Aquatic Exercise: Creating Opportunities for Wellness for Adults with Neurological Conditions Sarah Fishel, PT, DPT, NCS & Christine McNamara, PT, DPT

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Denver, CO October 18-20, 2017 Aquatic Exercise: Creating Opportunities for Wellness for Adults with Neurological Conditions Sarah Fishel, PT, DPT, NCS & Christine McNamara, PT, DPT Dr.

Dr. Fishel is a board certified specialist in neurologic physical therapy and has over 10 years of clinical experience designing exercise interventions for individuals with neurological conditions.

1 Denver, CO October 18-20, 2017 Aquatic Exercise: Creating Opportunities for Wellness for Adults with Neurological Conditions Sarah Fishel, PT, DPT, NCS & Christine McNamara, PT, DPT Dr. Christine McNamara and Dr. Sarah Fishel are faculty members in the Department of Physical Therapy at Ithaca College, in Ithaca, NY. Dr. McNamara has over 25 years of experience as a physical therapist, including 22 years of experience in aquatic physical therapy. Dr. Fishel is a board certified specialist in neurologic physical therapy and has over 10 years of clinical experience designing exercise interventions for individuals with neurological conditions. In addition to maintaining active clinical practices, Dr. McNamara and Dr. Fishel are also actively engaged in research investigating the benefits of aquatic exercise on the walking and balance for individuals with stroke. Abstract For adults with acquired progressive and non-progressive neurological conditions, impairments in strength, flexibility, endurance, and coordination can cause limitations in the ability to participate in activities of daily life and reduce participation in work and leisure. These limitations often lead to decreased quality of life, limited participation in exercise, and decreased community engagement. Fortunately, a growing body of evidence supports the use of exercise to improve fitness, cognitive function, and participation in work, leisure, and community engagement for adults with neurologic conditions. Long term participation in exercise programs also have the added benefit of improving overall health and reducing the impact of secondary conditions, as well as decreasing overall morbidity and mortality. Although these benefits have been achieved through various types of exercise, aquatic exercise provides unique and additional opportunities to safely improve function and promote lifelong wellness for people with neurological conditions. In this session we will provide information about the benefits of aquatic exercise for adults living with acquired progressive and non-progressive neurological system disorders, including stroke, multiple sclerosis, Parkinson disease, dementia, or traumatic brain injury. We will provide information about the components of successful aquatic exercise programs for individuals with these conditions. Potential barriers to implementation and strategies that may address these barriers will be discussed. Using this information, attendees will be better prepared to develop, enhance, and/or implement aquatic exercise programs for individuals with neurologic conditions. National Swimming Pool Foundation conference@nspf.org

2 Learning Objectives 1. Identify the benefits of aquatic exercise for individuals with neurological conditions, such as stroke, multiple sclerosis, Parkinson disease, dementia, or traumatic brain injury. 2. Describe components of effective aquatic exercise programs for people with neurological injury provided in a group or individual setting. 3. Identify the opportunities for lifelong wellness and fitness activity that aquatic exercise may provide. 4. Describe potential barriers to the implementation of an aquatic exercise program for individuals with neurological conditions and identify strategies to address these barriers.

Benefits of Aquatic Exercise reduced impact and loading consistent and variable

wellness activity cardiovascular conditioning For Those With Neurologic Injury safe

movement with less bracing and support VS. Tone Normalization http://www.beyondstroke.

3 Benefits of Aquatic Exercise reduced impact and loading consistent and variable challenges to balance supportive and resistive environment opportunity for lifelong wellness activity cardiovascular conditioning For Those With Neurologic Injury safe place to move/explore limits of balance, trunk mobility and control gravity minimized movement with less bracing and support VS. Tone Normalization

Support and Fun! decreased fear of falling and fear of moving psychological benefits: group exercise and support http://blog.cranesmill.org/2014/02/ fun!

4 Support and Fun! decreased fear of falling and fear of moving psychological benefits: group exercise and support fun! Diagnostic Specific Benefits Stroke Traumatic Brain Injury Parkinson Disease Multiple Sclerosis Stroke Result of impaired blood flow May result in: weakness abnormal tone impaired sensation cognitive and language dysfunction

Stroke Aquatic Exercise may improve balance more than practice on land can result in

Injury limited research, but benefits may be similar to those identified for

exercise Parkinson Disease Degenerative disease with key symptoms of tremor, rigidity,

5 Stroke Aquatic Exercise may improve balance more than practice on land can result in improved gait while walking over ground after training in the water Traumatic Brain Injury limited research, but benefits may be similar to those identified for individuals with stroke may have a role in fatigue management benefits of aerobic exercise Parkinson Disease Degenerative disease with key symptoms of tremor, rigidity, postural instability, and bradykinesia People with PD are 30% less active than healthy older adults van Nimwegen

Parkinson Disease Exercise and activity programs should include: Consistent, vigorous exercise sufficient to establish/maintain physical fitness Ashlskog Aquatic exercise : limited evidence available

6 Parkinson Disease Exercise and activity programs should include: Consistent, vigorous exercise sufficient to establish/maintain physical fitness Ashlskog Aquatic exercise : limited evidence available Carroll et al: aquatic program was safe and effective for those with early PD Carroll May result in similar improvements to land based program with walking, and greater improvement with balance Palamara Multiple Sclerosis Multiple Sclerosis Exercise and activity programs should include: Intermittent exercise, fewer reps, longer rest Allows for greater volume, increases tolerance to activity Motl et al ; Karpatkin Endurance and resistance training Sabapathy et al Use cooling to limit effects of thermosensitivity White et al Aquatic exercise: Can effectively improve fatigue and QOL Should be part of multimodal approach Kargarfard et al Cohen et al

aquatic environment Safety review of emergency procedures specific to pool managing locker room and pool deck appropriate hydration pre/post activity

