Aquatic : A Viable Therapeutic Recreation Intervention

Ellen Broach and John Dattilo

This paper presents a review of the literature concerning the effects of aquatic therapy utilizing and activity to improve function. Based on the literature, aquatic therapy appears to have numerous psychological and physical benefits. Research studies support the belief that participation in an aquatic therapy program can provide individuals with a realistic solution for maintaining physical fitness and continuing to achieve rehabilita- tion goals while engaging in enjoyable leisure pursuits. Implications of aquatic therapy to leisure generally and therapeutic recreation more specifically are highlighted.

KEY WORDS: Aquatic Therapy, Swimming, Water Exercise, Therapeutic Recreation

Aquatic therapy, utilizing swimming and improve functioning of all major muscle exercise activity to improve function, is be- groups without the impact that is unavoid- lieved to have beneficial consequences for able in land based physical exercise (Cam- physiological and psychological well-being pion, 1985). (Campion, 1990; Davis & Harrison, 1988; Physiological improvements achieved Hurley & Turner, 1991; Skinner & Thom- through involvement with aquatic therapy son, 1989). Hurley and Turner (1991) sug- have been documented in studies of individ- gested that for many individuals with disabil- uals who have multiple sclerosis (Gehlsen, ities the buoyancy as well as the increased Grigsby, & Winant, 1984), cystic fibrosis resistance and warmth of water creates an (Edlund, 1980), arthritis (Danneskiold- environment for exercise which is more con- Samsoe, Lyngberg, Risum, & Telling, 1987), ducive to achieving treatment goals than ex- orthopedic impairments (Skinner & Thom- ercise conducted on land. In addition, exer- son, 1989), cerebral palsy (Harris, 1978; cise achieved through aquatic therapy may Smith, 1985) and asthma (Haung, Veiga,

Ellen Broach is a doctoral student and John Dattilo is a Professor in the Department of Recreation and Leisure Studies at the University of Georgia.

Third Quarter 1996 213 Sila, Reed, & Hines, 1989). Furthermore, the restorative properties of , warm baths psychological benefits of participants in and the sea since the 5th century BC. Greeks aquatic therapy have been identified to in- and Romans recognized the value of the clude improved mood (Berger & Owen, warm water as an adjunct to their sporting 1992; Berger, Owen, & Man, 1993), en- activities and aquatic activity for rehabilita- hanced self-esteem and body image (Bene- tion of individuals with paralysis (Campion, dict & Freeman, 1993; Wright & Cowden, 1990). More recently, aquatic therapy has 1986), and decreased anxiety and depression been provided in the United States in swim- (Stein & Motta, 1992; Weiss & Jamieson, ming pools and therapeutic pools since 1989). In addition to physiological and psy- World War I (Reynolds, 1976). Aquatic ther- chological benefits, aquatic therapy may apy has been described as activity in the wa- promote the development of swimming as a ter based on hydrodynamic principles for lifetime leisure skill which helps maintain therapeutic purposes (Campion, 1990). The health and contributes to happiness (Beau- literature concerning use of water as a me- douin & Keller, 1994; Johnson, 1988; Pega- dium for therapy has been written by various noff, 1984; Smith, 1992; Tsukahara, Toda, individuals practicing in aquatics, including Goto, & Ezawa, 1994). therapeutic recreation specialists, physical Although various issues abound in the therapists, occupational therapists, general area of aquatics, from concerns re- therapists, physiotherapists, medical doctors, garding water temperature (Campion, 1990; sport psychologists and exercise physiolo- Franchimont, Juchmes, & Leccomte, 1983) gists. to qualifications of practitioners using the Aquatic therapy (Johnson, 1988), hydro- aquatic medium in therapy (Campion, 1990; therapy (Campion, 1990), water therapy Smith, 1992), the general consensus reported (Smith, 1992), swimming therapy (Campion, in the literature is that aquatics is a viable 1990), water exercise (Danneskiold-Samsoe, medium that has potential to enhance quality Lyngberg, Risum, & Telling, 1987) and wa- of life for people with . Based on ter physiotherapy (Smith, 1992) are some of the findings reported in the literature, aquatic the phrases used in the literature describing therapy appears to be an intervention that the use of the water for therapeutic benefits. can be used by therapeutic recreation spe- The term "" is presented pri- cialists to promote psychological and physi- marily in literature published in Great Britain ological improvement while facilitating in- and ' 'aquatic therapy'' seems to be the domi- dependence in swimming and water exer- nant phrase used in the United States. For the cise. purpose of this paper, the phrase "aquatic This paper begins with a definition of therapy" is used to include water exercise "aquatic therapy" and the issue of swim- and swimming as modes of prescribed activ- ming as therapy as discussed in the literature. ity used as rehabilitation/habitation to Subsequently, physiological, psychological, achieve goals of improved physiological, and leisure activity implications are ad- psychological, psychosocial and/or life ac- dressed. Implications for aquatic therapy de- tivity function under the supervision of indi- livered in community settings by therapeutic viduals qualified and competent in its tech- recreation specialists are presented as well. niques and utilization. Therapeutic recre- The paper concludes with recommendations ation specialists should be familiar with for the practice of therapeutic recreation. intervention strategies and benefits of aquatic therapy. An understanding of the po- Description of Aquatic Therapy tential of aquatic therapy to enhance an indi- Aquatic therapy has a long-established vidual's leisure lifestyle may be useful in and documented history. People have sought justifying treatment programs.

