The purpose of this study was to investigate the effectiveness of a 3-week daily physical activity program in outdoor spring hot water on joint mobility and mood state in 31 healthy elderly people aged between 60 and 82. The variables comprising mood state were positive engagement revitalization, tranquillity and physical exhaustion whereas joint mobility focused on shoulder flexibility. Subjects were allocated to one exercise group (n= 20) and one control group (n=11). The exercise group participated in a 45-minute-per-day aquatic exercise program in hot water for 20 consecutive days whereas the control group didn’t participate in any kind of organized exercise. Subjects were pre- and post-tested for the variables of mood state and shoulder flexibility. The results indicate that the elderly people who participated in the outdoor aquatic exercise program had significant improvements in positive engagement (z=2.4, p<.05), revitalization (z=2.8, p<.05), tranquillity (z=2.8, p<.05), physical exhaustion (z=2.7, p<.05), and shoulder flexibility (t=9.25, p<.05). No significant changes in these variables were observed in the control group. The results indicate that an aquatic exercise program is an alternative training method for improving psychological state and functional fitness performance in healthy elderly people.
**Key Words:** elderly, aquatic training program, mood state, joint mobility.
Evidence shows that increase of age is associated with the decline of many motor functions, (1,18,8,17) and the subsequent disenabling of performance of basic daily requirements. In addition, as individuals progress beyond 60 years of age, there are also tendencies for increased prevalence of mood disturbance; i.e., increased negative effect and decreased positive effect; (6). Past research on activity, aging and psychological well-being has concluded that exercise has a positive effect on psychological well-being (12). Exercise prescribed for the elderly differs from that of younger individuals in the method in which it is applied. Since an elderly person is more fragile and has to overcome more physical and medical limitations in comparison to younger individuals, training methods should not include high impact activities, and possibly a more gradual training progression (2).
Exercising in water has become widely prominent, and it has been reported that water exercise, especially in hot water, is therapeutically beneficial for elderly individuals (3).Water exercise is also a viable form of conditioning for those who are suffering orthopaedic problems (20). Training in water provides buoyancy and a required resistance for training, resulting in a training regimen that provides high levels of energy expenditure with relatively low impact on the joint extremities (21). Furthermore, this method of training is more motivating for overweight individuals because their bodies are not exposed to other participants (9). The authors of the present study hypothesized that participation of the elderly in a daily physical activity program in hot water, would improve their physiological and psychological status. Specifically, the purpose of this study was to investigate the effect of a daily physical activity program in an outdoor hot water spring, on joint mobility and mood state in older men and women.
Subjects in this study were 31 independently living elderly volunteers (6 males, 25 females) ranging in age from 60 to 82 years old (M = 71, SD = 5), with body weights between 63kg and 86kg (M=75.7, SD=5.5), and heights between 154cm and 163cm (M=156, SD=3). Subjects were recruited from a resort community in Edipsos, Greece during the summer of 2009. None of the elderly had been involved in any physical activity for at least 6 months before the exercise program began. They were assigned randomly into one experimental group (n=20) and one control group (n=11). Participants were graduates of elementary education (55.1%) and the majority of them were retired (71.5%). Their previous profession was 31.3% civil servants, and 42.3% free professionals. The majority of them (79.4%) were married and living with their spouses (65.4%). The greater part of the participants (65.5%) had a moderate daily mobility level according to the AAHPERD exercise consent form for adults (16). The subjects also had similar health status. Specifically, the participants of this study did not suffer from serious cardiovascular problems (coronary illness, infarction) respiratory or neurological diseases or serious orthopaedic problems. The more prominent health problems that they faced were of orthopaedic nature (34.4%) as well as high blood pressure (31.5%), which did not constitute obstacles to their participation in the research. Therefore, no subject was excluded for medical reasons. Subjects who missed more than four exercise sessions were excluded from the analysis.
