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Journal of Gerontology: MEDICAL SCIENCES

1996. Vol. 51 A, No. 5, M233-M238

Copyright 1996 by The Gerontological Society of America

Effectiveness of Water Exercise on Postural Mobility


in the Well Elderly: An Experimental Study
on Balance Enhancement
Valerie Simmons1 and Paul D. Hansen2
'Department of Physical Therapy, Northern Arizona University,
department of Occupational and Physical Therapy, University of Puget Sound, Tacoma, Washington.

Methods. Four groups of elderly subjects (80 5 . 8 years old) were placed into four groups: Water Exercisers; Land
Exercisers; Water Sitters; and Land Sitters. Each group met twice per week for 45 minutes for 5 weeks of simple exercises
or socializing in the designated medium. The distance each individual could reach (Functional Reach, FR) was measured
at the end of each week.
Results. Initially, each group was at risk (FR < 10 inches) for falling. Statistical testing showed that the Water
Exercisers (WE) increased their FR almost every week; the Land Exercisers (LE) increased only during the first week; and
the Water Sitters (WS) and Land Sitters (LS) did not increase at all. The FRs after 5 weeks were 13.4 1.6 (WE), 11.3
1.5 (LE), 9.6 1.3 (WS), and 9.3 0.71 (LS) inches for each group, respectively.
Conclusions. The data showed that the postural capabilities in these elderly people, as measured by the FR, were
enhanced by the production of movement errors that was facilitated in a water environment (in the case of the Water
groups) or the initiation of a novel exercise program (Land Exercisers). Alternative explanations, and implication of these
results, are discussed.

ALLS in the elderly population are a well recognized


health problem (1-3). A variety of studies have addressed this problem by looking at possible pathologies
(4,5), at risk factors (2,3,6-8), and rehabilitation strategies
which address potential pathologies or risk factors (9-11).
The present work addresses fall prevention in the elderly by
looking at the cause of poor balance as a self-induced motor
skill loss. Thus, training is done through the application of
principles that have been determined through motor skill
acquisition research.
Due to the prevalence of, and morbidity and mortality associated with falls in the aged population, the elderly individual tends to restrict his/her mobility so as to prevent the occurrence or recurrence of a fall. By limiting activity, the
elderly person may become trapped into a vicious cycle (Figure 1) of voluntarily restricting activities, which in turn causes
a decrease in functional mobility, which results in limited
activities, at which point the whole process recycles (3,8).
By constraining movement, the number of correctable
movement errors which occur will decrease; if the person
does not move, he/she will not experience novel movements. This reduction in errors will be evident not only in the
absolute number of errors, but also in the movements and
environmental settings that will produce these errors.
Furthermore, given the reduced sensory capabilities found in
the elderly (for example, 4,12-14), it would be anticipated

that the absolute magnitude of the movement errors would


need to be large in order for the errors to be perceived and
subsequently corrected.
Movement errors have been well documented as the
guidance for motor skill acquisition (for reviews see 15,16).
Similarly, the failure to make postural movement errors may
lead to a loss of skill in performing postural tasks. Thus,
elderly persons' limited mobility may cause a progressive
reduction in their postural capacity by their failure to produce errors while practicing these skills.
Postural tasks are unlike many other motor skills, for the
consequences of failing to correct a postural error can produce an injury resulting in the "fear-of-falling" that many
elderly individuals express (17,18). Thus, if postural skills
are to be practiced, they must be done in a safe environment.
Duncan, Weiner, Chandler, and Studenski (19) reported that
subjects who would only reach a short distance unsupported
could reach farther when placed in a protective, non-weight
supporting harness. Similarly, Pillar, Dickstein, and Zui
(20) found that patients with cerebral vascular accidents had
a quantitatively more normal gait pattern when harnessed,
even though the harness did not provide weight relief.
In the present research it was hypothesized that the elderly
would be more willing to move if in a safe environment; for
this study, water was chosen as the safe medium. This
increase in movement would produce more movement errors,
M233

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Background. The fear of falling may cause elderly people to limit their movement. As movement errors are known to
facilitate the acquisition of motor skills, the elderly may inadvertently cause the loss of postural skills by constraining
their movements, and hence avoid potential movement errors. It was hypothesized that by having elderly individuals
exercise in a risk-free environment water was utilized in this experiment their postural capabilities would improve.

