Aquatic Exercise Programming for People with MS | 2 Possible Considerations May Include: Strategies for •

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Aquatic Exercise Programming for People with Multiple Sclerosis

MATERIALS FOR AQUATIC EXERCISE INSTRUCTORS Edited by Deborah P. Hertz, MPH, National Director, Medical programs Clinical Programs Department National MS Society, New York, NY. 212-476-0468.

Contributors: Helen Tilden, RN, National MS Society, Georgia Chapter Clinical Advisory Committee and National MS Society, Special Project Consultant

Miranda Mirsec MA, CES, National MS Society Southern California Chapter Programs Manager, Physical Health and Recreation

Brian Hutchinson, MS PT, President, Heuga Center and National MS Society Clinical Consultant

December 2003

The Professional Resource Center The Professional Resource Center (PRC) of the Clinical Programs Department supports the work of health professionals by providing a range of library and literature search services, as well as information and consultation about the disease and its management, insurance and long-term care issues, and the Society’s professional education opportunities.

For more information: • Toll-free number: 1-866-MS-TREAT (1-866-678-7328) • Email: [email protected], [email protected] • Professional website: nationalMSsociety.org/For-Professionals/Clinical-Care

Acknowledgements This manual has developed over time thanks to the efforts of many Society chapter staff and volunteers.

Connie Divine, TRS, Patricia Finlay, McSP/PT and Helen Tilden, RN, of the Georgia Chapter, developed an aquatics manual in 1993 that was subsequently adopted as a national model.

The vision for the new format came from Denise Nowak, RD (certified by the American Council on Exercise) and Miranda Mirsec, MA, CES of the Southern California Chapter.

A special thanks is also due to Amy Brown (Mid South Chapter ), Suzanne Carrone (Gateway Area Chapter), Connie Nesbary (Michigan Chapter), and Jo-Ellen Zembruski (New York City Chapter) for their input.

Brian Hutchinson, MS, PT, National MS Society Clinical Consultant and Nancy Holland, EdD, RN, MSCN, Vice President, Clinical Programs Department reviewed this manual.

Front cover photo: Robert, diagnosed in 1990

Aquatic Programming for People with MS...... 2 Why Water Works?!?...... 2 Aquatic Programs for People with MS...... 2 ...... 2 Focus on Function...... 3 Benefits and Considerations of an Aquatic Program Strategies for Adapting Movement...... 3 Using the Physical Properties of Water...... 3 ...... 4 ...... 4 Considering Functional Levels Impact Options for Aquatic Exercise...... 5 Body Mechanics Use of Equipment...... 6 General Exercise Principles...... 8 Exercises for People with MS...... 8 Marching/Alternating ...... 9 ...... 10 Knee Lifts Static Hamstring Stretch...... 10 Side Steps ...... 11 Trunk Twists—Spinal Rotation...... 11 Active Chest Stretch ...... 11 Walking...... 11 Leg/Hamstring Curl ...... 12 Cross Country Ski...... 12 Pelvic Tilts Rocking Horse...... 12 ...... 13 ...... 14 Straight Leg Walk ...... 15 Side Tilt/Lateral Weight Shift Class Structure and Cueing...... 20 Additional Exercise Options Lesson Planning...... 23 Cueing...... 24 Music...... 24 Pool Safety and the Environment...... 24 A National Multiple Sclerosis Society Aquatic Program...... 26 ...... 26

Objectives Aquatic Programming for People with MS

WHY WATER WORKS?!?

for many people with MS. Cool water with MS provides an opportunity to maintain Water is a very inviting exercise environment mobility, prevent secondary symptoms of MS, maintain or improve flexibility, maximize temperatures—80-84 degrees Fahrenheit— muscle strength, and maintain or increase endurance potential. helps to keep coreIntro body to MS temperatures for Fitness andlow, Wellnessreducing the Professionals chances of overheating. As aquatics program for people with MS is 80–84 temporarymentioned worseningin of MS symptoms. The recommended pool temperature for an , overheating can cause degrees.BENEFITS AND CONSIDERATIONS OF AN AQUATIC PROGRAM The natural properties of water—including From Report of the Surgeon General buoyancy or weightlessness combined with learnresistance—create to use the properties an excellent of water environment to best , United for movement and exercise. Participants can States Department of Health and Human Services, (1996), “People with disabilities meet their specific exercise/fitness needs. are less likely to engage in regular moderate Likewise exercise in a pool offers stability and activity than people without disabilities, yet support to practice functional activities such as they have similar needs to promote their health ambulation. Water often provides support many and prevent unnecessary disease.” The report people with MS need to stand and maintain also recommends “community based programs balance for exercises that would otherwise be to meet the needs of persons with disabilities.” tooAQUATIC difficult onPROGRAMS land. A community based aquatic exercise program FOR PEOPLE WITH MS is an excellent way to add activity, strengthen The purpose of an aquatic recreational program the cardiovascular system, reduce body fat, and Waterdecrease offers stress. benefits such as: • senseis socialization of well-being. and exercise, The aquatic and class is intended is not to meet goals such as increased function and Less energy expenditure required for • movements intended to be a “hands on” treatment or water resistance Increased muscle strength due to use of therapy. A recreational program is designed • to offer people with MS with varying levels of disability or activity limitations an opportunity Opportunity to practice balance and • Relaxing effects of buoyancy on the skeletal waterto participate, in a group including setting withindividuals an emphasis who use on coordination (with more ease than on land) assistive devices. The class is taught in shallow structure and increased ease of walking in • fun and independence. Benefits will vary from water due to buoyancy individual to individual. • Opportunity to weight bear on the lower Protection from falls (“soft” landing) extremities An aquatic program can include aerobic exercise, strengthening, balance training, and • stretching in addition to a warm-up and cool- • Increased circulation enjoyable.down. Recreation The aquatic is diversion, program rest, for peoplerelaxation, entertainment, exercise, play and hopefully, A cool exercise environment which can increase endurance with activity National MS Society Aquatic Exercise Programming for People with MS | 2 Possible considerations may include: Strategies for •

water.Loss of balance due to upward thrust of buoyancy, use of foam equipment or deep • temperature is too warm Fatigue and muscle weakness if water Adapting Movement • Effects of incontinence Components of exercise design to be considered when developing a multiple sclerosis aquatic • Water properties • class include: • • Intro to MS Skin breakdown bearing for Fitness and Wellness Professionals Decreased opportunity for full weight Functional levels defined in the • Fear of water • Body mechanics—minor and subtle changes FOCUS ON FUNCTION byto handmaximizing position, or body minimizing alignment the andeffect body of watercomposition, properties alter movement intensity In general, most movement is beneficial for • Impact options—water is an excellent individuals living with MS. As you focus on developing programs for people with MS, consider movements that address functional medium for exercise because of the reduced gravitational forces experienced by the body Contributingactivities. factors include: exerciseswhen partially submerged. This produces • Weakness a lower impact alternative to land-based • Equipment • Spasticity/Spasms • • Lack of coordination Remember that symptoms of MS are different • Tremors for each individual and may change daily or Balance difficulties weekly. Be sure to discuss potential adaptations • Fatigue symptomsof a movement change. with participants, and always • Pain remind them to consult with their physician if USING THE PHYSICAL A focus on function in the pool means PROPERTIES OF WATER Familiarity with the physical properties of choosing exercises/activities with the goal of water can help instructors create exercise improving coordination, flexibility, balance, muscle strength, endurance, and possibly interesting. cardiovascular fitness. Exercises in these sessions that are safe, challenging and areas can improve functional mobility such as transfers, gait and stair climbing. Most importantly, the activities need to be engaging.