214 Therapeutic Recreation Journal The techniques of aquatic therapy vary. Physiological Implications Some popular interventions include Bad Ra- Although techniques such as Watzu, and gaz (Boyle, 1981) (employing the principles Bad Ragaz are discussed in the literature, of proprioceptive neuromuscular facilitation swimming and non-swimming water exer- using active and passive techniques for cise were the only mediums found to be ex- strengthening, muscle re-education and amined in the research literature. The physi- trunk elongation); (Dull, 1993) cal benefits of activity performed in the wa- (applying the moves of Zen Schiatsu to facil- ter may include relief of (Guillemin, itate decreased tension and improved psy- Constant, Collin & Boulange, 1994; Lan- chological well being); deep and shallow wa- gridge & Phillips, 1988; Woods, 1989), de- ter ambulatory exercise and therapeutic creased spasticity and increased relaxation swimming commonly implemented using (Davis & Harrison, 1988), improved bone the Method (Campion, 1985) or density (Benedict & Freeman, 1993; Tsuka- Sequential Swim Techniques (Carter, LeCo- hara et al., 1994), improved pulmonary func- ney, & Dolan, 1994) which inherently facili- tion (Haung et al., 1989; Whitley & Schoene, tates normal patterns of movement and pos- 1987), strengthened muscles (Gehlsen, Grig- ture (Neurodevelopmental Treatment). The sby, & Winant, 1984), improved endurance use of passive or active water exercise and (Burke & Kennan, 1984; Danneskiold- swimming as therapeutic media are technical Samsoe, Lyngberg, Risum, & Telling, 1987; processes that require the ability to teach Edlund, 1980; Edlund et al., 1986; Routi, swimming as well as understand the hydro- Troup, & Berger, 1994; Wright & Cowden, dynamics of the water and the implications 1986), and improved range of motion and and contraindications associated with use of increased circulation (Peganoff, 1984). The the water for therapy (Association of Swim- following is a review of articles describing ming Therapy, 1992). the physical benefits of aquatic therapy. Although swimming is considered to be a component of aquatic therapy in this paper, Decrease Pain for some individuals it is seen as a recreation Although water exercise and swimming activity not in the realm of aquatic therapy are commonly mentioned as recommended (Davis & Harrison, 1988). Some prac- forms of treatment for lower back pain titioners consider aquatic therapy as limited (Campion, 1990; Johnson, 1989; J^evin, to passive or active exercise techniques in 1991; Meyer, 1990; Siracusano, 1984; Skin- the water, while Campion (1985) and others ner & Thomson, 1989), it is a treatment mo- believe that swimming is an integral part of dality which has limited scientific research aquatic therapy, and is essential to the over- basis and reports in the back pain literature. all rehabilitation of some individuals. Nu- One study conducted by Guillemin, Con- merous examples of the benefits of swim- stant, Collin, and Boulange (1994), assessed ming when used in aquatic therapy are pre- the effects of spring water treatment on sented in the literature (Bar-Or & Inbar, chronic low-back pain by comparing a ran- 1992; Benedict & Freeman, 1993; Edlund, domly selected group of 50 people undergo- 1980; Haung et al., 1989; Johnson, 1988; ing an aquatic therapy program to 52 ran- Langridge & Phillips, 1988; Peganoff, domly selected people not receiving aquatic 1984). Thus, as suggested by Campion therapy. After three weeks (6 X week), the (1990), swimming is a critical aspect of people in the aquatic therapy group reported aquatic therapy because of its potential to a reduction in their daily duration of pain, be adopted as a life-long leisure and fitness pain intensity and drug consumption, and activity. showed significant improvement over the

Third Quarter 1996 215 control group in their spine mobility and post-treatment with participants serving as functional score on the Waddell index (Wad- their own controls. The Functional Ability dell & Main, 1984). The Waddell index is a Assessment Checklist indicated an improve- self report questionnaire designed to assess ment in functional ability (p <.O1). The an individual's ability in nine daily life activ- Functional Ability Assessment Checklist ities including lifting, sitting, traveling, was developed for this study to test flexibil- standing, walking, sleeping, social activities, ity and strength of the trunk extensors, trunk sexual activity, and foot wear. The long term flexors and lower extremities. Pain was as- effect assessed after nine months showed sessed using a portion of the McGill Pain that, although participants in the aquatic Questionnaire that denotes the intensity of therapy group maintained reduced levels of perceived pain (Melzack, 1983). No change pain and drug consumption and an increase was noted in the self report pain levels. Thus, in spine mobility over the control group, the no statistical relationship existed between functional score reported on the Waddell in- self-reports of pain and functional capacity dex returned to the original level. The au- for the participants. The author stated that thors concluded that aquatic therapy, if used the findings support a contention that reli- as a therapeutic medium for people with ance upon pain reports alone to determine chronic pain, may have positive short term readiness for the resumption of occupational and moderate long term effects on chronic or leisure activities is not judicious. Never- lower back pain. The authors suggested vari- theless, the non-experimental design of this ous factors that may contribute to the effec- study prevents generalization of results. tiveness of the aquatic therapy. First, warm To further assess group hydrotherapy for spring water is thought to have therapeutic participants with chronic back pain Langridge effect in hydrotherapy. Second, the authors and Phillips (1988) monitored subjective pain suggested the positive effects of the program levels and quality of life of 27 participants in could have been because of the change in a group aquatic therapy program. Ages were lifestyle during the program. Finally, the au- clustered around 41 to 60 years. Attendance thors concluded that aquatic therapy is bene- ranged from 4 to 33 sessions in a six month ficial because it occurs in an environment period. Prior to and after each session, each that is physically nonthreatening, thus lead- participant completed a visual analog pain ing to participants' relaxation and less scale expressing pain level. Pre-post question- guarded movement. naires included information on physician vis- An earlier study by Woods (1989) inves- its, quality of life, medication use, ease of tigated the use of aquatic therapy using pre- work and general pain level. Overall results scribed exercise and modified swimming of the subjective visual analog scores showed to improve strength, range of motion a diminution of pain for the participants (p and in the reduction of pain. Eighteen people <.OO1) while 11% expressed an increase in who sustained a lumbar/sacral strain or had pain. Eighty one percent reported an improve- received lumbar laminectomies for ruptured ment in pain before and after each session, discs participated in the study (3 X week at while 15% found that pain increased immedi- no greater than 1 hour each session) for six ately after each aquatic therapy session. weeks. The mean age was 39 years with two Ninety-six percent showed improvement in of the participants being female. Statistical their quality of life (p <.001) and sixty-seven analysis to determine whether any change percent showed a decrease in private medical occurred in either functional ability or pain cost. None of the participants showed an in- reports over the course of the treatment was crease in the number of drugs taken for back performed using a two-by-two chi-square pain and 44% showed a decrease in the test. Each participant was assessed pre- and amount of drugs taken. Caution in interpret-

