Health and Wellness: Aquatic Therapy and Aquatic Exercise
What are the Benefits for People with MS?
By Maryann B. Hunsberger
Aqua specialist Donna Adler (left) assists Lara Hempler through aquatic exercise.
Aquatic therapy, a sub-specialty in the fields of physical or occupational therapy that is done in a swimming pool, can benefit people with MS by improving flexibility and motion, allowing muscles to relax, and reducing pain. Aquatic exercise – exercises done in a pool – can also help achieve these same results. Knowledge of swimming is not required for either aquatic therapy or aquatic exercise.
The two fields are similar and can work together, explains Barbara Batson, an AEA-certified exercise specialist in Tennessee. “Insurance limits the number of physical or occupational therapy sessions a person can have, so after the therapy visits are over, it’s good for a person to then switch to aquatic exercise, which costs less. People without insurance coverage for therapy can start with aquatic exercise instead.”
Aquatic therapy can only be facilitated by a physical therapist or occupational therapist, while aquatic specialists typically lead aquatic exercise classes. Although aquatic specialists are generally not required to have any specific certification, most aquatic specialists take classes through the Aquatic Therapy & Rehab Institute (ATRI) or the Aquatic Exercise Association (AEA). Some facilities, such as the YMCA and the Arthritis Foundation, also require training through their own program. Other facilities sometimes require that the aquatic specialist be a personal trainer. Aquatic specialists and aquatic therapists can receive specific training to work with people who have MS through ATRI’s online class at www.atri.org.
Donna Adler, an Arizona-based aqua specialist and continuing-education provider for both the AEA and the ATRI, states that aqua exercise “is on the bridge between fitness and therapy.” She works with many people with MS who have spasticity and pain. “When muscles are tight, the body doesn’t move the way it’s supposed to. With individuals who lack range of motion, exercise will tire them more quickly, so we perform AquaStretch™ to improve their range of motion. AquaStretch is a technique performed in water that is three-to-four feet deep, where the therapist applies gentle pressure to the client’s skin and the connective tissue restriction underneath the skin, which facilitates or accentuates the client’s intuitive movement. In general, people can exercise in the water without the pain they would feel on land, since water allows them to have less pressure on their joints. They can move more freely since buoyancy lifts and pulls them up.”
Carolyn Sprehe, an aquatic specialist in Indiana, points out, “Water exercise helps gross and fine motor skills, flexibility, the sensory system, the cardiovascular system, the pulmonary system, the musculoskeletal system, bone strength, lung capacity for someone who is always in a wheelchair, and it increases breath control.”
PHYSICAL BENEFITS OF AQUATIC THERAPY
Buoyancy: In shoulder-deep water, about 90 percent of the body’s weight is removed from the body’s joints. This means a person submerged to the neck weighs one-tenth of their regular body weight. This causes increased blood supply to joints, reduces joint stress, and reduces pain. This also allows for a larger range of motion. Buoyancy reduces the risk and fear of falling, which improves confidence and decreases incidences of injury. Adler says, “When someone is up to chest level in water, they are able to function differently. I find that people with MS who can’t walk on land can often walk in a pool. I have seen it over and over again.”
Hydrostatic Pressure: Water applies pressure against the body, acting like compression support hose during water exercise, which reduces swelling. When the body is in shoulder-deep water, hydrostatic pressure shifts 60 percent of the blood to the heart, allowing the heart to work with less stress. The reduction in swelling of the lower extremities helps to minimize pain.
Resistance: According to the American Council on Exercise (ACE), water provides ten times the resistance of air, which forces individuals to work more muscles during exercise. This resistance strengthens and builds the muscles and fosters both trunk stability and postural alignment. Turbulence/Water Surface Tension: The body’s movement through water creates turbulence. As participants learn to stabilize their bodies against the turbulence, it allows weak muscles to gradually strengthen. This also challenges and improves balance, stimulates increased peripheral blood flow, and refreshes and energizes the individual.
Water therapy and water exercise also have psychological benefits. Sprehe says, “It improves the quality of life for people with MS. Moving better, getting out of the house, socializing at the pool, having fun, and relating to other individuals with MS are all important aspects.” Adler adds, “It’s something different from going to doctors’ offices. It gets people with MS out of the depressive cycle. Socializing is one of the most important attributes of aqua exercise, even if a person can’t do every step.”
As with other forms of exercise, people with MS should obtain medical clearance from their physician before participating in any aquatic exercise program. A physical therapist, occupational therapist, or aqua specialist should conduct a thorough physical evaluation to determine the level of required assistance, the appropriate methods of pool entry and exit, as well as the correct exercises.
