An Aquatic Therapy & Rehab Institute, Inc.

Publication

August 2005 Volume 7 Issue 2

Aquatic Rehabilitation for Medically Fragile and Terminally Ill Children: A Case Study Effects of Water Exercise on Muscle Strength and Endurance Aquatic Rehabilitation For Orthopedic Trauma: Part One

Table of Contents
Feature Articles
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 programs and activities. Articles may be submitted as a contribution to the profession; no remuneration can be made. Submissions should be directed to Managing Editor Susan J. Grosse, sjgrosse@execpc.com. For permission to reprint for academic course packets, please send a written request to info@aeawave.com. For Subscription and Membership information, please contact AEA, info@aeawave.com, phone: 941.486.8600 Opinions of contributing authors do not necessarily reflect the opinions of AEA and ATRI. 2005 AEA/ATRI-Nokomis, Florida Volume 7, Issue 2 Managing Editors: Sue Grosse Ruth Sova Graphic Design: Carolyn Mac Millan Printing: Palm Printing Aquatic Rehabilitation for Medically Fragile and Terminally Ill Children: A Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Kathryn Azevedo, Ph.D., ATRIC, Vladimir Choubabko and Karen Herzog, Founder and Executive Director Effects of Water Exercise on Muscle Strength and Endurance . . . . . . . . . . . . 12 Diane J. Marra, MA Aquatic Rehabilitation For Orthopedic Trauma: Part One . . . . . . . . . . . . . . . 21 Piero Pigliapoco, Piero Benelli and Lorena Cesaretti

Feature Columns
Pool Problems: Cloudy Pool Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Alison Osinski, Ph.D., Aquatic Consulting Services, San Diego, CA Interface: Aquatic Professionals Interact withPhysicians . . . . . . . . . . . . . . . 11 Gary Glassman, M.D., Emergency Physician, St. Mary Medical Center, Langhorne, PA Research Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 New for Your Library . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Around and About the Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Web Waves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Others
From the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Aquatic Therapy Journal Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

ATRI Mission Statement

The Aquatic Therapy & Rehab Institute, Inc. (ATRI) is a non-profit, educational corporation 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.

AEA 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.

US $17.00

On the Cover: From the Powerpoint presentation Fun and Functional Assessments for Children provided at the Aquatic Therapy and Rehab Institutes Specialty Institute, Chicago, IL, June, 2005. Courtesy of Aquatic Consulting & Education Resource Services.
1 Aquatic Therapy Journal August 2005 Volume 7 Issue 2

From the Editors

Welcome to the first subscription issue of the Aquatic Therapy Journal! Some of you are receiving this publication as part of your membership benefits from the Aquatic Therapy and Rehab Institute (ATRI) or the Aquatic Exercise Association (AEA). Others are brand new subscribers. By the end of the year, as part of the reorganization of ATRI, everyone will need to be a subscriber to continue to receive what we feel is the finest publication in the aquatic therapy industry. We hope this subscriber group will include YOU. As you read in our last issue, ATRI has completed reorganization and reaffirmation of its commitment to providing quality professional education opportunities in therapeutic aquatics. Part of that reorganization has included the involvement of the Aquatic Exercise Association as our new publisher, along with redesign of our publication. As usual, you will find detailed information on educational opportunities available through ATRI. We have also added Around and About, to keep you updated on news in our field. We will continue to bring you announcements from the International Council for Aquatic Therapy and Rehabilitation Certifications (ICATRIC). Each issue we will be including more substantive articles for your reading. This month we are proud to present the topics of orthopedic rehab protocols and effects of aquatic exercise on strength development. Of interest to individuals working in pediatrics is our presentation on aquatic therapy for medically fragile/terminally ill children. Alison Osinski kicks off her recurring Pool Problems column with a major article on cloudy pool water. Our Web Waves column continues, along with four additional new column offerings. Interface will be written by a different professional each issue, highlighting practical suggestions for communication and interaction with professionals in disciplines closely related to therapeutic aquatics. Dr. Gary Glassman is our column kick-off author for this issues interface with the medical profession. The very knowledgeable Alison Osinski is the on-going author of our new Pool Problems column. Noted for practical problem solving, Dr. Osinski will address many of the pool problems you, our readers, face daily. Interested in research? You will be able to find short, to the point, research summaries in Research Review. Last, but not least, new publications in the field will be reviewed in For Your Library. If you are reading someone elses copy of ATJ, its time to subscribe! Yes, library and business subscriptions are available also. Access http://www.aea wave.com/press.release.htm. Interested in authoring an article? Have industry news to share? Contact ATJ at sjgrosse@execpc.com. We would be pleased to receive your announcements and/or send you Author Guidelines. Were excited to be providing you with the best the only peerreviewed publication for aquatic therapy. We encourage you to keep moving forward with us. As Will Rogers said, Even if you are on the right track, you will get run over if you just sit there. Ride the wave with us and youll never get run over! N

Highlights February 2006

Dont miss the next issue of the Aquatic Therapy Journal, or you will miss out on the following: Aquatic Rehabilitation for Orthopedic Trauma, Part 2 by Piero Pigliapoco, Peiro Benelli, and Lorena Cesaretti. Discussion continues with conditions of the Shoulder & Elbow, Knee & Ankle and Pelvis & Hip. Guidelines for Phase A and Phase B of Treatment are discussed and specific exercise suggestions provided. A Questionnaire to Measure Use of Aquatic Physiotherapy in South Australia: Research and Development by Gisela M. van Kessel, Joshua J Stewart, and Auburn McIntyre. The aim of this study was to develop a valid and reliable questionnaire to measure current use of aquatic physiotherapy by aquatic physiotherapists. Ethics in the Aquatic Therapy Profession. Interface column targeting Educators.

Ruth Sova, Editor

Pool Problems with Alison Oskiski Alison Osinski, Ph.D., Aquatic Consulting Services Research Review Beginning in the February 2006 issue, readers can earn ICATRIC approved CECs and AEA CECs!

Sue Grosse, Editor

Aquatic Therapy Journal August 2005 Volume 7 Issue 2 2

Kathryn Azevedo, Ph.D., ATRIC

Aquatic Rehabilitation for Medically Fragile and Terminally Ill Children: A Case Study
The decision to bring into a pool a medically fragile child or a child having a life threatening illness requires careful consideration. Parents need to be enthusiastic and dedicated to the values of aquatic activity. Pool management must cooperate in the endeavor. Aquatic specialists accepting medically fragile and/or terminally ill children into their practices need to be highly skilled, aware of disease progression, and able to adapt handling skills to the childs specific needs. The goal of aquatic therapy for medically fragile children and/or children with life threatening illness is to, as much as possible maintain and improve quality of life. For some children this means providing palliative care. For other children this becomes end of life care. benefit from enhanced palliative care services: those who are born without an expectation of survival to adulthood but who live a long time with substantial suffering, those who acquire illnesses such as cancer, and those who suffer a relatively sudden death due to trauma. A great deal of preparation and planning is needed before the child enters the water. Following is a case study of a child with Niemann-Pick Disease, Type A (NPA) illustrating how close cooperation and collaboration among parents, practitioners, service agencies, and pool management can lead to a positive delivery of pediatric palliative care in the aquatic environment. CASE STUDY: AQUATIC THERAPY FOR A CHILD WITH NIEMANNPICK DISEASE TYPE A Children with lysosomal storage disorders, such as Niemann-Pick Disease Type A (NPA), are born without the expectation of a life expectancy beyond a few years. Children born with NPA are missing the enzyme acid sphingomyelinase (ASM), responsible for metabolizing and breaking down sphingomyelin, a special lipid component of cell membranes. If ASM is absent or not functioning properly, sphingomyelin abnormally builds up, leaving fatty deposits called foam cells in many body tissues and organs, primarily the brain, liver, spleen, lungs, and bone marrow. The sphingomyelin pairs with cholesterol and leaves the affected organ with a swollen, foamy appearance (Bank, 2002). Impact of this enzyme deficiency is enormous on the central nervous system, resulting in progressive neurological impairment, profound developmental delay, progressive spasticity, epilepsy,

Vladimir Choubabko Karen Herzog

enlarged liver/spleen, and a characteristic cherry red spot in the eye. Children with NPA exhibit a variety of symptoms including muscular weakness manifested by feeding difficulties, loss of early motor skills, abdominal distention, hepatosplenomegaly, hypotonia, hypersensitivity and skin with a yellowish brownish discoloration. Death usually occurs between 2-4 years of age.

Baby Sophia
In summer, 2002, we began caring for Baby Sophia in the aquatic environment. She was 14 months of age. Our aquatic program was initiated as part of Sophias Circle of Healing, a holistic model of care her parents had developed to increase the quality of Sophias life and search for a cure for NPA. At this time, Sophia required the assistance of one aquatic practitioner. Despite her small size, she demonstrated good head support. Sophia was flexible and able to perform supported kicking on her back. She was also able to support herself in an inner tube for a few minutes and her arm movements resembled a dog paddle. We were careful to keep her ears out of the water. The maximum endurance she had for an aquatic session was 25 minutes. At 16 months, Sophia began losing weight, her tactile sensitivity increased, and her tolerance for environmental noise in the pool environment decreased. However, Sophia was still able to achieve assisted flexion and extension of her legs in the water. By fall 2002, Sophia had frequent respiratory and fungal infections and was in neurological decline. In February 2002, two choking and apenic episodes led to a hospitalization and her return home on hospice. As a result, we temporarily suspended aquatic therapy through winter 2003.

The Decision to Proceed with Aquatic Rehabilitation

Warm water aquatic therapy can play a vital role in habilitation/rehabilitation of children with cerebral palsy, sensory processing disorders, arthritis, spina bifida, cancer, Down syndrome, orthopedic disorders, rare diseases such as Tay-Sachs and Niemann-Pick, as well as other syndromes where motion and breathing need improved synchrony. Children who have diseases severely limiting activities of daily living often can benefit the most from aquatic rehabilitation. These children, however, are the most challenging cases. Recently, there has been an increased effort for improving palliative and end of life care to our rapidly aging elderly population. In the United States, however, very few facilities and practitioners, skilled at providing care for children and their families as they confront lifethreatening illness, exist. The Initiative for Pediatric Palliative Care (IPPC, 2004) has outlined three segments of the pediatric population who would
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In spring 2003, we reconnected with Sophia at home, providing land-based work. As Sophia continued to grow, she lost postural strength and cognitive function, but her health stabilized. When she was 2 years, 6 months old (30 months), Sophias parents decided to have Sophia return for aquatic rehabilitation. We worked closely with her parents to reassess how we would proceed with Sophia in the aquatic environment. Vladimir Choubabko and Kathryn Azevedo worked together to provide aquatic rehabilitation for Sophia once a week.

cries when this happens. Since Sophia has very limited ability to swallow, great care is taken to make sure pool water does not enter her mouth. Sophia aspirates on thin liquids and does not elicit a protective cough. More specifically, Sophia has a difficult time swallowing her own saliva. When her abdomen is more distended than usual and her face more jaundiced, Choubabko will place one hand over her liver while the other arm cradles her head and upper torso. Meanwhile, Azevedo holds the disconnected indwelling nasal gastric tube out of the water with one hand, monitors her breathing, and leads Sophia in gentle range of motion and extension exercises.

medical practitioner already present who could determine if emergency services should be called. The aquatic environment provides Sophia with opportunities to experience weightlessness, muscle relaxation, and temporary reduction in pain. Her parents see direct benefits from her aquatic sessions. They report an increase in flexibility, and this experience has led to home-based bathtub aquatic therapy 2-3 times a week. The cognitive, visual, and auditory stimulation from the therapists singing, the voices of other clients and therapists in the pool, and music piped through the centers audio system provide stimulation different from the home environment. Social interaction with therapists, caregivers, clients, and staff at the Betty Wright Swim Center are also seen as a benefit. Our goal is to improve Sophias quality of life while her parents pursue life saving treatment to prolong her life.

At this time, Sophia is very facially expressive and communicates non-verbally, though her global developmental delay is apparent. Sophia does not bear weight on her legs and both her feet and ankles are externally rotated. Sophia is hypersensitive to movement and must be positioned carefully. She tolerates some massage, but joint movement is painful and Sophia does not like to have her limbs stroked. Instead she likes to have a hand gently placed on her, in one place. Sophia cries with pain when Choubabko lifts Sophia from her stroller to carry her into the pool. Due to her lack of head and neck control and the requirement of a continuous indwelling nasal gastric tube, Sophia now requires 2 experienced aquatic practitioners to achieve an effective 30-minute aquatic session. Despite the warm water temperature of 93 degrees, Sophia chills easily so we are careful to keep her close to our bodies. Since bowel incontinence has become a concern, she now uses 2 swim diapers. We closely monitor her abdomen and we are able to detect changes indicating whether or not she would need to be quickly removed from the pool environment. Bowel movements are very painful for her so she

Sophia responds best with some type of sound. Together, Azevedo and Choubabko sing to Sophia in English, Russian, and Spanish, reflecting their respective cultural heritages. They sing the songs in a certain order, so Sophia can recognize transitions. Singing is an important part of her therapy since it seems to soothe her, reduce her crying, and promote relaxation, harmony, and synchronization between the 2 aquatic practitioners. The rhythmic singing, our aquatic handling, and Sophias suspended movement through water allows for increased sensory input and allows her brain and body to work together. As her disease advances, Sophia has low-grade seizure activity while in the water. One of her parents, along with a nurse, brings Sophia to the pool and remains while she is in the water. Sophia experiences about 2 seizures per day and multiple arousals, a form of mild seizure activity manifesting in eye rolling and jerky arm and leg movements. If her seizure activity would become severe, as evident by drooling, choking, and/or gagging, there is a

In May 2004, Sophia reached a milestone as the family and community came together to celebrate her 3rd birthday. At 3 years old, she continued to grow new teeth and increase in length. She has gained 2 pounds, and has a full head of beautiful brown hair. Sophia shows increased comfort and tolerance in the warm water environment. Immediately following the session, results of the aquatic rehabilitation are apparent. Sophia takes a long nap after the session. She cries less and her parents report she is able to sleep more fully and deeper for the next few days. Her mother reports that after an aquatic session, Sophia is able to better tolerate painful medical procedures, such as blood draws. Since it takes a great deal of effort for the parents and the caregivers to prepare Sophia for an aquatic session, their consistency in
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attendance is a clear indicator of the positive impact that aquatic rehabilitation has had on this child with NPA.