The experimental procedure was 20 days in duration, with 1 day of pretesting and 1 day of post-testing. The pre- and post-exercise assessments were performed by the same person for both groups. In an effort to ensure maximum compliance with the program, the same instructor conducted the intervention program in all groups. The intervention program took place in an outdoor swimming pool consisting of 100 % spring water at 34 ºC located in the Revitalization Club. The 12-item Exercise-Induced Feeling Inventory (7) was employed to assess the responses of positive engagement (enthusiastic, happy and upbeat), revitalization (refreshed, energetic and revived), tranquility (calm, relaxed and peaceful), and physical exhaustion (fatigued, tired and worn-out) that arise as a result of exercise participation. On a 5-point scale, subjects were asked to indicate how strongly they had experienced each feeling state immediately after one hour of exercise. The scale ranged from 0 (do not feel) to 4 (feel very strongly). Internal consistency exceeded .70 for each subscale (11). Flexibility measurement focusing on the shoulder was based on the Senior Fitness Test. This test was done in the standing position. The subject placed one hand behind the head and back over the shoulder, and reached as far as possible down the middle of the back, with palm were touching the body and the fingers directed downwards. They placed the other arm behind their back, palm facing outward and fingers upward and reached up as far as possible attempting to touch or overlap the middle fingers of both hands. An assistant directed the subjects so that their fingers were aligned, and measured the distance between the tips of the middle fingers. If the fingertips touched then the score was zero. If they did not touch, the distance between the fingers tips was measured (a negative score). A positive score was measured by how far the fingers overlapped. Subjects practiced two times, and tested two times. The best score to the nearest centimeter was recorded. (18).
##### Preprogram procedures
Prior to enrollment in the training program, all subjects who wanted to participate in the study were required to provide a signed letter of clearance from their personal general physician regarding their participation in the program. At the onset of the program, individuals were informed that they would be participating in a 45-minute-per-day aquatic exercise program for 20 consecutive days, and were given a brief demonstration of the program content. Information forms were then distributed to all individuals volunteering to participate in the investigation.
Once informed consent forms were read and signed by all subjects, a preprogram questionnaire packet was distributed. During the first day, both experimental and control groups completed the Revised Physical Activity Readiness Questionnaire (22) and a short demographic questionnaire assessing age, height, weight, and mobility level (16). Finally, before the training program began, each participant completed the Exercise-Induced Feeling Inventory (EFI), and participated in shoulder flexibility measurements.
##### Intervention Program
The experimental group participated in a 45-minute aquatic exercise program for 20 consecutive days. The control group was not involved in the exercise program but participated in spring water bath therapy. The exercise program was based on the Long Term Physical Activity Workshop (4), and consisted of 15 minutes of warm-up and callisthenic exercises for the improvement of flexibility, 10 minutes of resistance exercise, 10 minutes of endurance-type exercise (walking and dancing), and 10 minutes of cool-down exercise and leisure activities for the reinforcement of self-esteem and self confidence. The exercise intensity recommended by the American Heart Association varied from 50% to 75% of the subject’s maximum heart rate, as determined by a pilot study. However, no heart rates were recorded during the study. Instead subjects were taught to monitor their pulse rate according to perceived exertion (4). During exercise, the Borg Scale (6 – 20) was used to monitor perceived exertion relative to exercise intensity. Self-monitoring how hard their body was working helped them adjust the intensity of the activity by speeding up or slowing down their movements. The elderly exercisers were working in the Moderate (12-14) exertion range. Also, subjects were able to speak in their normal voices and tones during the exercise, in order to maintain a consistent heart rate and exercise intensity.
##### Post-program Procedures
At the conclusion of the aquatic exercise program, on the 21st day, each participant once again completed the EFI and shoulder flexibility measurement.
##### Stastistical Analysis
All data analyses were performed using SPSS, version 14.0. The normality of the distribution and the equality of variances for all variables were checked with the Kolmogorov-Smirnov test for each group. Bartlett-Box and Cochran’s C tests were used to identify differences among groups of the selected items. From the pretest, there were no differences beyond the .05 level of significance between any of the two groups. Wilcoxon test for two related samples was used to compare differences of means scores between the initial and final measurements of both the experimental and control groups in the mood state variables. Comparisons of means scores between the initial and final measurements of two groups in the shoulder flexibility parameter were performed using a paired t-test analysis.
The results revealed significant differences between pre- and post- measures for the experimental group regarding the four subscales of mood state (Table 1). In contrast, there were no changes in mood state for the control group at pre- and post- measures on any of the 4 subscales. As shown in table 1, after a 45-minute-per-day aquatic exercise program for 20 consecutive days, there was a marked increase in reported variables of mood state for the experimental group while the control group showed no changes during the same period of time.
