants to
present and discuss their views in
response to others (Krueger, 2000).
Focus group methodology was used
because it is time efficient and cost
effective in exploring a question thor-
oughly prior to data collection. Ethics
approval was obtained from the
University of South Australia Division
of Health Sciences Ethics Committee.
To assist in the preparation for focus
groups, a short questionnaire was used
to establish demographics of Early
Intervention (EI) aquatic physiotherapy
groups offered at Novita. This question-
naire included such questions as day,
time and duration of the EI hydrothera-
py group, how many children attended
the group, how many therapists attend-
ed the group, how the group was run,
and attendance rates. This question-
naire was distributed via email to all
physiotherapists employed by Novita.
Information gained from the question-
naire assisted in formulation of ques-
tions to be used in focus groups aimed
at exploring participant understanding
of the definition of aquatic physiothera-
py, perceived benefits and downfalls,
potential barriers, structure of groups,
and carryover effects.
An information package was sent to
forty-one parents and fifteen therapy
staff 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:
Margarita Tsirios, BPhys, Senior Physiotherapist,
Novita Childrens 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 Childrens Services
Adjunct 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 the
invitations, resulting in only two focus
groups being conducted. The first
group consisted of three parents/carers
of Novita clients who were participating
in an EI aquatic physiotherapy group or
had participated in the previous 6
months. The second group involved
three therapists (two physiotherapists
and one speech pathologist) at Novita
who had participated in EI aquatic
physiotherapy groups at least 3 times
per term or had participated in the 6
months prior.
During focus groups, parents and
therapists were asked questions about
hydrotherapy including; their definition
of hydrotherapy, perceived benefits and
downfalls of hydrotherapy, potential
barriers to access/attend, structure of
hydrotherapy groups, and any carryover
effects. Focus groups were facilitated by
a research assistant, and proceedings
were audiotaped and transcribed verba-
tim. Completed transcripts were sent to
each participant for verification that the
transcript was a true and accurate
reflection of proceedings.
These transcripts were independently
read by three of the researchers, and
ideas about content and themes were
noted. Once researchers had independ-
ently completed their initial coding, the
research team met to group the codes
into similar themes. Coding was refined
until the main themes emerged. Themes
included perceptions of benefits of
aquatic physiotherapy, outcomes,
barriers and pool accessibility issues.
Results
Themes around the perceived benefits,
outcomes, and challenges of aquatic
physiotherapy emerged, and could be
classified into four main subgroups
relating to
Benefits for the child
Benefits for the parents
Benefits for the siblings, and
Barriers to participation.
Benefits for the Child
Parents mentioned a whole range of
benefits for their children, some of
which 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 the
waterthats a really big thing for kids.
And a therapist reported
Its really goodfor sensory kind of expe-
riences as well, like pouring water over
the kids and swishing them through the
water.
However, parents produced a more
extensive 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 think
shes come along quicker than if we hadnt
done it (hydrotherapy)
And another parent said
Hes started using his hands, he never
hes got very sensitive hands and for a
long time he would never use them, and
now hes starting to use his hands to prop
himself up cos weve put him on the mat
in the water and just the unevenness of it
and I dunno, for some reason he didnt
mind putting his hands in the water and
now hes used to it so thats good, very
good.
Additional benefits for the child as
mentioned by therapists were anecdotal
in 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 made
by therapists, including one therapist
who said
I think they really enjoy it, definitely.
Its really fun
Another therapist said
With all the kids its a chance to be in
water, which is different and especially for
the less mobile kids that perhaps are in
wheelchairs all the time or have limited
movement or whatever
Although therapists recognised oppor-
tunities for implementation of goal set-
ting and outcome measures, this was
not reflected in their comments. This
could well be related back to the lack of
evidence in the literature to support use
of aquatic physiotherapy in paediatrics,
leading to the perception by therapists
that aquatic physiotherapy is bit of
extra input and is not seen to be
as therapeutically valid as land based
therapy. One therapist said
Well, weve not actually done any meas-
urements of sort of range of movements
before and after hydro (aquatic physio-
therapy), which I suppose we could do to
get some real conclusive evidence. But
certainly weve seen them actively moving
their limbs in the water which theyve not
been able to do on dry land and that is
often one of our goals. They often move
their head a bit better in the water than
what they do on dry land but I dont know
how you prove that with your evidence
based practice.
In summary therapists appeared to view
aquatic physiotherapy as an adjunct to
land based therapy, whereas parents
viewed water based therapy as an essen-
tial stand alone component of their
childs program. This was reflected in
the complexities of definition responses
offered by the 2 groups
Its using water for therapy, I suppose
(therapist.) I say its physiotherapy in the
water In the water its a totally differ-
ent feel of freedom, the different move-
ments and it strengthens their muscles or
whatever (parent).
Benefits for the Parent(s)
When examining benefits for parents,

therapists comments suggested the
greater benefits of aquatic physiothera-
py were related to parent networking
and 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 the
biggest thing. They love coming along
and, you know, chatting to each other,
and yeah its good.
and
I think that one of the things as mums is
that the child is accepted. All the children
have got disabilities whereas a couple of
them said when weve been to the ordi-
nary swimming pool they have a lot of
stares In the hydro (aquatic physiother-
apy) group, Theyre all very supportive
of each other and its just fantastic.
Unlike therapists, parents did not
immediately recognise any benefits for
themselves until specifically questioned.
Then responses included
It was the first real contact with other
mothers or families that had children with
disabilities .. you become quite friendly
with those people and we catch up out of
work, we have a mums club and go out to
dinner every few months and its good,
you dont feel so alone, theres other people
out there that have problems.
Another parent said:
you get social interaction with other
parents and other children.. you get to
swap ideas and chat
Benefits for the Siblings
When examining benefits for siblings,
views of therapists and parents differed.
Therapists recognised sibling support
and involvement as an important com-
ponent of the aquatic physiotherapy
program and tried to include siblings in
the program. One therapist said
Yeah, I think definitely bonding with
their sibling and seeing what they can
doI guess they feel a bit of self-worth in
that theyre being useful and that they can
do somethingI guess we help to promote
that by telling the sibling what they can
do and how they can help and they seem
to really enjoy splashing around too
Parents on the other hand, viewed
aquatic physiotherapy as an important
therapy time for their child, and pre-
ferred, if possible, not to have the
siblings around. Hence, they did not
recognise any specific benefits for
siblings.
Barriers to Participation
Similar themes emerged from both ther-
apists and parents regarding barriers to
aquatic physiotherapy, pool accessibility
and 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 regarding
pool accessibility highlight challenges
presented when working in a community
based model of service delivery
Well weve got a choice of a couple of
different pools that we could use
The problem there is the water temperature
and also that even at the shallow end its
still too deep for some of our 4-year-olds to
stand 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 you
cant fit in a circle in a lane, youre kind
of in a big long line which isnt quite the
same. Also, I guess the storage of our
equipment at [the location], we can store
a lot of stuff there[and] theres not often
change tables.
Some service delivery gaps were identi-
fied by therapists:
We did a survey at the end of last year
and theyre all more than happy with it, a
lot of them would like it every week but
unfortunately we dont have the staff
resources...
and
I guess the fact that parents want it twice
a week and we can only provide it once a
week I think is probably a good indicator
that there could be more services out
there.
In general, parents highlighted similar
barriers and challenges as outlined by
therapists. Interestingly, however, par-
ents did not highlight travel as a barri-
er. This reflects the importance parents
place on aquatic physiotherapy as a
therapy modality.
I wouldnt care how far I had to travel,
if I had to come all the way here, Id come
here because you do it for your child
because your child needs that
Even when the timing of the group
clashed with other commitments and
routines, parents would rearrange their
schedules. This again reflects the value
parents place on aquatic physiotherapy.
Even the time Like [child] Even the
last time we were going, it really didnt
suit because that was when she wanted to
have a sleep but I wanted to go, so I
just sort of tried to drag her sleep time
out a bit or get her to have an early sleep
if she would and if she wouldnt Id just
keep her awake and shed just crash
after
Discussion
Parents perceived far greater benefits of
aquatic physiotherapy, and valued their
own and that of their childs involve-
ment, more than did the therapists.
Parents perceived the benefits associat-
ed with their childs gross motor skills.
In contrast, therapists talked about the
social benefits for the child, siblings
and parents attending the group.
Barriers identified by therapists were
location and temperature of the pool,
difficulties with travel, and parents
being unable to fit it into their day.
While parents concurred with this,
their focus was more on fitting it in
with other siblings, kindergarten/school
commitments, and sleep times, rather
than on the issue of travel.
Understanding benefits and barriers are
an important component of behaviour
change theory (Talbot and Verrinder