Programming Implications
When a parent approaches aquatic facility staff about the possibility of aquatic therapy for their child with a life threatening illness, they frequently face resistance since there are real risks to be addressed. Children with severe, progressive, life threatening illnesses often present with what most would call contraindications to pool therapy nasal gastric tubes, supplemental oxygen, seizures, urinary and bowel incontinence and high susceptibility to infection. Moreover, pool management may be concerned about scheduling, whether their facility is appropriate, issues of liability, cost of providing labor intensive care, and the impact providing care will have on other pool clients. The first barrier to consider is appropriateness of the pool environment and trained staff. Medically fragile children can be hypersensitive to sound, touch, water temperature, and water turbulence. So precision in pool scheduling will take cooperation between all staff members, as well as pool clients. How a child enters/exits the pool is another consideration. Ideally, the pool would be equipped with a pool ramp for easy wheel chair access. If the child is very small or has no postural control, he or she will need to be carried, which requires staff strength and skill. A parent or caregiver can be trained to assist. Appropriate aquatic clothing needs to be discussed. Warm water clothing made of Neoprene can be custom made to maintain thermoregulation. A child who has bowel/urinary incontinence should be double diapered with rubber pants over the diaper. Skilled aquatic practitioners with advanced handling skills should be able to palpate the abdomen, and monitor for changes that could indicate incontinence, being prepared to quickly evacuate the child if necessary. An additional precaution that can be taken to address incontinence is to coordinate the childs pool time around feedings and usual bowel movements.
5

If a child requires an indwelling nasal gastric tube or supplemental oxygen, 2 aquatic practitioners are needed one to carry the child and another responsible for making sure the tubing is not obstructed. A nasal gastric tube should be disconnected from the feeding source prior to pool entry. The exposed end can be covered with plastic wrap to prevent water contamination. Oxygen usually needs to be continued while in the pool. Children who require nasal gastric and oxygen tubing entail more risk, but with the appropriate length of tubing and an assistant responsible for the tubing, these risks can be managed and passive horizontal aquatic modalities can be performed on the child. If a child has a tendency to experience seizures, close communication with parent and physician can help aquatic practitioners distinguish between seizing activity that is serious or mild, in order to decide whether to continue the aquatic session or seek medical attention. If a child is highly susceptible to infection due to a compromised immune system, careful attention to the pool facility environment is required. Outside the water, parents should pay careful attention to where they dress and change the child. Since mold, mildew, and fungus thrive in the humid environment of indoor pools, to minimize exposure to these organisms, parents should bring their own towels and sheets to cover the changing table. Pool chemicals should be checked prior to the session and if chlorine or bromine levels are low, the childs aquatic session should be rescheduled. If the pool water is cloudy, most likely the chemicals and filtration are out of sync and parents should be wary to allow their child in the pool. With careful planning, many so called contraindications to pool therapy can be addressed. This labor-intensive work is costly and, ideally, public and private funding could subsidize pediatric aquatic rehabilitation sessions in order to diminish access barriers. Absolute contraindications to aquatic therapy, however, do exist and these include

active infections, diarrhea, fever, and recent persistent seizure activity.

Impact on Pool Staff and Clients

When we first brought Sophia into our facility for aquatic therapy, there were some challenges. Of prime importance was finding a time when Sophia would be awake, fed, diapered, and ready for activity. She needed a quiet protected space away from the commotion caused by our ambulatory clients. We decided on an 11:30 am timeslot since this was after our adapted aquatics program and before our senior swim at noon. This posed a slight delay for individuals in our senior program. However, the mother and nursing staff educated the pool clients on Sophias fragile health and this has promoted more cooperation and consideration of pediatric rehabilitative needs in a pool environment now dominated by therapeutic rehabilitation of our local elderly population. Many pool staff were concerned whether Sophia would actually benefit from aquatic rehabilitation. Staff who shared the pool during our session with Sophia quickly learned to work around us. Our pool colleagues limit movement to keep splashing and water turbulence to an absolute minimum. Eventually, other staff members learned to work with Sophia, and this opportunity enhanced staff training and fulfillment. PALLIATIVE CARE VERSUS END OF LIFE CARE When dealing with children having terminal illness, issues of liability are of special concern to pool management. Aquatic therapy, by its very nature, is relaxing and diminishes pain. By providing comfort care, palliative care seeks to prevent or relieve physical and emotional distress produced by chronic, life limiting or terminal illness. Pediatric palliative care helps a child and his or her family live as normally as possible, for as long as possible, by preserving the dignity and integrity of both the pediatric patient and his or her family. It is important to note palliative care is NOT limited to people thought to be

Aquatic Therapy Journal August 2005 Volume 7 Issue 2

dying. Palliative care can be provided concurrently with life-prolonging treatments (Institute of Medicine, 2003). For Sophia, we are providing palliative care in the aquatic environments, care that specifically addresses pain management, assistance in breathing and bowel functioning, and progressive muscle relaxation. We try to improve her quality of life by making her feel better, while her parents pursue potentially life saving experimental treatments. As the childs medical condition fluctuates, however, the distinction between palliative care and end-of-life care is not always clear. End-of-life care focuses on measures preparing for an anticipated death and in the warm water aquatic environment that usually means reducing pain. Those involved with pediatric hospice care understand death often finally occurs when a child is able to let go of pain. So there is a remote possibility passive, horizontal aquatic modalities that relieve pain and facilitate muscle relaxation can facilitate the dying process in children with life threatening illness. Although aquatic practitioners may want to relieve pain and suffering, while providing palliative care, it is not advisable to have the child pass away in most pool facilities. In the United States, most pools have parents sign a detailed waiver of liability directly addressing these issues, releasing both the aquatic practitioners and the facility from legal prosecution if death occurs in the aquatic setting. It is important to note, however, the first pediatric hospice in the United States, the George Mark Childrens House (www.georgemark.org), recently opened in San Leandro, California. This facility does provide aquatic therapy to children in their final days of life. Since the staff at this center has extensive training in hospice caregiving, issues of liability are of less concern to aquatic staff in this environment. Parents who wish to have aquatic therapy sessions for their child in the end stages of life should seek out these hospice facilities with warm water therapy pools.

deal of effort and coordination. Providing pediatric palliative care in the aquatic environment is possible and is not only a worthwhile endeavor, but a medically beneficial, morally justified, community building enterprise, and an important opportunity for staff learning. It is our hope this case study will inspire other practitioners to provide aquatic therapy for children with life threatening illness.

Program, SNAP , Richmond, CA

k_azevedo@hotmail.com, snapkids@earthlink.net

Acknowledgements
The authors wish to thank Sophia Herzog Sachs for the opportunity to witness her courage. We wish to thank the staff and patrons at the Betty Wright Swim Center for providing us the environment to care for Sophia. Black and white photos courtesy of Karen Schreiber, copyright 2004. We also acknowledge Sergey Loginowski in his color photo of our work. N

Kathryn Azevedo, Ph.D., ATRIC, is a clinical researcher at Stanford University Medical Center where she runs clinical trials. In her 20 years in aquatics, Dr. Azevedo has attained numerous aquatic and massage certifications and is a Master Trainer for the Arthritis Foundation. She began her aquatic career as a volunteer in the community based aquatics program designed by the late Betty Wright. In graduate school, she worked with Project PROJIMO a rural community based rehabilitation center for children in Sinaloa, Mexico. She wrote her masters thesis on communitybased rehabilitation and helped to edit the newer editions of Where There is No Doctor and Disabled Village Children. While at C.A.R, Dr. Azevedo won an Arthritis Community Grant to test a pilot pediatric arthritis program and developed assessment and training materials for their former adapted aquatics program. She now works with the Special Needs Aquatics Program (SNAP) as they seek to expand community based aquatics programs for children with special needs throughout the San Francisco Bay Area. Vladimir Choubabko West Valley College, Saratoga, CA Betty Wright Swim Center at C.A.R., Palo Alto, CA Vladimir Choubabko has achieved a broad base of expertise in his 40+ years in the aquatics field. In Russia, he graduated from the prestigious Institute of Physical Education and Sport with a degree in physical education, physical therapy, massage, and coaching. As a coach in Olympic swimming, he produced outstanding results in coaching 9 Olympic gold medalists. He is well known for his dedication towards his athletes and was also able to inspire hard work and commitment from his coaching staff. This success propelled him to the national level of sports administration in the former Soviet Union where he managed a budget of several million dollars. From 1980 to 1988 he was responsible for training, organizing, and budgeting Russian Olympic swimmers. Vladimir was awarded several medals of excellence for this work. In the United States he has continued his education in aquatics and geriatric physical education. Vladimir now works as a lead physical education instructor at both West Valley College and Mission College. At C.A.R, he is the lead aquatic personal trainer and massage therapist. Karen Herzog Founder & Executive Director Sophias Garden Foundation, Palo Alto, CA www.sophiasgarden.org Karen Herzog is the mother of Sophia Sachs, who is battling Niemann-Pick Disease, Type A (NPA). As an educator and advocate for childrens health, Ms. Herzog is a founding advisory board member of the UCSF-Stanford Jewish
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References
Bank, Michael G., University of Pittsburgh, Department of Human Genetics, Niemann Pick Disease (Type A) http: www.pitt.edu, 2002 The International Center for Types A and B Niemann-Pick Disease, Mount Sinai School of Medicine, Department of Human Genetics, http: www.mssm.edu/niemann-pick, 2004 Field, Marilyn, and Richard Behrman, Editors, When Children Die, Improving Palliative and End-of-Life Care for Children and Their Families, Institute of Medicine, Washington DC, USA, 2003 The Initiative on Pediatric Palliative Care http://www.iappcweb.org/about.asp

Authors Conclusions
Bringing a medically fragile child into the pool environment requires a great
Kathryn Azevedo, Ph.D., ATRIC Stanford UniversityMedical Center, Stanford, CA Special Needs Aquatic

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Genetic Disease Center. Out of what she learned from Sophias struggle for survival and her familys search for meaning in the midst of uncertainty, she created Healing in Community, a compassionate and highly effective communitybased approach to caring for children with lifethreatening conditions and their families. She cofounded Sophias Garden Foundation to share this knowledge with the world.

TRR

Feature Column: Pool Problems

Cloudy Pool Water

Alison Osinski, Ph.D. Aquatic Consulting Services, San Diego, CA Aquatic professionals often notice that pool water becomes turbid gradually throughout the day or immediately after lengthy periods of peak use. Cloudy water conditions may also occur immediately after chemical adjustments are made. Water may appear cloudy or milky. A fine white precipitate may settle out of the water. Water clarity frequently deteriorates to the point where it is not safe to continue operation and classes or programs must be cancelled. Although water clarity should exceed 0.25 NTUs (Nephelometric Turbidity Units), most public pool bathing codes permit swimming pools to be used until the clarity deteriorates to the point that either the main drains or a 6-inch diameter black disk cant be clearly seen from the surrounding deck at the deepest point in the pool, or the black and red (or black and white) quarter panels on a 2-inch diameter, Secchi disk cannot be distinguished at a depth of 15 feet. Aquatic professionals should insist water clarity be maintained within an acceptable range. It should be understood that activities will be cancelled rather than endangering users. Written pool rental agreements should outline how the instructor or therapists will be compensated for lost fees or wages if the pool is not able to be used. If cloudy water problems result in more than very infrequent pool closures, the cause of the problem should be identified and remedied. Water clarity problems can usually be traced to one of two possible causes either physical or chemical in nature. Physical problems are caused by the design of the circulation system or mis sized equipment. Chemical problems usually result from improper application of chemicals, incorrect dosing, or from not correcting water quality problems when they occur.

Reviewer Comments
Julie Meno Fettig This article brings awareness of the role aquatic therapy can play in management of pain and providing palliative care. Sophias case study is an excellent example of how coordinated professional disciplines, different services, and timing of treatment need to be for successful aquatic therapy with a medically fragile child. Warm water aquatic therapy is an excellent pain management modality. Aquatic therapy for the treatment of pain has greatest benefit when water is clean, temperature correct for patients condition, and environment is calm. The therapist should be knowledgeable about the specific condition, adaptable, reassuring, empathetic, yet humorous. This three dimensional supporting environment can be a great equalizer against pain. When suspended in water, without fear, it allows us to feel and sense ourselves from within. From within we can heal ourselves, feel strong, in control, and very much alive. N

Chemical Problems
Sometimes chemicals are added to water in too great a quantity in too short a period of time. With the exception of chlorine, pool chemicals should be added to the pool gradually, and in small quantities over an extended period of time. Pre dissolve solid, granulated or powdered chemicals prior to their addition. Try to limit chemical additions to 10 ppm changes at a time. Excessively high Total Dissolved Solids (TDS) can cause water to appear less than crystal clear. Use a TDS meter to determine the level of total dissolved solids. In pools with high bather load to water volume ratios, regular dilution is recommended at a rate of 8 gallons per pool user per day. If TDS levels exceed 1,500 ppm and are causing problems with taste, clarity, ability to maintain ORP levels, or galvanic corrosion, dilute significantly, or drain and refill the pool with fresh water. High concentrations of cyanuric acid will interfere with oxidation of organic contaminants in the water. Do not use cyanuric acid or chlorinated isocyanurates, such as trichloro-s-triazinetrione or sodium dichloro-s-triazinetrione, in indoor pools, or in outdoor pools and spas with extremely high organic loading problems. If cyanurates are used to prevent loss of chlorine and dissipation into the air due to exposure to ultraviolet light, use them in moderation. Keep cyanuric acid levels in the 10 ppm 20 ppm range since 95% of the staying power benefit is achieved in that range. Also, the negative effects on pathogenic organism kill time and depression of ORP are still within an acceptable range.