SIMMONS AND HANSEN

M234

Unsteady
Posture
Postural
Skill Loss

Fear of
Falling
Voluntary
Immobility

No Movement
Errors
Figure 1. The cyclical effects of immobility on balance control in an
elderly subject.

METHODS

Subjects
Fifty-two independently living elderly volunteers (80.0
5.8 years, range 74-90 years old, 7 males, 45 females) were
recruited from a residential retirement community in Phoenix, Arizona. The requirements to live in the retirement
community were that an individual be 65 years or older, be
an independent ambulator with or without an assistive device, and be independent with activities of daily living. All
subjects read and signed an informed consent prior to participation. Subjects also filled out a medical history questionnaire which was reviewed to identify any high risk subjects.
None of the participants was found to be at high risk.
Therefore, no subject was excluded for medical reasons.
Subjects who missed more than three exercise sessions were
excluded from analysis.
Groups
Participants were randomly assigned to one of four experimental groups of 13 subjects each. These groups were
designed to isolate the effects of exercise, water immersion,
and socialization, from pool exercise. They were descriptively called:
1. Water Exercisers; those who exercised in the pool.
2. Land Exercisers; those who exercised on the land.
3. Water Sitters; those who sat in water without exercise but
with supervised socialization.

All groups met separately for 45 minutes, twice per week,


for 5 weeks under the supervision of the experimenter (VS).
Experimental Tasks
Exercise tasks land and water groups. The exercise
regime, done to subject tolerance with rest periods as
needed, was identical for the water and land exercise groups.
Ten repetitions of standing tasks and four repetitions of 6.1
m (the maximal cross pool distance) for walking tasks were
requested. The participants were asked to complete the
activities to individual tolerance and with the minimal
amount of assistance required to complete the activities.
Assistance was provided to complete the activity on an asneeded basis when requested by the participant. The specific
exercises were:

walking forward and backward


walking backward while high stepping
marching forward and backward with knees bent
walking forward and backward with knees straight
sidestepping without crossing the legs
sidestepping with crossing the legs
heel-to-toe walking forward and backward
marching in place
standing partial squats
toe raises
heel raises
kicking in a diagonal
kicking in cardinal planes of motion
twisting

The water exercisers exercised in an outdoor pool and the


land exercisers exercised indoors in a large, carpeted empty
church congregation hall. The pool temperature was 29.432.2 C; pool area was 6.1-15.2 m. Its depth went from .9 to
1.5 m over the 15.2m length. Subjects exercised in 1 to 1.4
m of water depending on their height and stability in the
water (the water level was between their waist and nipple
line). Land exercisers could hold onto the back of a church
pew to attain stability.
Non-exercise tasks land and water groups. The
water sitters sat in the same pool to a level similar to the
water exercisers (between waist and nipple line) and were
asked to socialize among the group. No other people were in
the pool except the experimenter (VS).
The land sitters were involved in card playing activities
while sitting at a table and were supervised by the experimenter (VS).
Data Collection
The FR test (1,19) was utilized to assess each participant's
stability. The average of three consecutive reaches was
recorded prior to the experiment, and following the last
session of each week by the first author (VS). Data were
recorded in terms of absolute positions (i.e., initial = 20,
final = 35). The calculation of the reach (i.e., reach = 15)

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which would guide the development of postural control mechanisms. Improvement in these mechanisms would be evident
in an increase in the subjects' Functional Reach (FR) (19).
Several alternative hypotheses to the primary hypothesis
were apparent. First, exercise has been shown to enhance
balance control (9-11). Second, water's therapeutic benefits
have been commonly ascribed to its physical properties,
such as buoyancy, pressure, and thermal exchange (21-23).
Finally, socialization has been suggested as a means of
increasing physical activity (24). To demonstrate that the
effect of water exercise was through its influence on error
production, these alternative hypotheses were concurrently
tested.