216 Therapeutic Recreation Journal ing these results is advised since only a few group in this study supported previous re- participants were used and methodological search (e.g., Nilas & Christiansen, 1987) in- rigor was not employed. However, implica- dicating a decrease in BMD by 1-2% in post- tions of the study are useful to consider in menopausal women. Although the ongoing aquatic therapy interventions for individuals water exercise provided in this study ap- with chronic pain. The authors emphasized peared to have a suppressive effect on parti- that the participants derived much enjoyment cipants' bone loss, caution is advised when from the sessions, they perceived themselves interpreting the results due to major limita- to be having positive benefits regarding levels tions associated with the study design. of pain and expressed a general feeling of Benedict and Freeman (1993) found simi- improved well being which influenced their lar results to Tsukahara et al. (1994) regard- quality of life and eased their work capacity. ing bone densities and swimming. This non- The authors hypothesized that the positive re- randomized control group study included sults were due perhaps to the (a) peer support tests recorded on 73 volunteer participants found in the group approach and (b) partici- (32 men and 42 women) who were regular pants ability to take control in helping them- participants in a swimming and aquatic aero- selves through water exercise rather than de- bics program that had met for 6 hours a week pending on skilled practitioners in a clinic. for 10 years, and two volunteer control groups; a group of 73 (15 men and 58 Prevent Bone Loss women) who attended senior centers for ac- Bone loss has become a recent topic in tivity but not swimming and 12 individuals aquatic literature because of its relation to (10 women and 2 men) who neither attended osteoporosis. To examine the impact of wa- a senior center nor swam. The bone densities ter exercise in a warm pool in preventing of people who exercised in the swimming bone loss, Tsukahara, Toda, Goto, & Ezawa and aquatic aerobics program for more than (1994) conducted a cross-sectional study of three years were compared to those who had Japanese post menopausal women to deter- exercised for a shorter period of time and to mine improvement in bone mineral densities older people who had not exercised on a (BMD). In a nonexperimental control group regular basis. Sixty-two of the nonswimming post-test only design, the researchers mea- center attendees reported that they exercised sured the bone density of the lumbar spine regularly (mostly walking). Bone densities of 27 volunteers who had been exercising in of the femoral neck and spine were measured a sports club for two or more times a week by dual-energy X-ray absorbtionetry. Two- for 35.2 months (veterans), 40 participants way analysis of variance and chi square were who had been exercising two or more times used to compare the bone densities of people a week for three to four weeks (newcomers), who exercised in the swimming group for and 30 non-exercisers using BD Z-scores. more than three years to those in the other Length of sessions were not disclosed in the two groups. The swimmers' bone densities article. There were no significant differences of the hip (p <.01) and spine (p <.O4) were in participant's age, height, body weight, higher than the senior center attendees who body mass index, and body fat percentage. did not participate in water exercise or swim- Comparisons were performed by simple lin- ming. Length of participation in the program ear regression and stepwise multiple regres- was not significant. sion. Student's Mest found that for the vet- eran group, the BMD scores were signifi- Increase Strength cantly higher than the scores of the Although there is limited empirical evi- newcomers (p < .05) and the non-exercisers dence on strength benefits for individuals (p < .001). The results of the non-exercisers with disabilities, improved strength is often

Third Quarter 1996 217 identified as a benefit of aquatic therapy strength indicate a need for further research (Campion; 1990; Davis & Harrison, 1988; in this area. Skinner & Thomson, 1989). In an attempt to substantiate this contention, Gehlsen, Grig- Increase Endurance sby, and Winant (1984) examined the effects Although the efficacy of aquatic therapy of a 10-week aquatic program (3 X week, on cardio-vascular endurance has received 60 min sessions) on 10 people (M age = more attention in the literature than other 40) with multiple sclerosis (MS). Selection physical implications, there are few studies criteria required participants to be ambula- examining benefits specific to individuals tory and in remission. Testing occurred prior with disabilities. For example, Edlund to participation, midway into the program (1980) and Edlund et al. (1986) examined and in the week following completion of the the effects of a 12-week swimming therapy program. A Cybex II dynamometer was used program (3 X week, 60 min sessions) on the to measure components of strength (peak strength, endurance and pulmonary function torque and work) and fatigue in the knee of 12 children with cystic fibrosis to 11 chil- flexor and extensor muscles, and a swim dren who did not receive swimming therapy. bench was used to measure components of Volunteers residing in a children's hospital muscular strength (force, work, and power) were randomly assigned to an experimental and fatigue in the upper extremities. There group that consisted of 9 boys and 3 girls was a significant difference of peak torque and the control group that consisted of 5 for knee extensor muscles for pre-trial to boys and 6 girls between the ages of 7 and mid-trial (p <.05) with no significant im- 14. Participants in the swimming therapy provement after mid-trial. For the upper ex- group were required to attain a minimum tremities, a significant increase was seen level of their maximum heart rate during from pre-trial to mid-trial to post-tests in all each swim session set at 60% for the first force measurements accompanied by sig- five weeks, building up to 70% in the final nificant improvement in power and total four weeks of the program. The pre-tests and work (ps <.05). The authors warned that the post-tests for pulmonary function included greater improvement in the components of forced expiration volume, forced vital capac- the swim bench data for the upper extremit- ity, residual volume, residual volume over ies may be related to discrepancies in the total lung capacity, and diffusion capacity. testing protocols for the different instru- The pre-test and post-test exercise tolerance ments. Gehlsen and colleagues (1984) sug- was evaluated by testing the participants' gested that the lack of improvement in some maximum oxygen consumption, time on a areas may be attributed to the general muscu- treadmill, heart rate blood pressure and mi- lar weakness and contraction experienced by nute ventilation. The clinical state of the dis- people with MS, as well as the inability of ease was evaluated according to a Shwach- training to change previous central nervous man score (Shwachman & Kulezycki, 1958). system damage that occurs with MS. Al- The Shwachman scoring technique scores though the results were mixed, Gehlsen and history, physical evaluation, , and colleagues indicated that strength was im- chest roentgenogram. A single blind tech- proved for the individuals in this study. nique was used for score determination. An Thus, according to the authors, a positive experimental design of pre and post-test ex- change in strength can be expected through posure, with one control group with an aquatic exercise. The mixed results and non- ANCOVA to determine significance, was experimental design associated with this used. Although a significant improvement study and the absence of other investigation was found in their clinical state of disease assessing the effects of aquatic therapy on as determined by the Shwachman score (p