2005). Patients need to perceive suscep-
tibility and seriousness in their own sit-
uation, and then perceive benefits as
outweighing costs or barriers (Talbot
and Verrinder 2005). Therapists who
are focussed on encouraging all poten-
tial clients to attend aquatic physiother-
apy need to design their programme to
reinforce benefits perceived to be of
greatest importance to parents, which
are essentially the outcome of improv-
ing gross motor skills. It may be that
therapists remain ambivalent about this
benefit as there is still no research to
support this claim.
In encouraging participation and deal-
ing with the common problem of non
attendance the therapist needs to man-
age barriers to attending faceing par-
ents. This appears to be primarily an
issue about timing of sessions for par-
ents. To reduce a barrier for attendance
it is recommended sessions be sched-
uled to allow, as far as possible, for travel
time and school and kindergarten drop
off and pick up.
Limitations of this study are the small
number of participants in each focus
group, and the number of focus groups.
This was despite several recruitment
attempts and offering a range of flexible
times and venues for focus groups.
Although there may have been other
parents who were enthusiastic to partic-
ipate in the study, this may have been
outweighed by high demands on their
time as a result of just managing their
every 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 at
a number of different venues. It is also
possible a therapists lack of time and
resources were a barrier to their partici-
pation in the focus groups. In the
future, one alternative might be to
arrange individual interviews, either
face-to-face, or over the telephone.
However, an advantage of a focus
group over an interview method is it
allows a dynamic discussion, which
may 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 can
be more appropriate when the topic is
intense (Krueger 2000). Ideally, focus
groups should be repeated until no new
information is obtained, although it
may be appropriate to run fewer groups
if participants are in a congruent cate-
gory with similar backgrounds and
exposure, as in the case of the thera-
pists (Krueger 2000).
In future, if a focus group is to be imple-
mented, utilising a scheduled aquatic
physiotherapy group where the partici-
pants are a captured audience may result
in larger participant numbers. An alter-
native technique may be to use on line
discussions or email to collect informa-
tion. Consideration may also be given to
using a triangulated approach, whereby a
combination of interviews and focus
groups are utilised.
Conclusion
This exploratory study showed parents
and therapists have differing views on
benefits of aquatic physiotherapy. Some
difficulties and practical barriers to
aquatic physiotherapy were identified.
This study highlights the need to con-
duct more rigorous clinical studies to
examine effects of aquatic physiothera-
py for children with physical and/or
multiple disabilities so therapists can be
more confident and clear about promot-
ing benefits to families. N
References
Borrell-Carrio, F., Suchman, A., and
Epstein, R. (2004). The biopsychoso-
cial model 25 years later: Principles,
practice, and scientific inquiry, Annals
of Family Medicin,. www.ann-
fammed.org 2, 576-582.
Campion, M. (1991). Hydrotherapy
in 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 for
effective hydrotherapy, Physiotherapy,
88, 514-529.
Hall, J,, Bisson, D., & OHare, P. (1990).
The physiology of immersion,
Physiotherapy. 76, 517-521.
Krueger, R. & Casey, M. (2000).
Focus groups: A Practical Guide for
Applied Research 3rd ed, Thousand
Oaks, 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 Health
Care Approach 3rd ed, Sydney,
Australia: Elsevier.
World Health Organization (2002).
Towards a Common Language for
Functioning, Disability and Health:
The International Classification of
Functioning, Disability and Health.
Geneva, Switzerland: WHO.
Survey Questions
Therapist Focus Groups
What do you think are the benefits
of hydrotherapy for this group of
clients?
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?
Authors
Margarita Tsirios, B Phys
Margarita Tsiros has a Bachelor of
Physiotherapy from the University of South
Australia, and a Graduate Certificate in
Research Methodologies, for which she was
awarded the Health Science Student of the
Year. She is currently completing a Bachelor of
Health Science (Honours). Margarita now
works as a Senior Physiotherapist at Novita
Childrens Services, and is also a Visiting
Researcher at the University of South
Australia. She can be contacted at
Margarita.tsiros@novita.org.au.
Gisela van Kessel, MS
Gisela van Kessel gained a Bachelor of Applied
Science (physiotherapy) at the South
Australian Institute of Technology in 1983 and
completed a Masters in Health Service
Management at Flinders University in 2001.
She has many years of clinical experience in
aquatic physiotherapy and now lectures and
supervisors honours research in aquatic phys-
iotherapy at the University of South Australia.
She can be contacted at gisela.vankessel@
unisa.edu.au.
Susan Gibson, M.App.Sc.Physio
Susan graduated from the South Australian
Institute of Technology with a Bachelor of
Applied Science (Physiotherapy) in 1978, a
Graduate Diploma in Physiotherapy
(Paediatrics) from the South Australian
Institute of Technology in 1989, and completed
a Masters of Applied Science in Physiotherapy
(Paediatrics) at the University of South
Australia in 1993. Her areas of interest include
the promotion, and use of, research in clinical
practice in paediatric rehabilitation. Susan is
currently employed as the Research Senior
Physiotherapist, and has a clinical caseload at
Novita providing metropolitan and outreach
services for children with disabilities. She can
be contacted at Susan.Gibson@novita.org.au.
Parimala Raghavendra. Ph.D.
Dr. Raghavendra obtained her Ph.D. in speech-
language pathology from Purdue University,
USA and has extensive clinical, teaching and
research experience in communication disor-
ders and disability. Her current work focuses
on making research become an integral part of
high quality services, answering important
clinical questions through research, and pro-
moting evidence-based practice in paediatric
disability. She can be contacted at
Parimala.raghavendra@novita.org.au
The Aquatic Therapy & Rehab Institute (ATRI) had announced an online option
for their Aquatic Therapeutic Exercise Certification. This online exam will be a
benefit to practitioners who have limited travel options.
Anne Miller, Executive Director of ATRI, said, Many educational institutions are
offering online education and degrees. ATRI is following that trend so certification
can be attained more conveniently for people with busy lifestyles.
Practitioners will have to study ahead and will have 3 one-hour time blocks to
complete all three sections of the exam, consisting of 110 130 multiple choice
and 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?
ATRIs Aquatic Therapeutic Exercise Certification is for competent, knowledgeable
professionals in aquatic therapy, rehab and therapeutic exercise. The exam will test
your ability to meet the Aquatic Therapy and Rehabilitation Industry Standards to
practice. The Standards are available on the ATRI web site and can be downloaded
free 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 you
arent already one.
Exam Fees: The fee to sit for the on-site exam is $255 (pre-registered). The fee to
take the exam online is $195.
Prerequisite: The prerequisite for this exam is 15 hours of Aquatic Therapy, Rehab
and/or Aquatic Therapeutic Exercise education. It is preferable this education be
hands-on, but online or correspondence courses also qualify.
On-site Exam Date in Chicago:
Sunday, November 18, 2007
1:00 pm - Registration
1:30 pm - Exam Begins
Transfer Information:
If you have already taken an aquatic therapy certification exam through the
International Council for Aquatic Therapy and Rehabilitation Certifications (ICA-
TRIC), but have not received your test results, ATRI will let you take the online
ATRI 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't
pass, 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 your
certification.
For More Information and To Register: Go to www.atri.org/ATRICertification.htm
or call toll free 866-go2-atri (462-2874). N
ATRI Announces New Online Option for the
Aquatic Therapeutic Exercise Certification
TRR
Feature Column: Around and About the Industry
Physical exercise plays an important
role in reducing the physical and psy-
chological symptoms for individuals
having Parkinsons Disease (PD). One
form of exercise, water exercise, is a rel-
atively untested treatment method for
these individuals. In this pilot study,
four participants, aged 71-89 years,
with PD followed a six-week exercise
program in water, three days weekly for
a duration of from 20 minutes up to
one hour in an attempt to improve
physical and psychological functions.
Testing was done prior to and after the
water exercise program. This study
showed participants improved physical
strength, endurance, and balance. Tests
of perceived self-confidence showed no
difference between the beginning and
end of the study. Focus groups conduct-
ed with the participants and caregivers
after the completion of the water exer-
cise program showed positive psycho-
logical results from engaging in a water
exercise routine. Results suggest water
exercise is a beneficial medium for indi-
viduals with PD, and can be useful in
maintaining and/or improving strength,
endurance, and balance. Further
research with a randomized controlled
trial and a larger sample size is needed
to verify the beneficial effects of water
exercises for individuals with PD.
Parkinsons Disease
In 1999 Parkinson's is the most com-
mon neurodegenerative disease after
Alzheimer's Disease
1
. It is a chronic,
progressive disorder with no identifi-
able cause. It is estimated PD presently
affects 1.5 million people in North
America. As the population ages, the
prediction is that 1% of people over the
age of 60, and 2% of people over the
age of 70 will be affected with PD
2
.
There is no cure for PD. The funda-
mental defect in PD is a gradual loss of
brain cells, producing the chemical
dopamine, a neurotransmitter. This
results in messages from the substantia
nigra to the corpus striatum (the area of
the brain that produces smooth, con-
trolled muscle actions for movement
and balance) not being delivered or
being delivered incorrectly.
Symptoms of PD begin to appear when
60% to 80% of the dopamine has been
destroyed
3
. While not specifically
caused by the aging process, its rela-
tionship to aging could be because both
dopamine concentration and the num-
ber of cells in the substantia nigra that
produce it fall steadily from birth, some
60% or so having been lost in extreme
old age.4 Clearly, the older the person,
the smaller the additional deficit in
cerebral dopamine produced by whatev-
er mechanism that is required to pro-
duce Parkinsonian symptoms.
4
Most people with PD find they have
had the disease for several years before
initial diagnosis. This is understand-
able because many of the early symp-
toms of PD are also signs of aging expe-
rienced by everyone. Parkinsons
Disease exacerbates the normal aging
process. It affects each person different-
ly. In some it progresses quickly, while
in others progression is quite slow.
Some people become severely disabled
over time, while others experience only
minor movement problems.
Often, seniors who suffer from PD will
degenerate over time until a point is
reached where they can no longer take
care of themselves or where home care
is no longer sufficient, and they need
residential care. This places extra cost
pressures on the individual, family, and
finally the health care system, as dis-
cussed by Lesemann & Martin
5
who
believe if people remain well enough to
be able to be cared for in their own
homes, the resulting savings can be up
to 75% of the costs of equivalent care in
a hospital setting. Long term care insti-
tutions, such as nursing homes, are
more cost effective than hospital care
6
.
But home care is the most cost effective
way to support people no longer able to
function independently. The 2003
Health Care Renewal Accord recognized
home care as one of the priority areas
to receive substantial funding.
7
Additionally, PD carries many second-
ary symptoms that may affect people,
while passing unnoticed for several
years, thus increasing probability late
diagnosis. When diagnosis is made, two
or more cardinal signs are present.
These cardinal signs include resting
tremor (shaking affects approximately
75% of all sufferers and is usually more
evident on one side of the body), pos-
tural instability (impaired balance and
muscle weakness), muscle rigidity
(stiffness of the limbs and trunk) and
bradykinesia (slowness in initiating
movement and changes in the speed
and size of movement). Muscle rigidity
and bradykinesia affect almost all
sufferers of PD. There are also many
common secondary signs such as freez-
ing or having dyskinesis (involuntary
movements) associated with anti-
parkinsonian medications.
8
Benefits of Exercise for
Individuals with PD
Until the debate about the pathophysio-
logic cause of impaired movement in
Parkinsonism is settled, it will be diffi-
cult to develop a specific exercise treat-
ment for symptoms that include
hypokinesia, tremor, and muscular
rigidity.
9
Regardless of presence of any
disease condition, positive effects of
physical activity on a persons health
throughout the life span have been well
documented. Participation in a regular
exercise program is an effective inter-
vention to prevent or reduce functional
declines associated with the general
aging process. Endurance training can
help maintain and improve various
aspects of cardiovascular function.
Strength training helps offset loss of
muscle mass and strength typically
Water Exercise for Individuals with Parkinsons Disease:

A Pilot Study
Alexander M. Crizzle, MPH., PhD Candidate, University of Waterloo, Waterloo, ON, Canada
Ian J. Newhouse, PhD., Lakehead University, Thunder Bay, Ontario
associated with normal aging. If exercis-
es are performed in water, the resistance
of water can be used for strength train-
ing. Regular exercise improves bone
health and postural stability, increases
flexibility and range of motion.
10
Evidence also suggests that regular exer-
cise provides psychological benefits such
as an improvement in mood and subjec-
tive well being.10 These general benefits
can also accrue to an individual with PD.
There is growing evidence supporting
water exercise as a treatment method
for many other conditions, including
stroke, coronary rehabilitation and
other neuromuscular disorders such as
stroke or multiple sclerosis. This pilot
study, using descriptive measures, tests
of balance confidence and focus groups
attempted to show water exercise is
beneficial for individuals with PD to
help them maintain, and potentially
improve their physical and psychologi-
cal well-being. Individuals with PD
should benefit from water exercise ther-
apy because multidirectional hydrostat-
ic pressure of the water on the body vir-
tually eliminates falls, to which people
with PD are prone. Many people with
PD do not exercise because of the fear
of falling. Rehabilitation through water
exercise can provide a means for indi-
viduals with PD to maintain mobility
because they can exercise without the
fear of falling. Increased mobility will
enable them to remain independent for
a longer period of time, and costs to the
health care system could be reduced.
Symptoms of PD can be relieved
through a regular exercise program tar-
geted to increasing strength, flexibility,
endurance, balance and mobility by
using simple functional movements.
Research suggests physical exercise of
moderate intensity leads to an increase
in the level of dopamine, which sug-
gests an exercise program for individu-
als with PD would be beneficial.
11,24
A
clinical trial conducted at the School of
Physical and Occupational Therapy at
McGill University confirms the value of
therapy in maintaining functional inde-
pendence and in improving physical
and motor symptoms for persons with
PD. They perceived a significant
improvement in their psychological
wellbeing.
12
Other studies have obtained
similar results with improvements to
various degrees in mobility, dexterity
and flexibility.
10,13,14
There have been several studies related
to individuals with PD and improvement
of gait.1
5,16
The ability to generate a nor-
mal stepping pattern is not lost in PD.
Normal stride length can be elicited in
individuals with PD using attentional
strategies and visual cues, possibly
because both these methods focus atten-
tion on the criterion of stride size.
17
The first line of defence for treating
symptoms of PD is often drug therapy.
Exercise is not routinely added to that
regimen. However, chronic use of
drugs may cause more motor complica-
tions in those with PD.
18
Formisano,
et. Al., in 1992
19
found in a comparison
between individuals with PD treated
using drug therapy only and individuals
with PD treated with drug therapy and
exercise, there was a significantly lower
level of disability in the latter group. De
Goede, et.al., in a 2001 research synthe-
sis, concluded individuals with
Parkinson benefit from physical therapy
added to their standard medications.
25
However, there is conflicting evidence.
Pedersen, et.al. in 199020 reported a
deterioration of stride length and gait
velocity after physical therapy in ten
individuals with PD. Despite partici-
pants' reported subjective impressions
that the training was beneficial, there
was no statistically significant improve-
ment in the motor tasks. These results
suggest 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's
results disagree, because the training
program did not differ from those of
more successful group studies.
Research delineation between aquatic
therapy and general exercise for indi-
viduals with PD is sometimes unclear.
The majority of studies were done
using land-based exercise regimes, only
one study included exercises in water.
10
Water has rarely been tested as an exer-
cise medium, especially for people with
PD. One study showed hydrotherapy
produced greater benefits for people
with rheumatoid arthritis than exercis-
ing on land, combined with a progres-
sive relaxation program.
21
So why
would water be a good exercise medi-
um for individuals with PD? WaterArt
Fitness International Inc. a company
specializing in rehabilitation for neuro-
muscular, joint and other physical dis-
orders, in their manual for instructors,
27
claim one of the best places for training
posture and balance is in the water.
Water offers freedom from canes, walk-
ers and wheelchairs as these assistive
devices are replaced by a three-dimen-
sional support medium surrounding the
body. Postural improvement is achieved
as the body is stabilized in a vertical
position without the need for some-
thing to lean or sit on. Buoyancy pro-
vided by water allows participants to
practice 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 most
disabling symptoms of PD. If claims by
water exercise proponents were true,
being able to work on these impair-
ments on a regular basis would help to
maintain functionality and retard the
progression of the disease. Walking
through water can strengthen and
lengthen muscles with every stride as
moving 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 the
Parkinsons Association of SW Florida
under the direction of Marjorie Johnson
with 11 participants aged 63 to 88 years
in various stages of PD
22
At the end of
the 12 week project all participants had
experienced improved levels of func-
tionality through a water exercise pro-
gram targeted to their needs.
Pilot Study
The hypothesis of this pilot study was
that water exercise would help alleviate
symptoms of Parkinsons Disease. The
assumption was that water exercise
would have beneficial effects on the
symptoms of PD. The hypothesis was
generated from previous studies involv-
ing exercise and other joint or neuro-
muscular disorders such as arthritis,
osteoarthritis and multiple sclerosis.
Methods
This study took place at the
Scarborough Young Mens Christian

