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A 'Water Walkers' Exercise pate in the more traditional walking or low-impact Program for the Elderly aerobics programs currently available for seniors. A water-based program would allow these people to gain all the advantages of land-based exercise with CATHERINE A. HEYNEMAN out stress or strain on arthritic joints. In addition, DONELLE E. PREMO the use of water walkers (a buoyancy device which attaches easily around the waist) would allow total Ms. Heyneman and Ms. Premo are students at the Idaho freedom of movement without fear of deep water. State University School of Pharmacy. Their proposal won third prize in the 1991 Secretary's Award Those with various levels of disability could, there- for Innovations in Health Promotion and Disease Prevention fore, participate at their own pace. competition. The contest is sponsored by the Department of Health and Human Services and administered by the Health Two programs, including transportation, would Resources and Services Administration of the Public Health Service in cooperation with the Federation of Associations of be provided twice a week for 8 weeks each. An Schools of the Health Professions. The entry was submitted by individual 45-minute session would consist of a the Idaho State University School of Pharmacy. warm-up period with gentle stretching, a cardiovas- Tearsheet requests to Ms. Heyneman, 24 Yale, Pocatello, ID cular segment, a cool-down period, strength- 83201. training, and a final stretching time. All exercises would be conducted with participants wearing the Synopsis.................................... water walkers, allowing total immersion to the shoulder. Free to move about the pool, they would Recent studies have shown that older people, be encouraged to interact socially with one another. stereotyped as weak, frail, and inactive, demon- strate an equal capacity to reap the physical and The results of the program would be determined psychological benefits of recreational exercise. by measuring range of motion, cardiovascular en- durance, and strength before and after each 8-week A low cost aquatic exercise program is proposed session. Particpants' level of self confidence and that is geared towards those persons who, because life satisfaction will be estimated and any psycho- of their physical limitations, are unable to partici- logical improvement will be documented. O LD AGE IS A TIME characterized by loss-loss of Traditional low-impact and chair aerobics pro- family and friends, work-identity, and indepen- grams geared for seniors, such as Idaho State dence. Isolation and diminishing physical capabili- University's Senior Enhancing Lifelong Fitness pro- ties contribute significantly to feelings of helpless- gram, have been very successful. They are tailored ness and lack of control. In fact, reactive to and tend to attract, however, those seniors who depression may be the most common illness of the are already fairly active, outgoing, and indepen- elderly (1). dent. In the past few years, however, the stereotype of We propose the creation of a gentle aquatic frail, inactive older persons has been open to exercise program tailored to the less able seniors in question. The current interest in health, wellness, the community who are either homebound or in and the benefits of exercise has expanded to assisted-living environments. Transportation to and include both the very young and the very old. from the program would be provided twice a week Recent studies have demonstrated that the benefits for two 8-week sessions at no charge to the of an active lifestyle do not diminish at age 65. In participants. Additionally, the program would pro- fact, the physical and psychological aspects of vide "water walkers," a foam flotation device that aging make participation in an organized exercise is attached around the waist, allowing total immer- program very beneficial, both as a physical chal- sion in the water up to shoulder level. Thus, lenge and as a social outlet for the elderly. nonswimmers and those persons fearful of deep March-April 192, Vol. 107, No. 2 213 Moderate exercise training has also been associ- ated with a 20-percent increase in serum immuno- globulins (12). Any enhancement of the immune system would be of great importance to the elderly population because the susceptibility to and seri- ousness of infections increase dramatically with age (13). Aquatic exercise has been shown to have similar cardiovascular and musculoskeletal benefits for older people as "on the ground" aerobic exercise previously discussed (14). Beyond that, exercising in water with water walkers has specific advantages water would be able to stay buoyant with no effort for the elderly. Arthritis, a common affliction of on their part. Participants will have full range of the older person, is characterized by joint pain, motion with no joint