4. Land Sitters; participants who played cards in an activity


room with supervised socialization.

WATER EXERCISE AND POSTURAL MOBILITY

was done after the conclusion of the study to minimize


potential experimental bias that would affect the data collection. To maximize treatment and test consistency, the second author (PH) observed sessions with each group halfway
through the study.
Data Analysis
A repeated measures analysis of variance (ANOVA)
(BMDP, Program 2 V, Release 7.1, 1993) was used to detect
any differences in the FR between groups over the five
weeks. Follow-up testing analyzed the simple main effects
of group (within group repeated measures ANOVA and
Tukey's post hoc test) and week (one-way ANOVA).
Significance was set at/? ^ .05.
RESULTS

did significantly change [F(l,5) = 2.57; p = .059 and


F(l,5) = 0.47;/? = .798, respectively] over the 5 weeks.
A Tukey post hoc test was then used to determine where
differences existed across the weeks within each group
(Table 2). For the water exercise group, a significant improvement was found between: the initial measurement and
all other weeks; weeks 1 and 4; weeks 1 and 5; weeks 2 and
5; weeks 3 and 5; and weeks 4 and 5. For the land exercise
group a significant difference was found only between the
initial week and weeks 1 through 5. There was not a
significant change found between weeks 1 and 5.
To determine which group improved the most over the 5
weeks of training, a simple main effects analysis across
groups at each week was performed. This showed that there
was no significant difference between the groups at the end
of week 1 [F(l,3) = 2.72; p = .059] and week 2 [F( 1,3) =
2.38; p = .087]. There was a significant difference at week
3 [F(l,3) = 5.62;p = .003)] between groups although no
significant contrast between pairs was evident using Tukey's
critical values. At weeks 4 and 5 there were significant
differences in the FR test [F(l,3) = 5.62; p = .004 and
F(l,3) = 17.58;/? < .001, respectively]. Tukey's critical
values showed that at the end of week 4 the water exercisers
reached significantly further than the water sitters and the
land sitters, and at week 5 the water exercisers reached
significantly further than all other groups. Also, at week 5,
the land exercisers reached significantly further than the land
sitters.
In addition to their Changes in FR, three water exercisers
volunteered that they no longer needed their walkers for
community ambulation after 4 weeks of exercise. This
change in ambulation status was not reported in any of the
other groups.
There were 20 absences in all four groups for the 39
participants (Table 3). In the last 2 weeks of the study there

Table I. Initial Description of Experimental Groups


Group

Sex

Age (years)

Initial Reach (cm)

Water Exercisers

2M

82.0 5.4

21.6 5.33

8 F
Land Exercisers

0M

78.2 5.8

23.1 2.8

Weeks

12 F
Water Sitters

1 M
7 F

77.4 4.9

21.2 3.8

Land Sitters

3M
6 F

81.3 6.5

22.4 2.5

Water Exercisers
Water Sitters

Land Exercisers
Land Sitters

Figure 2. Differential changes in functional reach during the 5-week


experimental period.

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The mean age of all subjects was 80 5.8 years.


Descriptions of age, sex, and initial FR are presented in
Table 1. At the outset there were no significant differences
between the four groups for age [F(l,3) = 1.24; p = .223]
and initial FR [F( 1,3) = .60;p = .619]. Four subjects in the
water sitter group who failed to show for any session and
nine participants with greater than three absences were
excluded from all analysis, leaving 39 subjects. The FRs for
the nine participants excluded for absences were: Water
exercisers (15.2 cm, 17.8 cm, 25.4 cm); Land exercisers
(20.3 cm); Water sitters (15.2 cm, 17.8 cm); Land sitters
(27.9 cm, 20.3 cm, 17.8 cm).
The results, as shown in Figure 2, qualitatively demonstrate the FR changes during the 5 weeks in the four different
groups. As seen in Figure 2, the FR test of the water
exercisers improved a large amount for the first 2 weeks,
improved at a slower rate between weeks 2 and 4, and
finished with another large improvement between weeks 4
and 5. The land exercisers made their largest gain in the FR
test between the start and end of week 1, but only improved
slowly, if at all, between weeks 2 and 5. The water and land
sitters had only small changes in their FR over 5 weeks.
The results of the overall repeated measures ANOVA
showed a significant interaction for groups by weeks
[F(3,15) = 3.07; p = .050]. Therefore, the simple main
effects were analyzed within each group across the 5 weeks
with repeated measures ANOVAs. This testing showed
significant improvement in the FR test for the water exercisers [F(l,5) = 21.6; p < .001] and land exercisers
[F(l ,5) = 3.00; p = .026]. The water sitters and land sitters