Association (YMCA) in Ontario,
Canada, in the shallow-retractable end
of their pool. Depth of the pool water
was consistently four feet, mid chest
level of a person of average height.
Water temperature was between 87 F
and 91 F (31 C and 33 C) which is
fairly warm for water in a pool. Intent
of the warm water was to warm the
muscles and thus facilitate movement.
All participants in the study had to be
at stage two or below on the Hoehn and
Yahr scale28 and well enough to care
for themselves. Land use of walkers,
canes and wheelchairs was acceptable
and did not preclude participation.
Individuals with PD who had not exer-
cised during the last four weeks were
given preference for this trial.
Participants were hard to recruit, espe-
cially participants who were at Stage 2
on the Hoehn and Yahr scale and had
not exercised prior to the study. Also,
defining Stage 2 was difficult as medical
practitioners use different rating tools
(UPDRS, Hoehn and Yahr, Schwab and
England Activities of Daily Living).
Finding participants willing to exercise
was an additional problem.
Transportation to and from the exercise
facility also proved to be a limitation.
Facilities with supervised, heated pools
suitable for this special population are
scarce, so transportation to and from
the facility was a problem for potential
participants, many of whom did not
drive any longer and were either afraid
to use public transport or did not live
close to public transport.
Because of these limitations, and because
this was a pilot study, the relatively small
number of four participants was deemed
acceptable for this trial. Of these four,
two came from retirement homes. One
participant was referred by his doctor,
and one by a friend. This small sample
size does not necessarily accurately
describe the population of PD patients.
The sample included one racial minority
(Philippino), and both male and female
participants. The age distribution was
from 71 89 years of age. Half of the
participants had exercised previously, but
not during the exclusion period. There
was no age restriction.
Activity Program
The first week involved an orientation
session and allotment of time slots for
the pre-test. The orientation session
described the study in detail and showed
the layout of the facility. At this orienta-
tion, participants had the chance to ask
questions pertaining to the study. After
all questions were asked and answered,
an informed consent form, and a med-
ical history form were given out to the
participants to complete. Also, partici-
pants met all core researchers of the
study and had a chance to talk to each of
them. Familiarization with the facility
was provided through a personalized
tour of all equipment, program and
change rooms.
At their appointed times participants
came to the YMCA for the pre-exercise
test. The pre-exercise tests consisted
of ten different tests measuring balance
(dynamic and static balance), cardio-
respiratory endurance (two minute step
in place test), mobility (get up and go
test), flexibility (chair, sit and reach
test, back scratch test), muscular fitness
(stride length and speed) and muscular
strength (bicep curl, sit to stand test).
All physical tests were derived from the
American Council of Exercise.
29
The
only test that was modified was the
stride length and speed test, which,
because of the small size of the gym,
was changed from a 50-foot walk to a
32-foot walk. Testing was done on land
in the studio room. These test served
as a baseline test to compare with the
test results at the end of the trial.
Participants were also given two sur-
veys: the Activities-Specific Balance
Confidence Scale (ABC Scale)
30
, which
looks at the level of self confidence at
the time of completion, and the Vitality
Plus Scale
30
, which looks at how the
participant is currently feeling.
Once participants completed all pre-
tests, they were ready to start the water
exercise program the following week.
For the next six weeks, participants
exercised in the water. Protocol for the
subjects was to wear a bathing suit for
the pool. To preserve warmth in the
body, all participants wore a swim vest.
As movement is easier when the body is
warm, wearing a vest also facilitated
movement. We asked that participants
eat lunch prior to exercise and remain
on their normal medication regime.
An instruction sheet with general
guidelines of things that participants
should be aware of was given at the
beginning on the study.
Water exercises from the WaterArt
Fitness International, Inc., manual.
27
were used for this program. Participants
would always start the water exercise
session with slow warm up exercises to
loosen muscles. The first two weeks
encompassed many walking, gait and
balance activities. No upper body exer-
cises were performed until the third
week of classes. At the beginning of
the third week of classes, many more
complicated and challenging movement
exercises were incorporated, and upper
body exercises were introduced.
Progressions were then included to
increase lower body strength and bal-
ance, and use of aqua steps was includ-
ed in the water exercise classes until the
end of the 6-week program.
Classes took place three times per
week: Monday, Wednesday and Friday
from 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 participants
were evaluated on their post physical
tests to see if any improvements
occurred.
Data Collection
The collection of data used to evaluate
the study was made at the end of the
six week program. Several methods
were used, including repeating the
physical tests given prior to the start of
the project. Both surveys given at the
beginning of the trial were repeated,
and results were compared using a
paired t-test to see if any subjective
improvements took place.
A third method used to analyze results
involved conducting a focus group at the
end of the study. To eliminate the possi-
bility of bias, an independent researcher
not familiar with the study conducted
the focus group. Partici-pants comments
thus collected allowed the researcher to
assess feelings and thoughts of partici-
pants about the study.
Additional information was gained
through observation of participants
during activities.