218 Therapeutic Recreation Journal <.O5) for both studies, the children in both in ages and IQs and were all classified as the 1980 and 1986 swimming therapy pro- mildly or moderately mentally retarded in gram did not significantly improve their pul- school evaluations. The researchers used the monary function. They did, however, show 9-minute Run/Walk test (Governor's Com- a statistically significant improvement over mission on Physical Fitness, n. d.) to mea- the control group in endurance (p <.01). sure endurance and the Piers and Harris Burke and Keenan (1984) examined 5 Children's Self Concept Scale (Piers & Har- women (M age 36.6) and 5 men (M age 32.8) ris, 1964). Using a two way ANOVA with volunteers using the elementary backstroke the Scheffe' test as a subsequent test for to examine energy cost and to determine if mean comparison, significant F ratios were heart rate and perceived exertion are useful identified. Results showed that this program for monitoring intensity. The volunteers contributed to a significant increase in car- swam at four different intensities, while ve- diovascular endurance (p <.05) and self con- locity, V02, heart rate and perceived exertion cept (p <.05) for participants in the experi- were monitored. Each dependent variable mental group when compared to the control significantly increased with increasing inten- group. A variety of methodological concerns sity. In addition, Burke and Keenan found including the use of ANOVA rather than that the average energy cost was acceptably multivariate procedures for analysis should high. The American College of Sports Medi- be considered when interpreting the results cine recommended that healthy individuals of this study. work at 60% to 90% of their maximal heart In another study, Routi, Troup, and Be- rate reserve and a recommendation of 12 to rger (1994) examined the impact of a water 14 on the Borg perceived exertion scale exercise program on the muscular endurance (Borg, 1970). Both of these criteria were met and aerobic work capacity of older adults during the medium and fast intensities. The (age >50 years) by comparing the perfor- authors concluded that the elementary back- mance of 12 participants in a water exercise is suitable for an aquatic therapy pro- group and 10 participants in a control group. gram. The elementary backstroke is often The people in the control group reported that and comfortably used in instruction with they were not currently participating in any most individuals with disabilities because it organized exercise or recreational program. allows easier breathing due to the face being Participants were tested before and after a out of the water (Farrell, 1976; Garvey, 12-week water exercise program (3 X week, 1991; Hurley & Turner, 1991; Johnson, 30 min sessions) by measuring resting heart 1988). Therefore, although this non-experi- rate in a supine position, cardio pulmonary mental study consisted of individuals with- function through maximum oxygen con- out disabilities, this information may be ben- sumption (VO2 max), maximum heart rate eficial for the therapeutic recreation special- (HR) on an treadmill, and work capacity in ist using swimming in aquatic therapy. the water. Two tests of physical performance Endurance was also examined by Wright in the water were employed before and after and Cowden (1986) who examined the effect 12 weeks of training, including muscle en- of swim training on individuals with mental durance of the shoulder and HR response to retardation in a non-randomized pre-test walking four widths of the pool in the water. post-test control group study with one group The training effects were significantly of 25 (M age = 15.5) who participated in a greater for the water exercise group as com- 1 hour 10 week (2 X week) training program pared to the control group on all dependent and a control group of 25 (M age = 15) who measures. In spite of the use of a small sam- adhered to normal daily living activities. The ple size, the water produced physi- participants in the two groups were equated ological changes in the cardiovascular sys-

Third Quarter 1996 219 tern reflected in the reduction of resting HR use of a Student's f-test rather than a multi- and increase in VO2 and work capacity. Al- variate analysis raises concern when inter- though results of increased VO2 were the preting these results. same as findings reported by Pollock (1973), To further examine the effects of swim- who documented the training effects of older ming on children with asthma, Bar-Or and adults in 8 to 42 weeks of running, Routi Inbar (1992) conducted a comprehensive lit- and colleagues noted that an advantage of erature review to explore the benefits and del- water exercise was that it resulted in less eterious effects of swimming on children with joint stress. The authors contended that indi- asthma. The review of the evidence suggested viduals recovering from physical injury or that swimming induces less severe broncho- muscular disease may employ water exer- constriction than other active leisure related cises with expectations of a training effect activities (e.g., Fitch & Morton, 1971; in aerobic work capacity and in muscular Holmer, Stein, Saltin, Ekblom & Astrand, endurance. 1974). Although reasons for this protective effect of swimming are not clear, the authors Improve Pulmonary Functioning cited experimental evidence (e.g., Inbar, Do- The impact of aquatic therapy on pulmo- tan, Dlin, Neuman, & Bar-Or, 1980) implying nary functioning has been studied primarily that positive effects may result, in part, from as it relates to children with asthma. For ex- the high humidity of inspired air at water ample, Haung et al. (1989) examined the ef- level, which reduces respiratory heat loss and fects of swimming training on asthma mor- possible absorption of airway mucus. bidity. Participants included 45 children Deleterious effects of swimming on indi- (ages 6-12) with asthma who were matched viduals with asthma, according to Bar-Or and by age, sex and severity of illness and ran- Inbar, include the "diving reflex" which is a domly assigned to swimming training (3 X parasympathetic response to immersion of the week, 1 hour sessions) for 12 months or a face in water, especially colder water. After control group. Pulmonary function with a examining studies by Sturani, Sturani, and peak flow meter every three months, school Tosi (1983) and Mukhtar and Patrick (1984), absenteeism, emergency room visits, hospi- Bar Or and Inbar speculated that asthmatic talizations, days requiring daily medications, response of individuals may be enhanced in and days of wheezing both during the swim- cold water and water containing chlorine and ming sessions and for a period of 12 months its derivatives, especially when air recirculat- after the final swimming session were re- ing occurs. Recirculating the concentration of corded. These data were compared to data chemicals may irritate the airways, as ob- collected 12 months prior to the swim class served by Penny (1983), when he reported and to the control group. The Student's t- increased complaints of coughing when such test or the chi square test was used for the a system was in use. Because participants in analysis. Between group differences were Penny's study did not have asthma, more re- statistically significant on each of the depen- search is needed to determine if this airway dent variables when compared to the control irritation response induced asthma response group (p <.O1) and when compared to the of swimmers with asthma. 12 months prior to the swimming program Bar-Or and Inbar also described seven (p <.O1). Although Haung et al. concluded studies documenting how aquatic therapy re- that swimming may have therapeutic bene- sulted in improved fitness effects, most im- fits for children with chronic lung disease portantly, increased pulmonary function and (including children with asthma or cystic fi- the reduction of the incidence and severity brosis) and that the beneficial effects may of exercise induced asthma (Fitch & Morton, last longer than previously anticipated, the 1971; Haung et al., 1989; Mitsubayashi,