M235

SIMMONS AND HANSEN

M236

Table 2. Functional Reach Means and Standard Deviations for the Five-Week Program for Each Group
Weekly Reach (cm)
Group
Water Exercisers
Land Exercisers
Water Sitters
Land Sitters
Tukey Critical
Value (cm)

0
21 .6
23 .1
21 .1
22 .4

5 .3
2 .8
3 .8
2 .5

25 .7
27 .4
21 .6
23 .1

n.s.

2
6. 6
4. 8
3. 8
2. 0

28 .2
26 .9
22 .6
23 .6

7,.1
4..6
4 .1
3 .6

n.s.

n.s.

28 .7
27,.2
23,.1
23,.1

n.s.

4
7.1'
3.6
3.6
2.0

30 .2
27 .7
23 .6
22 .9

n.s.

Tukey Critical
Value (cm)

5
6. 4
3. 3
3. 8
2. 3

34.0
28.7
24.4
23.6

4 .1
3 .8
3 .3
1 .8

3.3
3.7
2.8
n.s.

n.s.

Note: n.s. = not significant;/? > .05.

Table 3. Absences During the Five-Week Experimental Period


for Each Group
Week
1

Water Exercisers
Land Exercisers
Water Sitters
Land Sitters

0
0
0
1

0
0
0
2

1
1
1
0

1
2
1
1

Totals

5
1

5
1
2
9

was an increase in absences in the land exercise group which


were mostly unexplained; while the water exercisers did not
show a change in absences, they had one participant absent
per week in the last 3 weeks of the study, and all three
absences were mentioned to the examiner prior to the date of
absence. The other groups had absences which were without
pattern, and were for the most part unexplained.
Follow-up telephone interviews were conducted between
10 and 12 months after the last session, and 19 of the 39
participants were able to be contacted. Through these interviews, information on the additional 20 participants was
elicited. Out of all of the participants, at 10-12 months, 80%
of the water exercisers were still exercising in the pool. None
of the land exercisers continued in an exercise program.
Three of the water sitters had joined a water exercise program. All of the card players continued to play cards and did
not participate in an exercise program. While this is a small
sample, it is also interesting to note there have been no
orthopedic injuries from falls (or other causes) in the water
exercise group since the study, while in the land exercise
group there has subsequently been one broken hip and one
fractured wrist. In the water sitters there has been one
fractured hip. In the land sitters there have been two deaths.
DISCUSSION

This study was designed to demonstrate if exercise in


water is an effective means of decreasing a participant's
risk of falling as shown by an increase in their FR. To test
this, multiple experimental groups were formed that tested
for factors which could also have improved the FR over the
5-week period of water exercise. It is clear in these results
(Figure 2, Table 2) that water exercise enhanced these
elderly subjects' postural control more than from the benefits
of exercise alone; more than from the benefits of water's

Fear of Falling
Many elderly people may limit their activity due to the
fear of possible injury from a fall. This decreased activity
may progressively limit functional mobility and social independence (3,24,25). Because of this fear of injury, a traditional land exercise program can be very difficult for an
elderly participant to complete without assistance. Water is a
dense and viscous medium that rapidly decelerates movements. Because of these physical properties a person is
cushioned from injury in the event of a fall, especially when
submerged at a level of waist deep or more where at least