A journal log of all water exercise
classes was kept. This allowed the
researcher to make daily notes of all
participants, exercises done, and their
feelings at the time.
Results
Six people started the study but two
dropped out. One drop out was due to
anxiety in the water, and the other due
to a change in medication. All four par-
ticipants had PD.
The remaining four participants in the
study attended 89.5 +/- 10.2 percent of
the scheduled training sessions during
the six-week period.
Results from the physical testing scores
showed individual improvements on all
tests except for flexibility, which exhibit-
ed a slight decrease in upper and lower
body flexibility in 2 participants. Three
of the participants improved in both the
static and dynamic tests. One partici-
pant was unable to complete both bal-
ance tests and any improvement was dif-
ficult to measure. All participants
improved on strength tests, the bicep
curl test and the sit to stand test.
Endurance improved for all participants
as all individuals demonstrated improve-
ments in the 2-minute walk in place test
and the get up and go test. All partici-
pants improved on stride length, taking
fewer steps to walk 32 feet, and the time
to complete the 32 -foot course
improved in 3 of the 4 participants.
Even though no statistical tests of sig-
nificance were performed due to the
small sample size, such as in this pilot
study, the trend of these results does
seem to show improvement in physical
functionality through the many exercise
battery tests completed after the water
exercise program. Some physical per-
formance improvements occurred in all
subjects, and in all physical dimen-
sions, with only two subjects losing a
small percentage of flexibility over the
duration of the exercise trial.
The focus group session provided use-
ful subjective feedback about partici-
pants opinions of the water exercise
program. When asked if their confi-
dence in doing daily activities
improved, three of the four participants
claimed they were more confident.
They felt more confident because they
felt better, and they felt as though they
had improved. Participants reported
daily tasks were easier to perform, and
they were not as tired as before.
Increased confidence in doing activities
of daily living after the water exercise
therapy program was expressed in the
focus discussion session by three out of
the four participants. The one partici-
pant who said no to having more
confidence said that although she had
increased ability to perform chores, she
had always been confident in her ability
to do chores. There were no significant
differences between confidence scores
on the ABC Scale. Even though the
ABC scale showed no difference, partic-
ipants three and four did improve on
their self-confidence and abilities to
perform activities. Also, three of the
four participants did improve on their
Vitality Plus Scale score, although no
statistical significance was computed.
Discussion
A major limitation is the small sample
size. However, results of this study pro-
vide some indication of what an exer-
cise program can do for people with
Parkinsons Disease. All four partici-
pants improved on measures of physical
performance, as well as assessment of
wellbeing. The strength of this study is
it was one of the first in the field for
individuals with PD. There have been
few studies involving water exercises
and their effect on individuals with PD.
One very important finding of this
study is it suggests improvement
achieved after water exercise is not
restricted because of age. Rather
improvement might be based on the
severity of the disease. Although all
four participants were classified as a
two on the Hoehn and Yahr28 scale, the
range of impairment along the two clas-
sifications is large. The more severe the
disease, the more difficult it is for indi-
viduals with PD to exercise. But even
at an old age, well into the 80s, individ-
uals with PD can improve their physical
capabilities. This has implications for
the treatment of PD, in as much as it
points 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 to
be active and out of their homes. This
was especially true of the participants
living in retirement homes.
There are many limitations to this pilot
study. The temperature of the pool var-
ied from 87
o
F to 91 F. The air temper-
ature outside the water varied, and at
times it was cold enough to shiver. The
time at which each participant began
the exercise sessions varied somewhat.
Also, exercises were not always per-
formed simultaneously as a group for
the duration of the exercise session.
Rather, participants would perform dif-
ferent types of exercises during some
part of the exercise session. Another
factor was that some of the participants
needed constant re-assuring that they
were doing well and improving over
time. They needed constant positive
feedback from the researcher, and this
could have biased their opinion of
themselves and the study. Other limita-
tions are that some of the participants
were more active than others. They
engaged in activities such as walking or
therapy, which prevented them from
being sedentary and seeing the true
effects of the water exercises.
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 that
one cannot indisputably specify that
exercise reduces symptoms of PD.
Physical improvements did occurred in
participants in this study. However,
many participants had other diseases as
well. Three of the four participants had
some form of arthritis. One participant
had both osteoarthritis and rheumatoid
arthritis, and all participants experi-
enced back and knee joint pain. Water
exercise can help improve all these
problems and has been proven to allevi-
ate pain and increase physical well
being in osteoarthritis
22
and rheumatoid
arthritis.
23
It is hard to tell if the water
exercises did indeed alleviate the symp-
toms of PD, or increased the strength
and range of motion in the joints of
participants with arthritis, although the
fact that dynamic balance improved
noticeably seems to point to improve-
ment in PD specific impairments.
As not many studies have been done
involving water exercise therapy and its
effects on individuals with PD, not
much literature exists for comparison
purposes. The study involving
WaterArt Fitness International Inc27
shows the positive effects of water exer-
cise. Results from this study support
results found in the WaterArt study.
Muscular strength, endurance, gait and
balance all improved with this study.
Flexibility was the only dimension not
to improve from exercise in the water.
In general, support for the assumption
water exercise can improve physical
functioning for individuals with neuro-
muscular disorders is increasing.
Previous studies22,23 have outlined the
benefits of water exercise on joint disor-
ders, stroke recovery and other physical
impairments. This pilot study has
shown moderate exercise performed in
water over a 6 week period provides
physical and psychological benefits to
those with PD. Future studies involv-
ing water exercise and PD should
include a larger sample to justify the
preliminary results of this pilot study.
With the ageing of the baby-boomers,
PD will become more prevalent, as PD
is an age related disease. It is important
to take into consideration that effects of
some forms of neuromuscular disorders
can be improved with exercise.
Participating in an exercise program
with resulting improved physical func-
tioning may reduce the amount of med-
ication needed by the person with PD.
Improved physical functioning may
allow the PD sufferer to remain inde-
pendent for a longer period of time.
The last two points would result in
considerable savings in health care
costs. To substantiate the preliminary
findings of the currently available
research, more funding is needed for
research into rehabilitation, for design-
ing specific exercises for conditions
peculiar to PD and for developing best
practices. Hopefully this study will
serve as a stepping-stone for future
research into water exercise programs
for sufferers with PD. N
Ed. Note: All forms referred to are
available from the authors.
Baun, M. (2007). Fantastic Water
Workouts. Champaign, IL:
Human Kinetics. 240 pp. paper.
ISBN 978-0-7360-6808-6.
This book provides water exercisers
with an easy to follow duige to
improving fitness and physique.
Contents include more than 90 photo-
graph-guided water exercises and 25
step-by-step workouts addressing a
range of fitness objectives and interest
groups. Suitable for older adults, preg-
nant women, people in physical reha-
bilitation, and people with special
health considerations.
Grosse, S. (2007). Water
Learning. Champaign, IL: Human
Kinetics. 190 pp, Paper $20.
ISBN: 0736067663.
Reinforce academic learning, apply
multi-sensory techniques to therapeutic
practice, enhance perceptual-motor
development, fitness, and social interac-
tion all through these fun water activi-
ties. Use poly equipment, noodles, aqua
steps, wonderboards, and a variety of
readily available home items to stimu-
late creativity in the pool, as well as
therapy setting or classroom. Over 100
photos, an activity index, and assess-
ment protocols make implementation of
water learning easy.
Sova, R. (2007). Water Fitness
After 40. Port Washington, WI:
DSL. Paper, 208 pp. $23.95. ISBN
1-889959-30-8.
Looking for a safe and enjoyable way
to stay healthy and fit and slow the
effects of aging? In Water Fitness After
40 Sova, explains how you can use
water 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 exercise
logs that you can use over and over,
you can create a program tailor-made
for 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, and
17 cool-down exercises. Youll even
find 11 post-rehabilitation activities.
Part III shows you how to create your
own program, as well as make modifi-
cations for specific medical conditions.
Goal charts create a path to personal
fitness, and exercise logs assist in doc-
umenting progress. Part IV features 69
illustrations of the exercises from Part
II, alphabetized for easy reference.
The Appendix provides the names,
addressees, and phone numbers of 36
agencies and organizations that can
help get you exercising in the pool.
Available through www.aqua_gear.com
or the Aquatic Exercise Association
(888-AEA-WAVE or www.aeawave.com).
Additional information can be found
on the Home Page of AEAs website at
www.aeawave.com, click on Fit Pro
News/Articles. N
TRR
Feature Column:
New for Your Library
All references and authors for
this article can be found on the
Home Page of AEAs website at
www.aeawave.com,
Topics Include: (Partial List)
Intro to Aquatic Therapy and Rehab
ATRI Rheumatology Certification
Ai Chi Balance & Trunk Stabilization
Arthritis & Rheumatology
Back Rehab
Bad Ragaz Ring Method
Balance and Gait Training
Balance Progressions for Orthopedic
Rehab Fusions and Amputees
Chronic Neck Pain
Closed Chain Functional Programming
Functional Therapeutic Training - ADLs
Interactive Posture I & II
Lumbar Stabilization
Burdenko Method
Lumbar Stabilization for Spinal Fusions
Manual Techniques I & II
Orthopedics
Pediatrics
PNF
Risk Awareness/Safety Training Cert.
The Safe Way
Shoulder Stabilization
Soft Tissue Injury Rehabilitation
Trunk Stabilization
Watsu
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 and
rehab. Aquatic therapy and rehabilitation is a growing market and pro-
vides an excellent service to clients. As a health professional, heres the
opportunity to enhance your career with the most current essential infor-
mation you need to get started. Experiment with the basic concepts of
Ai Chi, Aquatic Feldenkrais, Bad Ragaz, Pilates, PNF, Halliwick, the
Burdenko Method, BackHab, Ai Chi Ne, Unpredictable Command
Technique, and Watsu in the pool, and analyze modifications and
precautions, indications and contraindications of each aquatic protocol
with each client need.
Risk Awareness & Safety Training Certification
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 response
plans, supervision, and techniques for responding to emergencies
within a medical/therapeutic facility. Gain a safety perspective on
water temperature, principles and properties of water, use of
equipment, and patient problems as they pertain to the therapeutic
environment.
ATRI Rheumatology Certification
The ATRI Rheumatology Certification acknowledges your skills and edu-
cation by providing advanced learning for rheumatological, autoimmune
and arthritis conditions. Gain better success with challenging conditions
like FMS, TKR, THR, etc. Know why you are doing the exercises (why
an exercise should or should not be performed) and plan for functional
carry-overs to land activities. Create safe progressions with clients with-
out causing flare-ups.
ATRI Certification Online
The Aquatic Therapy & Rehab Institute (ATRI) announces an online
option for the Aquatic Therapy Certification Exam. The online exam will
be a benefit to practitioners who have limited travel options. Anne
Miller, Executive Director of ATRI, says, Many educational institutions
are offering online education and degrees. ATRI is following that trend
so certification can be attained more conveniently for people with hectic
lifestyles. 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 take
the 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 pm
Sunday, September 9 Washington, DC Sheraton Premiere
(Vienna, VA) 1:30-5:00 pm
Sunday, November 18 Chicago, IL Westin OHare
(Rosemont, IL) 1:30-5:00 pm
Featured Courses
Register for ATRI Courses Anytime Online at www.atri.org OR
Call 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 Education
The Aquatic Therapy & Rehab Institute is proud to present several
opportunities for your continuing education experience:
2007 Specialty Institutes November 15-18 Chicago, IL Westin OHare
2007 Professional Development Days Saturday, October 6 Tucson, AZ Edith Ball Adaptive Recreation Center
Saturday, October 13 Weston, WV William R. Sharpe, Jr. Hospital
Saturday, October 20 Houston, TX Texas Sports Medicine Center
2008 Aquatic Therapy Education 16th Aquatic Therapy Symposium June 30-July 3
Sanibel 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 OHare (Rosemont, IL)
October 30-November 2 Washington, DC Hyatt Fair Lakes (Fairfax, VA)
November 20-23 Chicago, IL Westin OHare (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 selected
aspects of overall health on a
fibromyalgia population.
Behavior of heart rate, at a constant
speed, in different positions of aquatic
cycling in young overweight adults.