Reviewer Bios
Julie Meno Fettig, CTRS, ATRIC, is the founder/owner of Therapeutic Aquatics, Inc. and aquaticcentral.com, specializing in consulting, information, and rehabilitation. She is the author and publisher of The Bad Ragaz Ring Method Visual Instructional Manual and video and co-producer of the PNF in the Pool video. She received the 2002 ATRI Tsunami Spirit Award. N
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If water is difficult to balance due to extremely high calcium hardness levels in the source water, use of sequestering or chelating agents is recommended. Sequestering agents increase the ability of water to hold dissolved minerals or metals in solution. It is a preventative treatment. Sequestering agents keep minerals from: oxidizing and staining, causing scale build-up, precipitating (coming out of solution) calcium and magnesium salts when pH and water temperature rise, discoloring or clouding the water, attaching to and discoloring bathers hair. Chelating agents remove metals or dissolved minerals from the water. They cure mineral staining problems. Organic water soluble molecules bond and react with ions to keep them from precipitating. Oversaturated water is one of the most frequent causes of cloudy pool water. Since water is the universal solvent, all things will inevitably dissolve in water until the water becomes saturated. Eventually, water will become unbalanced or oversaturated and excess products will be lost by precipitation. Well balanced water will increase bather comfort and will dramatically extend the life expectancy of the pool and its components. Water temperature, pH, total alkalinity, calcium hardness, and total dissolved solids act together to cause corrosiveness or calcification qualities of water. The Langelier Saturation Index formula and chart can be used to determine if pool water is balanced that is, neither aggressive nor oversaturated. To calculate the saturation index, use the formula: Saturation index equals pH plus the alkalinity factor, plus the calcium hardness factor, plus the temperature factor, minus the TDS factor. Use your test kit and testing instruments to find each of the five values. Write down the actual pH value found. Then for the remaining four values, find the corresponding factor on 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 higher value and use its factor.

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

Calcium Hardness
ppm factor ppm

TDS
factor

Total Alkalinity
ppm factor

66 77 84 94 105

0.5 0.6 0.7 0.8 0.9

75 100 150 200 300 400 800 1000

1.5 1.6 1.8 1.9 2.1 2.2 2.5 2.6

<1000 >1000

12.1 12.2

50 75 100 150 200 300 400

1.7 1.9 2.0 2.2 2.3 2.5 2.6

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 swimming pools. Negative values indicate aggressive water, while positive values indicate likely calcification and scale formation. Undersaturated water is aggressive and will cause circulation pipes, heater elements, and other metal components of the pool to corrode. Pool wall surface materials will deteriorate. Plaster will soften and etch, vinyl liners will become brittle, metal staining will increase, and tiles will become loose and begin popping off the walls. If water is oversaturated, calcium carbonate will begin to settle out of the water. Water will become cloudy and take on a milky appearance. Scale will build up on solid surfaces, making surfaces rough, and discoloring dark surfaces. Calcium carbonate scale will also build up on interior surfaces of the pool recirculation pipes, restricting flow and increasing water pressure. Sanitizer effectiveness will be reduced, and algae growth may increase. If the saturation index formula indicates the pool water is not balanced, make the appropriate chemical corrections, starting with total alkalinity, then followed by pH, temperature, calcium hardness, and TDS. Algae blooms may cause pool water to become turbid, cloudy, or discolored. Algae is a waterborne plant introduced into pools by swimmers, make-up water, rain, wind and windborne debris.

Although algae in and of itself is not harmful to swimmers, it does cause problems when allowed to grow in a swimming pool. Algae gradually removes carbon dioxide from the water in order to manufacture food and may cause a dramatic rise in pH. Pool surfaces can become slippery from a noticeable algae growth on the pool bottom or walls. Algae is a higher organism that may harbor pathogens or disease causing bacteria. Chlorine demand may be high, as chlorine is used in an attempt to kill or control algae growth. Pools filled with algae may give off unpleasant odors. To control algae growth, maintain adequate chlorine and oxidation reduction potential (ORP) levels, keep the water circulating continuously, make sure you have a uniform circulation pattern and absence of dead spots in the pool, superchlorinate regularly, and scrub or brush pool walls to prevent algae from adhering. If water is not continuously circulated, sanitized and oxidized, you may need to use commercially prepared algaecides or algaestats to keep algae growth under control. Some algaecides are more effective against a particular type of algae, and some are more appropriate for use in pools or in spas. If you continue to have serious algae problems, you may want to monitor nitrate levels more closely, and try to determine the source of contamination. Nitrates stimulate plant growth, and when high levels of nitrates (greater than 25 ppm) are present in pool water, uncontrolled algae growth often occurs even though unaccountably large amounts of chlorine are being used.
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Aquatic Therapy Journal August 2005 Volume 7 Issue 2

Nitrates are introduced into pools from: fill water in areas where fertilizer has worked its way down into the ground water, contaminated reservoirs or wells, rain, fertilizers or grass blown into the pool from the adjoining landscaping, human or animal urine or fecal matter, and bird droppings. Pools located in agriculture areas, screened pools, and pools that border large bodies of water often experience nitrate problems. To lower pool nitrate levels, try shocking the pool with chlorine to over 30 ppm, or partially drain and refill the pool with water not contaminated with nitrates.

flowrate in gpm. Divide the volume of the pool in gallons by the required flowrate to get the needed turnover time in minutes. Interestingly, since there are 1,440 minutes in a day, a short cut method of determining the correct turnover time is simply to equate bather load and flow rate. The flowrate in gallons per minute and the maximum bather load should be similar. For example, a pool with a maximum daily bather load of 300 swimmers should have a flowrate of around 300 gallons per minute in order to maintain good water clarity. Know your pools baseline readings, and monitor turnover time. Read the flowmeter and pressure gauges daily and record the results. Make sure that the normal flowrate is being maintained and that an obstruction or pump impeller damage due to cavitation is not restricting the amount of water moving through the filters. Make sure filters are properly sized. If water is allowed to flow through the media at a rate higher than recommended by the manufacturer and NSF International, debris will pass right through without being removed. To determine needed filter size, calculate square footage of each filter tank (or look on the permanently affixed plate on the front of the filter). Take the flowrate in gallons per minute (gpm) and divide by the design flow rate for the particular tank using the same media. The total media square footage should exceed this number. For example, a pool with a flowrate of 1,000 gpm, is being filtered with a bank of 4 horizontal high rate sand filters each with 13.5 square feet of #20 silica sand filter media for a total of 54 square feet of media. The design flow rate is a minimum 15 gpm/ft2. One thousand gpm divided by 15 gpm/ft2 equals 66.6 ft2. The filters are considerably undersized and water is likely to be cloudy during periods of heavy use. Assure that all valves are open or in the correct position to allow water to move through filters. Label all valves, and post a diagram on the pump room wall showing the correct position of valves

during normal operation and during backwash procedures. Broken laterals inside of a filter tank can allow debris to enter the pool and will cause a loss of filter media available for filtering particles from the water. Check bottom of the swimming pool first thing in the morning before the water has been agitated and look for regular deposits of filter media near the return inlets. Isolate individual filter tanks from the bank to try to determine which laterals have broken. Remove the filter media and inspect the laterals at the bottom of the tank, replacing those which have broken. If filters are not backwashed properly and for an adequate amount of time, fine particles start to work their way down into the filter bed. Eventually fines are carried into the laterals and back into the pool. On filter systems with automatic backwash valves, make sure booster pumps are bringing the pressure up to 50 psi during the backwash process. Perform regular filter tank inspection and maintenance on a monthly basis. Open the filter tank and make observations, being careful not to damage the filter tank or components. Dig or poke around with a trowel and look for: flatness of the media bed, channeling (holes), biofilms on the tank walls, media migration, and contamination caused by improper backwashing or improper chemical balance. While the tank is open for inspection, perform a settling test to determine make-up of the filter bed. Take a large glass jar (like a mayonnaise jar) and fill it with 2 cups of water. Add 1 cup of media from your filter. Add 1 teaspoon of dishwasher detergent or Calgon water softener. Replace jar lid and shake. Allow the solution to settle overnight. The sample should settle into a layer of sand with water on top. If instead, it settles into layers with sand on the bottom, silty material above the sand layer, and an organic layer on top, replace the filter media in the tanks. Clean the sand media inside the filter tank by adding a commercial sand

Physical Problems
Water clarity problems may be persistent if the pool circulation and filtration system was not properly designed or if the components were incorrectly sized. However, even the best designed system will not keep water sparkling clear if components are not properly maintained, or programming and bather loads increase beyond expectation. To maintain clarity, keep bather load to total filtered water in gallons per day ratio at 1 bather : 1,400 gallons or less. The onset of turbidity is constant and related to the number of bathers, not just turnover time. If debris is added to the pool water faster than the filter can remove it, turbidity will increase. Debris is introduced into a pool through airborne dirt, dust, plant matter, and pollen; rain water, and bathers. But the greatest amount of debris is brought into the pool by bathers. To determine maximum bather load: multiply flowrate (gpm) x 60 (minutes/hour) x 24 (hours/day) to get the total filtered gallons per day. Then, divide total filtered gallons per day by the constant 1,400 gallons to get the maximum number of bathers per day who can enter the pool before water clarity problems result. To find the needed turnover time required at a given maximum bather load: Multiple the actual number of bathers using the pool per day by the constant 1,400 to get total filtered gallons per day needed. Divide by 24 (hours/day), then divide by 60 (minutes/hour) to get the required
9

Aquatic Therapy Journal August 2005 Volume 7 Issue 2

cleaning solution or sodium bisulfate. Mudballs and channels which form inside the sand should be destroyed. Mudball formation is caused by calcium scale, organic debris, detergents, oils, and bather waste products. These oily products reduce sanitizer effectiveness, promote bacterial growth, and cloud water. In addition to forming scum lines at the water surface, they may also clog cartridge filters and diatomaceous earth filter elements, and contribute to mudball formation in sand filters causing reduced filter effectiveness. Use of enzymes or absorbent foam products is recommended to help prevent filter problems from occurring in the first place. Enzymes are catalysts that start or speed up chemical reactions. Enzymes are protein-like substances that form naturally in animal and plant cells, but today, synthetic enzymes have been developed. Enzymes slowly, over several days, digest and destroy oils in pool water by converting them to carbon dioxide and water. A similar process is used to clean up oil spills occuring in the ocean. An initial dose of one to two ounces of enzyme per 1,000 gallons of pool water is recommended, and then maintenance doses of about half that amount should be added to the pool on a weekly basis. Absorbent foam products can also be used to physically remove oils from the water. 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 period of time, can be cleaned and reused by removing the absorbent foam from the pool skimmer, hair and lint strainer or filter tank, squeezing out the oils and replacing it in its hidden location. Colloidal particles are particles smaller than 1 micron in size, which are suspended in water. Colloids are small enough to pass through pool filters, too light to settle on the bottom of the pool, and make water murky or cloudy. Flocculants and clarifiers make colloidal particles stick together or coagulate so that the particles become

large enough to be filtered out or heavy enough to settle so they can be vacuumed out. Although aluminum sulfate (alum) was the most common flocculant used in the past, today cellulose fiber or poly aluminum chloride are more common. The products are added directly to the filter bed and form a layer on top of or between the grains of sand media. Clarifiers are biodegradable organic polymers usually made up of the natural polymer chitin often extracted from sea organisms. Positively charged repeating polymer links attract negatively charged colloidal particles. The electric charge is neutralized, and the polymer coils up into a large particle, which can be filtered. Infrequent vacuuming of debris from the pool can contribute to cloudy water conditions. Make sure the pool is routinely being vacuumed on a daily basis, first thing in the morning, or after a period of quiescence of at least 2 hours, to allow debris which is heavier than water to settle on the bottom of the pool. Check that portable or robotic pool vacuum filters are being disinfected and cleaned properly. And finally, make sure the pool does not have any circulation dead spots. Perform a dye test of pool circulation patterns to make sure all inlets are operating properly. Note the inlet pattern, any inlets that don't work, inlets where the water stream is weak, inlets pointed in the wrong direction, or inlets in need of adjustment. Look for circulation eddies or weak spots where water does not change color and record. If filtered, heated, chemically treated water is not being uniformly distributed to all areas of the pool, it is likely algae will become established in the pool, and other water quality problems will develop. N TRR Pool Problems
Pool Problems is an on-going column. Does your pool have a persistent problem? Submit your pool problem and/or pool operations question to sjgrosse@execpc.com. The purpose of this column is to help you, our readers, operate safe, healthful facilities.

Why Join the eList Bulletin Board?