strain while receiving maxi- stiffness, tenderness, and immobility. The Ameri- mum benefit from the warm water. can College of Sports Medicine has stated that aerobic activity involving large muscle groups with Literature Summary an emphasis on joint range of motion is indicated for the arthritic elderly (5). There is an increasing Exercise has many advantages that are particu- body of evidence that aquatherapy increases fitness larly important to older people. Research has and mobility in patients with rheumatoid arthritis demonstrated both the conditioning and rehabilita- without exacerbating their symptoms (11,15,16). tive effectiveness of physical activity for elderly The use of water walkers to increase buoyancy men and women (2-4). Vigorous physical activity, would allow arthritic persons to gain the full especially if it is recreational, has been shown to be benefits of aerobic exercise with no strain or a strong promoter of longevity (5,6). There is pressure on tender joints. Warm water has particu- indisputable evidence that cardiovascular fitness is larly soothing and salubrious effects on those enhanced by exercise. At a given level of exertion, suffering from arthritis. physical training results in decreased oxygen re- A further benefit of water-based exercising is quirements of the heart as well as decreased periph- that swimming is known to cause less exercise- eral resistance and blood pressure (7-9). This is induced asthma than other forms of exertion (17). crucial for those suffering from hypertension, coro- It is believed that the humid air is protective for nary heart disease, or angina pectoris. Lipid and asthmatic exercisers (18). carbohydrate metabolism is altered as well, result- Water can be a great equalizer. People with ing in a blood lipid and lipoprotein profile consis- various levels of ability and disability can partici- tent with a decreased risk of atherosclerosis (10). pate at their own pace. Problems that would make On average, muscle mass declines by 30 percent land-based exercise difficult or impossible are less between the ages of 30 and 70 (5). Regular exercise apparent in the water. increases muscle mass and maintains muscular In addition to the physiological benefits of exer- strength, both of which are essential in the preven- cise, there is mounting evidence that there are tion and rehabilitation of many musculoskeletal significant psychological advantages as well. Sub- problems commonly found in the geriatric popula- jects participating in regular aerobic training have tion (8,11). Although all motor nerves and muscle reported feelings of increased well-being and de- fibers atrophy with age, type I (slow twitch) motor creased incidence of stress and depression (9,19). units are the last to degenerate (5). The type of Studies on older aerobics participants consistently exercise that enhances type I units is repetitive, low describe significant improvements in self-confi- resistance, continuous movement (5). dence, social life, sleep patterns, and sex life Osteoporosis, the loss of mineral bone mass, associated with moderate regular activity causes approximately 700,000 fractures per year, (14,20,21). Improvements in the cognitive function- one-third of which occur in the hip joint (5). ing of older adults from exercise also have been Physical activity may prevent or delay the onset of shown (22,23). osteoporosis both by stimulating the micro- The support of a spouse or a friend is extremely circulation in bone and by promoting bone deposi- important in encouraging participation in exercise tion (5). programs (24,25). Participants in the program we 214 Publc H"ah Report describe will be free to move about the pool with Budget for water walker exercise program for the elderly their water walkers and will have frequent opportu- nities to interact socially with one other. Also, the Personnel: Instructor (CPR and IDEA-certified) @ $8 design of the fee system (half price for two people per class ............................... $256.00 signing up together) encourages a "buddy system" Minivan driver-assistant @ $5.50 per hour.. 352.00 from the outset. Administrative overhead @ $6 per hour .... 72.00 Equipment: 1 15 Water Walkers (floatation devices) ...... 101.21 Project Objectives Music tapes ............................. 16.00 Advertising: The primary objective of this project is to Newspapers ............................. 84.00 demonstrate that a water-based exercise program Flyers ................................... 24.50 designed for relatively isolated, less-able senior Xeroxing of medical approval forms........ 4.00 citizens is both plausible and efficacious. The Total ................................ $909.71 innovative use of water walkers as a buoyancy Income from 30 persons @ $10 for device and the provision of transportation will every 2 persons..................... 