1 AEA Aquatic Fitness Research Journal October 2007 Volume 4 Issue 2
An Aquatic Exercise Association
Publication
October 2007 Volume 4 Issue 2
Published by the
Aquatic Exercise Association
PO Box 1609
Nokomis, FL 34275
Phone: 941.486.8600
Fax: 941.486.8820
Toll-Free: 1.888.AEA.Wave
Website: www.aeawave.com
Email: info@aeawave.com
AEA Aquatic Fitness Research
Journal Staff
Managing Editor:
June M. Lindle Chewning, MA
june@chewnings.com
Peer Review Committee:
Kimberly Huff, MS- chairperson
Paula Krist, PhD
Jodi Frank, PhD
Judith E. Powers, MS
Maria Sykorova-Pritz, MS
Please send all inquiries to the
Managing Editor.
Aquatic Exercise Association
Research Council
Jodi Frank, PhD
Jack Wasserman, PhD
Paula Krist, PhD
June Lindle Chewning, MA
Kimberly Huff, MS
Paulo Poli De Figueiredo, MS
Flavia Yazigi, MS
Maria Sykorova- Pritz, MS
The AEA Aquatic Fitness Research Journal
is a peer-reviewed journal. The journal
serves the aquatic fitness professionals
personal and professional interests
regarding research developments and
pertinent information in the aquatic
fitness industry. It is intended to stim-
ulate, support, and disseminate
research in the aquatic fitness industry,
as well as educational and research
institutions.
The AEA Aquatic Fitness Research Journal
may not be reproduced without written
permission from the managing editor.
Opinions of contributing authors do
not necessarily reflect the opinions of
the Aquatic Exercise Association.
Abstracts
A404 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The effects of a 24-week deep water
aerobic training program on bone density.
A405 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Effects of an aquatic strength training program
on certain cardiovascular risk factors in
early-postmenopausal women.
A406 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Effect of three months detraining on endurance
and maximum isometric force in elderly subjects.
Articles
Resisted training response in the water (Water Force) . . . . . . . . . . . . . . . . . . 3
for professional futsal (soccer indoors) players.
Fabrcio Madureira, Mestre; Faculdade de Educao Fsica de Santos- FEFIS- UNIMES Santos-SP
Henrique Frana, Especialista, Rodrigo Vilarinho, Especialista;
Antnio Michel Aboarrage Jr., Mestre; Dilmar Pinto Guedes Jr, Doutorando
The effect of water exercise on selected aspects . . . . . . . . . . . . . . . . . . . . . . . 6
of overall health on a fibromyalgia population.
Maria Sykorova-Pritz M.S.
Behavior of heart rate, at a constant speed, . . . . . . . . . . . . . . . . . . . . . . . . . 13
in different positions of aquatic cycling in
young overweight adults.
Ana Gouveia, Roxana Macedo Brasil, Ana Cristina Lopes Y. Glria Barreto,
Andra Cristiane Ferreira, Grace Barros de S
Table of Contents
October 2007 Volume 4 Issue 2 AEA Aquatic Fitness Research Journal 2
A404
The effects of a 24-week deep
water aerobic training program
on bone density.
E.Piotrowska-Calka,
B.Wajszczyk
2
J.Charzewska
3
Dept. of Swimming and Life Saving,
Academy of Physical Education,
Marymoncka 34, 01-813 Warszawa,
Poland
2
National Food and Nutrition Institute,
Epidemiology and Norms Department,
Powsiska 61/63, 02-903 Warsaw, Poland
3
Dept. of Anthropology, Academy of
Physical Education, National Food and
Nutrition Institute, Epidemiology and
Norms Department
OBJECTIVE: The purpose of this study
was to determine the influence of pro-
longed deep water aerobic training on
bone 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 of
women, between the ages of 30-62 par-
ticipated in this research. Additionally
the groups were divided: before
menopause (A2=6; 41.38,1yr; B2=10:
42.24,5yr) and postmenopausal
(A1=10; 54.64,5 yr; B1=9; 55.14,9yr).
METHODS: Group A participated in
a 24-week deep water training program,
exercising twice a week for 45 minutes.
Control group B was asked to provide
normal daily activity and not engage in
any physical exercises. Subjects in
group A were tested before and after the
24-week program and compared with
group B. Forearm bone mineral density
in the non-dominant arm was examined
using OSTEOPLAN+ p-DXA in the
mid distal and ultra distal section.
Information on dietary intake was
obtained by three-day food records (two
workdays and one weekend day).
RESULTS: The mean values of BMD in
both groups of postmenopausal women
(exercisers and control group) were
contained in the range of changes rec-
ognized as the progressive physiological
process. The study showed in both
groups many risk factors for osteoporo-
sis. The most important of them was
small in the relation to norms for con-
sumption of calcium, magnesium, zinc,
copper and vitamin D (except exercis-
ing postmenopausal women - A1
group) and excessive consumption of
protein, phosphorus and sodium.
The main irregularities are: insufficient
intake of calcium, magnesium, zinc,
copper and vitamin D (except group
A1) and excess in relation to RDA of
safe level intake of protein, phosphorus
and sodium.
KEY WORDS: Deep water aerobic
training-bone mineral density-
nutritional intake-women. N
Abstracts
A405
Effects of an aquatic strength
training program on certain
cardiovascular risk factors in
early-postmenopausal women.
Juan C. Colado
1
, Pedro Saucedo
2
,
Victor Tella1, Fernando Naclerio
3
,
Ivn Chulvi
1
, Jose Abellan
2
1
University of Valencia (Spain),
2
Catholic
University of Murcia (Spain),
3
European
University of Madrid (Spain)
Supported by PMAFI-PI-01/1C/04 from
Catholic University of Murcia (Spain).
Despite it being known that local mus-
cular endurance training has a positive
influence on the prevention of various
physiological parameters associated
with certain cardiovascular risk factors
among early-postmenopausal women,
there are still few scientific studies that
have shown the influence of said activi-
ties when carried out in the aquatic
medium.
PURPOSE: To identify the effects of a
periodized aquatic program for strength
training (PAPST) on certain cardiovas-
cular factors of early-postmenopausal
women.
METHODS: 40 sedentary women vol-
unteers without medical contraindica-
tions were chosen: Seventeen (54.73
1.98 yrs) subjects trained in the aquatic
medium and twenty three (52.90 1.85
yrs) were the control group (CG). The
aquatic exercise group (AEG) trained
for 24 weeks with a periodized program
for local muscular endurance based on
OMNI-RES and with devices that
increased drag force, carrying out ener-
getic movements at all times and using
the material that best allowed each sub-
ject to adapt to the prescribed intensity.
The program was: (a) 1st and 2nd
month: 8 full-body exercises (F-B E), 2
sets, 20 repetitions, 30 seconds rest
interval (RI); (b) 3rd month: 8 F-B E, 3
sets, 20 repetitions, 30 seconds RI; (c)
4th and 5th month: 10 F-B E, 3 sets, 20
repetitions, no RI; (d) 6th month: 8 F-B
E using the pre-exhaustion method, 15
repetitions, 30 seconds RI. They did not
change their eating habits.
Cardiovascular risk factors were
assessed using some pre-post tests.
RESULTS: The PAPST reduces the risk
of cardiovascular disease in the AEG vs.
CG, respectively: Systolic Blood
Pressure (mm Hg) -9.14, p0.01, 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. Basal
glycemia (mg/dL) +0.04, p>0.05, vs.
+6.74, p<0.05. Apolipoprotein B
(mg/dL) -8.21, p0.05, vs. +3.92,
p>0.05. Triglycerides (mg/dL) -7.65,
p<0.01, vs. +2.11, p>0.05. Waist
perimeter (cm) -3.667, p<0.01, vs.
+2.35, p<0.05. Total fat mass (kg) -
2.942, p0.01, vs. -0.611, p>0.05.
CONCLUSION: The PAPST is seen to
be effective in reducing cardiovascular
risk factors during the critical early-
post menopause period. N
A406
Effect of three months detrain-
ing on endurance and maximum
isometric force in elderly subjects.
Author Block: Flvia G. Yzigi, Paulo A S
Armada-da-Silva. Faculty of Human
Kinetics, Oeiras, Portugal.
Email: fyazigi@fmh.utl.pt
Compared to what is known about the
effect of exercise programs on
endurance and strength capacities in
the elderly, the effect of detraining is
much less documented.
PURPOSE: The purpose of this study
was to evaluate the effect of 3 months
of discontinuation of participation in an
exercise program in elders on general
endurance and maximum strength of
the lower limbs.
METHODS: A total of 21 elderly sub-
jects agreed to participate in this study.
The subjects (12 females, age 72.54.9
and 9 males, age 70.47.7 yrs) were
participants of a community exercise
program, composed of 1-hour sessions
twice a week designed to improve
endurance, muscle strength and resist-
ance, balance and coordination.
Subjects were tested just before the 3-
month summer holidays (BSH) and
immediately before resuming the exer-
cise program after the summer holidays
(ASH). Endurance was assessed by the
six-minute walk test (6MWT). Maximal
lower limb isometric force (MF) and
maximal rate of force development
(RFD) were measured on the right side
during static leg-press against a force
platform. Total physical activity was
assessed by applying the Portuguese
version of the International Physical
Activity Questionnaire (IPAQ). Results
of BSH and ASH were compared by
paired t-tests. Relationships between
variables were explored by linear corre-
lation.
RESULTS: MF and the outcome of the
6MWT were significantly correlated
(p<0,000 and p<0.05 at BSH and ASH,
respectively). The 6MWT results
declined by around 6.5%, decreasing
from 658.581.6m at BSH to
615.99.0m at ASH (p<0.05) whereas
body mass and total daily physical
activity declined by around 2.5 kg
(p<0.05) and 879755 METS
(p<0.000), respectively. No differences
in MF and RFD existed between BSH
and ASH.
CONCLUSIONS: A three month inter-
ruption of physical exercise significant-
ly decreases endurance. The decrease in
body mass registered after the 3-month
holiday might indicate loss of lean
mass, but this change was not accompa-
nied by decreased lower limb muscle
strength. This study indicates that
endurance and walking ability are lost
at higher rates with detraining than iso-
metric muscle force generation capacity
in elderly subjects. N
With the changes in the rules in futsal
over the last decade, components such
as maximum strength, strength resist-
ance and explosive strength have
become pivotal skills in a players per-
formance. With that principle as a start-
ing a point, we analyzed the effects of
resisted training in the liquid environ-
ment, particularly the Water Force
(WF) program, on futsal professional
players. The study was performed with
athletes of the Santos Team, with expe-
rience of more than 10 years in the
sport. Motor skills tests, as described
by Giannichi (1998), were used in the
pre and post-tests as comparative
parameters. The program lasted 4
months, with a 3 day per week sched-
ule and 50 minutes for each session.
The results of the study showed that
the WF program can boost the increase
of the physical skills inherent to the
game, 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 and
physical aspects resulting from the
changes in the games rules. The new
aspect of the game mainly modified the
determinant physical characteristics for
an athletes good performance. In the
matches proposed by the International
Federation of Futsal (FIFUSA), the
game was considered to be slower; the
official ball was heavier, of smaller cir-
cumference and difficult conduction,
causing the tactical standard to be slow-
er. In the 90s, after FIFUSA joined
forces with FIFA, those characteristics
were modified in order to make the
game more dynamic and attractive. One
of the major changes happened with
the main instrument of the game, the
ball, which became bigger, with a sixty-
four centimeter circumference, and
lighter, with in the maximum weight of
four hundred and thirty grams.
According to Santos (1998) the changes
in the ball allow it to be faster, which
requires a better domain and control
from 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 to
Weineck (1998), for a good perform-
ance during the game, the athlete
should give priority to the physical fac-
tors of performance, leading us to
Resisted training response in the water (Water Force)

for professional futsal (soccer indoors) players.
Fabrcio Madureira, Mestre; Faculdade de Educao Fsica de Santos- FEFIS- UNIMES Santos-SP, shark@usp.br
Henrique Frana, Especialista, Rodrigo Vilarinho, Especialista; Antnio Michel Aboarrage Jr., Mestre; Dilmar Pinto Guedes Jr, Doutorando
TRR
Article
believe in the importance of highlight-

ing the training of the physical capacity
determinants of a game. The higher
pace during the matches caused the
structure of the physical training of the
players to be modified, as opposed to a
higher cardiovascular condition that
was emphasized in the seventies as the
best way to increase resistance for the
game. Thus, the development of mus-
cular strength should be prioritized
during specific training as proposed by
Shinkarenco (1997). For Guedes Jr.
(2003), strength is the capacity to exer-
cise muscular tension against a deter-
mined resistance, being able to boost
the speed as it increases, boosting two
fundamental specific characteristics for
the futsal athletes: reaction power and
changes of direction in speed. These
factors enable a better tactical and tech-
nical use of the player. Therefore,
training programs that favor strength
development and hypertrophy will
become indispensable strategies for
futsal today.
The liquid environment seems to be a
unique environment for the develop-
ment of strength, due to the waters
resistance to the movements such as in
water aerobics. When trying to propel
a segment in fluid, an individual experi-
ences a force known as drag
(Maglischo, 2003). The nature of this
force is explained by the physical char-
acteristics of the water, such as the
internal pressure, density, and viscosity.
The reaction of the water to body
movement appears as: a) forces of per-
pendicular pressure to its frontal area;
and b) forces of friction acting along
the body surface (Vorontsov &
Rumyantsev, 2004). Thus, mechanical
work performed by the water aerobics
practitioner is aimed to overcome
hydrodynamic drag. This resistance
can be divided in two categories: pas-
sive and active (Kolmogorov &
Duplisheva, 1992). The magnitude of
the reaction of the first results of the
vortex produced behind the segment
being propelled (when we propel our
leg forward, the vortex produced
behind it pulls the segment backwards)
may be influenced by the speed of dis-
placement of the segment; by the
stream of the water (laminate or turbu-
lent); friction of the fluid with the skin
(Sharp) and depth of immersion
(Vorontsov & Rumyantsev, 2004). The
active drag, on its turn, occurs when
the water aerobics practitioner moves
masses of water with his body seg-
ments; therefore, this drag is considered
a function of the movements, as well as
the anthropometry of the practitioner.
Since it is an environment of great plas-
ticity regarding the interaction with
other organisms, one of the most fan-
tastic characteristics of the water is that
it is unlimited when it comes to pro-
ducing resistance loads. This means
that as the practitioner gets stronger,
the counter-resistance produced by the
water to this organism gets proportion-
ally bigger, and what is extraordinary is
that this fact occurs automatically and
in a specific way for each individual.
Based on the assumptions previously
discussed, professors of the Santos
Metropolitan University Physical
Education College, created a program
of resisted training in the liquid envi-
ronment called Water Force (WF). The
results 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 caused
us to ask the following question: if the
program proved to be efficient with
university youths, what would be the
responses with professional futsal ath-
letes? Thus, we tried to elaborate local
exercises applied to the specificity of
the motor gestures performed during
the games, aiming to boost the determi-
nant capacities of a match: maximum
strength, strength resistance, and explo-
sive strength.
Equipment and Methods: 16 male
athletes, with an average age between
18 and 25 years, with average heights
of 1.770.06 meters and weight
71.2406.56 kg took part in this study.
All of the individuals were professional
futsal players from the Santos team
with more than 10 years of practice
experience. A point that must be
stressed is that this group of players
had already trained for six months
before the strength work in the liquid
environment began, aimed at the sec-
ond semester of the season. Before col-
lecting the data, the athletes underwent
a week of training tests in which the
information about the procedures was
administered. Each player performed
the tests experimentally, under the pro-
fessors supervision in order to point
possible errors in the performance of
the procedures. The week of evaluation
was 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 the
pre-training, intermediate training and post-training periods.
Pre Inter Post
TBW (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 [confidence
interval 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 the
players had positive modifications for all the tested variables: ABD (rep),
APU (rep), MDLP (kg), FL (cm). These variables are extremely important for
the maintenance of the condition of the game, preventing injuries and
stress by early fatigue.
mental testing week, with the following
analyses: total body weight (TBW);
height (H); fat percentage (FP); thin
mass (TM); anaerobic power (ANAP),
aerobic power (AEP); flexibility (FL);
agility (AP); maximum dynamic leg
press (MDLP); abdominals (ABD); arm
push ups (APU); and stand long jump
(SLJ). All of the tests administered in
the week of evaluation are described
by Giannichi (1998).
Program Description: The athletes
participated in training sessions of 50
minutes each, three times per week.
Exercise sets were performed for the
following muscle groups: chest and
dorsal muscles through horizontal
adduction and abduction of the shoul-
der, front and back thigh muscles by
flexing and extending the knee, biceps
and triceps brachii with vertical flexion
and extension of the elbow, thigh
adductors and abductors through hip
abduction and adduction. Three sets
of 12, 14 and 16 repetitions were per-
formed for each muscle group, with a
45-second recovery interval between
sets. Between the muscle group
changes, there was a 1 minute interval
of active recovery (stationary running).
All the athletes were instructed to use
maximum contractions during the
series. In order to better quantify the
training loads, hints for amplitude and
performance acceleration were routinely
presented. During the training of the
muscle groups chosen for the sets, the
lower limb exercises approximated the
execution and use of, as specific as pos-
sible, motor gestures used during the
futsal match. The objective was the
possible transference of strength gain
for the specific gestures involved in the
game, movement and changes in direc-
tion. After three months of training,
the athletes were submitted to re-evalu-
ation aimed at analyzing the response
imposed by the training, observing
points that might have possibly helped
in maintenance of the game condition.
Statistical Handling: After an
exploratory analysis of the data and fur-
ther corroboration of the normality of
the characteristics evaluated, the aver-
age (standard deviation) and the confi-
dence interval were calculated, with a
confidence coefficient in 90% for the
description of the studied sample. The
analysis of variation for repeated meas-
ures was applied to assess the statistical
significance of the effect of the training
used. Whenever necessary, a post-hoc
LSD was used along with the
Bonferroni correction for multiple com-
parisons in order to determine at which
points of the training the changes took
place. The statistical significance level
was 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 press
weight (MDLP) and flexibility (FL) between the pre-training,
intermediate training and post-training periods.
Pre Inter Post
ABD (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- training
for 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 Water
Force 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-training
periods.
Pre Inter Post
SLJ (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 [confidence
interval 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.
Results: The anthropometry data