National MS Society Aquatic Exercise Programming for People with MS | 3 Laws and properties include: • Be sure to discuss specific limitations with each • Inertia Buoyancy versus gravity student. In addition, involve participants when • Resistance modifications of exercises are necessary so that they can adapt a movement to best meet their • needs.BODY MECHANICS • Leverage • Action and reaction Body mechanics can be a useful strategy for • Surface tension Hydrostatic pressure adapting movement. Minor and subtle changes • Drag maximizingto hand positions, or minimizing body alignment the effect and of lengthwater of body levers changes movement intensity by • • Turbulent flow properties. Additionally, the impact body • Temperature composition has on movement execution can Speed, power and force assist instructors to make effective movement Here are examples of how to use water choicesHAND and POSITIONS: adaptation. • Fist • • properties to maximize pool activities: Webbed—hand(s) clenched to form a fist Change the surface area and speed • —fingers spread apart and of movement • Clawed bearing properties extended Change the depth of water altering weight —fingers flexed in claw fashion but • • notSliced clenched as a fist • Vary impact levels —fingers together and moving hand Enlarge a movement, using the property BODYin “chopping” ALIGNMENT movement • of buoyancy to support the lever • Change the planes of movement Neutral spine is keeping the vertebral spine CONSIDERINGTravel in its natural alignment with normal curves in FUNCTIONAL LEVELS alignmentthe cervical is and noticeable lumbar withareas. new The participants importance of maintaining torso control and proper body Intro to MSWhen for designing Fitness and a session Wellness keep Professionals in mind the who haven’t made the adjustment from three levels of ability (defined in the movement in a gravity-based environment ) to a buoyancy-based environment. Adjusting to better meet the needs of all your students/ participants.to a new center Instructors of gravity can (from help hip participants area to clients. Movements can be altered to match the bylung encouraging area) is sometimes them to maintaindifficult for a neutral new mayabilities concentrate of individuals. more onFor lower example extremity individuals interested in improving sit to stand transfers changing planes can challenge torso control. spine. As participants become more skilled, strengthening and stretching exercises.

Remember, symptoms of MS are different for Posture is more difficult in water if the depth each individual and may change daily or weekly. is above the navel toward the mid-chest area.

National MS Society Aquatic Exercise Programming for People with MS | 4 BODY COMPOSITION

theThe class upward to a thrust more shallowof buoyancy area createsof the pool an to instability and improper foot placement. Bring The ratio of lean body mass to fat body mass affects buoyancy and therefore can affect the permit control, alignment, and foot strike. The intensity of executing a movement. Someone shallow water affords cooling, protection from with a high percentage of body fat easily floats Properfalls, and standing body awareness. alignment: while a more muscular individual would sink. • A person with limited strength and/or who is less lean may have more difficulty controlling Feet parallel, slightly apart with weight buoyancy and buoyancy equipment. Teaching evenly distributed on the heels, outside body mechanics as a means of movement • borders, and balls of the feet adaptation enables participants to increase or • decrease movement intensity. Here are some Knees soft and relaxed • • examples: Hips are tucked, slight posterior pelvic tilt • “Place hands in a webbed position to The abdomen is flat increase surface area, which increases • • Chest is high with rib cage lifted movement resistance.” Shoulders are level, with shoulder “Keep knees extended while walking to • • Offer support/buoyancy equipment to assist blades flat increase resistance.” Head is centered over trunk with chin • slightly retracted and ears over shoulder individuals experiencing difficulty because IMPACTof low body OPTIONS fat composition. Arms are relaxed with palms facing the • FOR AQUATIC EXERCISE sides of the body Spine is in neutral position, meaning when viewed from the side there is an anterior Water is an excellent medium for exercise cervical curve or lordosis, followed by a because of the reduced gravitational forces posterior thoracic curve or kyphosis and a experienced when partially submerged. This LEVERSlumbar lordosis provides a lower impact alternative to land- based activities. Impact forces can be modified ofeven water further exercises in water. but Keepmay notin mind physically that some be Our body consists of levers. Bones act as lever ableindividuals to increase will adaptthe impact. to increasing the intensity exercisearms and to joints increase function resistance--the as fulcrums longer of these the levers. An extended arm can be used in water REBOUND

lever the greater the surface area. The opposite is true if the desire is to decrease resistance, a Rebounding is standing in an upright position shortened lever or flexed elbow joint created and pushing off from the pool bottom. It is a less demand on the shoulder than an extended common movement used in aquatic programs elbow joint. It is understandable why taller becauseGROUNDED/NEUTRAL it is most similar to land-based activities. people, with longer limbs, find it more difficult to move through water than someone with requireshorter morelimbs. time Keep to in execute. mind that longer lever movements integrated into a class format The grounded or neutral position involves flexing at the hips and knees to lower the body to a position where the shoulders are a few inches above the water’s surface. This level National MS Society Aquatic Exercise Programming for People with MS | 5 of impact is also seen with standing upright correctly is essential. Improper use can decrease bottomactivities but without without the the bounce/rebound jumping force. inThis the Theeffectiveness types of and equipment possibly causethat may injury. be useful movement. The feet will still contact the pool in your classes are: • allows the reduced impact benefit of exercising • at chest depth without compromising control Buoyant/floatation equipment ofSUSPENDED movement. • Drag equipment Gravity (weighted) equipment • The suspended position involves flexing at the Considerations:Rubberized equipment hips and knees to lower the body to a position where the shoulders are at the water’s surface • while keeping the feet elevated from the pool bottom for several counts. This simulates Home-made or make-shift devices such deep-water exercise in the shallow area of the as milk jugs are inappropriate and unsafe. pool. Suspended position requires increased Be sure to use equipment that is designed notinvolvement be comfortable of the upperfor non-swimmers. body musculature To take brokenfor pool parts. use and inspect each piece before every class to ensure there are no missing or to maintain the suspended position, and may • equipment has the risk of increasing fatigue advantage of this level, without the upper body Extra buoyancy and resistance of some strength requirements, buoyancy equipment • can be used. and loss of balance. Impact Option Positions Recognize muscle weakness and the • Rebound position: places the most impact on the body. deconditioned state of participants. Weak amuscles participant tire quickly is familiar and with are inefficient.his/her places some • Grounded/ neutral position: Therefore, do not use equipment until impact on the body. • Suspended position: does not place any personal level of fatigability and balance impact on the body. in the pool. It may take several classes to acclimate to the upward thrust of buoyancy, the program.extra buoyancy Ask participants of foam equipment, to practice USE OF EQUIPMENT and the intensity that equipment adds to

