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September/October 2021
Exercise: Swimming to Fitness — Aquatic Exercise for Older Adults Swimming has been called the perfect lifelong exercise by many in the health and fitness field. It can be continued well into older age with a low risk of injury, unlike land-based activities such as running and cycling in which injury risk due to impact or falls increases with age. Swimming provides excellent full-body muscle strengthening, cardiovascular conditioning, and flexibility benefits for older adults. However, not all older adults learned to swim with the skill needed for continuous lap swimming; generally, lap swimming for exercise is primarily performed by those who learned to swim well when younger and may have participated in competitive swimming. While older adults can learn to swim, they may never progress to being able to perform sustained lap swimming for effective cardiovascular and muscular conditioning. “Swimming could be a challenge for those that are not comfortable with the movements or the breathing patterns,” notes Kimberly Huff, MS, CSCS, director of fitness and wellness at Acts Retirement-Life Communities and an aquatic training specialist for the Aquatic Exercise Association (AEA). Upright aquatic exercise, in which the participants always have their heads above water, is a better exercise option for most older adults. “Research studies have shown that the benefits of aquatic exercise, such as water aerobics, water walking, and resistance training in the water are similar to land-based exercise, provided the exercises are performed at a similar intensity,” Huff says. When performed at the duration and intensity recommended by exercise guidelines, upright aquatic exercise is just as effective as land-based exercise at helping prevent and manage medical conditions, such as hypertension, diabetes, and cardiovascular disease. Like land-based exercise, aquatic exercise also helps with weight loss and management and improving mental health, especially for those who have difficulties exercising on land due to impact-related side effects.1 The buoyancy of water allows both cardiovascular and strength training to be performed with less stress on the joints than with land-based exercise; therefore, older adults with joint pain or other limitations affected by land-based exercise may have more success exercising in the water, Huff emphasizes. The AEA cites the following additional research-supported benefits of aquatic exercise1: • improved cardiovascular fitness, muscular strength, endurance, and flexibility; • increased coordination, power, and agility needed for functional movements; • improved balance and gait to help decrease fall risk; and • management of musculoskeletal conditions, such as arthritis, osteoporosis, back pain, and other chronic joint pain, that may be aggravated by land-based exercise. Aquatic exercise is typically performed in a water depth to participants’ chest or shoulders, allowing those who don’t know how to swim to participate. With the body at this depth, stress loads on the joints are decreased by 60% or more, according to hydrodynamic studies. The reduced stress on the body often causes the exercise exertion to be perceived as less strenuous than the same activity performed on land, even though cardiovascular and muscular effort is similar or greater. Therefore, participants often consider aquatic exercise “more fun” than the same land-based exercise.2 And fun often motivates older adults to commit to regular exercise. Fall prevention and improved physical functioning are two primary goals of exercise for older adults. However, fear of falling or other injury during land-based exercise may cause exercise avoidance, especially for those with existing mobility and balance issues. “Water provides a supportive environment for balance exercises and gait training without the fear of falling,” Huff notes, and research studies have confirmed this. A February 2019 systematic review of 14 randomized controlled trials assessed aquatic exercise for reducing fall risk in older adults aged 60 to 90 years. The researchers found that aquatic exercise improves fall risk factors, such as lower body strength and stabilization, and should be practiced by those most at risk of falling. The water turbulence created by underwater movements continuously activates muscles that contribute to stabilization, and aquatic exercises significantly improve lower limb strength. Although the review did not find any significant differences between land-based and aquatic exercise for balance, results suggest that participants viewed aquatic exercise as safer; the researchers found no adverse effects or injuries associated with aquatic exercise for older adults.3 An August 2020 systematic review and meta-analysis of 10 studies