(See Table 1) show that the Water Force
program was efficient for the reduction
of (FP%) and an increase of muscle
mass, variables that are extremely
important for that game considering
that predominant movement in the
game is intermittent (Turibio, 2005)
requiring the athlete to be lighter in
order to boost speed and strength.
Conclusion: Training in the liquid envi-
ronment has been largely used with the
purpose of helping the post-exercise
recovery process for players. In this
study, we were able to observe that this
environment can also be presented as a
viable alternative to combine with the
training of futsal players, enabling the
improvement of motor capacities inher-
ent to the game, as well as positive
alterations in body composition. Thus,
water aerobics, specifically the Water
Force program, can be seen as another
efficient training alternative for highly
skilled athletes. N
Bibliographical References:
Ferreira, R,L. Futsal e a iniciao. Rio de Janeiro:
Sprint,1998.
FIilho J, L,S. Manual de futsal. Rio de Janeiro: Sprint,
1998;
Giannichi, R,S. Avaliao e prescrio de atividade fsi-
ca. So Paulo: Shape, 2 edio, 1998.
GuedesJr., D. P. Musculao: esttica e sade feminina.
So Paulo: Phorte, 2003
Guedes Jr, D. P.; Rocha, A.; Guerardi, F.; Madureira, F.
Treinamento de Fora no Meio Lquido. 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.
Comparao do treinamento abdominal dentro e fora
da gua. 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: preparao fsica.
So 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-
aes morfolgicas decorrentes do treinamento de
fora no meio lquido, Revista Cientfica JOPEF, v.1,
n.1, p.27, 2004.
Vorontsov, A. R. & Rumyantsev, V. A. Foras resistivas
na natao. In Zatsiorsky, V. M. (Ed.) Biomecnica do
esporte: performance do desempenho e preveno
de leso. Rio de Janeiro: Guanabara Koogan, 2004.
Weineck,J. Treinamento Ideal, 9 edio; Rio de Janeiro:
Manole, 2000.
The effect of water exercise on selected
aspects of overall health on a fibromyalgia
population.
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 of
a water exercise class on the overall health of a study group diagnosed with
Fibromyalgia Syndrome (FMS).
To achieve the first aim, 18 FMS subjects were compared with 18 healthy subjects
using 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-fitness
agency, using an aquatic group exercise program (Aquajoy) twice per week for 14
weeks. Integrated within the group treatment were techniques such as somatic exer-
cises, passive stretches, progressive muscular relaxation, visualization, biofeedback
and cranial-sacrum relief. The program was designated specifically to treat the
physiological 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 the
second aim, observations of overall health were collected based on self-reports from
the participants using both quantitative and qualitative information. Quantitative
measures observed participants perception of how they were feeling on several
aspects 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 included
response to three questions: 1) What did Aquajoy do for you, how did it make you
feel? 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 healthy
subjects a between group comparison. Data analysis for the second aim was per-
formed by comparing scores for each subject on different aspects of overall health
during 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 with
Aquajoy maintained their level of pain, improved slightly in stiffness and soreness,
and improved substantially in energy and strength, mood and loneliness and overall
health during the within group comparisons.
Evidence from this study suggests that aquatic exercise can aid the FMS population
by improving overall health. This may contribute to increasing quality of life and
improving the ability to cope with the disease.
Maria Sykorova-Pritz M.S. sykorovasynchro@hotmail.com
TRR
Article
Background:
TERMS: The term, Fibromyalgia
Syndrome (FMS), is a combination of
the Latin roots:
FIBRO-connective tissue fiber;
MY-muscle; AL-pain; GIA-condition of;
SYNDROME-a group of signs and
symptoms that occur together which
characterize a particular abnormality.
Although the term, Fibromyalgia (FM),
has appeared in literature for more than
100 years, the disease is still a mystery
and the medical profession has called it
many different names: chronic rheuma-
tism, myalgia, pressure point syndrome
and fibrosis.
In 1987, The American Medical
Association (AMA) recognized FMS as
a true illness and major cause of dis-
ability. In 1993, the World Health
Organization (WHO) established FMS
as 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 and
fibrous tissue that causes widespread
fatigue, sleep disorders, stiffness, anxi-
ety and chronic aching. FMS is referred
to as a syndrome because it is a set of
signs and symptoms that occurs togeth-
er consistently (Mau, 1987). This does
not mean that FMS is any less serious
or potentially disabling than an ordi-
nary disease.
CAUSES: The causes of FMS are
unknown, but current FMS researchers
have uncovered a number of clues as to
what triggers FMS or causes a predispo-
sition. A physical stressor, such as the
flu, can lead to certain hormonal or
chemical changes that promote pain
and disturb sleep. Emotional stress is
linked to increasing rates of psychiatric
disorders like anxiety, depression and
distress which can trigger dysfunction
in the hypothalamus, pituitary and
adrenal glands if the stress is persistent
(McBeth, 2001).
In 2001, researchers discovered that
people with both the FMS and chronic
fatigue syndrome (CFS) were more like-
ly to have experienced physical, emo-
tional, or psychological abuse. These
findings support the belief that chronic
stress plays a pivotal role in the devel-
opment of FMS and CFS (Van
Houndenhove, 2001).
SYMPTOMS: The basic symptoms of
FMS occur in approximately 2-4% of
people in industrialized societies
(Littlejohn, 2001), of which 90% are
middle-aged females slightly younger
than 50 years old. The number of chil-
dren with FMS is growing. It is referred
to as Juvenile Primary Fibromyalgia
Syndrome (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, or
nothing, and instead rules out other ill-
nesses. This can be termed diagnosing
FMS by a diagnosis of exclusion
(Remington, 2001). After ruling out
other illnesses, a diagnosis of FMS by
health professionals is based on taking
a careful personal and family history
and pinpointing tender areas in specific
locations of muscle throughout the
body called tender points. The crite-
ria for FMS classification determined by
the American College of Rheumatology
in 1990 state that for the patient to be
diagnosed as having the condition, she
first must have a history of widespread
pain. The pain must be long term
and ongoing, and it must be present in
all four quadrants of the body lasting at
least three months. Pain must be pres-
ent in at least 11 of 18 tender points
that are painful to the touch.
Goals and Hypotheses
of Study:
Goals of the study: The goals of this
study were to: 1) to establish that a
study population with FMS have higher
life stress than healthy subjects; and 2)
to test a comprehensive water exercise
program called Aquajoy in a group
setting.
Hypotheses of the study: 1) Subjects
who have FMS will have higher levels
of stress than healthy subjects as
measured by the Stress Analysis
Questionnaire; 2) Subjects who have
FMS will have improved health after
treatment with Aquajoy as measured
by observing several aspects of overall
health such as sleep, pain, stiffness,
soreness, energy/strength, tiredness
and mood/loneliness.
.
Materials and Methods
of the Study:
Subjects: 1) 36 subjects were recruited
to participate in the Stress Analysis
Questionnaire: 18 subjects had FMS as
diagnosed by a physician, and 18 were
healthy; 2) a separate group of six
female subjects diagnosed with FMS by
a physician were recruited to participate
in the Aquajoy treatment.
Materials: To explore the first hypothe-
sis, we used the Stress Analysis
Questionnaire, which was specially
designed to assist with a stress status
evaluation. It measures three specific
aspects of stress: level, causes and
associations with personality types (A,
B, Ab, and Ba). It is a self-administered
questionnaire that requires minimal
training to take and probes stress expe-
riences during the previous year. The
various items across the level and caus-
es of stress were weighted differently
and 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 compiled
to represent the FMS subjects and
healthy subjects as separate groups
for comparison.
To explore the second hypothesis, a
water exercise treatment program was
developed and executed as a group
program. The program was embedded
in concepts that supported aquatic
exercise as therapeutic physiologically
and psychologically. During the
course of this study, we monitored and
documented (by a self-rating method)
the effect of the water exercise pro-
gram by observing the level of severity
of FMS symptoms across several spe-
cific dimensions: sleeping habits, pain,
stiffness, soreness, energy/ strength,
tiredness, mood/ loneliness. These
dimensions were selected for measure-
ment because they are typical symp-
toms of FMS and they represent broad
aspects of overall health. Each dimen-
sion was measured using a 6-point
Likert scale that was adapted from a
visual analogue that measures pain
according the following progression:
0 = feeling very horrible; 1 = feeling