equipment.movements without equipment until they Equipment is not needed to conduct an effective understand how it should “feel”, then add program. However, floatation devices such as • noodles, bar bells or kickboards will assist with balance when walking and will add interest and Devices used to assist buoyancy, resistance, or floatation are not intended as life saving variety to the class. Safety of participants is, of • course, the most important consideration. devices. appropriate aquatic exercise equipment is to Lifts, steps, or chairs for pool entry are An important first step in selecting the oravailable reaching through sticks majorfor the pool locker suppliers. room are Assistive devices such as shower chairs determine the needs of the participants. Next, determine which type of equipment will best available locally in many areas (check the meet these needs. Once you have made an yellow pages under medical equipment or equipment selection, knowing how to use it durable medical equipment.) National MS Society Aquatic Exercise Programming for People with MS | 6 • Disadvantages: 1. Equipment made from latex material should 2. be carefully considered due to potential Tend to be bulky Priorproblems to using with any latex equipment, allergies/sensitivity it is important 3. to evaluate the following, to determine Difficult to store appropriateness: Can cause overload injuries on joints • GRAVITYand muscles (WEIGHTED) • EQUIPMENT Establish intended use/application • Rate effectiveness Weights use different muscle groups than those Assess for correct body mechanics with • worked with buoyancy equipment. and without use of equipment With weighted equipment, all movements Identify contraindications/risks toward the bottom of the pool are “assisted” • (musculoskeletal injury) and all movements toward the pool’s surface • Determine benefits Typesare “resisted”. of weighted equipment Identify limitations (cost, availability, • Ankle weights BUOYANT/FLOTATIONability level) • EQUIPMENT Advantages:Medicine balls 1. Offers an opportunity to work on Buoyancy works in the opposite direction of weight bearing gravity. Buoyancy/flotation equipment reduces 2. the effects of gravity on the body and assists 3. with floatation. The tendency of this equipment Can add variety to program is to rise to the surface of the water, therefore any movement toward the surface of the water Disadvantages:Reasonably inexpensive and easy to store is “assisted” and any movement toward the 1. Typesbottom of is buoyancy/flotation“resisted”. equipment: 2. • Difficult to transport • Recommendations:Difficult to recover when dropped in pool Floatation belts/ankle floats • • Noodles, rods up well in water • Balls Make sure the weighted equipment will hold Foam dumbbells • • Use of ankle weights during aerobic exercise Advantages:Kickboards is not recommended due to the increase of 1. DRAGpotential EQUIPMENT injury to muscles and joints 2. Adaptable to most fitness levels 3. Lightweight Drag equipment can be very useful in a water environment. The shape of equipment, velocity Relatively low expense or speed of movement, turbulence and water depth affect the amount of resistance that can be achieved during water exercise. National MS Society Aquatic Exercise Programming for People with MS | 7 Types of drag equipment: GENERAL EXERCISE PRINCIPLES • It is important to keep general exercise • Drag parachutes Webbed gloves exercises for people with multiple sclerosis as • principles in mind when recommending aquatic • Water boots Hand held paddles, bells, and boards • Shoes it is common to see diverse ability levels among people with MS. Likewise, ability levels may change from session to session depending upon Advantages: a number of factors. However, there are some • —Encourage normal breathing 1. generalBreathing principles to keep in mind: 2. Can be used in nearly all directions 3. during exercises. Holding one’s breath Adaptable to most fitness levels • —It is important to encourage shouldPosture be discouraged. Disadvantages:Lightweight and easy to transport 1. proper postural alignment during activities • by the instructor toPositioning avoid undue musculoskeletal stress. Requires more knowledge of water skills 2. —Have participants use their stronger side for support – a pool wall is • —It is Can place adverse stress on joints and fineListen when to what initially the learning body is thesaying exercise. RUBBERIZEDmuscles if inappropriately EQUIPMENT used important to listen to the signals the body is sending to avoid fatigue. Exercising to the Rubberized equipment is designed as circular point of fatigue is NOT recommended. Stop bands or tubing cut to a desired length. before becoming tired and progress slowly. Different tensions are available, varied by width or thickness of the band or tube. This Exercises for equipment can be beneficial for strength Typesbuilding of or rubberized out of the water. equipment: People with MS • The following exercises are examples of many • Tubing Bands • Balls activities that can be beneficial to people Advantages: living with MS. By combining exercises and integrating movement strategies (e.g., changes 1. in movement direction and speed, body 2. positioning and use of equipment) an instructor Inexpensive 3. can develop an effective, challenging and Easy to transport and use motivational format for the class. Disadvantages:Adds variety to exercise program functionalThe exercises mobility. noted Peopleaddress with flexibility, MS may strength, require 1. Short life span of equipment endurance, balance, coordination and overall 2. mechanics additional attention in one area based on their May adversely affect proper body 3. Potential allergies to latex materials— condition. However, a well rounded program explore latex substitutes will include a variety of categories of exercise.

National MS Society Aquatic Exercise Programming for People with MS | 8 Level 2 NOTE: Fatigue, weakness or other symptoms may increase with over activity or heat and • may change daily, weekly, or suddenly (during class) with no apparent cause. Be prepared to Start with feet firmly planted and weight make changes in the midst of class to address evenly distributed in chest deep (nipple line) the situation of the day. Participants should water level, use pool wall for support and lift one knee up at a time, returning to starting leave the class feeling refreshed, with a sense of • well-being and accomplishment. Do not work position and repeating on other side them to exhaustion. People need to be reminded Lift knee up to create a 90 degree angle each class that if they experience any increase in • (or less) in the hips symptoms either due to pool temperature or the one at a time exercises, they need to seek reevaluation. If unable to lift knee, bend or soften knees •

MARCHING/ALTERNATING Hands are active (holding onto wall) yet • KNEE LIFTS relaxed (not overly gripping) • Level 1 Body alignment is in neutral • liftIf individual their knee experiences up paralysis in one leg, s/he can actively assist with one hand to While in chest deep (nipple line) water Level 3 level, march (alternating knee lifts) traveling • forward using arms in opposition of knees • angle in the hips Knees come up to create an 80–90 degree • If individual can weight bear and can bend both knees, start by facing wall and bend Hands are in a fist, webbed, claw or knees while holding onto wall with both • Foot placement focus is on heels • sliced position hands as if sitting back into a chair (squats). • If unable to weight bear, start seated utilizing pool steps or grounded pool equipment, Body alignment is in neutral or slightly horizontally suspended on a floatation mat forward flexed at the hip (maintaining or suspended vertically with a floatation head and shoulders in alignment, no more belt. Bend or soften knees one at a time, • than 10 degrees forward flexion at the hips alternating from left to right or vice versa. and abdominals are contracted to support TIP:lower If an back)individual needs balance support If unable to bend knees voluntarily, try to actively assist legs by placing hands behind have him/her march along the pool wall or use • a floatation piece of equipment (noodle, comfy thighs to bend and lift knees. log, etc.) in front of his/her body for support. Pay close attention to ankle mobility and Discourage leaning on equipment or wall—it is if possible encourage participant to dorsi only to be used when needed. returningand plantarflex to starting foot. Dorsiflexionposition. while Increase or decrease distance and speed lifting/bending knee, planter flexion while according to the individual’s goal and ability. Use of pool equipment can also be added to TIP: Variation—use an aqua step. Step over or on increase intensity. For example a floatation belt and off the step to build balance and strength. can be used to walk suspended and speed can Some individuals will require assistance, due be increased to turn marching into jogging. to balance, range of motion and strength Equipment usage, direction change and increase limitations. In group settings, it is recommended in speed can also add variety to this exercise and that individuals with needs bring an assistant to increase intensity. class with them.