7 Now what? Components of Effective Programs: prerequisites Physician clearance for aquatic exercise Including medication effects/interactions Client orientation to aquatic environment Safety review of emergency procedures specific to pool managing locker room and pool deck appropriate hydration pre/post activity Independence: ability/arrangements for changing clothes Components of Effective Programs: prerequisites Attire: protection Water shoes: peripheral vascular disease impaired sensation neuropathy prevention Incontinence swimwear Temperature regulation Dri fit or any other fabric that moves moisture away from skin

Consider client s goals Group vs. Independent exercise program Advocate for a workout partner!

8 Components of Effective Programs Warm up and accommodation to the environment Training Sessions: Strengthening Balance Exercises Walking Exercises Cardiovascular Conditioning Functional Training Cool Down Components of Effective Programs Session structure Consider client s goals Group vs. Independent exercise program Advocate for a workout partner! Circuit training HIIT Task specific training Considerations Always recognize the impact of exercise on the cardiovascular system for those who may have limited capacity

Warm Up Accommodating to movement in the water temperature effect of reduced gravity Sensory impact of laminar flow along the body Moving warm up Increase blood flow to muscles Increase body

9 Warm Up Accommodating to movement in the water temperature effect of reduced gravity Sensory impact of laminar flow along the body Moving warm up Increase blood flow to muscles Increase body temperature Advise gradual increase in intensity Strengthening: Upper and Lower Extremities (UE/LE) Focus on proximal muscles to support posture and trunk Shallow water exercises will incorporate entire LE and core Ex: LE PNF patterns (diagonals) standing in chest deep water Ex: UE with noodle (see video) Incorporate exercises that client may not be able to safely perform on land Squats, walking lunges, plyometrics Strengthening: Upper and Lower Extremities (UE/LE) links for videos: noodle pull downs, reverse pull downs, noodle assisted squats

Posture: achieving and maintaining good alignment This will feel different in the water!

10 Strengthening: Upper and Lower Extremities (UE/LE) Remember! Be sure to strengthen both sides of body Maintain optimal technique Emphasize core strength throughout UE/LE ex Include deep water if possible Strengthening: Trunk Posture: achieving and maintaining good alignment This will feel different in the water! Trunk movement: the ability to move in a controlled way in and out of that alignment Symmetrical rotating, bending, reaching Interact with environment/objects to accomplish these movements Deep water: increases range of movement Functional movement simulation and practice Prone <-> supine Include a core component into most exercises Strengthening: Trunk

11 Strengthening: Trunk Strengthening: Trunk and LEs Sidelying ski video Strengthening: Trunk and LEs Supine pendulum video

12 Strengthening: Trunk and LEs Combination video Balance: variables to consider and progress Static balance: maintaining foot position Wide BOS to narrow BOS Eyes open to eyes closed Add motion Upper extremity Trunk Add turbulence Add cognitive challenge Combine and manipulate these (and other!) variables to progress challenge Sample progression: maintaining foot position Wide base of support Static standing balance Eyes open (EO)/ Eyes closed (EC) EO with turbulence EC with turbulence EO with upper extremity movement Forward, lateral, angles in between To a target that changes Short reaches, long reaches Add turbulence while reaching Low intensity High intensity

Balance: variables to consider and progress Static balance: changing foot position Alternating width of base of support Integrate variables to progress challenge

exercise With UE movement: reach and touch forward, lateral, angles in between 50 yards SW walking for time Add turbulence: anterior/posterior/lateral/diagonal

13 Balance: variables to consider and progress Static balance: changing foot position Alternating width of base of support Integrate variables to progress challenge Example BOS (feet ~ 6 in apart) /EO: change width with ea. exercise With UE movement: reach and touch forward, lateral, angles in between 50 yards SW walking for time Add turbulence: anterior/posterior/lateral/diagonal Remove turbulence, add trunk movement (shifts in each direction) 3 min. trunk pendulums (with noodle) UE and trunk movement with turbulence Balance: Eliciting Stepping Reactions To prevent a fall! Unexpected In all directions Walking Water Depth Speed Direction Resistance

Functional Training Cardiovascular http://aqua4balance.

14 Functional Training Cardiovascular Repetition of one activity with minimal breaks shallow water walking or functional mobility task Circuit Training Deep water vertical exercise with flotation walking jogging/running vertical kicking (kicking in all directions) How should I structure the session/class?

15 What are the barriers? Facility Accessibility Parking lot Building Locker Room Access to the Water

16 Barriers to Participation Fatigue associated with getting to pool/getting changed etc. Bowel/bladder control/management Fear of the water Temperature regulation Barriers to Participation Knowledge of the availability and potential program benefits àeducate clients, neurologists, families, area therapy practices about your program and enrollment opportunities! start classes for those with a specific diagnosis if the need exists Precautions Cardiac conditions COPD, respiratory dysfunction and/or limited vital capacity Diabetes Recently healed wound absent or impaired peripheral sensation incontinence pool chemical sensitivity fear of water any precaution to land based exercise that is not mitigated by properties of water

17 Summary Questions? Christine McNamara: Sarah Fishel:

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