220 Therapeutic Recreation Journal 1984; Schnall, Ford, Gillam, & Landau, cystic fibrosis, the lack of a control group 1982; Svenonius, Kautto, & Arborelius, limits interpretation of the results. 1983; Szentagothal, Gyene, Szocska, & Os- Another population that has been exam- vath, 1987; Tanizaki, Komagoe, Sudo, & ined in relation to pulmonary function is Morinaga, 1984). Bar-Or and Inbar con- muscular dystrophy. Adams and Chandler cluded from their review of the literature that (1974) investigated the effects of swimming swimming was less asthma inducing than and breathing exercise of three participants other physically active leisure activities and (11 years old) for 11 months (30 min X 2 found swimming as the most suitable exer- wk). Vital capacity measurements were cise therapy for children with asthma. taken on a wet spirometer three times In their assessment of the physiologic and weekly. After four months, each participant clinical effects of exercise in children with improved in vital capacity. During a three- cystic fibrosis, Edlund et al. (1986) (detailed week vacation, two of three participants in the section of this paper on endurance), showed marked losses in vital capacity. Con- found no change in pulmonary function but tinuing the swimming therapy resulted, once did report that the sputum production during again, in improvement. When the program chest physical-therapy decreased when parti- was, again, canceled for two weeks during vacation, the participants showed a slight cipants were involved in the program. The loss which was regained after continuing the authors concluded that the exercise associ- program. The authors stated that a regular ated with the swimming apparently helped program of therapy can result in increased to clear the lungs of sputum, and that a swim- vital capacity with supervised treatment. ming program (at least 3 sessions per week) Further investigation of methods of main- is an excellent way to improve the clinical taining vital capacity is needed for children status and quality of life of a person with with muscular dystrophy due to the lack of cystic fibrosis. studies in general, and more specifically, due Zach, Purrer, and Oberwaldner (1981) to the non-experimental design and small examined the effect of swimming therapy on number of participants used in this study. forced expiration and sputum clearance of 11 participants with cystic fibrosis (mean age Psychological Implications = 10 years 7 months) who participated in Although some psychological benefits of swimming therapy for seven weeks (17 ses- aquatics are reported in the literature, there sions of 1 hour each). The f-test and analysis is a lack of literature documenting the psy- of variance were used for statistical analysis. chological benefits of aquatic therapy or Ventilatory status, assessed by spirometry aquatic activity, in general, for individuals one day before the first session and one day with disabilities. The majority of studies after the last session showed significant im- have been conducted with people without provement in forced vital capacity, forced noted disabilities, mostly college students expiratory volume and peak expiratory flow and older adults. Information about psycho- rate. The sputum, collected by the children logical improvements such as improved who registered daily volumes in milliliters, body image, self concept, mood and de- was higher on swimming days than on non- creased depression can be useful to the thera- swimming days. Ten weeks after the end of peutic recreation specialist and will be de- the training most of the measurements re- scribed in the following section. turned to their pre-swimming levels. Al- though the authors contended that swimming Improve Body Image as therapy can assist in mucus clearance and The impact of aquatic therapy on body improve ventilatory function in children with image was noted by Benedict and Freeman

Third Quarter 1996 221 (1993) who observed older adults swim- nificant improvement occurred in both ex- ming. In this study (detailed in the section perimental groups in self concept and de- of this paper on preventing bone loss), the pression, when compared to the control (p researchers assessed body image by projec- <.001). Stein and Motta concluded that, in tive drawings and the use of a semantic dif- the case of individuals with disabilities who ferential survey. Although there was no sig- are unable to withstand land-based weight nificant differences in the projective draw- training, water exercise may be a valuable ings, an improved body image of swimmers option for enhancing self esteem and de- was observed when compared to the control creasing depression. group who did not participate in water exer- Weiss and Jamieson (1989) conducted a cise (p <.O5) as measured by the semantic retrospective study to evaluate the effect of differential. an aquatic exercise on subjective depression of participants. The length of time in the Decrease Depression program for the participants was 8 weeks to Reduction in depression, noted as a bene- 5 years. The ages of the 88 women ranged fit in the literature of aquatic therapy (Skin- from 21 to 75 years with the majority clus- ner & Thomson, 1989), has mixed support. tered between 45 and 64. All 21 participants For example, in the aforementioned nonex- who reported symptoms of depression when perimental study by Benedict and Freeman beginning the class reported less depressed (1993), morale and depression scales were feelings with 90.5 percent of these individu- administered. Although results showed that als attributing the aquatic therapy class as a swimmers reported higher morale than the contributing factor to their improved emo- control group (p <.O1), there was no sig- tional state. According to the authors, the nificant difference in the level of depression findings suggest that this particular program between swimmers and the control group. was an effective intervention in the dissipa- In a related study, Stein and Motta (1992) tion of depression related symptoms of sub- compared the effects of anaerobic weight jectively depressed women. The authors training to aerobic swimming on depression claimed that the findings add to a growing and self-concept. This study was conducted body of literature affirming links of exercise to examine the effects of resistive exercise and psychological well-being including the in the water or through an aerobic regimen treatment of mild depression and prevention such as swimming on chemical changes in- of major depression. In addition, the authors fluencing depression. Participants could not stated the study agreed with other research have had previous training in aerobic or non- suggesting that the positive effects may oc- aerobic exercise for at least three months cur in conjunction with social concomitants prior to the initiation of this experiment. The because the women (a) viewed the program 98 volunteers (M age = 20) were assigned as a support group, (b) made new friends in randomly to a 14-week structured swimming the classes, and (c) found it helpful to con- for fitness aerobic class (2 X week, 50 min verse with the others in the group about sessions), a structured progressive resistance health, humor and feeling. The subjectivity, weight training (2 X week, 50 min sessions), lack of information on interview methods, or a control group that did not exercise. De- and the retrospective nature of this study pendent measures were assessed using the raises concern in interpreting the findings Beck Depression Inventory, Depression Ad- and suggest a need for further study. ductive Check Lists, Tennessee Self-concept Scale and Cooper's 12-minute swim. After Enhance Mood the ANCOV A indicated a significant interac- Berger and Owen (1992) examined tion, the post hoc analysis showed that sig- swimming classes and yoga to determine if