Despite accreditation not being required for aqua specialists, Sprehe said aqua specialists with ATRI/AEA certification, particularly those who have taken the ATRI MS class, are more knowledgeable. Therefore, individuals with MS should check the credentials of any aqua specialist before embarking on water-exercise classes. According to Batson, people with MS considering taking part in aquatic therapy with an occupational or physical therapist should also ask if the therapist has received additional education in performing aquatic therapy.
An aqua specialist or therapist should be able to identify the individual’s MS symptoms and determine how these symptoms will affect that person’s ability to partake in aquatic exercise. Anyone facilitating water exercises should also be knowledgeable about pain, whether MS-related or not. This information should be used as a benchmark to assess pain during or after exercise. In addition, a baseline measure of strength, fitness, spasticity, and range of motion should be used to monitor exercise outcomes.
“It’s important to know this to understand how to treat the person,” said Sprehe. “An aqua specialist will usually recommend a regular aqua exercise class for a person at a higher functional level, who has mild or no symptoms. However, if someone uses a walker or wheelchair, it’s important that they seek out a physical therapist, an occupational therapist, or an aquatic specialist with knowledge of MS.”
Finding a completely accessible facility is important for people with MS. Adler recommends looking for elevators, lift chairs, and shallow steps. “Everything should be designed so people can be as independent as possible.” Sprehe further explains, “Pool chair lifts are now required to be in all [public] pools. The lift looks like a chair that rotates and goes into the water. Individuals should look for a facility that allows a personal-care attendant to help the person to transfer, if needed, and to go into the pool with them, if necessary.” Sprehe points out that wheelchair users will need PVC wheelchairs to access pools with beachfront entries. “If a facility doesn’t have this, the individual should ask for accessibility to the pool.”
Because MS symptoms can worsen with overheating, individuals with MS need to consider pool temperature. “Some people can’t handle the heat,” says Adler. “Therapeutic pools are usually set between 88 to 90 degrees in wellness settings. In hospital settings, the temperature can be up to 96 degrees. I prefer no more than 86 degrees for people with MS. It depends on the client and his or her preferences.” In general, Sprehe uses a pool temperature of 84 to 86 degrees when working with people with MS. “Warm water helps reduce pain because an individual with a contracture can relax in it.” But care needs to be taken that the pool is not too warm, i.e., above 86 degrees, to avoid the symptoms of overheating for individuals with heat-sensitive MS.
Swim for MS is a national ongoing fundraiser in which volunteers are encouraged to dive into action and create their own swimming activity or challenge while collecting pledges and online donations toward their goal. Activities can range from individuals swimming laps or a distance over a set period of time, to similar group swims organized by clubs and teams, from youth through college and beyond. Whatever you decide to create for your Swim for MS fundraiser, make it fun, make it challenging, and make it yours! To learn more and register, please visit SwimForMS.org or call (800) 532-7667, extension 157
People with MS should also consider their fatigue level before starting a water-exercise program. Adler shortens the length of exercise time for people who experience fatigue. “I don’t want them to be exhausted.” Sprehe adds, “People naturally try to do too much without a specialist, so they need the help of a professional.”
Most facilities have the equipment that individuals will need to take classes – such as noodles, small barbells, and kickboards. Individuals can check with the aqua specialist who will be teaching an aqua exercise class to be sure.
When looking for an aquatic exercise program suitable for people with MS, Adler recommends checking out the gentle aquatic exercise classes given by the Arthritis Foundation at www.arthritis.org/.
Sprehe also recommends researching local YMCAs as well as city and community recreation facilities to find aqua exercise classes suitable for people with MS. “Call where water exercise classes will be held and ask if the trainer is experienced in working with someone with MS,” says Sprehe. She points out that swimming is also beneficial for people with MS. “Higher functioning individuals who want to swim and move through the water will find this to be a great form of exercise. An aqua specialist can monitor so they don’t fatigue themselves. Since aqua exercise, aqua therapy, and swimming help with pain, fatigue, and depression, any of these activities can be very beneficial for people with MS.”
According to Batson, aqua exercise serves to improve the quality of a person’s entire life. “People need to exercise so they can do the things in life that make them happy, like getting down on the floor with the grandkids and being able to get back up, or shopping, or traveling. People with MS are not exempt from the illnesses that the general population gets, such as diabetes, high blood pressure, heart disease, or untimely strokes. Much of this can be minimized or avoided by maintaining a healthy weight, exercising daily, and maintaining healthy relationships. So, bring yourself to the water where you can safely exercise in a group setting with people who will come to know and love you.”