150.00 Net cost............................. $759.71 make the program accessible to those unable to use walking or the more traditional exercise programs 1The swimming pool and tape players will be supplied by Idaho State University. currently available for seniors in the community. NOTE: CPR - Cardiopulmonary resuscitation; IDEA - International Dance Exercise Association. Secondary objectives include the collection of data to quantify the physiological and psychologi- cal benefits of an aquatic program for inactive, the water. Heart rates will be checked every 5 older adults for whom traditional exercise pro- minutes to ensure that no person's exceeds 120 grams are inaccessible. We hope to demonstrate beats per minute. The movements will be per- significant increases in strength, trunk and ham- formed to the beat of swing-era music (110-130 string flexibility, cardiovascular endurance, life sat- beats per minute). The first 5 minutes will consist isfaction, and self confidence at the end of the of a general warm-up period with slow deep-water 8-week session. jogging, followed by 10 minutes of gentle stretch- ing at the side of the pool. The next 15 minutes Methodology will consist of large, calisthenic-like movements where the target heart rate range will be 100-120 Participants will be recruited from assisted-living beats per minute. The remaining 15 minutes will be programs in Pocatello, ID. Advertisements will be spent in the shallow end of the pool, slowly cooling posted in community areas and announcements down, working muscle groups essential for daily made during congregate meal times. It will be activities, and gently stretching. announced that the charge for one 8-week session is $10 per person, but if any two people sign up Significance of the Project together, the charge will be $10 for both. This should promote the development of a support Heart disease is the leading cause of death in this system for all participants right from the begin- country, accounting for 44 percent of all deaths ning. Class size will be limited to 15 persons so that among the elderly in 1978 (13). Researchers at the each person may be monitored carefully while Centers for Disease Control give a sedentary li- exercising. Written clearance will be required from festyle the same overall weight as a major risk each participant's personal physician for them to factor for coronary artery disease as cigarette participate. Total cost of the program has been smoking. Exercise does not need to be of high estimated at slightly more than $750 (see table). intensity to be beneficial. The total amount of Classes will be held twice weekly at Idaho State activity is more important for health than higher University's Reed Gymnasium swimming pool. The intensities. Even in the presence of existing cardio- exercise class itself will consist of adapted aquatics vascular disease, regular physical activity is benefi- and calisthenics movements requiring little skill or cial if prudent guidelines are followed (26). coordination. Water walkers will be attached Anaerobic exercises such as weight lifting are around the participants' waists to allow complete contraindicated in the elderly because of the in- buoyancy in the water. For those with difficulty creased afterload placed on the heart and resultant climbing down the ladder into the pool, there is a danger of cerebrovascular accidents (8,27). The motorized chair available to lower them gently into resistance and buoyancy allowed by aquatic exer- Marc-AprIl 19M, Vol. 107, No. 2 215 cise, on the other hand, provides all the aerobic to a 12-week program of regular physical activity. J and flexibility benefits while minimizing movement Gerontol 30: 565-573 (1975). 4. Martin III, W. H., et al.: Exercise training enhances leg and weight-bearing stress on muscles and joints vasocilatory capacity of 65-yr-old men and women. J Appl (28). Physiol 69: 1804-1809 (1990). The 1980 U.S. Census reported that 25 million 5. Perez, H. R.: Physiology of aging. In American College of Americans ages 65 and older constituted 11.3 Sports Medicine vol. IX. American College of Sports percent of the population. By the year 2035, it is Medicine, Indianapolis, IN, 1989. pp. 1-6. 6. van Saase, J. L. C. M., Noteboom, W. M. P., and estimated that those ages 65 or older will amount Vandenbroucke, J. P.: Longevity of men capable of pro- to more than 20 percent of the population (29). longed vigorous physical exercise: a 32-year follow up of Studies of the elderly have revealed that those 2,259 participants in the Dutch eleven-cities ice skating engaged in regular physical activity maintain a tour. BMJ 301: 1409-1411 (1990). higher level of functional capacity and do not 7. Choquette, C., and Ferguson, R. J.: Blood pressure reduc- experience the typical declines in later years (30,31). tion in borderline hypertensives following physical training. Can Aviation J 108: 679-703 (1973). Thus, programs that foster a sense of personal 8. McHenry, P. L., et al.: Statement on exercise: a position control and responsibility for health maintenance statement for health professionals by the Committee on and disease prevention in the elderly can have a Exercise and Cardiac Rehabilitation of the Council on great impact in the future. Clinical Cardiology, American Heart Association. Circula- tion 81: 396-398 (1990). 