National MS Society Aquatic Exercise Programming for People with MS | 9 SIDE STEPS STATIC HAMSTRING STRETCH Levels 1 and 2 Level 1 • •

While in chest deep (nipple line) water level, gentlyWhile gentlystraighten holding leg. onto wall with one take a step to the right or left side while hand, reach under knee with the other and • keeping legs straight (knees soft). Repeat • several times then change directions. Maintain body alignment in neutral. Arms move like wings (as the leg move (Encourage participants to lengthen spine to • out to the side the arms move up toward maintain alignment and to not hold breath.) the surface of water then back to sides of Hold position for 5–30 seconds and then body when legs are together). Hands are in • repeat on other side. clawed, webbed or slice position. Level 2 • Toes face forward (frontal plane). TIP: To increase intensity, increase range of motion, speed and change direction after a few While facing wall gently hold onto to it for • repetitions. If individual needs balance support balance with both hands. have him/her move along pool wall or use a alignment place the heel of one foot in front flotation piece of equipment (noodle, comfy approximatelyStanding upright 10 with inches body in frontin neutral of the log, etc.) to hold in front of body for support. other foot. Discourage leaning on equipment or wall—it is be • used only as needed. maintainGently bend other knee leg of straight. supporting leg as if Level 3 sitting back into a chair behind you while • • • Lift toes up (dorsiflexion). While in chest deep (nipple line) water level, stand next to wall hold on with one hand, Hold for 5–30 seconds and then repeat on lift leg to the side (abduction in horizontal Levelother 3 side. plane), return to starting position and then • repeat on other side. Optional-free arm can pool equipment lengthen one or both legs in follow leg movement according to ability. If While seated on pool steps or grounded more stability/support is needed face wall • • and hold on with both hands. front of body. Hand(s) are active (holding onto wall) yet • • Dorsiflex foot toward body. relaxed (not overly gripping). Slowly bend forward from the hips. Do not • If participant is unable to weight bear Body alignment is in neutral. allow spine to round forward as you reach • toward toes. but has voluntary movement of lower Body alignment is slight forward flexed at extremities this movement can be done the hip maintaining neck and shoulders in vertically suspended utilizing a floatation supportalignment. lower No moreback. than 10 degrees flexion samebelt or time horizontally or one at suspendeda time. using a at the hips and abdominals are contracted to floatation mat. Both legs can be done at the • TIP: If hamstrings are tight, bends knees slightly. If spasticity or tremors occur, stop and rest; If participant is unable to voluntarily move resume activity when comfortable to do so. lower extremities focus is placed on upper extremities and or focus on trunk mobility Nationaland MS controlSociety while seated or suspended. Aquatic Exercise Programming for People with MS | 10 ACTIVE CHEST STRETCH • Level 1 at your neck or hips. Make sure to twist at the waist and not only • •

While walking reach hands forward then If standing, keep knees soft and shoulders • open to sides as if doing the breast stroke. TIP:relaxed. Variation—Level 1: This can be done while walking (see Walking Twist on page 18.) As arms move to side squeeze shoulder • blades together. Lift sternum and maintain spine in neutral LEG/HAMSTRING CURL • alignment and shoulders down. Levels 1 and 2 Focus is placed on moving shoulder joint • through a full range of motion (horizontal buttocks. Bend knee and lift foot behind body toward Levelsabduction). 2 and 3 • • • Alternating from left to right and vise versa. theWhile breast standing stroke. in place or seated reach Maintain neutral spinal alignment (do not hands forward then open to sides as if doing • TIP:hyperextend To increase intensityback). one can increase speed, add rebound impact option and/or travel. As arms move to side squeeze shoulder To decrease intensity, stand in place, decrease • blades together. speed and maintain grounded impact option. Lift sternum and maintain spine in neutral • alignment and shoulders down. Level 3 • Focus is placed on moving shoulder joint through a full range of motion (horizontal While vertically suspended, bend knee and abduction). TIP: If balance problems do not allow participant lift foot behind body toward buttocks. to maintain an active range of motion, this movement can be done as a static stretch by If participant does not have voluntary reaching both hands behind body and holding movement of lower extremities, strengthen position. Wall (if standing face away from the wall) or seat can assist in maintaining posture. gluteals (buttocks) by contracting, holding contraction and releasing (see gluteal sets in chart below). TIP: If balance difficulties exist, keep participant TRUNK TWISTS—SPINAL ROTATION near wall with assistant. All Levels

• WALKING Stand with feet shoulder width apart Levels 1 and 2 • (seated—Level 3) surface. • If possible, shoulders are below water • alignment.Start with feet firmly grounded, weight evenly distributed and spine in neutral Hands are extended out to each side at • • shoulder height. in opposition. Take a step forward as arms naturally swing Rotate slowly from one side to the other while looking over each shoulder.

National MS Society Aquatic Exercise Programming for People with MS | 11 • Focus on heel-toe-heel placement of foot • Place arms opposite of legs one in front of • motion of walking. the body the other in back of body (left arm Exaggerate push off and knee flexion stage/ • forward, right leg back and vise versa). TIP: Use buoyancy (flotation) and drag Quickly switch leg and arm positions equipment to increase and decrease resistance • Maintain spine in neutral alignment. and balance demands. Individuals with balance and repeat. problems may need to first practice near a wall TIP: Use hand variation and flotation equipment and/or march in place. to modify intensity. To increase intensity bend and extend knees (combination flexion and Level 3 extension of knees) - this can be done in rebound • or suspended (with flotation equipment). Another variation involves keeping legs extended If weight bearing is possible, start by and use of a pendulum motion while suspended. • standing facing wall. • Place feet slightly forward. Level 3 imaginaryWhile gently chair. holding onto wall, bend • knees and sit back as if sitting back into an • While seated move arm and leg (knee flexion and extension) in opposition (right Return to starting position and repeat. leg forward, left hand forward and vise • versa). If individual cannot weight bear, start by working on weight shifting/transfer skills and If individual does not have voluntary ankle dorsiflexion and plantarflexion. control of lower extremities, focus on upper PELVIC TILTS extremities. If one side of body (arm and All Levels leg) is paralyzed, then focus on side that has • voluntary movement control (arm forward ROCKINGas leg goes HORSE back). MakePlace backsure youagainst are walllow enoughand press in thesmall water Level 1 (lumbar spine) area of back against wall. • • that shoulders are below water. • Rock/shift body weight forward onto the Keep head and shoulders in alignment. right leg while lifting the left heel up behind • Hold pelvic tilt (posterior tilt) for a few the body. • Then press tail bone back against wall as the left leg while lifting the right knee up in seconds, release and repeat. Rock/shift body weight backward onto the • Maintain spine in neutral alignment top of your hipbone tilts forward creating a front of the body. backslight into anterior position tilt andthat the causes small pain. of the back comes away from wall. Do not over extend throughout entire movement, never arch/ • CROSS COUNTRY SKI hyperextend the lower back. Levels 1 and 2 Counter balance weight of body by moving the arms back (scoop/push water back) as • • you shift weight forward and vice versa. Stand with one leg forward, the other leg Repeat with left leg forward. behind (approximately 2–3 feet apart).