222 Therapeutic Recreation Journal aerobic exercise improved mood by em- these speculations call for further examina- ploying a pre-post control group design with tion of the psychological effects of swim- 87 college student volunteers who enrolled ming in aquatic therapy. in two swimming classes (2 X week, 40 min To examine further the complex relation- sessions), a yoga course (1 X week, 80 min ship between exercise and mental health sessions) and a lecture control group course across cultures, Berger and Owen (1993) (3 X week, 50 min sessions). The initial pre- studied 15 swimmers and 15 controls from class mood and anxiety scores of the three Czechoslovakia (Czech) for 12 weeks (1 X groups were compared to examine variabil- week, 90 min sessions); and 20 swimmers ity of students selecting physical activity as and 28 controls from a large metropolitan compared to the more sedentary lecture college in the United States (US) for 14 class. The three groups were not different weeks (2 X week, 50 min sessions). Partici- significantly in social desirability, gender, pants were involved in either a beginning state anxiety, tension, depression, fatigue swimming course or a lecture control course. and confusion on the initial pre-class scores, Although the duration of the swimming ses- except for differences in age, with the yoga sions in the two countries differed, the total group being older (M age = 28.4) than the time participants swam each week was the swimming (M age = 20.3) and control group same. The POMS was utilized to measure (Af age = 21.1). Participants completed the tension, depression, anger, and confusion Profile of Mood States (POMS) inventory and an increase in vigor. The POMS was immediately before and after class on the administered to all groups before and after second session, midway through the study class on the second session, mid semester, and on the last day of instruction. A signifi- and at the end of the courses. The resulting cant reduction in anger, confusion, tension pre-post and activity interactions were sig- and depression was reported for the swim- nificant for the Czech (p <.00) and US (p ming and yoga groups when compared to <.00) swimmers. The US. and Czech swim- the control group (p <.0002), indicating that mers showed a significant mood shift (p aerobic exercise and exercise below one's <.00) on every scale except fatigue. All target heart rate may enhance mood. Berger scores were similar except for tension where and Owen suggested that since swimming Czech swimmers reported a larger reduction and Hatha yoga can facilitate deep, rhythmi- than the US swimmers. Results indicated cal diaphragmatic breathing, which is a com- that the students felt better after enrolling in mon element in many stress reductions tech- the swimming course than before they began niques, the rhythmical breathing may facili- the course. This study provides additional tate mood alteration. In addition, Berger and support for the belief that swimming posi- Owen suggested that lap swimming and Ha- tively influences mood. tha yoga may influence mood by " Although the aforementioned studies do and relaxing large muscle groups in the not include individuals with disabilities, the body, an internal awareness, findingtim e for results have implications for people with dis- oneself and a focus on the present ..." abilities, individuals receiving psychiatric (p. 1340). This study has implications for services, and individuals without a clinical individuals with disabilities because some mental health diagnosis. An acquired physi- individuals have difficulty performing land cal often results in decreased self- based aerobic activity and the water environ- esteem, self-determination and consequen- ment may be one of the few environments tial mood alterations (Krause & Crew, 1987). that a person could do aerobic activity inde- Since many individuals with physical disa- pendently (Campion, 1985). Because this bilities are unable to participate actively in study was not specific to (re)habilitation, land based aerobic activity (Campion, 1985),

Third Quarter 1996 223 it may be useful for therapists to consider tion of the right upper extremity. She began additional benefits from aquatic therapy be- using her right upper extremity during activi- yond physiological ones and examine psy- ties of daily living at home. Although the chological benefits such as improved mood. participant refused to swim with others ini- tially, after learning how to swim at the be- Leisure Implications ginner level, she continued the activity in her A major advantage of aquatic therapy is free time in the presence of family and peers. that it may enhance functional ability that According to Peganoff, this skill acquisition encompasses all areas of life and helps to also resulted in an increase in incidence of develop a life-long leisure activity that can satisfaction and compliance with the pro- be enjoyed with other people (Campion, gram as compared to her traditional therapy. 1985; Peganoff, 1984). Specifically, Cam- Thus, for this participant, treatment goals pion emphasized that once a person is inde- achieved through instruction in the basic pendent in the water, opportunities for so- swim strokes were enhanced by incorporat- cialization are increased. There is, however, ing a new leisure skill of interest. limited research on the benefits of aquatic In another case study, Johnson (1988) de- therapy to a person's leisure lifestyle. Never- scribed a 62-year old man (Charlie) who was theless, many authors have emphasized the diagnosed with amyotrophic lateral sclerosis importance of transitioning the person with a (ALS) three years prior to this aquatic ther- disability from the clinical environment into apy intervention. Upon entering the pro- recreational programs in the community to gram, Charlie had respiratory weakness, achieve psychosocial and functional benefits trace to poor lower extremity muscle (e.g., Duley, 1983; Martin, 1983; Slade & strength and fair to good upper extremity Simmons-Grab, 1987). Although not data- strength. Aquatic therapy was prescribed for based, there are numerous reports of the ben- Charlie for 10 weeks (2 X week, 45 min efits of using recreational activity, commu- sessions) to facilitate an increase in strength, nity re-entry or family training in aquatic flexibility, and conditioning, as well as pro- therapy to meet goals and to facilitate contin- mote recreation and socialization. Charlie ued participation (e.g., Duley, 1983; Martin, improved from not being able to swim to 1983; McNamara, 1994; Melvin, 1976; swimming 26 lengths of a 20-yard pool with Priest, 1976; Smith, 1985; Smith, 1992). The an adapted vest and minimal assistance. following are examples of two case studies Johnson concluded that aquatic therapy for that include information relative to the lei- Charlie achieved, not only increased endur- sure experience. ance and strength, but improved reported en- Peganoff (1984) presented a case study to ergy level and happiness in daily activity exemplify the use of swimming as a leisure as a result of utilizing a challenging leisure activity that incorporates therapeutic goals activity. According to Johnson, an aquatic for individuals with disabilities. The partici- therapy program may provide a person who pant was a 12-year-old girl with spastic right has ALS with a realistic alternative for main- hemiparesis who participated in an 8-week taining physical fitness or continuing with swimming program (2 X week, 45 min ses- rehabilitation goals while participating in an sions). The treatment goals included improv- affordable leisure activity. ing (a) range of motion, (b) functional use In further support of aquatic therapy as a and coordination of the right upper extrem- means to independent leisure involvement, ity, (c) bilateral integration, (d) balance and Beaudouin and Keller (1994) described a equilibrium skills, and (e) self image. The program developed by a therapeutic recre- participant showed a 15° increase in shoulder ation practitioner that was designed to im- flexion and a 10° increase in shoulder abduc- prove functional abilities, facilitate psy-