9. Norris, R., Carroll, D., and Cochrane, R.: The effects of Summary of Evaluation Methods aerobic and anaerobic training on fitness, blood pressure, and psychological stress and well-being. J Psychosom Res The first class will be devoted to determining 34: 367-375 (1990). 10. Tran, Z. V., and Weltman, A.: Differential effects of baseline indices of the blood pressure, flexibility, exercise on serum lipid and lipoprotein levels seen with functional strength, and cardiovascular endurance changes in bodyweight. A meta-analysis. JAMA of the participants. Hamstring flexibility will be 254: 919-924, Aug. 16, 1985. assessed by measuring the degree of straight leg 11. Lowenthal, D.: Practical approaches to geriatric exercise. flexion from a supine position with a protractor. Geriatrics 45: 76-82 (1990). 12. Nehlsen-Cannarella, S. L., et al.: The effects of moderate Trunk flexibility will be determined using the exercise on immune response. Med Sci Sports Exerc sit-and-reach test. Strength will be measured using 23: 64-70 (1991). the test in which subjects stand upright from a 13. Pulliam, C. C.: Characteristics of the elderly. In Pharmacy seated position as many times as possible within a practice for the geriatric patient, edited by B. Ameer and 30-second time span. Cardiovascular endurance will J.L. Bootman. American Association of Colleges of Phar- macy/Eli Lilly and Company Geriatric Curriculum Project, be assessed by asking participants to rate their Carrboro, NC, 1985. p. 16. perceived exertion rate between 0 (very light) to 10 14. Stevenson, J., Tacia, S., Thompson, J., and Crane, C.: A (very hard) after 2 minutes of performing a jogging comparison of land and water exercise programs for older movement in the pool with the water walker to individuals. Med Sci Sports Exerc (supp.) 20: 537 (1988). music at 120 beats per minute. Resting heart rate 15. Harkcom, T. M., Lampman, R. M., Banwell, B. F., and Castor, C. W.: Therapeutic value of graded aerobic exer- will not be used to assess fitness level, since many cise training in rheumatoid arthritis. Arthritis Rheum of the participants will be taking beta blockers or 28: 32-39 (1985). other antihypertensive medications that would con- 16. Minor, M. A., et al.: Efficacy of physical conditioning found the results. An assessment of life satisfaction exercise in patients with rheumatoid arthritis and osteoar- and self-confidence will be made using the Profile thritis. Arthritis Rheum 32: 1396-1405 (1989). 17. Reggiani, E., et al.: A comparison of various exercise of Mood States self-report instrument. Both physi- challenge tests on airway reactivity in atopical swimmers. J ological and psychological measures will be re- Sports Med Phys Fitness 28: 394-401 (1988). peated at the end of the 8-week session. 18. Bar-Yishay, E., et al.: Differences between swimming and running as stimuli for exercise induced asthma. Eur J Appl Physiol 48: 387-397 (1982). References.................................. 19. Doyne, E. J., et al.: Running versus weightlifting in the treatment of depression. J Consult Clin Psychol 1. Brody, S. J.: The graying of America. Hospitals 54: 63-66 5: 748-754 (1987). (1980). 20. Perri, S., and Templer, D.: The effects of an aerobic 2. Adams, G. M., and deVries, H. A.: Physiological effects exercise program on psychological variables in older adults. of exercise training regimen upon women aged 52 to 79. J Int J Aging Hum Dev 20: 162-172 (1985). Gerontol 28: 50-55 (1973). 21. Emery, C. F., and Blumenthal, J. A.: Perceived change 3. Clark, B. A., Wade, M. G., Massey, B. H., and VanDyke, among participants in an exercise program for older adults. R.: Response of institutionalized geriatric mental patients Gerontologist 30: 516-521 (1990). 216 Publc Helth Reports 22. Dustman, R. E., et al.: Aerobic exercise training and 27. Sagiv, M., et al.: Comparative analysis of cardiopulmo- improved neuropsychological function of older individuals. nary responses during dynamic exercise with wrist weights Neurobiol Aging 5: 35-42 (1984). in the elderly versus young hypertensive responders. Geron- 23. Molloy, D. W., et al.: Acute effects of exercise on tology 36: 333-339 (1990). neuropsychological function in elderly subjects. J Am 28. Evans, B. W., Cureton, K. J., and Purvis, J. W.: Meta- Geriatr Soc 36: 29-33 (1988). bolic and circulatory responses to walking and jogging in 24. Weiss, C. R., and Jamieson, N. B.: Affective aspects of water. Res Q 49: 442-449 (1978). an age-integrated water exercise program. Gerontologist 27: 29. Hopkins, D. R, Murrah, B., Hoeger, W. W. K, and 430-433 (1987). Rhodes, R. C.: Effect of low-impact aerobic dance on the 25. Shutter, D. J., and Freyman, J. F.: Spousal support and functional fitness of elderly women. Gerontologist exercise compliance in females. Med Sci Sports Exerc 30: 189-192 (1990). (supp.) 20: 536 (1988). 