comparing aquatic and land-based exercise for balance training in older adults also found that both offer comparable benefits for improving dynamic balance in adults aged 65 years or older. The researchers concluded that aquatic exercise is an appropriate alternative to land-based exercise that can provide clinically meaningful improvements in balance. They also noted that the supportive qualities of water can help older adults exercise at higher intensities than they would on land without risk or fear of falling.4 Exercising at higher intensities—such as in high-intensity interval training (HIIT)—has been shown to provide greater improvements in cardiovascular fitness than does moderate-intensity exercise. However, most HIIT activities may not be safe for many older adults because they often involve impact and plyometric (jumping) movements. These types of movements can increase risk of falls and injury, as well as aggravate arthritis symptoms, and are not appropriate for those with osteoporosis. Hence, even though they may be capable of more vigorous cardiovascular exercise, older adults may not be capable of achieving that exercise intensity during land-based exercise due to physical and medical limitations. The supportive properties of water allow older adults with mobility limitations and concerns for falling to safely participate in aquatic HIIT and experience its benefits, Huff says. Research has shown that the hydrodynamic properties of water create a safer and lower-impact alternative to land-based HIIT. Originally used most commonly for rehabilitation of injured athletes, aquatic HIIT has expanded into aquatic exercise programs for older adults.2 The AEA notes that aquatic HIIT allows older adults to perform higher-intensity plyometric movements without further damaging joints, aggravating joint pain, or falling. “The ability to generate power declines with age. Power is needed for many functional movements, as well as to recover from loss of balance and prevent a fall. Research has shown that older adults can safely increase power by performing power and plyometric training in the water,” Huff explains. A biomechanical comparison of jumping performed on land and in water found that older adults were capable of longer jumps with increased mechanical power in water compared with on land.5 An August 2017 randomized controlled trial compared aquatic HIIT with leisure land-based activities in older women with mild knee osteoarthritis. Four months of three weekly aquatic HIIT sessions significantly decreased body fat and increased walking speed.6 Aquatic jumping also has been shown to help improve bone health, a critical factor for helping prevent osteoporosis and bone fractures. A March 2017 systematic review and meta-analysis of 11 studies compared aquatic exercise with land-based exercise in postmenopausal women. The researchers found no significant differences between the two types of exercise for improving bone density of the femur, though land-based exercise resulted in more favorable changes in lumbar spine bone density. They concluded that aquatic exercise can maintain or improve bone health in older women, though its benefits are not as great as that achieved with land-based exercise.7 In a June 2019 study of postmenopausal women at risk of developing osteoporosis, 10 minutes daily of interval water jumping training, five days per week, resulted in similar improvements in bone density as three days of similar jumping on land.8 These recent studies have dispelled the long-held belief that water exercise does not provide bone health benefits due to its reduced impact. The results of these studies are good news for older adults whose land-based exercise capabilities are limited. Numerous other studies have been published and support the many benefits of aquatic exercise for older adults. This research is very important because fall prevention programs for older adults have traditionally been land-based, which may unintentionally deter those with fear of falling and other conditions that make it difficult or risky to perform land-based balance training. Making aquatic exercise more accessible for older adults and encouraging their participation—especially those who avoid exercise due to falling fears—can contribute to improved outcomes related to fall risk and daily physical functioning. For geriatric professionals interested in starting or referring clients to an aquatic exercise program, the AEA offers aquatic instructor training and certifications and program guidance. Organized programs for older adults are generally in class formats that include shallow water walking, movements similar to those in land-based aerobics classes, resistance training with aquatic equipment, and stretching. Several land-based activities, such as tai chi, Pilates, and yoga, have been adapted