very poor; 2 = feeling poor; 3 = felling
fair; 4 = feeling good; 5 = feeling very
good (See Figure 1). In addition to
quantifying these dimensions of FMS
and the response to treatment, we also
asked the subjects to answer three
open ended questions that probed how
they subjectively responded to the
treatment (See Figure 1). Subjects
were treated twice weekly over 14
weeks, and they were instructed to fill
out the data collection sheet (See
Figure 1).
First, we evaluated the stress score by
comparison of the two groups organ-
ized by age, participants diagnosed with
FMS (FSMP) and a healthy population
not diagnosed with Fibromyalgia
syndrome (HP)) and a stress score.
All results were statistically proven with
the same method we evaluated the
Relationship of Stress Score to
Personality Type.
Second, to see if the Aquajoy water
exercise class was beneficial for the
improvement of overall health to the
subjects of our study group, we evalu-
ated progress of Average Overall Well
Being/ Overall Heath; Average
Overall Sleep Patterns; Average
Overall Pain; Average Overall
Stiffness; Average Overall Soreness;
Average Overall Tiredness; and
Average Overall Mood/ Loneliness.
We compared a week-to-week rating of
Percentage of Improvement- Overall
Well-Being/ Overall Health for the
first five weeks.
Results of Study and
Discussion:
Results of the Stress Analysis
Questionnaire were organized in four
tables (Table #1 and Table #2 for results
of subjects with FMS (FSMP); Table #3
and Table #4 for results of healthy
subjects (HP). We documented
name (initials), age, gender (M- male,
F- female), stress level number and type
of personality.
Results of Stress Analysis Questionnaire
Survey:
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 Aquajoy
Participants Feeling Journal were
gathered in Table #6. We established
a weekly average feeling number for
Figure #1 AQUAJOY PARTICIPANTS 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 Sun
Aquajoy
How do you feel in the following areas: (5) feeling very good; (4) feeling
good; (3) feeling fair; (2) feeling poor; (1) feeling very poor; (0) feeling very
horrible.
Total# Mon Tue Wed Thu Fri Sat Sun
Sleep
Habits
Pain
Stiffness
Soreness
Energy/
Strength
Tiredness
Mood/
Loneliness
Total #
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 average
number 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 of
participants.
Sleep disorders are probably one of the
most devastating symptoms associated
with FMS. Sleep disruptions interfere
with the production of growth hormone
needed 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 with
sleep. Restful sleep is one of the keys
to restoring health and returning to an
active lifestyle. Average Overall Sleep
Patterns of the study group did improve
over the course of 14 weeks.
Pain is a logical side effect of perpetual
muscle contraction and insufficient,
inadequate sleep. The participants of
Aquajoy did not improve during the
course of this study, but maintained
Chart #2
Relationships of Stress
to Personality Type
Chart #3 Average Overall
WellBeing/Overall Health
Sleep Patterns
(The dark grey line is the beginning
well-being number, and the light grey
line is the weekly updated average
well-being number).
Table #1 Results of Stress Analysis Questionnaire of FMSP
Initial Age Gender Stress Score Personality
Type
1. SVT 27 F 147 B
2. DC 60 F 98 A
3. DA 42 F 307 A
4. BSU 37 F 147 A
5. SFR 58 F 94 B with A
tendency
6. BH 51 F 155 B with A
tendency
7. SD 45 M 109 Strong A
8. ENB 40 F 311 A
9. BP 62 F 146 A with B
on way
10. IM 54 F 165 B
11. JLF 72 F 14 B
12. CP 35 F 302 B with A
tendency
13. RR 42 F 101 B
14. BF 27 F 170 B
15. MP 42 F 97 B
16. BMC 54 F 318 B with A
tendency
17. LC 40 F 206 B
18. 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
Type
1. JH 26 F 61 B
2. HH 26 M 136 B with A
tendency
3. JF 30 F 100 A with B
tendency
4. JW 19 F 180 B
5. DC 20 M 44 B
6. EB 24 M 98 A with B
on way
7. JC 32 M 26 B with A
tendency
8. PR 40 F 54 B
9. MB 23 F 68 A with B
tendency
10. MF 42 F 28 B
11. AMC 23 F 47 A with B
tendency
12. SM 26 F 72 B
13. AK 23 M 120 A with B
tendency
14. AO 22 F 217 B
15. SL 42 M 47 B
16. DSB 20 F 209 A with B
tendency
17. SKR 18 F 116 B with A
tendency
18. SM 22 M 56 B
Table #4 Average stress score of HP
Age Range # of Participants Average
& Gender stress score Total #
18 29 13 (8F & 5M) 109.54
30- 39 2 F 63 215.54
49 - 49 3 (2F & 1M) 43
Table #2 Average stress score of FMSP
Age Range # of Participants Average
& Gender stress score Total #
18 29 2 F 158.5
30 39 2 F 224.5
40 49 6 (5F & 1M) 188.5 875.5
50 59 4 F 183
60 69 3 F 107
70 - 79 1 F 14
their level of average overall pain (See
Chart #6). FMS is a chronic pain condi-
tion and maintained levels of pain with
increasing physical activity means that
the particular method used in this study
is a great advocate for pain control.
Stiffness is one of the major symptoms
of FMS. When remaining in one posi-
tion for any length of time, the body
stiffens in that position due to inflexi-
ble myofascia, producing a low range
of motion and affecting flexibility. By
exercising in water the participants
increased blood flow to muscle tissue.
This enhances the transport of oxygen
and nutrients to the muscle fiber, help-
ing restore and maintain the health of
muscle tissue. When muscles, liga-
ments and tendons become more
resilient, it means that stiffness will be
reduced. We documented a slight
improvement of Average Overall
Stiffness of the study group, which also
improved overall muscle and joint
function.
Soreness is a type of pain, created by
toxins and all the wastes from cellular
processing, which must pass through
the connective tissue to reach the
lymph and blood vessels. When the
myofascia sticks together, neurotrans-
mitters cant work properly. Muscles
receive insufficient fuel and oxygen.
This can result in a sensation of sore-
ness. Participants in the study slightly
improved and maintained Average
Overall Soreness, which shows that the
Stiffness
Aquajoy water exercise program served
as 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 the
overall physical and emotional response
of the participants bodies to the Aquajoy
program. We can also see how well the
body and mind did connect due to this
exercise program. Average Overall
Energy/ Strength in the group did
improve greatly during the length of the
study. Improvement of Average Overall
Energy/Strength was gradual as in every
chronic pain and stress management
treatment. We can also see a pattern of
Chronic Pain Cycle and Flare Ups
(the period of improvement is followed
with a period of slight regression or
maintenance). Generally the aspect of
Overall Well- Being/ Overall Health
and in our case Average Overall
Energy/Strength, is improved.
Tiredness is the bodys warning sign
Table #5 Relationship of Stress Score to Personality Type
Fibromyalgia Population (FMSP)
Personality A Ab Ba B
Type
# of 5 1 4 8
participants
Average 194 146 217.25 122.25
Stress Score
Regular Healthy Population (HP)
Personality A Ab Ba B
Type
# of 0 5 4 9
participants
Average - 119 81.25 84.33
Stress Score
Table #6 Weekly feeling average number of study group based
on symptoms of FMS
Symptoms:
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 161.9 157.55 154.7 151 172.7 159.45 163 193.25 174 186 180 186 205 187
level of
Well-Being
After 14 weeks of rating themselves, the participants of the Aquajoy Water Exercise Program did improve in Average
Overall Well-Being. See Chart #3 showing the results of the Aquajoy class for a FMSP.
Soreness
that the organism is overwhelmed and

needs to be rested. It is also a sign of
how efficiently the body can function.
Having energy for endurance of the body
and mind, without feeling tired, enables
you to live a more functional and full
life. Average Overall Tiredness of the
study group did improve very gradually,
which is an encouraging result.
Depression, isolation and feelings of
worthlessness are common feelings
among the FMS population. A substan-
tial improvement in Average Overall
Mood/Loneliness was noted in the
study group. The results indicate that
the Aquajoy program had a positive
effect on the emotional health of the
group, which is a significant part of
success in fighting FMS. Aquajoy classes
also served as a support group reducing
isolation that can lead to the feeling of
loneliness.
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 method
of evaluation of six participants and
by evaluating progression in several
aspects of overall health during the 14-
week study, we did see an improvement
in overall health. Exercise class was
designed not only as an activity of the
physical body, but also as an activity to
benefit emotions, intellect and spirit.
The aspects of overall health screened
for 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 nervous
system 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 influence
the function of the central nervous
system and quality of the sensory-
motor learning process.
It is recognized that physiological
symptoms can arise from psychological
causes such as stress. This is very char-
acteristic for FMS patients and for our
group participants as well. This is a
somatic viewpoint; namely that every-
thing we experience in our lives is a
learned adaptive response and can be
unlearned. By adapting this behavior in
life it affected our subjects to feel less
tired and have more energy/ strength.
This is exemplified in Participant # 3,
J.E.M., who learned how to listen to
signals of her body (biofeedback) and
ultimately performed better.
Pain and continued injury can be
avoided by reinforcing a participants
good postural alignment with three
functions that water provides
assistance, resistance and support.
Participants can exercise with little or
no pain, perhaps for the first time in
years. This builds hope and breaks
isolation/loneliness providing the moti-
vation to continue water activity.
Aquajoy did serve as a natural, gentle
and safe tool to manage chronic pain,
relive stress and restore freedom of
movement.
Conclusion:
Making a lifelong commitment to an
exercise program is an important aspect
of reduced medicinal treatment. Low
impact or non impact exercises and
activities have been advocated to
improve symptoms and well-being,
making an aquatic exercise environ-
ment an excellent medium for reducing
symptoms of FMS. The emotional/mind
component of the class is to stabilize
emotions, stimulate the central nervous
system and improve social participation
and relationships. The socio-psycho-
logical aspects of the class are to build
positive behavioral changes in very gen-
tle ways and to create positive expecta-
tions, trust, respect and feelings of nor-
malcy in an abnormal situation. Being
with others who are suffering and
working together to find relief dispels
the feeling of isolation. The physical/
body component of the class has the
goal to improve general fitness,
strength, endurance, increase circula-
tion, oxygen consumption and prevent
injuries by improving the biomechanics
of movement. Improving posture for

Energy/Strength
Tiredness
Mood/Loneliness
Behavior of heart rate, at a constant speed, in different positions of