The eList is a free way to network with other aquatic professionals, to exchange ideas and gain the knowledge necessary to best serve my patients.
Stacy Yagow, COTA/L, ATRIC

Networking is the key to having the latest information to provide the highest level of care every day. Since so many of us are not part of large service delivery teams, participating in the bulletin board gives immediate access to co-workers of diverse experience enabling me to do a better job for each person in my pool.
Barbara L. Batson

I read almost everything on the bulletin board and have a very valuable file of information. Also, it is nice to begin to get to know other aquatic professionals as questions and information comes from them and I am able to respond back. Thanks to all. I always look forward to the mail.
Patti Crimer, COTA/L Downers Grove, IL

The ATRI eList has proven to be a plethora of useful aquatic information as well as a device to network with other aquatic specialists. As a small business owner of an aquatic physical therapy department, I continue to stay informed with current aquatic information and connected with aquatic specialists through the ATRI eList.
Julie Huber, Owner, Mission Beach Water & Sports Physical Therapy

Join the ATRI Bulletin BoardFREE

When you subscribe to the Bulletin Board (its free), youll get the Aquatic Therapy Bibliography of Books free also. To subscribe go to www.atri.org and click on eList Bulletin Board then follow the directions.
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Aquatic Therapy Journal August 2005 Volume 7 Issue 2

TRR

Feature Column: Interface

Aquatic Professionals Interact withPhysicians

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

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

Orthopedic Surgeons
Be precise with what you need to know. Many times you are dealing with postop patients or post-injury patients and you need to know what limitations they haveso ask just that and gear your pre-printed form to the specific joint(s) affected. Another, better alternative is to state what you usually do with these post-op/post-injury patients and see if the physician agrees with that plan. If not, allow spaces for changes to be made. Again, be precise with your various parameters including weight, duration, equipment, time, etc. As things continue with the patient, plan on providing the physicial progress notes with updated info. Once again, these can be given directly to the patient to give to the doctor, so the doctor can see the patients improvement through your skillful hands.

of aquatic therapy, so this can be an excellent source of education for them and, if all works well, perhaps a source of patient referral for you. If they agree with what you have briefly proposed, have them sign the form and return it with the patient.

Cardiac or Pulmonary Clearance

Brand new aquatic therapy clients having underlying cardiac or pulmonary disease should be cleared for exercise by their cardiologist or pulmonologist. These patients may have graduated from cardiac or pulmonary rehab and are looking for some further exercise; before undertaking this endeavor, its prudent to obtain medical clearance first. Once again, provide the cardiologist or pulmonologist with your program parameters and goals, target heart rates, length of activity, etc., in a simplified, pre-printed form and allow the patient to deliver and return this form. Finally, for patients without any known cardiac activity or history of exertional angina, and with only one known risk factor (diabetes, high cholesterol, hypertension, smoking, family history, morbid obesity), some cardiologists might not recommend a pre-exercise stress test. But if two or more risk factors exist, a pre-exercise stress test is definitely warranted. Either way, getting their written clearance for your exercise program is still sensible.

INTERFACE is a column devoted to the interaction between aquatic therapy professionals and professionals in other disciplines. Since many of your aquatic clients are under care of a physician, effective communication with their doctors is important for your patients ultimate health and well being. What follows is a brief guide to promote this communication.
General Points
As a general rule, remember a physicians time is very limited, so whatever form of communication you expect in return, try to make it very simple. After discussions with numerous colleagues of mine in various sub-specialties, I have summarized what works well for them. A preprinted form that asks specific questions about what you need to know, is most helpful. This will need to be adjusted for each patient, but having several templates on your computer would be a good place to start. Forms where boxes can be checked will make it even easier for the physician to fill out. Having the patient take the form with him/her to their next appointment, directly hand it to the physician and have the doctor fill it out immediately (and return it to the patient during that office visit) will hasten the flow of information. Any other form of communication just takes too long, and its too easy for busy doctors to forget to fill out
11

Neurologists/Rheumatologists
Patients with chronic conditions oftentimes are under the care of these specialists. Some are early in their disease process, some very advanced. Examples include Parkinsons, Multiple Sclerosis, Lupus, Rheumatoid Arthritis, Fibromyalgia, Reflex Sympathetic Dystrophy and Stroke. Forms will need to be individualized to the specific patient, yet try to keep the information simple. Once again, utilize forms that are easy to fill out. If these are physicians that are unfamiliar with your expertise and experience, I suggest providing them with a cover letter introducing yourself, including a brief resume. Then indicate on your form what you can provide to their patients. Im sure that many of you already know that too many physicians dont understand the benefits

Conclusion
Effective communication with busy physicians needs to be concise. Providing doctors with easy-to-fill-out forms and having the patients be the mailpersons will readily provide you with updated info. In addition, this may not only promote the aquatic industry as a whole to doctors, but also serve as a marketing tool for future referrals from physicians. N

Aquatic Therapy Journal August 2005 Volume 7 Issue 2

Effects of Water Exercise on Muscle Strength and Endurance

Busy people need time saving, comprehensive workouts, balancing aerobic activity with upper body, lower body, and trunk strength training. The purpose of this study was to contribute to the limited body of literature on effects of typical water aerobics classes on muscular endurance and strength in working age people. This research examines performance of muscular endurance and strength measures in community water fitness participants who typically utilize class for an aerobic workout. adults (Judge, J. O., Schectman, K., Cress, E., & the FICSIT group, 1996; Laukkanen, Heikkinen, & Kauppinen, 1995). Losing lean body mass, strength, and flexibility, gaining fat mass, losing cardiovascular capacity, and developing glucose intolerance have been associated with inactivity. These are not products of aging, as previously thought (Hu, Li, Colditz, Willett & Manson, 2003; DiPietro, 2001; Nelson, 1997; Pate et al., 1995). Age/ Population Specific Data People of working age also suffer degrees of disability in performance of ADLs, most commonly from low back pain (LBP) (Sullivan, Dickinson, & Troup, 1994 ). Epidemiologists report LBP affects one in three Americans by age forty-five, 80% of the population experiences LBP at least once (Jenkins & Borenstein, 1994). The least fit people examined in a study of 1652 firefighters, were found to have a substantially higher incidence of LBP than the most fit. Patients with LBP often become further de-conditioned from inactivity, creating more risk for continued pain and loss of income (Jenkins & Borenstein, 1994). Prevention and rehabilitation programs make sense for preserving functional abilities, and have proven effective in avoiding long-term healthcare (Girouard & Hurley, 1995). Loss of lower extremity strength and balance are primary risk factors for loss of physical function (Nelson, 1997; Wolfson et al., 1996). Typically, there is a 40% decrease in strength from age 20 to age 70 attributed to loss of lean tissue (Eckmann, 1997; Wolfson et al., 1996). Sanders et al. (1997) documented significant effects of 16 weeks of water exercise on functional measures simulating ADLs among 44 exercisers (73.6 + 7 years). Winter & Burch (2000) also measured significant improvement on the Get up and Go test among her

Diane J. Marra, MA

small group (62 + 10 years) with painful osteoarthritis (OA) after only 8 weeks of exercise. Vertical water exercise offers resistance to increase muscle strength (Winters & Burch, 2000; Sanders et al., 1997) and improve or maintain bone mass (Tsukahara, Toda, Goto, & Ezawa, 1994) in postmenopausal women. Varied intensity levels are accommodated in one class with proper instruction (Marra, 1998; Ruoti, Morris, & Cole, 1997; Sanders, 1993), allowing for a bridge into more vigorous activity for the sedentary or overweight. Water fitness research has also demonstrated the cardiovascular benefits of water exercise programs for all ages (Bushman et al., 1997; Whitlach & Adema, 1996; Taunton et al., 1996; Ruoti et al., 1994; and Sanders, 1993). The literature addressing functional benefits for ADLs and strength measures, however, has primarily used senior adults as subjects. For todays busy working-age adult it appeared important to assess the possibility of achieving an aerobic workout with overall resistance training at the same time, as life becomes more sedentary for everyone. Activity Specific Data Resistance training on machines strengthened each isolated muscle, but functional performance did not improve without integration of multiple joint movements, utilizing several muscle groups concurrently (Cress, Conley, Balding, Hansen-Smith, & Konczak, 1996). Specificity of training in a vertical posture similar to ADLs, while overloading several muscle groups, occurs within water fitness classes. Varied intensity levels are accommodated in one class with proper instruction (Marra, 1998; Ruoti, Morris, & Cole, 1997; Sanders, 1993). Water fitness increased the adaptation associated with muscle strength
12

Background
Physiological declines of an inactive lifestyle and benefits of exercise are clearly documented, yet 25% of Americans are completely sedentary, and another 53% are not active enough to attain many health benefits (CDC, 2003; US Surgeon General, 1996). Since modern technology has tied many to desk jobs and computer recreation, estimates of obesity in American children, as well as adults, are at epidemic levels (Giammattei, Blix, Marshak, Wollitzer, & Pettitt, 2003). Although the most common excuse for not exercising is lack of time (Pate et al., 1995), Americans average more than 4 hours of TV viewing daily (Nielsen Report, 1998). Maintenance of good body mechanics is at higher risk due to our trends towards limited activity (Kendall, McCreary, & Provance, 1993). Repetitive, restricted motion and faulty posture over a period of time can cause discomfort, pain, or disability, depending on severity and duration of muscle weakness (Kendall, et al., 1993). Disability in performance of activities of daily living (ADLs) has been strongly associated with depression, arthritis, loss of mobility, loss of physical capacity and function, and increased risk of mortality in older

Aquatic Therapy Journal August 2005 Volume 7 Issue 2

(Winters & Burch, 2000; Marra, 1998; Whitlach & Adema, 1996; Ruoti et al., 1994; Sanders et al., 1993) and has been linked to maintaining or increasing lean body mass. Wilber, Moffatt, Scott, Lee & Cucuzzo (1996) measured blood lactate levels in land-trained water runners to be 31% higher than those performing submaximal treadmill running at the same volume of oxygen consumed (VO2) on land. Researchers concluded the waters resistance elicited this anaerobic response, typically associated with strength training, not endurance training. Absolute muscular endurance, the ability to perform repeated dynamic or static muscle actions for extended periods, may be increased through strength training (Wilmore & Costill, 1994). Researchers have used muscle strength testing to assess the capability of muscle groups to provide support, stability, and function in locomotion (Kendall et al., 1993). Chest and shoulder muscle endurance measures showed significant gains in several aquatic fitness studies. Whitlach and Adema (1996) measured a 25% anterior deltoid strength gain in older adults (mean age 71.5 years) after 12 weeks of hot water (94-96) exercise. In an underwater test, 59-75 year old individuals, after 12 weeks of water exercise, achieved significant endurance gains (p < .05) when moving the shoulder through a 90 joint range in both abduction/ adduction and horizontal flexion/extension to a one repetition per second tempo. (Ruoti et al.,1994). Sanders (1993) measured the youngest water exercise participants (39.9 + 13.99 years), and found significant muscle endurance gains in the YMCA timed bench press performance (counting the greatest number of repetitions at a 60 bpm cadence) after 9 weeks of participation. In the same study, Sanders also found significant performance gains in abdominal muscle endurance via a bent-leg curl-up test. Since no crunch training was utilized in the study, improvements were attributed to dynamic, vertical, postural alignment training within the water fitness classes. Several researchers reported improve13

ment in muscle strength. Isometric quadriceps strength improved significantly and correlated highly with improvements in the functional sit to stand time of 70- year old women in 16 weeks of water aerobics (Sanders, et al., 1997). In 12 weeks of hot water exercise, Whitlach and Adema (1996) measured 58% increase in quadriceps strength on leg extension machine among fifty-six older adults (mean age 71.5 years). This group also increased their walking speed by 40% on the treadmill. Sanders, during her 1997 study of older women, examined changes in knee flexor performance by measuring isokinetic strength, but only extensor strength changed significantly (p< .05). Hoeger (1994) also measured knee flexion and extension isokinetically in participants aged 15-35 years. He found improvements in both muscle groups, but only hamstring performance increased significantly (p < .05). Since pre-training strength of individuals greatly affects relative gains from an exercise program (Kraemer, Deschenes, & Fleck, 1988), this discrepancy may have occurred because Sanders used women in their seventies. Quadriceps strength and size among this population tended to show greater declines relative to hamstrings strength and size (Sipila & Suominen, 1995), therefore demonstrating more dramatic improvements after training. Cardiovascular benefit of water exercise has been documented for all age groups (Bushman et al., 1997; Ruoti et al., 1994; Sanders, 1993; Taunton et al., 1996; Whitlatch & Adema, 1996). However, available information regarding strength gains and functional benefits for ADLs is limited. This project addresses this gap in the literature. Data in 9 muscular endurance and strength measures were gathered from 22 working age women (24-55 years), before and after 8 weeks of participation in a community water aerobics program.