for aquatics classes. Water-based tai chi, sometimes referred to as Ai Chi, mimics land-based tai chi movements using the water for added resistance. Aquatic yoga and Pilates may use pool noodles, kickboards, and pool walls for exercises. Webbed or weighted gloves, foam barbells, and paddles are available to create added resistance for aquatic strength training. Older adult clients who prefer to exercise on their own and who have access to a pool can easily perform aquatic walking on their own. “We all know that walking is one of the most recommended forms of exercise because it is easy to do, doesn’t require special equipment, and is safe and effective for all ages. And, walking can happen almost anywhere—including the pool,” says Julie See, director of education for the AEA. “Walking in the water is an easy-to-do exercise format, is fun, keeps one cool in the summer, and provides a great workout for all ages and abilities.” For safe aquatic walking and aerobics classes, See recommends the following: • physician clearance to perform aquatic exercise; • supervised workouts for safety; • sunscreen and sunglasses for outdoor workouts; • easily accessible drinking water (participants will sweat but might not notice in the water); • aquatic exercise shoes for cushioning and support during the workout and to reduce risk of falls when getting in/out of pool; • time spent on a “cool down” to bring heart rate down to preexercise levels, followed by stretching of all muscles; and • short workout sessions to start, and progressively adding time and intensity to reach at least 30 minutes of continuous activity at a moderate intensity, if possible. Aquatic exercise can be adapted for all abilities, including more fit and active older adults and those requiring a more therapeutic setting. For fit older adults comfortable in the water, specially designed flotation vests can be used for deep water running and calisthenic movements; some aquatic facilities offer deep-water class formats. Aquatic exercise can also be delivered in a more therapeutic setting, such as pools heated to temperatures greater than a typical pool for those with arthritis, fibromyalgia, and other conditions where heated water may help pain and other symptoms. Aquatic exercise has also been adapted for those with Parkinson’s disease and multiple sclerosis, as well as for stroke and injury rehabilitation. Some aquatic facilities may have a separate therapy pool; however, most aquatic therapy is delivered in a physical therapy/rehabilitation setting by trained therapists with access to equipment such as underwater treadmills and cycles. Aquatic exercise offers something for everyone in terms of exercise needs, and is easily adapted to accommodate a range of abilities and capabilities in the older adult population. — Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.
RESOURCES • Silver Sneakers Splash (silversneakers.com/class/signature-splash) is a shallow-water exercise class that uses a signature splash-board to increase movement and intensity options. Splash is suitable for all skill levels and is safe for nonswimmers. Visit Tivity Health (instructor.tivityhealth.com) for certification and training programs. • WATERinMOTION (waterinmotion.com) offers instructor training and certification and prechoreographed water exercise classes, approved by Silver Sneakers for older adult exercise.
References 2. Nagle EF, Sanders ME, Franklin BA. Aquatic high intensity interval training for cardiometabolic health: benefits and training design. Am J Lifestyle Med. 2016;11(1):64-76. 3. Martínez-Carbonell Guillamón E, Burgess L, Immins T, Martínez-Almagro Andreo A, Wainwright TW. Does aquatic exercise improve commonly reported predisposing risk factors to falls within the elderly? A systematic review. BMC Geriatr. 2019;19(1):52. 4. Kim Y, Vakula MN, Waller B, Bressel E. A systematic review and meta-analysis comparing the effect of aquatic and land exercise on dynamic balance in older adults. BMC Geriatr. 2020;20(1):302. 5. Louder T, Dolny D, Bressel E. Biomechanical comparison of countermovement jumps performed on land and in water: age effects. J Sport Rehabil. 2018;27(3):249-256. 6. Waller B, Munukka M, Rantalainen T, et al. Effects of high intensity resistance aquatic training on body composition and walking speed in women with mild knee osteoarthritis: a 4-month RCT with 12-month follow-up. Osteoarthritis Cartilage. 2017;25(8):1238-1246. 7. Simas V, Hing W, Pope R, Climstein M. Effects of water-based exercise on bone health of middle-aged and older adults: a systematic review and meta-analysis. Open Access J Sports Med. 2017;8:39-60. 8. Chien KY, Chang WG, Sanders ME, Chen CH, Wu WC, Chen WC. Effects of land vs water jump exercise: implications for exercise design targeting bone health. Scand J Med Sci Sports. 2019;29(6):826-834. |
