// Osteo-Fit: bone-conscious aquatic exercise

by Connie Jasinskas, MSc

People who like to exercise in the water are often told that aquatic exercise is not an effective way to maintain or build bone mass. This article examines some of the literature pertaining to this issue, as well as important information and exercise ideas to share with your bone-conscious clients.

Some facts about bone loss

Osteoporosis is defined as ‘a chronic, progressive skeletal disorder in which the architecture of bone deteriorates and bone mass decreases. This results in fragile, weakened bones that fracture easily, even in the absence of trauma.’ Common fracture sites are the forearm, wrist, vertebrae, pelvis, and hips.

How does osteoporosis happen?

Healthy bone is constantly being formed (osteogenesis), broken down and reabsorbed (osteolysis). When osteolysis is greater than osteogenesis, we have a net loss of bone mass – bones become weaker, more brittle, and more likely to fracture. Humans achieve peak bone mass in their early 20s, and usually maintain that mass until their 40s. Following menopause in women, there is a period of more rapid bone loss for five to seven years. Osteopenia may be diagnosed when bone mass falls below normal levels. Men continue to lose bone more gradually, and later in life. There is no cure for osteoporosis. Treatment to help restore or maintain bone mass can include dietary supplementation (calcium, vitamin D), bone-building drugs (bisphosphonates, calcitonin) and exercise.

Who is at risk for osteoporosis?

People with slighter skeletons and low BMI, a genetic predisposition to osteoporosis (European and Asian ancestry), early menopause or hormone loss (due to medical or other issues), immobility/lack of exercise, alcohol abuse, certain medications and disease states are all factors increasing risk for bone loss. Advanced age is a key risk factor; ‘After 40 years of age, the risk for osteoporosis increases fivefold for each decade of life’ (Weppner, 2009). By age 75, women have lost 25 to 40 per cent of their bone mass (≥30 per cent loss defines osteoporosis).

What are the consequences of osteoporosis?

Osteoporosis affects one in three women worldwide. In Australia over two million people are affected by the disease. According to the Garvan Institute osteoporotic problems cost the Australian community an estimated $1 billion per year in direct costs, and $7 billion in total costs (which includes factors such as carers and lost income). Once a fracture has occurred, pain, deformity, loss of function, and mortality increase dramatically. Falling and fracture risk are increased by weak leg muscles, poor vision, poor balance, dizziness or disorientation (from medicines, blood pressure or other health issues). Prevention of falls is a key component of fracture avoidance.

How does aquatic exercise help?

Weight-bearing exercise is commonly recommended to encourage the building and maintenance of bone mass; however, recent research is supporting the power of pool exercise.

  • We know exercise adherence and tolerance are better in the pool (especially when arthritic joints are also involved).
  • Pool programs are cost effective, and readily available to most people.
  • Aquatic exercise programs can be designed to improve balance, core and lower extremity strength – all factors that reduce the risk of falls and fractures.

‘The benefits of water exercise are well documented. A regular routine can be as beneficial to the cardiovascular system as jogging or fast walking. It has also been shown to increase muscle strength, improve balance and help prevent osteoporosis’ according to David Cosca, MD.

Colado et al (2009), showed similar, significant fitness training results when comparing aquatic exercise and land-based elastic resistance exercise. Aquatic exercise proved to be superior to land exercise in improving core strength. ‘Although weight-bearing physical activity is known to be superior to non-weight-bearing activity to increase the bone mass, our present evidence shows that aquatic and weight-bearing exercises both can increase calcaneal BUA’ (bone mass of the heel, measured by ultrasound), (Ay, 2005).

Aquatic exercise goals and guidelines for people with osteopenia or osteoporosis

  • Regular exercise, most days of the week, for 30 to 45 minutes per session, targeting all fitness components possible (cardiovascular endurance, strength, endurance, flexibility). A well-rounded program will include activities like walking, pool exercise, and the weight room.
  • Exercises to build muscle mass – especially strength of the core and lower extremities.
  • Exercises to strengthen postural stabilisers, especially spinal extensors.
  • Activities and challenges to improve balance and fall recovery.
  • Avoid: loaded spinal flexion (activities like rowing, crunches, lifting heavy loads), high impact exercises, and activities that might result in falling.

Ideas for the pool

Naturally, you should consider the age, strength, and health of your clients when trying more difficult exercises.