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Group

physical properties; and more than from the benefits of


socialization. This is evident in the water exercisers' FR of
nearly 35 cm at the end of the 5 weeks and also in their
discarding of assistive devices and lack of morbidity and
mortality in the year after the study.
Duncan et al. reported that the distance one can reach was
directly correlated with their margin of stability (19) and
their probability of falling in the coming year (1). The results
of the initial testing of the FR (Table 1) demonstrated that the
average FR of all participants was within the at-risk range for
falls at least a two times greater risk of falling in the
coming year (1). After the first week of exercise, both water
exercisers and land exercisers had an average FR of greater
than 25 cm and therefore were within the normal risk for falls
category. However, by the end of the 5-week study, the
water exercisers reached significantly further than the land
exercisers.
Not only did the water exercise group reach further than
the other groups by the end of the study, but they were more
compliant with the exercise program, as seen in their absenteeism during the last 3 weeks of the study. Furthermore,
many of the water exercisers have continued in a water
exercise program, whereas none of the land exercisers have
continued with exercises. Thus, water exercise may have a
longer-term benefit than land-based exercise with the elderly
due to better compliance with the water exercise program.
The dramatic improvement in the water exercise group's
FR may have been due to an increase in the movement errors
they made, detected, and corrected while moving in the
water. It is suggested that the exercise in water helped the
participants to make and detect errors because the water
allowed a larger bandwidth of movement in which the
participants could error, receive the feedback that they have
erred, and then correct for that error without an increase in
their fear of injury.

WATER EXERCISE AND POSTURAL MOBILITY

50% of his/her weight is supported by the water. As the risk


of injury from falling is minimal when exercising in water,
the subject's fear of falling should be decreased. It is speculated that by decreasing this fear these elderly subjects were
willing to increase the movement magnitude (19,20) and
thereby experience greater movement variability and errors.

Another consideration is that the water exercise may have


provided a more strenuous exercise program than when
exercising on land. This effect could be caused by the greater
viscosity of water than air. However, the buoyancy provided
by the water can assist the movement when the movement is
in an upward direction; movement which is against gravity
on land. Furthermore, when exercise is completed on the
land, physiological lower extremity extension against the
earth lifts the full weight of the body, while in water, the
weight of the body is partially lifted by the buoyancy
provided by the water: Therefore, based on the buoyancy
effect arguments, physiological postural extensor muscles
may not be strengthened as much as they would be if the
exercise was completed on land. Consequently, it is difficult
to say that the water exercise group performed the exact
same exercise intensity as the land exercise group even
though the same exercise movements were completed during
the land and the water session.
Finally, the use of only the FR measure when the treatment and data collection were done by the investigator has
the potential for experimental bias. While attempts were
made to minimize this potential bias, any replication of the
results reported herein should attempt to minimize this bias
by utilizing multiple measures of balance control as well as
blinding the data collection personnel to the participant's
group.
In conclusion, this study suggests that the participants of
the water exercise program described in this study may have
been able to experience a wider range of movement without
an increase in the risk of injury due to a fall. Through the use
of these movement errors, these elderly subjects were able to
enhance their postural control as shown by their increase in
FR to an extent that was not seen in any of the other groups.
ACKNOWLEDGMENTS

The authors would like to thank Dr. Mark Cornwall and Ms. Karen
Mueller for their assistance with preliminary drafts of the manuscript. This
research was completed in partial fulfillment of the requirements for Ms.
Simmons' MA degree at Northern Arizona University.
Address correspondence to Ms. Valerie Simmons, 3255 South Debbie
Road, Flagstaff, AZ 86001.

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Variability of Practice
The beneficial effects of the variability of practice have
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errors. Thus, making errors guides learning (15,16,26). In
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minimize the continuous postural perturbations which occur
while standing in water.

M237

M238

SIMMONS AND HANS EN

The 49th Annual


Scientific Meeting
Till- GlRONTOLOGICAL
SOCIITY or AMi-RICA
November 17-20, 1996
Sheraton Washington Hotel
Washington, DC

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Received June 9, 1995


Accepted February 9, 1996

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