aquatic cycling in young overweight adults.
Introduction:
Prospective studies show that accumu-
lation of fat and physical ineptness are
risk factors for the development of sev-
eral diseases (Machado; Sichieri, 2002,
Maranhao Neto et al, 2005). The rise of
obesity is causing an increased need to
control and to measure some variables
during the performance of exercises, for
instance the hemodynamic variables.
Recently, aquatic activities have been
increasingly used for rehabilitation,
therapies and general physical readiness
(Fujishima; Shimizu, 2002). Among
aquatic activities, aquatic cycling is an
alternative for cardio-respiratory condi-
tioning, applicable to all age groups and
different fitness levels (Ferreira et al,
2005).
The particular physical properties of
water such as flotation, density, viscosity
and hydrostatic pressure among others,
promote the individual's corporal phys-
iologic adaptations when totally or par-
tially immersed (AEA, 2006; Park et al
1999), turning the aquatic environment
into a pleasant atmosphere (Caromano
et al, 2003).
Ana Gouveia, Roxana Macedo Brasil, Ana Cristina Lopes Y. Glria Barreto,
Andra Cristiane Ferreira, Grace Barros de S
roxanabrasil@superig.com.br
TRR
Article
relief of pain involves a conscious con-
trol over learned habits. This happens
by applying the powerful neurological
rule: less muscular effort produces more
sensory motor learning and physical
improvement.
The mind/ body connection component
works via somatic exercises. The water
is 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 motor
learning process improves, which in turn
improves the biomechanics of move-
ment. In this study we focused on
screening several aspects of overall
health and improvement over 14 weeks,
attending an Aquajoy class every
Monday and Thursday.
From results based on self-screening, we
established that the structure and
method of teaching the Aquajoy water
class benefited the FMS population
through the method of relieving symp-
toms. All participants in the study did
improve overall health. After 14 weeks,
the participants experienced better sleep-
ing habits, less pain, stiffness and sore-
ness, as well as reporting more
energy/strength. They reported feeling
less 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 of
participants life as well as the capacity
to cope with this health condition.
For more information contact
Maria Sykorova Pritz M.S.; at
sykorovasynchro@hotmail.com N
References:
1. Clark, SR; Prescribing exercise for Fibromyalgia
Patients, The American College of Rheumatology
1994 0893- 7524/94
2. Cousins, Norman. Anatomy of an Illness: As per-
ceived by the patient, New York w.w. Norton & co.,
1979
3. Devin, J. Starlanyl MD.; The Fibromyalgia Advocate,
New Harbinger Publications, INC. 5676 Shattuck
Avenue, Oakland, Ca. 94109
4. Devin, J. Starlanyl MD., Mary Ellen Copeland, MS
MA.; Fibromyalgia & Chronic Myofascial Pain
Syndrome a Survival Manual, New Harbinger
Publications, INC. 5676 Shattuck Avenue, Oakland,
Ca. 94109
5. Dunkin, MA; Fibromyalgia. Arthritis Today/
September-October issue 1993
6. Elrod, J.M.; Reversing Fibromyalgia, Woodland
Publishing, P.O.BOX 160, Pleasant Grove, Utah
84062, USA; (800) 777-2665
7. Elkin, R., M.M.; Solving the depression puzzle.
Pleasant Grove,
8. Utah: Woodland Publishing, 2001
9. Flood, J.: Fibromyalgia from A to Z A Rhematuo-
logists View, The FMS OHIO NEWSLETTER- devel
oped to people with Fibromyalgia syndrome/ winter
1994
10. Hammerly, Milton MD.:Fibromyalgia: How to combine
the best of traditional and alternatives therapies,
Holbrook, Massachusetts: Adams Media Corporation,
2000
11. Hanna, T. Somatics; Peseus Books, Cambridge,
Massachusetts,USA http/www.perseuspublishing.com
12. Harrison, S. and Gepetti, P.;Substance P INT J
Biochem. Cell Biol. 33,106 (June 2001):555-576
13. Heim, C. et al. The potentional role of hypocorti-
solismin the pathophysiology of stress- related bodily
disorders. Psychoneuroendocinology. 25, no.1
(January 2001):1-35
14. *Yunus, H.B.; The role of gender in Fibromyalgia
syndrome Curr Rheumatol rep. 3, no. 2(April
2001):128-134
15. Kuntzleman, C.; Living well workbook, Arbor Press,
133 Teft Arbor, P.O.Box 507, Spring Arbor, Michigan
49283-0507
16. *Littlejohn, G.Fibromyalgia. What it is and how do
we treat it? Aust FAM Physician. 30, no. 4.
(April2001):327-333
17. May, K. P.et al. Sleep apnea in male patients with the
Fibromyalgia syndrome American Journal of
Medicine. 94(1993):505
18. *McBeth, J. and A.J. Silman The role of psychiatric
disorders in Fibromyalgia Curr Rheumatol Rep. 3.
no.2 (April 2001):157-164.
19. McGain, G.A. at al. A controlled study of the effects
on a supervised cardiovascular fitness training pro-
gram on manifestation of primary Fibromyalgia.
Arthritis Rheumatology. 31(1988):1135
20. Mueller, H.H. et al.Treatment of Fibromyalgia incor-
porating EEG-driven stimulation: a clinical outcomes
study. J. Clin Psychol. 57, no. 7 (July 2001):993-952
21. Mur, E et al.Electromyography biofeedback therapy
in Fibromyalgia. Wien Med Wochennschr. 149, no.
19-20
22. Norregaard, J. et al. A randomized controlled trial of
citalopram in the treatment of Fibromyalgia. Pain.
61 (1995): 445-9.
23. Park, J. H. et al. Evidence for metabolic abnormali-
ties in the muscles of patients with Fibromyalgia.
Curr Rheumatol Ref. 2, no.2 (April 2000): 131-140.
24. *Remington, J.New research on Fibromyalgia.
January 31, 2001. http/www.americasdoctors.com
25. Sheon, R.P., MD. Et al. Coping with Arthritis, New
York: McGraw-Hill, 1987
26. Simonton, O. et al. Getting Well Again. 3rd Ed. New
York: Bantam Books, 1992
27. Sova, R. Aquatics, Jones and Barlett Publishers, 20
Park Plaza, Boston, Ma 02116
28. Sova, R. and Kono, J. Ai- Chi 1998
29. *Van Hodenhove, B. et al. Victimization in Chronic
Fatigue Syndrome and Fibromyalgia in tertiary care;
a controlled study on prevalence and characteristics.
Psychosomatics. 42, no. 1(January-February
2001):21-28
30. Wolfe, F. and Smythe H.A. Yanus M.B., et al.The
American College of Rheumatology 1990 criteria for
the classification of Fibromyalgia. Report of Multi-
center Criteria committee. Arthritis Rheum 30:160-
172, 1990.
31. Wolfe, F. Fibromyalgia the clinical syndrome. Rheum
Dis Clin NA 15:1-17,1989
In spite of some authors investigating
the hemodynamic variations in the
aquatic environment (Park et al, 1999;
Perk et al, 1996; Masumoto et al,
2007), few studies investigate the alter-
ations of cardiovascular responses in
different cycling positions possible in
water. Thus, the objective of this study
was to analyze the behavior of heart
rate (HR) in different positions of the
body during aquatic cycling, at constant
speed, in overweight individuals.
Material and Methods
Sample:
The study was conducted with eight
volunteers, four males and four females,
with ages ranging from twenty to thirty-
three years, with Corporal Mass
Indexes (IMC) varying from 28.4 to
29.6 Kg/m2. As criterion for inclusion
in the study, the participants should
have a healthy appearance, with a mini-
mum of three months of practice in this
specific modality and characterized as
overweight according to the classifica-
tion of the American College of Sports
Medicine (ACSM, 2000).
Procedures for data collection:
An analysis was performed and the
RPar-q questionnaire was administered.
Corporal mass and stature were meas-
ured with the aid of a digital scale pro-
vided with a stadiometer, with accuracy
of 0.05 kg (Filizola, Brazil).
The positions of aquatic cycling in the
study were seated or standing.
Regarding the hands the following posi-
tions were used: 1 (centralized, with
relaxed shoulders and elbows), 2
(hands in line with the shoulders, at
the width of the handlebar), 3 (stand-
ing up, with hands at the extremities of
the handlebar), and 4 (simulating a
horizontal bicycle, the trunk will be
behind the saddle) (Torreao et al, 2003;
Brasil; Dimasi, 2005).
The subjects remained immersed to the
shoulder line (at a temperature of
29C) for five minutes to check their
heart rate at rest. In sequence, an aquat-
ic cycling protocol adapted by Torreo
et al (2003) was used, consisting of
pedaling for three minutes at a constant
speed of 144 RPM, controlled by a
metronome (Wittne, Germany) in the
four positions. Heart rate was meas-
ured with a heart rate monitor (Polar
A-1, Finland) at each minute, for all
positions. Between the positions, the
subjects were submitted to a 5-minute
rest in partial immersion.
Data Handling:
The definition of the dataset profile
required an estimate of the locations cen-
tral tendency measures. Initially, the vari-
ables were evaluated in relation to their
proximity to the Normal Distribution,
using the Shapiro-Wilk Test (Costa Neto,
2002). The confirmation of the normality
allowed evaluations of differences of the
variable HR in each one of the positions
during the three minutes of the test (HR
x position x minutes), and to analyze
these differences by applying a Variance
Analysis Test of 3 x 4 (3 minutes x 4
positions) with measures repeated for the
2nd factor. The Bonferroni post hoc test
was used to identify possible differences
between the variables. The study admit-
ted a significance level ( = 0.05), there-
fore H0 rejection occurred with the value
of p < .
Results:
Figure 1 shows the results of the aver-
age HR values in each one of the min-
utes analyzed. It is speculated that
hydrostatic pressure and the tendency
for body flotation, caused by the water
properties, facilitates blood displace-
ment to the central area of the body
when submitted to immersion. This
may increase systolic volume and
reduce HR (Becker; Cole, 2000; Graef;
Kruel, 2006). However, the hypothesis
that the positions with smaller immer-
sion gradient would induce a larger CF
response 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 were
close. Position four presented average
values of 137 bpm.
In minute two, position three demon-
strated the highest average values
(165.75 bpm). Position two showed
values of 142.38 bpm for HR, while in
position four the subjects presented
average values of 146.00 bpm. In posi-
tion one the smallest measures were
recorded (139.25 bpm).
The heart rates measured in minute
three were 145.25; 149.63; 172.00 and
147.25 respectively for positions 1, 2, 3
and 4.
The statistical test showed significant
differences in minute one of position
three 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 and
position one (p = 0.01) and two (p =
0.04). In minute three differences were
found between position three and posi-
tions one (p = 0.01) and four (p =
0.03). These results corroborate, in
part, the findings by Torreo et al.
(2003) who found significant differ-
ences in position three in all minutes in
relation to the remaining positions
when applying the same protocol. It
can be suggested that the increased
hydrostatic pressure in the remaining
positions caused a redistribution of the
blood volume in the central area of the
body when compared to position three.
Possibly, immersion generates an incre-
ment of the ejection volume; conse-
quently, the pressure receivers of the
aortic arch and carotid are stimulated
and cause a reflex reduction in HR
(Avellini et al., 1983; Figueredo et al.,
2005).
Torreo et al. (2003) also observed that
in position one there was no difference
in relation to position four. HR in posi-
tion two, diverging from the present
study, showed significant values in rela-
tion to positions one and four. The fact
that the group of volunteers in this
experiment comprised overweight sub-
jects may justify the similarity of posi-
tion four in relation to positions one
and two, because the accumulation of
corporal fat reduces corporal density,
favoring flotation, in other words, hin-
dering the maintenance of the body in
partial immersion (AEA, 2006) (See
Figure 1).
Conclusion:
The society we live in has many diverse
problems, among them the issue of
overweight and obesity. Nutrition
habits, inactivity, genetic and hormonal
problems are some of the most common
causes for the rise in total corporal
weight in individuals.
When associating aquatic cycling to
overweight individuals, posture adjust-
ments and adaptation of the intensity of
the class sessions are required for better
training adequacy and safety of the
practitioners.
Activities in the pool attract a heteroge-
neous clientele to workout in an enter-
taining and pleasant way, including a
perception of less effort if compared to
exercises on land. Therefore it becomes
important to have control over the
characteristics of the aquatic space as
well as its different modalities and their
applicability. N
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,
Flrida, 2006.
3. American College of Sports Medicine.
Manual do ACSM para teste de Esforo e
Prescrio de Exerccio. 5ed. Rio de Janeiro:
Revinter, 2000.
4. Becker,B.E.; Cole, A.J. Terapia aqutica
moderna. So 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 fisiolgicos da imerso
e do exerccio na gua, Fisiologia Brasil, v.4,
n.1, p. 61 66, 2003.
7. Costa Neto, PLO. Estatstica. So Paulo:
Edgard Blcher, 2002.
8. Ferreira A; Brasil R; De Sa BG; Barreto AC;
Santos MA; Vale R; Novaes J. Comparao das
respostas hemodinmicas entre o ciclismo
indoor e aqutico. 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. Freqncia cardaca e
percepo subjetiva de esforo no meio
aqutico: diferenas em relao ao meio ter-
restre e aplicaes na prescrio de exerccios
uma reviso. Revista Brasileira Medicina do
Esporte, v. 12, n. 4, p. 221 228, 2006.
12. Machado PAN; Sichieri R. Relao Cintura-
quadril e dieta em Adultos. Rev Sade
Pblica v.36, n.2, p.198-204, 2002.
13. Masumoto K; Takasugi S; Hotta N; Fujishima
K; Iwamoto Y. A comparison of muscle activity
and heart rate response during backward and
forward walking on an underwater treadmill.
Gait & Posture V.25, P. 222228, 2007.
14. Maranhao Neto GA; Polito MD; Lira VA.
Fidedignidade entre peso
15. E estatura reportados e medidos e a influncia
do histrico de atividade fsica
16. em indivduos que procuram a prtica super
visionada de exerccios. 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 freqncia cardaca em
diferentes posies para uma mesma veloci-
dade no Aquaspin. XXVI Simpsio
Internacional de Cincias do Esporte, 2003.

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A

Creating Optimal Healing Environments

completely present to our clients has a

Optimal health is the balance of physical, emotional,

WATSU, water shiatsu, uses floating

student population. In addition to the

While the physiological effects of aquatic

19 Aquatic Therapy Journal October 2007 Volume 9 Issue 2

October 2007 Volume 9 Issue 2 Aquatic Therapy Journal 20

Water Exercise for Individuals with Parkinsons Disease:

October 2007 Volume 9 Issue 2 Aquatic Therapy Journal 24

25 Aquatic Therapy Journal October 2007 Volume 9 Issue 2

Resisted training response in the water (Water Force)

believe in the importance of highlight-

October 2007 Volume 4 Issue 2 AEA Aquatic Fitness Research Journal 6

Results: The anthropometry data

0 = feeling very horrible; 1 = feeling

the group in each symptom for all

Table #3 Results of Stress Analysis Questionnaire of HP

that the organism is overwhelmed and

Chart #8 Average Overall

Behavior of heart rate, at a constant speed, in different positions of

Figure #1 Relation between HR x Position x Time

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