National MS Society Aquatic Exercise Programming for People with MS | 12 Level 2 STRAIGHT LEG WALK • Level 1 on wall gently for balance. • While standing next to wall place one hand • straight legs. Walk forward or backward with • Shift body weight forward onto right leg • • (standing leg) as left leg curls behind body. Use extended arms in opposition. Use left arm in opposition, swing/reach arm • Maintain spine in neutral alignment anotherPause in step.mid motion and hold leg and arms forward as body weight shifts forward. in opposition for 2–3 seconds before taking • neutral alignment. throughout entire movement, never arch/ • Lengthen spine while maintaining it in hyperextend the lower back. •

Shift body weight back as left leg lifts • Resume movement and repeat, forward (knee lift on left leg). remembering to hold each time in weight shifts back. • Left arm swings/reaches back as body mid motion. • LevelCue 2 “toes up and heels down.” • Repeat sequence several times. • Change sides and repeat this movement using right arm and leg, using left leg as Start with feet together and firmly planted, while standing next to wall or holding a Levelstanding 3 leg. • supportive flotation piece of equipment. • • Lift one leg straight in front of body. While seated or vertically suspended, rock • position.Pause and hold leg in mid motion for upper body weight forward and back. 2–3 seconds before returning to starting • Swing/reach arms in opposition (one • Maintain spine in neutral alignment neutral alignment. forward the other back). Lengthen spine while maintaining it in • • Use wall or partner for support. throughout entire movement. LevelRepeat, 3 using other leg. TIP: A good way to introduce this movement • is to teach upper body movement, lower body movement and weight shift separately. Start seated with knees and hips at a • Participants find success in fine tuning and 90 degree angle. perfecting each component of this movement Place arms at surface of water and allow before combining. Also in breaking down this • them to gently float. movement all levels are able to learn weight shift position. and arm movements together. Leg movements Close eyes and try to maintain upright can then be given as level 1 and 2 options. • neutral alignment. Lengthen spine while maintaining it in TIP: To increase challenge of this movement, ask participant to lift knee, pause and hold for 2–3 seconds.

National MS Society Aquatic Exercise Programming for People with MS | 13 SIDE TILT/LATERAL WEIGHT SHIFT Level 3 Level 1 • • While seated on pool steps or grounded Start in a suspended vertical position (use liftpool off equipment, of seat. shift body weight to right • side of body. If possible, allow left buttock to flotation belt). • Lean toward the right and reach with right hand (just a few inches) toward pool bottom Reach with right arm away from body as you • • while leg sway slightly toward the left. lean toward right. Do not bend at the waist, maintain spine in onTry seat. to maintain control of movement by alignment (Envision a line connecting the utilizing core stabilizers, rather depending • • head, shoulders, hips, knees and feet). • • Return to upright vertical position. Return to upright vertical position. • Repeat on left side. Repeat on left side. TIP: This activity can be modified by keeping participant near wall or using an additional onTry seat. to maintain control of movement by utilizing core stabilizers, rather depending floatation device (example: a noodle or water log) • for added support. • Return to upright vertical position. Repeat on left side. Level 2 TIP: This activity can be modified by keeping • participant near wall or by holding onto floatation device (example: a noodle or water wallStart 2–3 in a feet grounded away from vertical wall. position log) for added support. Noodle can also be standing next to wall, place leg closest to wrapped around back of participant for balance. • Encourage participant not to depend on assistive equipment. Reach hand closest to wall gently toward • Allow leg farthest from wall to slightly wall as you lean toward wall.

float apart from other leg (no more than • 2 feet apart). Do not bend at the waist, maintain spine in alignment (Envision a line connecting the • head, shoulders, hips, knees and feet). Try to maintain control of movement by utilizing core stabilizers, rather depending • on leaning on or holding onto wall. • Return to upright vertical position. Repeat on left side.

National MS Society Aquatic Exercise Programming for People with MS | 14 ADDITIONAL EXERCISE OPTIONS

EXERCISE BENEFIT ACTION CUEING/TIPS UPPER BODY Elbow bend Starting with arms at sides of body, Aim palm or thumb to shoulder Elbow flexion/extension bend elbow joint, return on the way up and palm or index Strengthens arm and improves finger down on return flexibility in elbow joint Side arm raises Starting with arms at sides of body, Keep thumbs forward. Shoulder adduction and abduction raise arms to shoulder height or When raising arms overhead, turn Strengthens shoulders lower, return palms toward sky at midway point- then reverse on return.

Forward arm raises Starting with arms at sides of body, Keep arms in water. When moving Shoulder elevation raise arms forward, return arms overhead use caution Shoulder strength and flexibility breaking water surface and remember to keep palms facing each other. Arms swings Swing arms forward and backwards Keep palms facing body and Shoulder strength and flexibility by sides of body thumbs up Arm circles With hands on shoulders, down Circle forward, then backwards. Shoulder strength and flexibility by sides or out to shoulder level, Start with small circles then slowly circle the arms from the enlarge. shoulders Overhead reach Start with hands on shoulder, Never raise arm to a point of Shoulder strength and flexibility, slowly reach overhead discomfort trunk Butterflies Starting with arms by sides at For variation, turn into a swimming Horizontal shoulder shoulder height, bring hands motion and play with hand adduction/abduction together in front of body, return positioning Improves strength and flexibility in chest, back and shoulders Shoulder rotation Holding arms at side with elbow Use hand variation to change Shoulder strength and flexibility bent to 90 degrees, move hand resistance—cup hands, make a fist toward belly and then to the or spread fingers starting position Punching Hands in a fist, alternate arms Keep elbows soft Strength, endurance, hand and punching. Push arms to full wrist flexibility extension—apply hand variations.