form approved by the Ethics Committee for the Rights of Human Subjects at California (Sonoma) State University, Rohnert Park, CA. Twenty-two women (N=22) with a median age of 42.05 + 8.3 years completed the program designed to address the question regarding the effects of vertical water exercise classes on muscular strength and endurance. Data from 7 additional volunteers were excluded, due to lack of attendance. Subjects activity levels were reported as exercising 0-2 days per week for the previous 3 months, while engaging in little or no forceful upper body activity during daily job performance. All indicated they felt comfortable in water and agreed to exercise only within the designed water exercise program for 9 weeks, until all testing was completed. Participants attended their choice of 3 one-hour water aerobics classes per week for an 8-week training period. Classes were a part of pre-existing City Parks and Recreation Department program at a heated outdoor pool with an average water temperature of 83F , where research participants exercised alongside non-research participants. Subjects attended two testing sessions before and two sessions after the 8week exercise program. First appointments were at a local athletic club for baseline vital signs and 7 land-based muscular endurance and strength measures, followed by two to three days of rest, before 2 muscular endurance measures were performed in the water at the city pool. Exercise Testing Land Evaluations: The Protocol began with 7-minute treadmill warm-up at 3.0- 4.0 mph, followed by measures in seven categories. Shoulder adduction, knee extension, shoulder abduction, knee flexion, a one-repetition maximum (1RM) leg press, isometric abdominal test, and back extension measures were given, The session concluded with a 5 minute stretch (Marra, 1998). The first four muscular endurance evaluations were modeled after the YMCA bench press test (Golding, Myers, & Sinning, 1989). Quadriceps endurance was measured on a seated CYBEX leg extension machine set at 10 lbs. Each subject

Methods
Twenty-nine apparently healthy women were recruited from the community through public service announcements, and gave informed consent to participate in the study. Before beginning the program, each woman signed a consent

Aquatic Therapy Journal August 2005 Volume 7 Issue 2

performed repeated non-preferred leg extensions in the sagittal plane at 60bpm. Hamstrings endurance tests on the CYBEX prone leg-curl machine were performed with 10 lbs of resistance also (Marra, 1998). The one-repetition maximum (1RM) (Baechle & Earle, 1995) was estimated using the CYBEX reclining leg-press to observe performance of gluteal muscles, hamstrings, and quadriceps. Two trunk measures were used, an isometric abdominal muscle test (Kendall et al., 1993), and second trunk test, from the Purdue Fitnessgram battery (Cooper, 1994). Water Evaluations: Participants began water testing with a 5 minute jogging and arm-pumping warm-up. Then two tests were given. First, a modified version of an upper body water test used by Ruoti (1994), where subjects began in a standing position, water at the axilla level, while wearing a weighted diving belt adjusted to 30lbs for increased stability and Sprint Aqua Gloves for increased surface area (Model Nos.725 and No.780, Sprint Rothhammer International, Inc., San Luis Obispo, CA). Beginning with palms touching the lateral part of the thighs, the test consisted of a 90 abduction/adduction flapping movement, maintaining straight wrists aligned with the arms, lifting until the top of the hands just touched the surface of the water, and returning to touch the palms to thighs (Marra, 1998). The second and final water evaluation for quadriceps endurance was adapted from Sazaklidou (1994). It required a 75 bpm cadence for appropriate difficulty as determined from pilot testing. Participants were positioned in water approximately waist deep,facing the wall, hands grasping the deck rail while standing on the preferred leg, on top of a Speedo Aquatic Step (SPEEDO, City of Commerce, CA). The non-dominant leg was dangling off the side of the step with a Sprint Buoyancy Cuff. An additional 3-piece Beltfloat was worn for resistance. Femurs remained parallel to each other throughout the movement to avoid involvement of the hip flexors. Subjects flexed the working knee to a 90 degree angle and then extended the leg to the original position, repeatedly (Marra, 1998).

Exercise Intervention Program Subjects then participated in the 8-week water exercise program, as described earlier. Each 1-hour exercise session consisted of: a 10 minute warm-up, 20minutes of shallow water activity wearing webbed gloves, followed by 25 minutes of deep water activity using flotation bells with feet suspended off the bottom of the pool, ending with a 5minute stretch (Marra, 1998). Data Analysis Descriptive statistics were used to analyze data. The Wilcoxon Matched-Pairs Signed-Ranks test was used to determine significance of changes, pretest to posttest. A nonparametric test was selected because of lack of normal distribution in the pretest data. The Wilcoxon test considers both t magnitude of the differences in scores, and direction of change. An alpha level of p = .05 was chosen a priori for criteria of significance. Since most results were significant at the p = .005 level, it was reported. Note, the Wilcoxon test chart used for this study (Pagano, 1986) indicates highly significant numbers at the p = .005 level, not at the more commonly used p = .001 level. Pearson Product Moment correlations were calculated to determine relationships

between water and land measures (Marra, 1998).

Results
Upper Body Muscular Endurance: Both shoulder adduction and abduction measures on land showed increases of statistical significance (p < .005) following the exercise training. However, the mean number of land adduction repetitions performed was nearly tripled from the baseline scores, while the mean number of land abduction repetitions improved only about 20% (Marra, 1998). The combined shoulder adduction / abduction water test also revealed significant improvements (p < .005), with an average post-test score nearly 5 times that of the pre-test (Marra, 1998). The descriptive results are shown in Table 1. Lower Body Muscular Endurance: Both hamstring and quadriceps performances on land increased significantly (p < .005). The mean number of knee flexion repetitions improved approximately 51% from baseline (Marra, 1998). During posttest of the knee extension measure, participants demonstrated a mean increase of around 15% (Marra, 1998).

Upper Body Muscular Endurance Measures Land

Shoulder Adduction Shoulder Abduction

Water
Combination Shoulder Add/Abduction

M Pretest Posttest Difference

SD

SD

SD

164.14 67.57 466.05* 251.83 +301.91 repetitions

70.55 20.84 83.27* 25.01 +12.72 repetitions

63.89 33.38 293.27 228.62 +229.38 repetitions

*Significant improvement at p<.005 level.

Table 1

Lower Body Muscular Endurance Measures Land

Knee Flexion Knee Extension

Water
Knee Extension

Pretest Posttest Difference

SD M 43.32 16.08 61.20* 18.01 +17.88 repetitions

M 44.59 50.95*

SD 15.10 18.67

+6.36 repetitions

M SD 200.50 125.00 911.95* 493.75 +711.45 repetitions

*Significant improvement at p<.005 level.

Table 2

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14

Summary of Trunk and Lower Body Strength Measures Land

Leg Press 1 RM Spinal Extension Abdominal Angle

Pretest Posttest Difference

SD M 104.55 21.04 118.18* 23.12 +13.63 pounds

M SD 11.53 3.69 13.92* 4.00 +2.39 inches

M SD 32.27 20.28 28.27 17.49 4 degrees improvement

*Significant improvement at p<.005 level.

Table 3 Remarkably, the scores of quadriceps performance in the water, after exercise training, were almost four times the pre-training scores (p < .005) (Marra, 1998). Scores for lower body endurance are displayed in Table 2. Strength Measures of the Lower Body and Trunk: Participants significantly improved 1RM on the leg press machine by approximately 13% after the exercise intervention (p< .005) (Marra, 1998). Trunk extension posttest scores also were improved by more than 20% (p < .005) (Marra, 1998). During abdominal testing, the average body angle to the floor decreased by 14%, which indicated an improvement, although not statistically significant (Marra, 1998). See Table 3. Correlations of Changes in LandWater Scores: There were very low correlations between changes in scores on land, and related muscle group tests in the water. The strongest relationship was only r = 0.30, between improvements in knee extension on land and knee extension in water. Correlation between improvements in the shoulder land adduction measure (the more improved land-shoulder measure) and the shoulder water combination measure yielded an r of only - 0.099. There were no detectable patterns within or between individuals (Marra, 1998). small sample size limited the statistical power and interpretation of results. The direction of change was expected, however the magnitude of change was unexpected. This study has provided evidence that after only 8 weeks of water aerobics, both muscular endurance and strength improved. Upper Body: In the water, shoulder abduction/adduction final scores were almost five times the pre-training scores. These results eclipsed even the greatly improved shoulder adduction test on land, which finished with numbers nearly three times those of the pre-tests (Marra, 1998). The nearly 20% improvements on the land shoulder abduction test, while statistically significant, seemed disproportionately low (Marra, 1998). These findings supported an aspect of the specificity of training principle (Wilmore & Costill, 1994), demonstrating more noticeable gains in tests duplicating the aquatic training environment (Marra, 1998). This corroborates Ruotis (1994) findings of significant improvements in this same water measure performed without webbed gloves by individuals aged 59 to 75 years after 12 weeks of water training. The dramatic difference in the isolated land-based shoulder abduction scores from the shoulder adduction results, demonstrated the focus on adduction activities in vertical water exercise. Assuming an erect position in the pool, shoulder adduction is resisted by buoyancy and further challenged by use of flotation equipment, whereas shoulder abduction is assisted by buoyancy (Marra, 1998). Order of testing may have also

contributed to weaker performances in shoulder abduction through fatigue of stabilizing muscles. It is possible there was greater improvement in upper body relative to most lower body measures, because upper body muscles were weaker in pre-testing. It appears even among inactive adult females, lower body muscles maintain greater muscular strength and endurance due to daily work against gravity, whereas the upper body usually is not challenged in this way. Lower Body: Results of lower body muscle endurance tests in water indicated an almost five-fold increase in number of knee extensions performed after training. This substantial change in quadriceps endurance in water seemed disproportionate to the 15% average improvement on land using CYBEX equipment (Marra, 1998). Also worth noting, is the impressive underwater quadriceps scores recorded during post-testing are only an estimate of participants actual abilities. The posttesting evaluations unexpectedly continued for such long time periods, that some women quit, due to personal time constraints or impatience, before they experienced muscle failure. As noted in upper body measures, these dramatic findings appear to demonstrate the specificity of training principle (Marra, 1998; Wilmore & Costill, 1994). The water measure originally intended for hamstrings endurance was eliminated during pilot testing due to problems in stabilizing subjects against buoyancy. However the land CYBEX knee-flexion test was successfully completed, indicating a 51% average improvement (Marra, 1998). Sanders (1997), Hoeger (1994) and Winters & Burch (2000) report the only other available knee flexion tests, following vertical water exercise treatments. Winters & Burch used a 1RM hamstring strength measure with their OA patients and reported a mean increase of more than 20% after only 8 weeks. Using isokinetic strength measures, Sanders (1997) and Hoeger both reported improvements in hamstring performance with Hoeger noting significant changes at p<.05. Like Hoegers research, the current land tested results showed greater relative improvement of hamstrings compared

Discussion, Recommendations, and Conclusions

The purpose of this study was to contribute to the limited body of literature on the effects of typical water aerobics classes on muscular endurance and strength in working age people. Clearly the quasi-experimental design and
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to quadriceps performances (Marra, 1998). Hamstrings typically produce 60% to 80% of isometric strength to that of quadriceps muscles in healthy adults (Baechle, 1994; Fine & Weiss, 1995). Therefore it makes sense that participants in this study, like Hoegers, achieved more dramatic results in posttests of hamstring strength over comparable quadriceps strength, given average pre-training age and status of the healthy participants (Kraemer, Deschenes, & Fleck, 1988). On the contrary, older adults tend to have declining quadriceps strength (Nelson, 1997; Sipila & Suominen, 1995). This would explain the dramatic gains in quadriceps measures compared to hamstrings, among Sanders (1997) septuagenarian female participants, given the typical pre-training status of that population. Increases in the 1RM leg press averaged 13%, indicating improvements in strength of the quadriceps, hamstrings and gluteal muscles (Marra, 1998). These findings corroborate significant improvements in sit-to-stand, and getup-and-go functional field tests (Winters & Burch, 2000; Sanders, 1997). Improvements in strength from water aerobics training is an important finding because these results indicate participants can achieve an aerobic workout (Brown, 1991; Ruoti et al., 1994; Sanders et al., 1993), a muscle endurance workout, and a strength training session concurrently, during the same water class (Marra, 1998). Trunk Measures: The more than 20% average improvement in the spinal extension evaluation indicates not just increased strength, but likely an improvement in range of motion (Marra, 1998). Although these two factors cannot be separately distinguished in the given test, this is an important finding since spinal mobility decreases with age and extension shows the greatest decline (Einkauf, Gohdes, Jesnsen, & Jewell, 1987; Sullivan, Dickinson, & Troup, 1994). Abdominal leg lowering measure proved difficult to administer. This test included only one tester and one spotter, but would have been more accurate

with two testers and a spotter due to the poor body awareness demonstrated by subjects during pre-testing. Pretest scores may have been better than actual performances had warranted from this partially self-reported test. Since the water aerobics program included training in postural control, it became clear to the tester and participants at posttesting, that participants awareness of their abdominal region had changed substantially through instruction. Individuals at post-testing were very aware of the moment their low backs began to pull away from the floor and self-reported, cueing the spotter and concluding each test. Many women recalled how inaccurately they may have self-reported body position during pre-testing, so it is likely the 14% average improvement is only a portion of actual gains derived by participants (Marra, 1998). Although crunch exercises are not performed in water, this improvement in abdominal strength may be attributed to emphasis on maintaining postural alignment throughout each class (Marra, 1998; Sanders et al., 1993). Thus, vertical water exercise allows comprehensive trunk training, balancing a strength workout of both spinal extensors and flexors in the safety of immersion in an upright position, which simulates many ADLs (Marra, 1998). Few workouts on land can duplicate this type of trunk workout with its low risk of injury. This is promising, especially for de-conditioned or disabled populations with limited body awareness.

ply learning factors (Marra, 1998). More water fitness training research is needed to further investigate changes in muscle strength throughout the body, perhaps with less focus on muscular endurance. Multiple pretests and the use of already conditioned participants to address learning factors may determine more precisely, actual strength gains. This study also produced promising evidence for improving trunk strength, during water aerobics (Marra, 1998). Due to overwhelming statistics of back problems, including LBP and chronic pain syndromes, more research is needed to assess training effects on trunk performance. Development of better measures for testing performance of back and abdominal muscles would improve our ability to accurately examine the specificity of training vertically in the water. To compare water aerobics to swimming, as well as comparing land aerobics to water aerobics while assessing trunk performances, would provide valuable information on this topic. Since it is becoming more common practice for coaches to train very fit athletes in water prior to injury, research designed to serve this population could open new doors for water fitness programs to be taken more seriously, and shed the reputation they are only for grandmothers.