30. Spirduso, W. W.: Physical fitness and psychomotor 26. Fletcher, G. F., et al.: Exercise standards: a statement for speed: a review. Gerontology 35: 850-865 (1980). health professionals from the American Heart Association. 31. Rikli, R., and Busch, S.: Function of age and physical Circulation 82: 2286-2322 (1990). activity. J Gerontol 40: 645-649 (1985). ABSTRACTS OF SEMIFINALISTS' PAPERS A Program of Parental formance reinforces the adolescent's Groups in this study would be com- and Group Mental Health negative self-perceptions, continuing posed of adolescents with affective the cycle. Problem solving skills have disorders; groups of patients with After Care for Adolescents been found to be lacking among de- schizophrenia or personality disorders pressed adolescents, and low self- have not been shown to be highly Maryde Arnold, BSN esteem seems to follow when an ado- successful. At least three groups would lescent is not performing well socially. be studied, each at a different facility Many communities lack treatment and Many adolescents are hospitalized to see if results are replicated. A con- support groups for adolescents on an after suicide attempts, but few who trol group of adolescents with similar outpatient basis after their hospitaliza- attempt suicide are inpatients at the problems would not receive after care. tion for a serious and common affec- time. Hospital admissions of adoles- Adolescents would be randomly se- tive disorder, such as depression. Par- cents have been increasing in the past lected for both the control and the ents of such adolescents also need a few years, with more than 80,000 per- experimental groups. The parents of strong support system, along with edu- sons younger than 18 years admitted those in the experimental group would cation that is specific to the needs of to inpatient psychiatric facilities in participate in a group as well. A paral- the family. 1980. Group therapy has been shown lel parent group would increase com- Adolescents who have been hospital- to be a successful treatment for de- pliance of adolescents to attend. All ized for psychiatric disorders generally pression. Groups are the main method subjects would sign informed consent agree that their most helpful experi- of treatment in most inpatient psychiat- forms. ences in the hospital had been gained ric settings and are viewed as the The groups would meet once weekly through group therapy sessions. They treatment of choice in adolescents. for a minimum of 3 months. The opti- tend to miss the safe, structured, and The major objective of this proposal mum number of participants in each supportive atmosphere of group ther- is to provide group support to the group is seven to eight. The study apy and to feel as if they need to depressed adolescent to decrease re- groups would be closed in order to return to the hospital when problems hospitalizations, decrease suicide obtain proper statistical information. If arise. Parents often see a need for rates, and increase the social, problem the study is successful, subsequent continued care to assist the family in solving, and cognitive skills of the ado- groups may be open to newly dis- the period of adjustment when the lescent. The second objective is to charged outpatients to enhance peer adolescent becomes an outpatient. provide support and education for the learning. Much current literature speaks of a parents of depressed adolescents. This The adolescent groups would focus positive correlation between the use of effort should help guide the parents in on improving social skills, problem- groups to provide support and therapy working with their child to achieve solving skills, and negative cognition, for adolescents and the adolescents' better mental health. A long-term goal and would use specific activities to increased social skills. Frequently defi- is to help these young persons be- achieve these goals. Group activities in cits in social skills are associated with come contributing members of society. themselves may help with each of some degree of social isolation in the All these efforts should, in turn, in- these. Structured role assignments depressed adolescent. One study pos- crease knowledge of affective disor- during meetings, homework assign- tulates that when depressed adoles- ders and decrease the stigma of men- ments using negotiation, communica- cents perform poorly socially, this per- tal disorders. tion, or handling conflicts, and per- March-April 1992, Vol. 107, No. 2 217
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