224 Therapeutic Recreation Journal chosocial adjustment and ultimately lead one referrals for aquatic therapy are increasing to independent participation in other com- (Meyer, 1990; Smith, 1992). In addition, munity recreation programs. Assessments aquatic therapy is being viewed by third were conducted on participants' psychoso- party payers as a viable treatment (Beau- cial and physical skills (endurance, strength douin & Keller, 1994). Therapeutic recre- and flexibility) as well as their personal inter- ation specialists who have the educational ests and functional needs. The program used training may use aquatic therapy to encour- water exercises and swimming to meet the age participants to achieve independent lei- treatment goals, which, generally, included sure participation while realizing functional moving from individual to group sessions. benefits (Beaudouin & Keller, 1994, Cam- Although no data were reported on the effec- pion, 1988; Johnson, 1988; Peganoff, 1984) tiveness of the program, the relevance of this and enhancing their life satisfaction and lon- article is its focus on transitioning partici- gevity (Krause & Crew, 1987). pants to community programs and the infor- To address the demand and the educa- mation presented on the reimbursement rate. tional training needs in aquatic therapy for Beaudouin and Keller reported that insur- therapeutic recreation specialists, systematic ance companies provided 85% reimburse- instructional sessions on aquatic therapy are ment for treatment which was attributed to being developed by various organizations organized and continuous communication and individuals as seen by a recent increase with physicians and case managers. The au- in aquatic therapy workshops sponsored by thors stated that successful intervention and the National Therapeutic Recreation Society documentation strengthened the reputation (NTRS) and the American Therapeutic Rec- of the program with physicians and third reation Association (ATRA). Both organiza- party payers. Beaudouin and Keller's de- tions have recognized the importance of scription, in conjunction with information training for therapeutic recreation specialists from the previous articles described in this in aquatic therapy and expressed a commit- section, provide information on how aquatic ment to address this need. Based on senti- therapy has been used as a means to promote ments expressed by Broach (1995a) and La- individuals' functioning and leisure partici- Tourette (1995) that therapists, at a mini- pation. mum, have an understanding and be Although a benefit of aquatic therapy proficient in the use of properties of the wa- could be the potential for independence in ter, safety and rescue, swimming methodol- the aquatic activity after functional goals ogy, equipment use, patient indications and have been met, there has been little discus- contraindications, handling and therapy sion concerning the leisure implications of techniques, NTRS and ATRA have formed the interventions. Therapeutic recreation aquatic therapy committees to address issues specialists can address leisure implications and increase networking. The NTRS aquatic by including leisure related dependent vari- committee conducted a survey to assess the ables in aquatic therapy research such as sat- status of aquatic therapy use and needs isfaction, enjoyment, intrinsic motivation (Broach, 1995b). In response to the survey, and self-determination. the committee has developed yearly aquatic therapy institutes at the national conference. To address further practitioner concerns, a Implications of Aquatic Therapy NTRS aquatic therapy network has been es- for Therapeutic Recreation tablished. The network disseminates aquatic Aquatic therapy is a viable intervention therapy information through bi-yearly corre- which can be employed by therapeutic recre- spondence, including an updated list of net- ation specialists. The number of physician work participants. ATRA has a committee

Third Quarter 1996 225 of experts to serve as resources, advocate for individuals with disabilities. However, there reimbursement and research aquatic therapy. is limited documentation on the implications In addition, ATRA sponsors aquatic therapy of aquatic therapy to therapeutic recreation. workshops throughout the year. These ef- Therapeutic recreation specialists can ad- forts demonstrate an increased interest in dress these shortcomings through efficacy- providing instruction and disseminating in- based research using various experimental formation on aquatic therapy and, thus, in- and non-experimental designs. Areas of re- crease the ability of practitioners to incorpo- search could include examining the benefits rate aquatic therapy into their repertoire of of (a) similar exercises on land versus water services. and continuation of such programs after clin- Aquatic therapy is delivered in various ical intervention, (b) effects of combining a settings. In the past, therapeutic recreation leisure education model of cognitive behav- has been provided most often in residential ior therapy with aquatic therapy in relapse centers as a part of individual rehabilitation. prevention after discharge, (c) cost effective- A recent trend showing a reduction in hospi- ness of aquatic therapy interventions by tal length of stay has resulted in many indi- comparing lengths of stay of participants and viduals not having the opportunity to take non participants, (d) psychological effects of full advantage of therapeutic recreation ser- swimming on individuals with a variety of vices during hospitalization (Carter, 1991). disabling conditions and (e) effects of Therefore, the range of therapeutic recre- aquatic therapy interventions on activities of ation services needed in the community is daily living and activity level. Therapeutic expanding to include services such as aquatic recreation specialists are encouraged to con- therapy that are designed to have participants duct rigorous studies using efficacy-based achieve treatment goals (Beaudouin & Kel- research documenting the role therapeutic ler, 1994). Further, physicians and insurance recreation practitioners play in improving in- companies are acknowledging the benefits dividuals' functional abilities as well as en- of aquatic therapy and referrals to aquatic hancing their enjoyment and life satisfaction programs are increasing (Smith, 1992). In through aquatic therapy interventions. addition, some physicians and people in need of treatment are searching for alternatives to Conclusion expensive outpatient care due to the decrease There is evidence to indicate that aquatic in insurance reimbursement and rising health therapy has numerous psychological and care costs (Heyneman & Premo, 1993). physical benefits. Furthermore, aquatic ther- Thus, as Johnson (1988), Heyneman and apy appears not only to improve physical and Premo (1993), McHugh (1995), and Slade psychological functioning, but also maintain and Simmons (1987) stated, much of the health and daily life functioning. In addition, long term process of rehabilitation can occur aquatic therapy is valuable because it is con- in aquatic therapy programs within the com- ducted in water which often improves parti- munity. Aquatic therapy provided by thera- cipants' comfort and increases their confi- peutic recreation specialists in a community dence in achieving functional independence pool can facilitate participants achievement (Guillemin et al., 1994; Hurley & Turner, of treatment goals while simultaneously pro- 1991). The health care trend of shorter hospi- moting inclusion in their communities tal stays and an emphasis on outpatient care (Beaudouin & Keller 1994). has resulted in a need for therapeutic recre- Based on the review of the literature, ation interventions to be applied across a there is some support for the use of aquatic myriad of environments. It may be useful for therapy by therapeutic recreation specialists therapeutic recreation specialists to consider as a viable intervention to meet the needs of employing aquatic therapy as a facilitation