Conclusions
Water aerobics provides an effective muscle strength and endurance workout for a de-conditioned, healthy population (Marra, 1998). Although the 8week program resulted in whole-body improvements, there appeared to be particular benefits for those weak in upper body and trunk strength. Water exercise may be especially beneficial for people who have sedentary jobs, like most of the participants in this study. Noting the large range of scores recorded, individuals with varying abilities improved their personal fitness levels while attending the same classes together (Marra, 1998). Properties of water offer advantages over gravity-based land-exercises, for instantly changing and controlling individual workout intensities mid 16

Recommendations for Further Research

Prior research indicates the possibility of learning factors affecting the current post-testing performances (Kroll, 1972; Sale, 1988). Kroll (1972) noted learning effects accounted for approximately 8% to 25% of improvements in repetitive isometric strength and endurance activities among college-age women. The current study included performances of isometric, concentric, and eccentric muscle activities with improvements ranging from 13% to over 400%, indicating much of the improvement occurred as a result of training not sim-

Aquatic Therapy Journal August 2005 Volume 7 Issue 2

movement. This concept agrees with therapy professionals who use the water environment as a gentle place for postinjury, older adult, and obese populations who must control intensity and impact while exercising. Water aerobics is an excellent lowimpact activity for beginning exercisers and can be further adapted to any fitness level, providing a unique whole-body workout including a 3-dimensional resistance-training environment. Although this study only measured single plane movements, strength-training experts have noted such resistance workouts, which utilize various angles, movements, and velocities, achieve optimum results (Kraemer et al., 1988). Multiple joint involvements in propelling the body forward, backwards and laterally through water in a variety of ways, follows this strength training principle. Results of the current study indicate substantial changes in upper body, lower body, and trunk muscular endurance and strength following an 8-week water aerobics program. To accommodate exercise needs of busy working-age people, this study provides evidence water aerobics delivers the desired comprehensive workout (Marra, 1998). N

Reviewer Comments
Marty Biondi I applaud this authors attempt to quantify the benefits of a vertical, cardiovascular-based water exercise program with respect to strength and muscular endurance acquisition. It provides a reference point from which instructors, therapists, aquatic enthusiasts can plan workout sessions to accomplish specific goals related to these parameters. In addition, it is an attempt to improve our knowledge base concerning the effects of water exercise on the strength and muscular endurance. Lastly, it provides a basis for additional research in our quest for utilizing waters specific properties in the areas of strength and muscular endurance. Doug Kinnard WOW! This information is going to be great material to put into presentations about the value of water exercise. N

Mary O. Wykle, Ph.D., ICATRIC. Adjunct Professor, Northern Virginia Community College. In addition to her college teaching, Mary is dedicated to expanding the use of aquatic therapy and rehab through teaching, research, and briefings. She is vicechairman of ICATRIC, chairman of the National Aquatic Coalition, and Aquatic Exercise and Rehab Director at Burke, VA Racquet & Swim Club. She holds multiple additional certifications. N

AUTHOR, AUTHOR
Interested in authoring an article for the Aquatic Therapy Journal? Author guidelines may be obtained by contacting our Editorial Office, c/o Sue Grosse, 7252 W. Wabash Avenue, Milwaukee, WI 53223; sjgrosse@execpc.com

Editor's Note
Reference list available upon request. Contact sjgrosse@execpc.com.

Reviewer Bios
Marti Biondi, PT, CSCS, ATRIC is an outpatient orthopedic physical therapist with approximately 25 years of water experience in a variety of areas. Currently she is involved in working in both clinic and pool settings with a variety of individuals, from spinal cord injured adults to Olympic potential athletes. Douglas W. Kinnard, BA, NCTMB, ATRIC, founder Kinnard Seminars has been a massage therapist and educator since 1976. He presents at ATRI educational events, and with a team doing review workshops for the ICATRIC exam. Doug has a practice in aquatic therapy and rehabilitation in Portland, Oregon, and received ATRIs Tsunami Spirit Award in 2000.

Author
Diane J. Marra, MA has served, since 1999, in a variety of civilian medical research positions for the US Army and is currently working as a Research Analyst for the US Army Human Factors Field Element, Army Medical Department Center & School, Fort Sam Houston, TX. She continues to do freelance consulting part-time in fitness, wellness, and nutrition, She teaches regular water exercise classes at a local San Antonio, TX hospital wellness facility, and is a guest lecturer for graduate students in occupational therapy and in adapted physical education programs at local colleges and universities. Marra would like to acknowledge the Santa Rosa, CA Parks and Recreation Department (Finley Aquatic Center) and Ms. Donna Burch, MA (their generous Aquatics contractor) for key support. This study could not have happened without them! Marra can be contacted at msdiane@satx.rr.com.
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CECs
ICATRIC approved CECs will be available through the Aquatic Therapy Journal, beginning with the Winter 2006 issue. Dont miss this opportunity to apply your professional reading to your certification as an aquatic therapy professional.

Subscribe!
Are you reading someone elses copy of ATJ? Individual, as well as library subscriptions, are available through the Aquatic Exercise Association, www.aeawave.com.

Aquatic Therapy Journal August 2005 Volume 7 Issue 2

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Feature Column: Research Review

result and initially suggests that promoting exercise controlling socializing would be good for aerobic fitness exercise; however the study does lend support for allowing older adults to exercise in a social environment as HR and RPE scores did approach minimum suggested targets for a group of older adults (average age 75) during a 30 minute exercise regimen. It is recommended that socializing while engaged in aquatic exercise or therapy NOT be discouraged in the older adult population. Exercise leaders and therapists can supervise low to medium impact deep water exercise programs that focus on the social benefits as well as the physiological benefits of exercise. Aerobic fitness can be achieved while participants visit during exercise. This appears to be a key finding as providing adequate aerobic exercise for the older population without contraindications to the exercise is difficult. To determine the validity of this study future research should focus on various exercise regimen, workout intensity, and age consideration. In addition, research should also determine the cost effectiveness of buying a $30-$50 heart rate monitor similar to the ones chosen for this study so participants can monitor their own heart rates. The only concern centers on atrisk populations exercising at levels unsafe based on age and condition. Heart rate monitors and close scrutiny of RPE are excellent tools to limit this concern. Finally, future research should consider other measure of aerobic fitness such as the JAB method and maximal aerobic power (VO2max). Although studies have used these methods in past research with older adults none have considered the socialization effects. Hoeger, W., Gibson, T., Kaluhiokalani, N., Cardejon, R. & Kokkonen, J. (2004). A Comparison of physiologic responses to self-paced water aerobics and self-paced treadmill running. Published in ICHPER-SD Journal. 40(4), Fall. 27-30. 15 refs. Purpose of this study was to compare exercise heart rate, oxygen uptake, and rate of perceived exertion between selfpaced water aerobics exercise and selfpaced treadmill running. Thirty-three subjects performed two exercise sessions in random order. Subjects were allowed to work at their preferred aerobic intensities during an 11-minute session in water and on land. The first five minutes of exercise were used as warm-up. During this phase, subjects gradually increased exercise intensities to their desired aerobic pace. For the final six minutes, subjects exercised at their preferred paces, but were allowed to increase or decrease intensities as they wished. No verbal or physiologic feedback was provided during the tests. Exercise heart rate and oxygen uptake data were collected at one-minute intervals during the workouts and an average of the last six minutes of exercise used for data analysis purposes. A rate of perceived exertion was obtained at the end of each exercise session. A maximal treadmill test was also administered to determine HRmax, VO2max, and RPEmax. Repeated measures ANOVA revealed significant differences (p<0.1) between the two exercise modalities in HR only. Although exercise heart rate was 7.1% lower during self-paced water aerobics, no differences were found between the two exercise modalities in oxygen uptake and perceived exertion. During self-paced water aerobics, subjects exercised at 79% and 69% of land-based HRmax and VO2max respectively. For self-paced treadmill running subjects exercised at 85% and 69% of land-based HRmax and VO2max. These results indicate when subjects were asked to exercise at their preferred aerobic intensities, both water aerobics and treadmill running were of similar exercise intensity. Furthermore, during self-paced exercises, both of these activities met ACSM guidelines for developing and maintaining cardiorespiratory fitness. These results have specific implications for individuals having muscularskeletal problems, exercise injuries, or those susceptible to high-impact exercise-related injuries. In the quest for an appropriate fitness activity, many such persons have turned to water exercise as an alternative activity to improve and maintain cardiorespiratory endurance. N
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Beason, K., McLemore, T., Chambers, J. (2005). Socialization Effect on Heart Rate and Rate of Perceived Exertion during Deep-water Exercise in Older Adults This study was conducted as part of a research project funded by the Aquatic Exercise Program and the University of Mississippi. This comprehensive research project investigates the effect aquatic exercise has on gait, bone density, body composition, depression level, boredom, and life satisfaction in older adults. For senior participants to receive benefits, aquatic exercise programs must 1) achieve the appropriate aerobic fitness level for older adults and, 2) foster steady and on-going participation. Accordingly, the purpose of this study was to determine if older adult subjects participating in a deep-water, low-tomoderate aerobic intensity exercise program could maintain adequate aerobic output while allowed to socialize during exercise. It was posited there would be no significant relationships between heart rate (HR), and rates of perceived exertion (RPE) based on the level of socialization that occurs. Expectedly, there was a significant positive correlation between mean heart rates of the subjects and their RPE scores. There was a significant inverse relationship between RPE and heart rate and socialization which indicates that subjects chose to exercise alone more as the exercise intensity was increased. Comparisons of mean HR and RPE scores observed at each stage of exercise showed as the cadence or intensity of the exercise was increased both heart rate and RPE increased. There were significant (P<.05) inverse relationships between the HR and RPE scores and the levels of socialization which indicates that socialization while exercising in older adult populations had a suppression effect on both heart rates and rates of perceived exertion. This refutes the null hypothesis of the study that older adults who socialized during exercise would not have significantly greater or lesser heart rates and RPE scores. This was not an unexpected

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Feature Column: New for Your Library

Fawcett, P. (2005). Aquatic Facility Management. Champaign, IL: Human Kinetics. Hardcover, 296 pp, illustrated, $49.00. ISBN 0-7360-4500-7. There is a great deal of detail in this reference publication. Written as a course text for college work in aquatic management, and as a reference book for aquatic professionals, this publication covers a wide range of topics in an easy to read format. Information about how to develop, manage, and program for instructional swim and competitive aquatics is the main focus. The pool is the venue of choice. Topic coverage is comprehensive for entry-level management. Numerous charts, diagrams, photos and illustrations, along with a glossary and index, make this a very user-friendly text. For college courses, the review questions for each chapter will aid the student. For the aquatic therapist, this is an excellent reference manual. While aquatic therapy, as a professional discipline, is not included in content, many aquatic management issues faced by aquatic therapy professionals are considered. Promoting programs, public relations, budgeting, and developing staff are major sections, along with managing risks, planning for emergencies, managing water chemistry and filtration, and general facility operations. While some aquatic therapy programs have their own venues, other aquatic therapy professionals must rely on use of public pools. Knowing how aquatic managers select and/or drop programs, develop program policies, work with outside groups and agencies, and program for individuals with disabilities can help an aquatic therapy professional work collaboratively with local pool management. Appendix material includes a reference list of aquatic related agencies, a compilation of contacts for the bathing codes of each state, aquatic and safety equipment sources, and over 50 pages of templates for commonly used forms. This section, alone, makes this book a good source. Need a press release, a facility rental form, a chart for tracking equipment, or an audit evaluation sheet? Theyre all here, with many more besides. While lack of direct reference to aquatic therapy is regrettable, the quantity of information useful for aquatic therapy professionals, particularly those who may have limited background in aquatic management, is outstanding. Make this publication a must for your reference library! Kasser, S. & Lytle, R. (2005). Inclusive Physical Activity: A Lifetime of Opportunities. Champaign, IL: Human Kinetics. Hardcover, 288 pp, Illustrated, $49. ISBN 0-7360-3684-9. This text is intended for courses in adapted physical activity, and as a resource for teachers and specialists who work with people with disabilities. A functional approach to modifying movement experiences (FAMME Approach) is the overriding theme. The extremely practical material included provides practitioners with strategies and hands-on applications for physical activity programming for all individuals regardless of age and/or disability. Special features, including scenarios, boxed Helpful Facts and supplementary information, Think Back questions for further reflection, and What would you do? situations, facilitate practical application of theoretical information. Photos, charts, and references are prevalent throughout. Users of this test are encouraged to become critical thinkers and problem solvers as they develop knowledge and skills to provide meaningful, inclusive physical activity. This includes designing games, modifying sports, and individualizing health-related fitness, adventure, and outdoor recreation activities not just for school children, but for anyone of any age. This, at first glance, might not seem like a reference for professionals in