National MS Society Aquatic Exercise Programming for People with MS | 15 EXERCISE BENEFIT ACTION CUEING/TIPS Forearm rotations With elbows bent, face palm of Keep hands and fingers relaxed Forearm strength and flexibility hands down then up

Wrist circles Rotate hands clockwise/counter Keep hands and fingers relaxed Wrist strength and flexibility clockwise

Wrist flexion/extension Start with hands flat and parallel to Relax fingers and isolate Wrist strength and flexibility the surface of the water, move hand movement at the wrist and fingers up toward sky, then down toward feet Chin tucks Pull you chin back as if to make a Keep head straight—don’t look Reduces neck fatigue double chin, then raise your neck down Improves posture/appearance straight up as if someone was pulling up on your hair. Release and repeat. Head turns Start with a chin tuck then turn Avoid lifting shoulders to meet Improves cervical/neck flexibility your head to look over your chin. Relax shoulders. shoulder. Return to the center and repeat over other shoulder Head tilts Start with a chin tuck then slowly Never roll head backwards. Lateral flexion lower head toward right shoulder Maintain good alignment with Improves cervical/neck flexibility as if to touch ear lobe to shoulder. head over shoulders and chin Repeat on other side. tucked. Shoulder rolls Roll shoulders backwards slowly Keep shoulders at chin level. Retraction/protraction through full range of motion Do not drop head. of scapula Improves posture Shoulder shrugs Lift shoulder toward back of head, Breathe normally and do not tilt Elevation/depression of scapula then relax head from side to side when doing Improves posture Variation: lift and depress one one shoulder at a time shoulder at a time Upper back stretch Rap arms around upper body and Breathe normally while rounding Flexibility give yourself a hug shoulders.

LOWER BODY Gluteal sets Squeeze the buttocks tightly Maintain soft knees. Strengthens buttocks and together. Hold, release and repeat. lower back Front leg lifts Lift extended straight leg up Maintain soft knees, spinal Hip flexion forward, alternating or one at alignment and flexed foot. Avoid Improves balance, coordination, a time hyperextension and spasticity. and flexibility

National MS Society Aquatic Exercise Programming for People with MS | 16 EXERCISE BENEFIT ACTION CUEING/TIPS Leg curls Lift foot towards buttocks. Maintain spinal alignment straight Knee flexion and extension Alternating or one at a time. back. Contract abdominals by Improves strength and flexibility of Variation: Lift right heel to left moving front hip bones upward legs and lower back buttocks and left heel to right toward rib cage (keep chest lifted). buttocks Side leg lifts and cross-overs Lift extended leg out to side Maintain soft knees, spinal Hip abduction and adduction Variation: Cross leg in front then in alignment and flexed foot to avoid Improves balance, coordination, back of the other hyperextension and spasticity flexibility and leg strength Karate kicks Lift leg with a bent knee and extend Always maintain soft knees and Improves coordination, flexibility with power. spinal alignment and strength Variation: out to side or rear Calf stretch Stand facing wall with one leg in Avoid hyper-extending the knee Flexibility front of the other. Press heel down on back leg. Rear leg lifts Slightly lift extended leg behind Maintain spinal alignment. Hip extension you. Alternating or one at a time. Contract abdominals by moving Improves lower body flexibility and front hipbones upward toward rib strength cage (keep chest lifted). Ankle circles Make circle with foot. Repeat in Relax toes Ankle strength and flexibility opposite direction and on opposite side. Ankle dorsiflexion/plantarflexion In seated position, point toes up Move foot directly up and down Ankle strength and flexibility and then down while keeping bent and not in and out (avoid inversion knee and eversion) Front thigh/quad stretch While standing near wall, bend Maintain spinal alignment. Flexibility knee and hold ankle with hand. Thigh should stay in alignment, Extend thigh back and press front perpendicular to the pool bottom. hip bone forward. Jacks Starting position: Standing with Use hand variations for intensity Double leg abduction/adduction legs together. modifications. Improves coordination, flexibility End position: Legs apart *Using flotation/buoyancy and strength Variation: Can be done with or equipment is recommended to without side arm raises, and as reduce the effects of gravity on the double cross-overs. skeletal system.

National MS Society Aquatic Exercise Programming for People with MS | 17 EXERCISE BENEFIT ACTION CUEING/TIPS TRAVELING MOVEMENTS/WATER WALKING Step over walk Walk forward as if stepping over an Maintain spinal alignment and Balance, mobility, flexibility, arm object. Use swimming arms. keep focus of eyes ahead instead and leg coordination; endurance of toward floor.

Cross-over steps With or without arms, cross Use hand variations for intensity Balance, mobility, flexibility, arm leg over the other when taking a modification and variety and leg coordination; endurance step Jogging Same as alternating knee lift done Remain in upright position, Improves stamina, coordination as a rebound move. (See page 5 maintaining spinal alignment and strength for rebound definition) Walking twist With elbows bent in front, lift knees Remain in upright position, Coordination, flexibility of trunk high so that right elbow meets left maintaining spinal alignment knee, then left elbow meets right knee

JUMPS Frog Jump with knees bent and out to Remain in upright position, Strength, balance and endurance sides maintaining spinal alignment. Avoid leaning forward. *Using flotation/buoyancy equipment is recommended to reduce the effects of gravity on the skeletal system. Curl tuck Jump with knees bent and heels Remain in upright position, Strength, balance and endurance toward buttocks maintaining spinal alignment. Avoid leaning forward. *Using flotation/buoyancy equipment is recommended to reduce the effects of gravity on the skeletal system. Knee tuck Jump with both knees together Remain in upright position, Strength, balance and endurance and in front of body maintaining spinal alignment. Avoid leaning forward. *Using flotation/buoyancy equipment is recommended to reduce the effects of gravity on the skeletal system.

National MS Society Aquatic Exercise Programming for People with MS | 18 EXERCISE BENEFIT ACTION CUEING/TIPS TRUNK Knee hugs Standing near a wall reach under Breathe normally. Relax shoulders Balance and flexibility knee and gently bring knee up and feet. toward chest. Use right hand for right leg. Variations: Use right hand for left leg. Stand upright or release upright position and round upper body toward knee. Twists-spinal rotation Feet shoulder width apart, Knees soft, move body as a unit. Coordination, flexibility shoulders in water, twist slowly Avoid twisting spine (especially and strength from side to side. with hop). Wall press/modified push up Facing wall, lean forward, and hold Focus on maintaining spinal Strengthen lower back and pelvic for 5 seconds. Return and repeat. alignment by using the floor, improves posture muscles that support the spine (abdominals, erector spinae and lower back) Suspended double side While using floatation equipment, Relax shoulders leg extensions to support body without restricting Stabilization, strength and movement around trunk, extend flexibility both legs to one side while slightly leaning toward the other side. Alternate from left to right.