226 Therapeutic Recreation Journal technique. The facilitation technique of Burke, E. J., & Keenan, M. D. (1984). Energy cost, heart rate, and perceived exertion during aquatic therapy can result in an increase in the elementary backstroke. The Physician and participants' functional ability while they Sports Medicine, 72(12), 75-79. participate in an enjoyable leisure activity which encourages inclusion in their commu- Campion, M. R. (1990). Adult hydrotherapy. Ox- ford: Heinemann Medical Books. nities (Dattilo, 1994). Campion, M. R. (1985). Hydrotherapy in pediat- rics. Oxford: Heinemann Medical Books. Carter, M. J. (1991). Designing therapeutic recre- References ation programs in the community. Reston, VA: Adams, M. A., & Chandler, L. S. (1974). Effects AAHPERD. of program on vital capacity Carter, M. J., Dolan, M. A., & LeConey, S. P. of patients with muscular dystrophy. Physical (1994). Designing Instructional Swim Pro- Therapy, 54, 494-496. grams for Individuals with Disabilities. Reston, Association of Swimming Therapy. (1992). Swim- VA: American Alliance for Health, Physical ming for people with disabilities, London: Bed- Education, Recreation and Dance. ford Row. Danneskiold-Samsoe, B., Lyngberg, K., Risum, Bar-Or, O., & Inbar, O. (1992). Swimming and T., & Telling, M. (1987). The effect of water asthma: benefits an deleterious effects. Sports exercise therapy given to patients with rheuma- Medicine, 14, 397-405. toid arthritis. Scandinavian Journal of Rehabil- itation Medicine, 19, 31-35. Beaudouin, M., & Keller, J. (1994). Aquatic Solu- tions: A continuum of services for individuals Dattilo, J. (1994). Inclusive Leisure Services: Re- with physical disabilities in the community. sponding to the Rights of People with Disabili- Therapeutic Recreation Journal, 28, 193-202. ties. State College, PA: Venture. Benedict, A., & Freeman, R. (1993). The effect of Davis, B. C, & Harrison, R. A. (1988). Hydrother- aquatic exercise on aged person's bone density, apy in practice. New York: Churchill Living- body image and morale. Activities, Adapta- ston. tion & Aging, 17, 67-85. Duley, F. H. (1983). A theoretical aquatic service Berger, B., & Owen, D. (1992). Mood alteration intervention model for disabled children. Phys- with yoga and swimming: aerobic exercise ical and in pediatrics, 3, may not be necessary. Perceptual and Motor 83-92. Skills, 75, 1331-1343. Dull, H. (1993). WATSU: Freeing the body in wa- Berger, B., Owen, D., & Man, F. (1993). A brief ter. Harbin Springs publishing. review of the literature and examination of the acute mood benefits of exercise in Czechoslo- Edlund, L. D. (1980). Effects of a swimming pro- vakian and United States swimmers. Interna- gram on cystic fibrosis children. Dissertation tional Journal of Sport Psychology, 24, 130— Abstracts International, 33(01), (University 150. Microfilms No. H420E414.E33). Borg, B. V. (1970). Perceived exertion as an indi- Edlund, L. D., French, R. W., Herbst, J. J., Rut- cator of somatic stress. Scandinavian Journal tenberg, H. D., Ruhling, R. O., & Adams, T. D. of Rehabilitation Medicine, 2, 92-98. (1986). Effects of a swimming program on children with cystic fibrosis. American Journal Boyle, A. (1981). The . of Diseases in Children, 140, 80-83. Physiotherapy, 67, 265-268. Farrell, R. J. (1976). Hydrotherapy for high cervi- Broach, E. (1995a). Aquatics survey. NTRS Re- cal cord lesion. Physiotherapy Canada, 28, 8- port, 20(3), 6. 12. Broach, E. (1995b, October). Aquatic Therapy and Fitch, K., & Morton, A., (1971). Specificity of Therapeutic Recreation. Presented at the exercise in exercise-induced asthma. British Aquatic Recreation Therapy Institute held at Medical Journal, 4, 577-581. the National Recreation and Parks Association National Conference, San Antonio, TX. Franchimont P., Juchmes J., & Leccomte, J.

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228 Therapeutic Recreation Journal ance training programs. In Wilmore J. H. (Ed.), sympathetic activity assessed by diving reflex Exercise and Sport Science Reviews (pp. 155- and by airway response to chlorine in bronchial 188). New York: Academic Press. asthma and rhinitis. Respiration, 48, 321-328. Priest, L. (1973). Academic remediation in aquat- Svenonius, E., Kautto, R., & Arborelius, M. ics. Therapeutic Recreation Journal, 10, 35- (1983). Improvement after training of children 46. with exercise induced asthma. Acta Paediar- tica Scandinavica, 72, 23-30. Reynolds, G. D. (1976). Agency development of aquatic programs for special populations. Ther- Szentagothal, K., Gyene, I., Szocska, M., & Os- apeutic Recreation Journal, 10, 61-64. vath, P. (1987). Physical exercise program for children with bronchial asthma. Pediatric Pul- Routi, R. G., Troup, J. T., & Berger, R. A. (1994). monology, 3, 166-172. The effects of nonswimming water exercises Tanizaki, Y., Komagoe, H., Sudo, M., & Mori- on older adults. Journal of Sports Physical naga, H. (1984). Swimming training in a hot Therapy, 19, 140-144. spring pool as therapy for steroid dependent Schnall R., Ford, P., Gillam, I., & Landau, L. asthma. Arerugi, 33, 389-395. (1982). Swimming and dry land exercises in Tsukahara, N., Toda, A., Goto, J., & Ezawa, I. children with asthma. Australian Pediatric (1994). Cross-sectional and longitudinal stud- Journal, 18, 13-27. ies on the effect of water exercise in controlling Shwachman, H., & Kulezycki, L. (1958). Long- bone loss in Japanese postmenopausal women. term study of 105 patients with cystic fibrosis. Journal of Nutrition and Science Vitaminology, American Journal of Diseases in Children, 96, 40, 37-47. 6-15. Waddell, G., & Main, C. J. (1984). Assessment of Siracusano, G. (1984). The physical therapist's use severity in low back disorders. Spine, 9, 204- of exercise in the treatment of chronic pain. 208. The Journal of Orthopedic and Sports Physical Weiss, C. R. & Jamieson, N. B. (1989). Women, Therapy, 6, 41-43. subjective depression, and water exercise. Health Care for Women International, 10, 75- Skinner, A. T., & Thomson, A. M. (Eds.). (1989). 88. Duffield's Exercise in the Water (3rd ed.). Phil- adelphia: Bailliere Tindall. Whitley, J. D., & Schoene, L. L. (1987). Compari- son of heart rate responses: Water walking ver- Slade, C, & Simmons-Grab, D. (1987). Therapeu- sus treadmill walking. Physical Therapy, 67, tic swimming as a community based program. 1501-1503. Cognitive Rehabilitation, 5(2), 18-20. Woods, D. A. (1989). Rehabilitation aquatics for Smith, R. (1992). Kids take the plunge. Rehabilita- low back injury: Functional gains or pain re- tion Management, 12, 31-36. duction? Clinical Kinesiology, 43, 96-103. Smith, V. M. (1985). Aquatic remediation of com- Wright, J., & Cowden, J. E. (1986). Changes in munication disorders. Academic Therapy, 21, self-concept and cardiovascular endurance of 229-236. mentally retarded youths in a special Olympics swim training program. Adapted Physical Ac- Stein, P. N., & Motta, R. W. (1992). Effects of tivity Quarterly, 3, 177-183. aerobic and nonaerobic exercise on depression and self-concept. Perceptual and Motor Skills, Zach, M. S., Purrer, B., & Oberwaldner, B. (1981). 74, 79-89. Effect of swimming on forced expiration and sputum clearance in cystic fibrosis. Lancet, 11, Sturani, C, Sturani, A., & Tosi, I. (1983). Para- 1201-1203.

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