White, M. (2004). The Aging Spine. Lincoln, NE: iUniverse. Paper, 81 pp, illustrated, $11.95, ISBN 0-595-32887-3. Martha White brings 20 years of experience as an occupational therapist to the content of this concise and informative book designed to help individuals with degenerative diseases of the spine manage the pain of their conditions. The first half of the text, divided into 3 well formatted sections, is a well documented overview of anatomy of the spine, movement mechanics, and reasons to exercise. Eleven different degenerative conditions are explained, with clear diagrams to facilitate understanding. Section 4, comprising approximately 30 pages, contains a collection of illustrated aquatic exercises, each selected for the contribution made to alleviation of back pain. Lastly, Section 5 contains recommendations related to activities of daily living. Believing managing back pain successfully is a matter of mind control, White provides numerous helpful hints to help individuals with back pain lead active, healthy, lives in as pain free a circumstance as possible. This book is written for the lay person. According to White, 8 to 10 individuals will suffer from back pain in their lifetime. For individuals having back pain as a result of a degenerative process (as opposed to acute trauma), this book contains a wealth of information. The background information can help anyone develop greater understanding of his or her spine, how it functions, and how pain can be avoided or mitigated. The exercises, while illustrated with land photos, are described in simple enough terms that anyone can apply the principles and implement the program. For the aquatic therapy professional, this text can be a valuable reference. The spinal anatomy and kinesiology material can be referenced in working with clients. The exercises can become the foundation of any aquatic therapy program designed for individuals with degenerative conditions of the spine.
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aquatic therapy. However, look closer. Inclusive Physical Activity helps practitioners to bridge the gap between school-based and community-based programs by providing guidelines for planning, assessing, and implementing meaningful inclusive physical activity. On a daily basis, therapy professionals work to help their clients bridge this same gap. Resources presented here can help. Specific groupings of activities are considered in terms of what individuals with specific disabilities might face as they start or resume this activity. Implications, as well as suggested modifications are concisely presented. There is a very complete chart detailing motor assessment instruments. Human growth and development information is well integrated in text content. Accessibility is presented in detail, as are summaries of all relative legislation. Aquatic activities are not, specifically, referenced. However, Kasser and Lytle have compiled a large quantity of useful information, making this a handy reference and welcome addition to the library of any professional working with individuals with disabilities. Note: An Instructor Guide and a test package are also available for this text. N

TRR

Feature Column: Around and About the Industry

courses and materials, while a network of Starfish Aquatics Institute authorized training centers will provide traditional in-water instruction. ICATRIC Announces New Re-Certification Requirements. ICATRIC, the International Council for Aquatic Therapy and Rehabilitation Industry Certification, has developed updated requirements for recertification, according to Executive Director Laree Shanda. The revised criteria reflect the variety of contributions ICATRIC-certified practitioners make to the aquatic therapy industry. Where old requirements were weighted toward continuing education and practice hours, new criteria strongly support teaching, writing, research, and service to the aquatic therapy community. Safety requirements also have been changed to be more representative of the duties and responsibilities of therapists, as compared to lifeguards. Currently certified aquatic therapy practitioners may choose either the original or the revised recertification until January 1, 2008. Several months of intensive work by the ICATRIC board of directors - especially Mary Wykle, PhD, ATRIC, Marty Biondi, PT, ATRIC, and Laree Shanda CTRS/R, ATRIC went into creating the new standards. Input came from certified providers, medical professionals, educators and research into the certification criteria for similar organizations and professions. Dr Wykle, who created the RAST (Risk Assessment and Safety Training) Program, also was instrumental in drafting the new safety standards. Information on ICATRIC Certification and Re-Certification, including application forms, is available at the organization's website www.icatric.org or by phone at 425.444.2720 N

ICATRIC Names Vargas to Board of Directors. Luis G Vargas, PhD, PT, has been named International Directorat-Large for ICATRIC, the International Council for Aquatic Therapy and Rehabilitation Industry Certifications, according to Executive Director, Laree Shanda, ATRIC. Dr Vargas is recognized as an international expert in the field of aquatic therapy. Author of Aquatic Therapy-Interventions and Applications, he developed the widely used Diagnostic Aquatics Systems Integration (DASI) Theory. He is an Associate Professor of Physical Therapy at Hamilton University, and introduced aquatic rehabilitation as a clinical specialty to the Commonwealth of Puerto Rico. He continues to conduct training programs and specialty workshops worldwide. In 2000, Dr Vargas received the Dolphin Award from the Aquatic Therapy and Rehab Institute (ATRI). Most recently he was bestowed the highest honor in the aquatic rehabilitation industry, the 2004 Aquatic Therapy Professional of the Year Award. For further information, contact ICATRIC, www.icatric.org or e-mail at support@icatric.org. Address: 2829 S. Manito Blvd., Spokane WA 99203-2542. Phone: Voice: 425-444-2720; FAX: 509-747-8278. Human Kinetics Expands Into Aquatics Training. HKP has signed a long-term collaborative agreement with Starfish Aquatics Institute, based in Savannah, Georgia, to offer texts and courses on aquatics. Human Kinetics will develop online courses and associated resources to expand Starfish Aquatics Institutes existing StarGuard and Starfish Swim School programs, as well as add new courses to create a full line of aquatics education offerings. A new Human Kinetics unit the Starfish Aquatics Education Center will be created to market and deliver the online

You know you're good but how does that new patient know?

ICATRIC setting the standard for excellence in Aquatic Therapy and Rehabilitation INTERNATIONAL COUNCIL FOR AQUATIC THERAPY AND REHABILITATION INDUSTRY CERTIFICATION www.icatric.org

Watch www.atri.org for the 2006 conference schedule.

Aquatic Therapy Journal August 2005 Volume 7 Issue 2 20

Piero Pigliapoco

Aquatic Rehabilitation For Orthopedic Trauma: Part One

Historically, aquatic rehabilitation has been used with clients having neurological or orthopedic diseases. Today, therapeutic application includes traumatic, acute and chronic diseases; a wider scope of individuals; and many types of disciplines and facilities. Professionally, this expansion is a positive step. However, it is important treatment be provided by competent practitioners, and according codified and scientifically recognized guidelines. There is no standard protocol in orthopedic rehabilitation. Therefore, it is important to customize the treatment on the basis of the type of problem and ongoing therapeutic progress. While all injured clients have pain, loss of mobility, decrease in strength, and proprioceptive impairment, involvement will vary. In addition, consideration of other existing conditions is important. The therapist must be aware of any condition that affects their client. These conditions will differ from one individual to the next: pain onset, progress, location, intensity, frequency mobility the part of the body and the parameter of movement involved strength tonic, phase-related proprioception the specific movement involved lead to postures and motor situations (static and dynamic) that develop aquatic skills and motor control not necessarily possessed by all clients, whether or not they already have water skills. Determining type of medical condition and resulting motor responses of the client are the first elements of information for the plan of care. During this adjustment phase, functional assessments are performed. For an appropriate evaluation, the practitioner should determine history of pain and its onset, mobility and strength (preventive, intermediate and final), training level in general, and specific proprioception. This initial assessment allows us to consider the whole person, discovering any static or dynamic asymmetries, which will have surely been exacerbated by the trauma and/or are its cause.

Piero Benelli Lorena Cesaretti

Walk in place, coordinated with movements of the upper limbs. Move in a vertical position, first forward, then to the side and finally, backward, using the upper limbs in coordination with the lower limbs. The forward movements should be made in a linear fashion, offering the frontal resistance of the entire body, so as to mirror as accurately as possible forward motion on the ground. To assess static-dynamic balance in deep water with flotation belt or aid (Caution: when performing this test, avoid over-floating the client with too many belts or flotation aids. Also be sure any device fits properly and is secured correctly. A client in a flotation device should always be within reach of safety, as well as within hands on reach of the therapist.) Check clients ability to: Float vertically using small movements of the legs, with the hands resting on the pool edge. Maintain buoyancy without support from hands, which are used only to maintain balance in a vertical position. Demonstrate a cycling movement with the body in a vertical position, not necessarily with the aid of the arms. Check for control of the flexion-extension of the lower limbs, with particular attention to the tibiotarsal joint. Use the arms and hands as a means of propulsion (sculling, in both a symmetric and alternating mode and in coordination with the movements of the lower limbs.) Light weights may be used on ankles for proprioception assessment in deep water and for stability in shallow water walking. Most individuals can develop adequate water skills in approximately 3-5 sessions. During these sessions, its important to maintain some concern for general conditioning work.

Introductory Sessions
We begin by assessing clients knowledge of their own bodies, and his or her ability to control various positions, in particular the vertical position, in the water. We test the client in mediumdepth and/or deep water. For most clients, we use deep water. Mediumdepth water is used for clients who encounter difficulty in the water environment. However, there are medical conditions which preclude any weight bearing (such as recent fractures of the lower limbs or vertebral problems), and where the use of medium-depth and/or shallow water is possible only in a later phase of the treatment or, in some cases, never. To assess static-dynamic balance in medium-depth water Check the clients ability to: Maintain the vertical position with the hands resting on the edge of the pool. Make small movements of the upper limbs without resting hands on pool edge.

Water Adjustment
When treating orthopedic clients, we begin with adjustment to the water environment and development of aquatic skills. This general phase is relevant to all medical conditions, including cases in which vertical position cannot be achieved on dry land. Even in the case of an individual with welldeveloped water skills (swimmers and/or specialists in other water activities) it is important any rehabilitation procedure be introduced only after completion of the introductory phase. Activities are specifically designed to
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Additionally, intervals can be taught for self-help and monitoring. Assessment can be simplified. However, these sessions are important for learning correct postures, both static and dynamic, used in the process of rehabilitation.

The Rehabilitation Phase

Once the water activities have been introduced and developed, a rehabilitation protocol specific to the medical condition diagnosed is applied. Work during this phase is focused on determining and developing joint capacity, flexibility, and muscle mass This phase allows us to pursue the reactivation and awareness of the portion of the body temporarily excluded from overall motor activity. Remembering the body operates as whole, we then focus on specific areas of the body with a work program designed for the spine, shoulder-elbow, pelvis and hip, and knee-ankle. The way in which these areas are combined is determined by the existing motor correlations. SPINE Conditions of the spine seen most frequently include herniated disks, fractured vertebra, spondylolysis, spondylolisthesis, scoliosis, and arthrosis. Despite body weight being significantly reduced in the water, during the first phase of treatment, some conditions affecting the spine call for non-weightbearing, deep-water exercises. Regardless of condition and progress, immersion in deep water can lead to decrease of pain symptoms, as a result of the load reduction and tissue decompression. In addition, immersion and buoyancy lead to vascular stimulation (venous return) and a further restoration of the nucleus of the intervertebral disk, something that would not take place in medium-depth or shallow water. When working with clients, consider trunk stability and avoid extra movement caused by assistance of water. Phase A of Treatment During this phase exercises are designed to improve joint mobility and muscle elasticity. These exercises include general motor skills for the maintenance of body alignment while suspended, as well as actions related to

motor skills developed through the use of the lower limbs during exercises performed in place or with the aid of equipment. Following a brief postural analysis, performed both on dry land and in the water, the treatment focuses directly on controlling the joint mobility and its limitations. Exercises These exercises are performed in a vertical position with the aid of a flotation belt. The client is positioned near the pool edge with the water touching the shoulder line and hands resting on the edge. All the exercises of this phase are performed at low intensity and low speed. Cycling with both hands resting on the edge: the client slowly makes small flexion-extension movements of the hip joint and the knee, simulating the cycling movement (sagittal plane). This exercise makes it possible to reach and maintain the vertical position through active-assisted muscular control. Cycling with one hand resting on the edge: the client performs the same exercise with the support of first one hand and then the other. Cycling without support: instruct the client to perform the cycling exercise off the pool wall, so the control of the vertical posture must be totally active. Leg flexion on the sagittal plane: the client slowly flexes both knees toward the chest with both hands placed on the edge of the pool. This exercise makes it possible to analyze the mobility of the sacroiliac joints and the hip joint, as well as the flexibility of the lumbar spine on the sagittal plane. Leg adduction and rotation of the hip: the client begins to perform exercises of the lower limbs to control the mobility of the lower spine, first in a long-lever mode and then as a short-lever movement. Phase B of Treatment Exercises suggested during this phase are still designed to reinforce joint mobility and muscle elasticity, but an even more important objective is improvement of muscular response, muscle mass, and a restoration of the general functional capacity of the individual, along with specific capacity of

the injured part. Work gradually increases in intensity and includes variations in the speed of execution and in joint range proposed. These exercises focus on achieving overall motor skills geared toward a retraining of body patterns, and a restoration of the basic automatic actions, accomplished through movements in complete suspension or through more analytic motor skills involving exercises carried out in place or with the aid of equipment, and at increasingly higher intensities. Exercises Exercises involving motion in deep water. Forward movements in the water cycling, walking, and running (with and without use of the arms) Forward movements with ankle cuffs cycling, walking (with and without use of arms), running Sideways motion in the water sliding (gliding while lying on ones side, as in a sidestroke position) on one side, using legs only, sideways movements with use of an arm and legs, sideways movements with arms and legs Backwards motion in the water moving backward in sitting position (with and without use of arms), flexion-extension of legs (with and without use of arms), inverted breaststroke Exercises (bilateral) performed in place in deep water with both hands resting on the pool edge. (If good body alignment is possible and there is no forward flexion). If performed unilateral, a side of the body is placed against the wall of the pool and the movement is performed one limb at a time, first without equipment and then with equipment. Forward cycling Backward cycling Alternating front leg swinging Long-lever scissors kicks Adduction and abduction of the legs in the long-lever mode Alternating crossed scissors kicks Flexion of the knees above 90 of hip flexion and abduction of the knees, plus return Flexion of the knees above 90 of hip flexion, right and left lateral twist.
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Aquatic Therapy Journal August 2005 Volume 7 Issue 2