National MS Society Aquatic Exercise Programming for People with MS | 19 Class Structure • New students may want the option of observing a class from the deck the first day. They can decide if they will be comfortable STRUCTURING AN AQUATIC CLASS with the class, determine if they will be able FOR PEOPLE WITH MS fatigue.to get in and out of the pool, and enter the and Cueing building from the parking lot without undue A successful aquatic class for people with MS •

Monitor new students until there is a • is founded on principles similar to those used general comfort level reached. to teach a general aquatic class. Basics include Create the proper atmosphere (comfortable, personally greeting each student, asking friendly, noncompetitive and safe.) about relevant physical conditions, modifying workRecommended well in higher water water temperature temperatures. is movement and using equipment for various 80–84 degrees; however, some individuals abilities and incorporating new students into an established class. An emphasis should be placed While each individual is unique, extremes on greeting and understanding the students' within temperature MS. Talk to in participants either direction about seem physical conditions and goals, and structuring necessary—make sure that each participant is to adversely affect most individuals class appropriately,Do not leave making anybody modifications out! as temperature regulation (hydration, “chill involved. Use a DIRECT vests”, undershirts, etc.) so that they are lesson planning. comfortable (not too warm or too cool) approach during class and for • D while in the water and after getting out of the water. In addition, don’t forget humidity, • I efine levels of ability (assessment) direct sunlight, and other environmental • Rncrease intensity and duration gradually temperature.factors that can affect a person’s ability • E to maintain appropriate core body epeat cues and directions GREETING • Cncourage efficient movement patterns • ontrol (speed, range of motion, surface • Temperature of the water area, direction, turbulence) interactions.A positive attitude is important when leading a class, it sets the tone for all BEFORE YOU START • Be aware of any physical changes in

• the last class. participants either during a class or since If possible talk with all students privately • before the first class to discuss goals, an class format. overview of the program, class structure Familiarize students with the facility and and format. Be clear that the class is not SAMPLE CLASS STRUCTURE physical therapy, swimming lessons, or An aquatic session often consists of a warm- water aerobics. (For students with fatigue, offer suggestions to conserve energy such as pool.wearing Another a bathing tip is suit use under of a backpack warm-up rather suit up, stretching/range of motion exercises for to class so only one change is required at the flexibility, upper and lower body strengthening, endurance activities (if tolerated), cool down, than the standard beach or gym bag. and (optional) games.

National MS Society Aquatic Exercise Programming for People with MS | 20 This program emphasizes the whole person.

ROM exercises are designed to maintain and/ health.The lesson A group plan sessionshould reflectusually the lasts emphasis 30–45 on or achieve maximal joint movement. These minutes.wellness, by including information on overall exercises can be used to improve flexibility of a specific joint and/or increase muscle strength. Remember: The essentials of instruction It is important to move the joint through its are content and presentation. Content full range of motion. Muscles of the lower leg, includes concepts, skills, and knowledge to posterior thigh (i.e., hamstrings), buttocks, select exercises and plan the exercise session. and lower back are often weak and may make Presentation is the delivery and interaction walking more difficult. Select exercises to with participants. strengthen these muscles: hip flexors, hip extensors, ankle dorsiflexors, hip abductors, oftrunk motion for flexion impairment and extension. to ensure It that is important the proper TIPS: that a rehabilitation therapist evaluates a range 1. Inquire about symptoms experienced since last class. Stretching:stretching techniques are utilized. 2. Consider adding a “mini lecture” 2–3 minutes about health, wellness, energy conservation Gentle, slow stretching may help tips, etc. to maintain the interest of reduce the effects of spasticity. Stretching the participants. An invited guest is an option, following muscles—quadriceps, calves, gluteals, as well. lower back, shoulders, neck, hip adductors, rotators of the hips, spinal extensors, and WARM-UP pectoral or chest muscles—will provide a comprehensive flexibility program for most impairments.people. Some people may require specific stretching exercises to address range of motion This can consist of gentle, rhythmical movements to acclimate to the temperature of REPETITION the water and the effects of buoyancy/reduced gravity. These can include walking, marching in place, and or continual upper/lower body Repetitive exercises help improve endurance movements.FLEXIBILITY/RANGE OF MOTION and may improve problems with coordination and performance of activities of daily living. mayUse low tire weights,out the muscle high repetition, rather than if weights strengthen are used. However, weights are not necessary and Flexibility exercises involve two components— it. The resistance of the water with changes in stretchingjoint range the of motion, muscle. moving each joint through it’s full range of motion, and muscle flexibility, or ofspeed, most force, participants. hand or leg position, and depth of Range of motion: the water will suffice to strengthen the muscles Range of motion (ROM) is COOL DOWN defined as the movement at a particular joint. The length of soft tissue structures, such as muscle and ligaments, which surround the joint The cool down involves slower activities, can affect movement as well as pain and joint patterns of walking, relaxation, and a return to flexibility. the effects of gravity.

National MS Society Aquatic Exercise Programming for People with MS | 21 POINTERS •

• amongProvide participants. opportunity for socialization to help create support and encouragement Think overall wellness, not just strength or • • Use an exercise-rest-exercise-rest or high cardiovascular fitness. Encourage participation by all. Modify ormovements left out. or activities as needed. No intensity-low-intensity format (H-L-H-L) one should be made to feel discouraged to prevent fatigue and overheating. (Rest • may be an active rest and recovery, or a relaxation). Encourage breaks as needed. participantsExplain exercises experiencing clearly and short-term repeat the Encourage participants to find their own movement during the execution to assist comfortable intensity levels. Encourage use • Encourage the use of senses to enhance of a rate of perceived exercise (RPE) scale to memory loss or coordination issues. • learning. Use images to accompany new monitor intensity during exercise. Use body awareness techniques to increase they experience to encourage a sense of relaxation and postural awareness. One sensations. Ask students to articulate what session could be used solely for relaxation • ("feel the water support you”, “listen to the discovery, curiosity and observation. • Explain the rationale for choosing the ripples”). Recognize each individual as an adult learner, with specific abilities and restrictions. Do not impose your exercises (e.g.; to work towards a better • Make it fun! gait pattern and improve balance and expectations or level of ability. coordination). This assists participants to • CLOSING AND AFTER CLASS set realistic and functional goals. Vary order of activities from class to • class. Classes should be goal oriented not their questions. • Make yourself available to students for “routine"—and always enjoyable. • Emphasize the use of a flat foot when results. Avoid making any promises regarding leading exercises for gait training (as in warm up exercises) as walking on the toes may induce extensor spasticity in the legs. For these exercises, use cues, “heels to the bottom or strike with heel.” However, it is not essential to emphasize use of a flat foot • for exercises to improve strength or balance. Eliminate actions that involve the exercises.participants “hanging” on the pool wall. A noodle is preferred to wall-handing • Encourage participants to exercise at their

own pace, listen to body signals, and to make modifications as needed.

National MS Society Aquatic Exercise Programming for People with MS | 22 Circuit training utilizes the equipment on

equipment for each person at the same time. LESSON PLANNING: HOW THE hand, and does not require a large purchase of BODY WORKS Lesson Planning Kick boards, pull buoys, bar bells, balls, gloves, and noodles offer a myriad of possibilities for Evaluate the exercises you select for your a circuit. It is possible to have a circuit without class for functional activities and wellness. exercisesequipment. from Plan your stations routine. of rocking horse, Use normal movement patterns and a range scissors, figure 8s, biceps curls, and other of motion that will not create injury, pain, or undue fatigue. Next, evaluate whether or not the movement can be performed at an intensity The stations and number of stations you select and position to permit proper body alignment depends upon the ability of your class. Use The intensity and design of the movement laminated cards or waterproof paper with large should produce a controlled, smooth printWARM-UP: to describe 5 MINUTESeach station. movement without momentum as the primary • Thismoving work force. sheet may be useful to you in • Walk forward, arms push water away Walk backward, arms pull water designing a lesson plan. Think about posture, • range of motion, safety, the impact on functional toward body • Headactivities, ______and the ability of your participants. Straight leg walk, arms front to back Side step, arms scissor Shoulders ______CIRCUIT: 10–20 MINUTES • Arms ______• Bar bells—shoulder elevation Elbows ______• Bar bells—shoulder rolls • Hands and wrists ______Leg/hamstrings curls • Gluteal sets or rear leg lifts—hip extension Front leg lifts—hip flexion Spine ______• • Bar bells—elbow extension Pelvis ______Bar bells—elbow flexion • Legs ______Pull buoy, place heel on top of strap and • Foot and ankle ______side leg lift • Noodle, straddle and bicycle for count of 25 SAMPLE LESSON PLAN FOR CIRCUIT • Punching Bar bells, arm crossover under water • Rocking horse time.Circuit The training participant adds interest selects stationsto the class within and • accommodates various ability levels at one Marching/alternative leg lifts his/her ability or moves on if a station is too difficult or tiring.