  1. Be sure your pool deck is free of trip hazards, and insist that clients wear appropriate footwear.
  2. Be the posture police!  People will strengthen postural stabilisers by maintaining a long, strong spine and stable, neutral pelvis throughout all movements.
  3. Slow your music and movement to allow people time to stabilise properly.
  4. Anchor! Take impact out of your class. Although impact helps build bone, it can be painful for joints, and may not be appropriately controlled in the pool. Level II, III, and grounded movement promote increased core activation and training.
  5. Avoid loaded spinal flexion: tucks, spinal twisting or lateral flexion loaded with resistance such as a noodle or flutter board can be risky. Often, osteoporosis isn’t diagnosed until a fracture occurs.
  6. Train the core by maintaining perfect posture during well-controlled movements of the arms and legs. This provides functional, safe core conditioning.
  7. Use a variety of pool depths, if possible. Shallow water walking loads bones more; deep water vertical stabilisation is excellent core and balance training.
  8. Incorporate balance challenges: if necessary, start with the support of a pool wall or trainer. Teach fall recovery before escalating challenges. As mastery is achieved, increase stability challenges by altering base of support (narrow versus wide), standing surface (pool floor versus an unstable object), proprioception (close the eyes, turn the head away from direction of travel) and multi-task – do activities to challenge balance during mental distraction. Perform all examples with perfect posture:
    • Weight shifting foot to foot – progress to lifting the trailing foot.
    • Single leg stance, ‘tight-rope’ (tandem stance) balance or walk, with postural perturbations such as single arm circles.
    • Single leg, feet together, or tandem stance – reach out to the point of loss of balance, and initiate fall recovery.
    • Add attention challenges while maintaining posture and balance – look away from where you are stepping; transfer a small ball from hand to hand while walking or holding a stance.
    • Stand on unstable surfaces, such as a noodle under one or both feet, in contact with the floor, or balance suspended vertically in deep water (wearing a flotation belt) while you do any of the following:
      • Toss a small ball between partners.
      • Move across the pool with small hops (shallow) or arm propulsion (deep).
      • Change directions of movement unpredictably (laterally, diagonally).
      • Keep the body straight and still while you move only one arm vigorously.
      • Partner tug-of-war using a towel or one or two noodles.

As confidence and strength improve, try the above activities with eyes closed, while counting, singing or saying the alphabet backwards, turning the head away from the direction of attention.

References and Resources

  • Ay, A., Yurtkuran, M., Influence of aquatic and weight-bearing exercises on quantitative ultrasound variables in postmenopausal women. Am J Phys Med Rehabil. 2005 Jan; 84(1):52-61.
    Colado, J.C., Travis Triplett, N., Tella, V., Saucedo, P., Abellán, J., Effects of aquatic resistance training on health and fitness in postmenopausal women, Eur J Appl Physiol (2009) 106:113–122
  • Cosca, D., , Aquatic exercise is a great activity at any age, U C Davis Health System, www.ucdmc.ucdavis.edu
  • Melzer, I., et al, A water-based training program that include perturbation exercises to improve stepping responses in older adults: study protocol for a randomized controlled cross-over trial,
  • BMC Geriatrics 2008, 8:19
  • NIH Consensus Dev. Panel. “Osteoporosis Prevention, Diagnosis, and Therapy.” JAMA 285 286 (2001): 785-795.
  • National Center for Biotechnology Information. National Library of Medicine. 18 Oct. 2008 <PMID: 11176917>.
    ‘Osteoporosis.’ MedlinePlus. 10 May. 2008. National Library of Medicine. 23 Dec. 2008 <www.nlm.nih.gov/medlineplus/osteoporosis.html>. “Osteoporosis: Symptoms and Remedies.”
  • Johns Hopkins Medicine. 2008. 23 Dec. 2008.Slovik, David M., and Jonas Sokolof. ‘Osteoporosis.’ Frontera: Essentials of Physical Medicine and Rehabilitation. Eds. Walter R.
  • Frontera, et al. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.
  • Wallace, B. A., and R. G. Cumming. Systematic Review of Randomized Trials of the Effect of Exercise on Bone Mass in Pre- and Postmenopausal Women. Calcified Tissue International 67 1 (2000): 10-18. National Center for Biotechnology Information. National Library of Medicine. 18 Oct. 2008 <PMID: 10908406>.
  • Weppner, Dennis M., and Ruben Alvero. ‘Osteoporosis.’ Ferri’s Clinical Advisor: Instant Diagnosis and Treatment. Ed. Fred Ferri. Philadelphia: Mosby Elsevier, 2009.
  • Woollacott, M., Shumway-Cook, A., Attention and the control of posture and gait: a review of an emerging area of research, Gait and Posture 16 (2002) 1 – 14, www.elsevier.com/locate/gaitpost

Reprinted with permission from the Aquatic Exercise Association, www.aeawave.com

Connie Jasinskas, MSc
Connie is AEA certified and teaches land and water classes for bone-conscious clients in Cambridge, Canada. She brings over 30 years of experience, passion and humour to her work as an international health educator. Through her company For the Love of Fit, she has educated exercise specialists in the UK, Europe, South Africa, Australia, the US and Canada. For more information visit www.fortheloveoffit.com

 Network Magazine • Winter 2010 • PP61-62