Exercises involving motion in mediumdepth water. The client is treated in water of medium depth, approximately chest height, with a load of roughly 33% of the weight on land. Thus, we can begin a process of rehabilitation to prepare for standing/walking on dry land. The client becomes increasingly conscious of his or her body weight in both static and dynamic situations. Forward walking: a slow forward walking motion, with correct dynamics of step, with arms resting on a floating device (kickboard) so shoulders can be kept motionless, and in the correct position while walking. Sideways walking: sideways walking motion, both with straight and flexed legs, moving to either direction; the arm on the side of the leg moving sideways is used to assist balance and motion (rowing). Important: during walking, always keep the body oriented to one side, avoiding undesired movements of twisting and rotation on the transverse axis. Backward walking: a slow backward walking movement respecting correct dynamics of the step, arms resting on a floating device (kickboard) so that the shoulders can be kept motionless and in the correct position while moving. Exercises performed in place in medium-depth water (progressively increasing load). These bilateral exercises are performed with both hands resting on the edge of the pool. In the case of the unilateral exercises, a side of the body is placed against the wall of the pool, and movement performed one limb at a time, first without equipment and then with equipment. Circling exercises in vertical position: circular movements with straight leg on the transverse plane, first with one limb and then the other, maintaining correct posture of the trunk. The circles begin with a limited radius, later growing more extensive. Flexion of the knees to the chest in vertical position: alternating flexion of the knees to the chest, at first with the thigh at a 90 angle, and then moving beyond this working angle, always staying beneath the pain threshold.
23

Abduction and adduction: starting with a knee flexed at 90 and with the other leg touching the floor, abduct and adduct with the flexed leg, maintaining a slow rhythm at the start and increasing the intensity as the treatment continues. Repeat on the other side. Vertical breaststroke: a breaststroke kick performed in a vertical position. Leg adduction and internal rotation of the hip: alternating leg swings, both straight and flexed, with the hands resting on the pool edge, keeping rotation within a pain-free range and at gradually- increasing rhythm, intensity, and range of motion. Combined exercises: having reached this point, we suggest exercises combining different planes of work and axes of movement, coordinating simple and complex movements, including the use of the arms, all in order to come as close as possible to the complete set of motor skills. Flotation devices, such as ankle cuffs and kickboards, are introduced, making it possible to increase the intensity of the exercises. Part two of the article will appear in the next issue of the Aquatic Therapy Journal. N

University of Rome, La Sapienza Campus. Benelli has also been a teacher for the Technical Instruction Department of the F .I.N. (Federazione Italiana Nuoto - Official Italian Swimming Federation), and a regional and national teacher for the Italian Olympic Committee. Lorena Cesaretti holds a Degree Certificate as a rehabilitation therapist from the School of Medicine and Surgery of the University of Ancona (Italy), following a specialised course of study. Her dissertation was on heart rehabilitation based on experimental scientific work entitled A Comparison between Different Modes of Ergospirometric Testing in Cardiac Rehabilitation: Stepper vs. Cycloergometry. She has also worked as a volunteer therapist at the Clinical Rehabilitation Service of the Lancisi Heart Hospital in Ancona, performing activities of rehabilitation and research in the field of cardiac rehabilitation.

Reviewer Comments
Mary B.Essert, B.A., ATRIC The author has clearly set forth a progressive program for orthopaedic patients. His/her material is comprehensive and offers the reader a smorgasbord of ideas. Thank you for a fine article. Attention to safety and risk management (teaching recovery and sculling and stabilizing techniques early on, for example) could be emphasized with consideration for the whole person, other existing conditions and capabilities. Patient education is essential and part of that requires listening for whole person stories by the therapist. Knowing the comfort level of a patient re: water is vital and time must be spent in orientation. That was dealt with. Ellen Broach, Ed.D., CTRS An orthopedic rehab protocol such as this that involves assessment and whole person treatment for all levels of injury is important for quality practice.

Authors
Piero Pigliapoco has a lifelong expertise in aquatics, first as a swimmer and then as a swimmer coach. He holds a Degree Certificate in physical education. He is Aquafitness Instructor and Head of the Department of Aqua Training and Aqua Therapy of the E.A.A. (European Aquatic Association). He has participated in major national and foreign events as an E.A.A. presenter. Pigliapoco has been involved in functional rehabilitation in the water for sports orthopedic trauma since 1995. Currently, he is Athletic Director at three swimming clubs, is a hydro-spinning and Reebok step instructor, and a certified hydrotherapist. He is also a certified personal trainer of athletes doing land sports, such as volleyball, basketball and soccer. You can contact Piero by email: pieropigliapoco@libero.it or tiziana@atservizi.it Piero Benelli has a university degree in Medicine and Surgery from the University of Bologna, with a dissertation on sports medicine entitled Functional Assessment for Swimmers. Benelli also has advanced studies in Sports Medicine, cum laude, at the

Aquatic Therapy Journal August 2005 Volume 7 Issue 2

Paula Briggs, MS, ATRIC This article describes the exercise in enough detail so that the reader can visualize it. In addition, the author applies the physics of water, along with the physiological responses involved when movements are performed in different water depths. This helps the reader by giving them enough information to justify aquatic therapy referral for patients with orthopedic problems. The language used to write this article reflects knowledge of anatomy and correct anatomical positions, which in turn reflects a high degree of professionalism. N

instructor and American Red Cross corporate instructor in Lincoln, NE. Mary Essert, BA, ATRIC, has been acively involved in teaching aquatics since 1949. Her workshops, seminars and videos are attended and used worldwide. Expertise includes aging and disability program, rehab work in the pool, arthritis, fibromyalgia, breast cancer and warm water bodywork; Watsu and Jahara Technique.Currently she is employed by Conway Regional Health Systems in Conway, Arkansas. She has been honored for Lifetime Achievement by AEA and was the ATRI Aquatic Professional of the year for 2002 and Whos Who in Aquatic Leadership in the USA 2000-2003. She may be reached at www.maryessert.com or messert@mindspring.com. Ellen Broach, Ed.D., CTRS is an Assistant Professor in The Department of Health, Physical

Education and Leisure Studies at the University of South Alabama. Broach has been involved in aquatics for over 20 years and was an aquatic therapy coordinator in physical rehabilitation for 10 years. Dr. Broach is co-chair or the AT committee for NTRS, is a frequent speaker at conferences, conducts workshops on the topic of aquatic therapy and outcome based assessments, and has published research in the areas of aquatic exercise and aquatic therapy. Paula Briggs, MS, ATRIC is Assistant Professor and Exercise Physiologist at West Virginia University School of Medicine where she teaches in the Aquatic Therapy Curriculum. The curriculum consists of fifteen credit hours and a two hundred hour internship in a therapeutic pool. Paula was the recipient of the prestigious Aquatic Therapy Professional award from ATRI in 2000. N

Reviewer Bios
Bonnie A. Johnson, MS, ATRIC, has a Masters Degree in Exercise and Sport Science from the University of Memphis, TN. Her emphasis area of study was aquatic exercise. Currently she is a fitness

TRR

Feature Column: Web Waves

WEB SITES YOU MIGHT FIND HELPFUL

More than a Ripple
Advance On-line for Physical Therapists: Navigating the Start-up and Maintenance of an Aquatic Practice http://physical-therapy.advanceweb.com/ common/EditorialSearch/printerfriendly. aspx?AN=PT_05Apr11_ptp43.html/&AD=0411-2005 Not a web site in and of itself, this offering is an extremely informative article related to professional practice in aquatic related therapy. Written by Robert Frampton, DHCE, PT, it contains valuable practical advice for individuals considering or involved in such practice, including preparation, building a client base, operating and managing the practice, and avoiding pitfalls. The document is easy to download and/or directly print at no cost. Save yourself hours on research and much trial and error by accessing this useful site. CDC Issues in Healthcare Settings www.cdc.gov/ncidod/hip/Aresist/ca_mrsa.htm DermNet NZ http://dremetnz.org/bacterial/methi cillin-resistance.html MMWR Weekly www.cddc.gov/mmwr/preview/mmwrhtml/ mm5233a4.htm NetDoctor www.netdoctor.co.uk/diseases/facts/mrsa.htm Professionals in Infection Control & Epidemiology, Inc Greater Omaha Area Guidelines for Control of MRSA http://poapic.org;MRSA.htm guide, and links to additional resources in physical therapy are all readily accessible at this easy to navigate site. Also included are author guidelines for professionals considering to submit material for publication. Merck Source http://www.MerckSource.com A world of health information at your fingertips is the slogan of this web site by the authors of the popular Merck Manual. Dedicated to providing credible health information unbiased by product advertising, features of the site include condition guide to enable one to learn more about a specific medical condition, as well as suggestions to help patients prepare for doctors appointments. Also available through this site is a complimentary subscription to the Harvard Health E-Newsletter. N Contribute your favorite site. Contact WebWaves editor Sue Grosse, sjgrosse@execpc.com. Citation in this column does not indicate endorsement of any sites sponsor, information, or product.
24

and For Your Address Book

Resources Advance for PT On-Line http://physical-therapy.advanceweb.com Searchable back to 1996 for print, as well as on-online publications, this resource site has many resources to offer. Results of professional surveys, a job databank, a buyers

Spotlight on
METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) About MRSA Infections in Children http://pediatrics.about.com/od/mrsa/

Aquatic Therapy Journal August 2005 Volume 7 Issue 2

The Aquatic Therapy Journal (ATJ) is now available by subscription or as an option through the Aquatic Exercise Association (AEA). Prior to this time, the ATJ was only available as a member benefit of the Aquatic Therapy and Rehab Institute (ATRI). Now this prestigious publication is available to all professionals in the field of aquatics, regardless of membership affiliation. Many popular features of the ATJ continue, including peer commentary on articles, publication reviews, Web Waves, and the most current aquatic therapy applications and research. New are repeating columns on research highlights, on pool problems, and on interfacing with specialists in allied professions. The ATJ is also expanding options to authors by adding double blind peer review (without published reviewer commentary) for those professionals who wish to publish for academic advancement. AEA Members receive a discount for ATJ subscription. For ATJ subscription only: Complete the form below and remit with payment of $30.00 for a one-year subscription to: AEA Journal Subscription P.O. Box 1609 Nokomis, FL 34274-1609 TOLL-FREE: (888) 232-9283 PHONE: (941) 486-8600 FAX: (941) 486-8820 WEBSITE: www.aeawave.com Name: ______________________________________________________________________________________ Phone: ______________________________________________________________________________________ Business (Only if Sent to a Business): ____________________________________________________________________ Fax: ________________________________________________________________________________________ ____________________________________________________________________________________

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25 Aquatic Therapy Journal August 2005 Volume 7 Issue 2

2005 Aquatic Therapy Education

The Aquatic Therapy & Rehab Institute is proud to present several opportunities for your continuing education experience: Specialty Institutes
August 9-12 Palm Springs, CA Renaissance Esmeralda Resort & Spa September 8-11 Chicago, IL Westin OHare October 6-9 Washington, DC Sheraton Premiere at Tysons Corner

Professional Development Days

Saturday, October 29 New Braunfels, TX (30 miles NE of San Antonio) Saturday, November 5 Springdale, OH (Suburb of Cincinnati) Sunday, November 6 Lancaster, PA (35 miles Southeast of Harrisburg) Saturday, November 12 Encino, CA (Suburb of Los Angeles) Sunday, November 13 Birmingham, AL Brochures available at www.atri.org or 866-go2-atri (462-2874)

Topics Include:

(See brochures for details)

Intro to Aquatic Therapy and Rehab ICATRIC Exam Review Ai Chi Basic Certification Aging Activities Ai Chi Balance & Trunk Stabilization Ai Chi Ne Arthritis & Rheumatology Back Rehab Bad Ragaz Balance Training Breast Cancer Cerebral Palsy Chronic Pain Endurance Energy Medicine

Gait and Balance Halliwick Lumbar Stabilization Management Track Manual Techniques Myofascial Release Neurological Techniques Pediatrics PNF Rehabdominals Sacroiliac Dysfunction Protocol SCI Sports Water Massage Watsu Yoga

13297 Temple Blvd. West Palm Beach, FL 33412 Phone: 866-go2-ATRI or 906-482-7097 Fax: 561-828-8150 E-mail: atri@atri.org www.atri.org

2006 Aquatic Therapy & Rehab Institute Awards

Attention Aquatic Therapy Professionals:
Nomination forms for the 2006 Aquatic Therapy Awards are available now at www.atri.org. The 2006 Aquatic Therapy Awards will be presented at the 16th Aquatic Therapy Symposium in August 2006. The Aquatic Therapy Dolphin Award recognizes individuals who have made a difference or been an inspiration to others by creating harmony in the field of aquatic therapy and rehabilitation. Examples of the Dolphin Award include: going beyond the call of duty, fostering kindness for other participants at aquatic therapy events, sponsoring or subsidizing an event or action in aquatic therapy, guiding others into aquatic therapy and rehab, volunteering time and resources to further aquatic therapy and rehab, displaying grace and gentility in dealing with problems, cooperating in gathering information to promote aquatic therapy or assist others in the industry, and guiding the aquatic therapy industry or individuals in it with affinity, amity and devotion.

We are looking for nominees for the following awards:

The Aquatic Therapy Professional Award for distinguished service to the profession is the highest award ATRI members can bestow on each other in recognition of long and distinguished service to the Aquatic Therapy field. The Tsunami Spirit Award offers well-deserved recognition to creative and innovative individuals and businesses in the industry. This award was developed to recognize individuals, businesses, facilities and publications who have shown an innovative spirit in the aquatic therapy and rehabilitation industry.

We look forward to receiving your nominations. Please mail, fax or email the nomination forms by April 1, 2006 to have your nominee considered for an award.

Thank you for your support of the aquatic therapy industry.

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