National MS Society Aquatic Exercise Programming for People with MS | 23 STRETCH/FLEXIBILITY: 5–10 MINUTES Music • Major muscle groups

• Range of motion exercises Music can be a great tool for motivation, relaxation, maintaining cadence, or achieving COOL DOWN: 5–10 MINUTES the desired intensity if used appropriately. • However, whatever your reason for using music in a group setting it should always complement smaller ranges of motion the purpose or goals of the class. If music is Walk patterns similar to warm-up in slower, your class and never distract or take away from not adding benefit, and/or is making it hard to Cueing understand cues, it is best not to use music at all.

Correctional, Motivational Transitional. There are three categories of cueing, and • Correctional or “form” cue: to take note of Pool Safety and Cueing provides a signal to class participants: SAFETY AROUND THE POOL theWATER Environment SAFETY body alignment and technique. Always use positive cues, such as “knees soft”, rather • thanMotivational “don’t lock cue: your knees”. reinforcement Water adds an element of danger that is not for encouragement and present during land activities such as falls on • Transitional cue: to make a change in slippery decks or drowning. Keep the following • If a person cannot participate in the aquatic in mind: tempo/rhythm, activity or direction, such »» class without assistance, s/he need to have as: • an aid in attendance at each class. »» Directional “forward, back etc.” Have class participants use the buddy Numerical “1, 2, 3, 4, etc." or system when in the pool even if the »» “4, 3, 2, 1, etc.” waterlifeguard alone. is on duty. Do not overestimate »» Footwork “right, left, right, etc” the ability of participants or leave them in • »» Step “rock, kick, swing, etc.” Keep the deck clean and free of equipment Rhythm “half time”, “double time” equipment after each class. to reduce incidence of injury. Store or stack of both. Variety in cueing is Important because • Assist participants when entering or exiting Cues can be vocal, visual, or a combination capabilities. participants are different in their learning the pool. Use volunteers if needed (not other participants). Be aware of individuals who TIP: Remember many people with MS experience after the class. may be fatigued and need extra assistance cognitive impairment that could affect • Do not allow participants to eat or chew concentration and/or memory.

gum during class. Do not allow glass bottles • on pool deck. Do not leave objects floating in the pool.

National MS Society Aquatic Exercise Programming for People with MS | 24 • Do not allow horseplay in the pool area or • Shoes may increase stability on the pool

• running on the deck. deck and offer protection if participant has a shuffling gait, ataxia (uncoordinated withOrient the all class participants at least once and volunteersa month. to movements), or decreased ankle emergency protocol. Practice a safety drill • Encourage participants to exercise at their • Check water temperature before each class. dorsiflexion during gait. Optimum water temperature is 80–84 own pace and listen to their body for signs fatigue in many people with MS. degrees. Higher temperatures may cause of heat, weakness, or fatigue. • Be aware of the following symptoms that may occur during or immediately following class: Examine the building and parking lot for • • General weakness • Pain possible hazards or handicaps. • Fatigue • Stress or anxiety There should always be a lifeguard on duty • Blurred vision • Nausea during a class. PARTICIPANT SAFETY • Tremor • Rapid eye movement • Tingling • Coordination or balance disturbance Precautions to remind participants of at the • Slurred speech • beginning of each class: • Spasticity Rubber tips on canes and walkers lose their grip on wet surfaces and can become a risk. MORE ON SAFETY Remind participants to be aware of this • Stress the importance of each participant around the pool deck. • exercise at his/her own pace. The class must knowing his/her own limitations and to Most exercises are performed in the shallow end of the pool for safety and to decrease not be competitive in nature. It is OK for the effects of buoyancy. This depth, at people to take short breaks during the class approximately the navel (or somewhere • if needed. between the navel and nipple), affords ease protectionof movement, from some falls. weight bearing input to Remind participants of the difference in the brain, a cooling effect on the body, and significant feeling between buoyancy and • gravity. They will feel lighter in the pool Some participants do not have the strength backand once to the they changing begin walking rooms. Participantsout of the pool they will need to use extra strength to walk to swim or have never learned to swim. aIdentify performance those who swim. can This swim is necessary and those if may want to sit wrapped in a towel for a who cannot. If there is a doubt, request few minutes and have a cool glass of water, • giving the body a chance to acclimate. you plan a deep water relaxation session. Floatation devices are not life saving suggestIf at any contactingtime, a person the physician.begins having Do not devices, therefore, do not take a person who trouble in the water or symptoms increase, is afraid of the water or cannot swim to deep water. make a judgment or give medical advice.

National MS Society Aquatic Exercise Programming for People with MS | 25 A National Multiple Sclerosis Society Aquatic Program

OBJECTIVES Speak to our chapter staff about potential 1. opportunities. 2. Improve socialization, decrease isolation Call 1-800-344-4867 to contact the chapter in esteem your area or visit . Promote well being and improve self- nationalMSsociety.org 3.

temperatureProvide an atmosphere to exercise that minimizes or prevents a rise in core body 4.

Prevent symptoms secondary to MS (i.e.: muscle atrophy, joint contractures 5. pressure sores) Maintain or improve range of motion and 6. flexibility of joints 7. Maximize muscle strength Maintain or increase endurance potential

National MS Society Aquatic Exercise Programming for People with MS | 26 The National Multiple Sclerosis Society (“Society”) is proud to be a source of information on multiple sclerosis related topics. The information provided is based on professional advice, published experience, and expert opinion, but does not constitute medical or legal advice. For specific medical advice, consult a qualified physician. For specific legal advice, consult a qualified attorney.

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Early and ongoing treatment with an FDA-approved therapy can make a difference for people with multiple sclerosis. Learn about your options by talking to your healthcare professional and contacting the National MS Society at nationalMSsociety.org or 1-800-344-4867.

The Society publishes many other resources about various aspects of MS. Call 1-800-344-4867 or visit nationalMSsociety.org/brochures.

The National MS Society mobilizes people and resources so that everyone affected by MS can live their best lives as we stop MS in its tracks, restore what has been lost and end MS forever. To fulfill this mission, the Society funds cutting-edge research, drives change through advocacy, facilitates professional education, collaborates with MS organizations around the world, and provides programs and services designed to help people with MS and their families move their lives forward.

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