The aquatic exercise program induced significant improvement in shoulder flexibility. In particular, the t-test for paired groups analysis revealed that shoulder flexibility had significantly improved in the experimental group (t=9.25, p<.05), while no significant difference was observed in the control group (t=0.89, p>.05). Scores for the pre- and post-tests for both groups on the selected variable are shown in figure 2.
The results reveal that a 45-minute-per-day aquatic exercise program for 20 consecutive days produced significant improvements in mood state as well as in shoulder flexibility of sedentary elderly people. The lack of improvement for the subjects of the control group gives additional support to the idea that the program applied was responsible for the improvement of the experimental group. It seems that even a 20-day aquatic exercise program is capable of producing significant changes in basic physiological and psychological variables similar to the ones in the present study. Significant improvements in the elderly in a number of physical abilities after following a training program have been reported by researchers. Takeshima et al., (21), reported significant improvements in 45 elderly women (60-75 yrs. of age) who had participated in a 12-wk supervised water exercise program, 70 minutes per day, 3 days per week, in cardiovascular fitness, muscle strength and power, flexibility, agility, and subcutaneous fat. Additionally, the exercising group demonstrated an improvement in pulmonary function and blood lipids. In 2006, Tsourlou et al. (23), reported significant improvements in a number of physical abilities (maximal isometric torque of knee extensors and knee flexors, grip strength and dynamic strength during chest press, knee extension, lat pull down, and leg press, jumping performance functional mobility, and trunk flexion) in 22 healthy women over 60 years of age, after their participation in a 24-week aquatic training program.
Furthermore, these results are consistent with the conclusions of previous studies reporting changes in elements of psychological well-being in terms of physical activity. These changes are referred to as enhanced perceptions of mastery (11), improved life satisfaction (14), and mood (15,5,10) as well as reduced negative affect of psychological state. Moreover, similar results were found in a 12-week investigation by Whitlatch et al. (24). In addition, Moore and Blumental’s narrative review (13) with older adults, focusing on specific elements of mood, supported the positive role of aerobic exercise in reducing negative affect.
The results of the present study indicate that water-based exercise elicits significant improvement in psychological well-being and joint mobility in the elderly. Specifically, a 45-minute–per-day aquatic exercise program in hot water for 20 consecutive days can result in considerably better positive engagement, revitalization, and tranquillity, as well as joint mobility focused on shoulder flexibility, in older men and women. Moreover, it may provide additional benefits by reducing negative mood in terms of physical exhaustion. Therefore, water-based exercise is one of the most potent alternative training methods for improving basic elements of their psychological and physiological health.
### Applications In Sport
Overall, the findings of the present investigation should be adopted by public and private institutes that offer water-based exercise programs for older men and women. Elderly people’s participation in a 45-minute aquatic exercise regimen for 20 consecutive days with various enjoyable activities results in significant improvements to general shoulder range of motion, facilitating their performance at common activities of daily living and allowing them to maintain independent lifestyles. Besides, their participation in this kind of program makes them familiar and sociable persons. This suggests that water-based exercise may be a valuable short- term strategy for the self regulation of mood in older people. Finally, practical exercise prescriptions from instructors must take into account the special interests and needs of the elderly, inducing happiness, tranquillity, pleasant tiredness and, at the same time, initiating progressive improvement in general physical and psychological health.
We acknowledge the participants for their voluntary involvement in this study.
#### Table 1
Means, Standard deviations and Wilcoxon test for mood state variables in the pretest and post-test measurements for elderly people in experimental and control groups.
|Variables||Experimental Group||Control Group|
#### Figure 2
Pre-test and Post-test shoulder flexibility in older men and women in both experimental and control groups.
1. Agre, J.C., Pierce, L.E., Raad, D.M., McAdam, M., & Smith, E.L. (1988). “Light Resistance and Stretching Exercise in Elderly Women: Effect upon strength” Archives of Physical Medicine and Rehabiliation, 69, 273-276.
2. American College of Sports Medicine. (1998). The recommended quantity and quality of exercise for developing and maintaining cardio respiratory and muscular fitness,and flexibility in healthy adults. Medicine and Science in Sports and Exercise, 30, 975-991.
3. Douglas, J. C. (1999). Exercise in the Heat. I. Fundamentals of Thermal Physiology, Performance Implications, and Dehydration. Journal of Athletic Training, 34, 246-252.
4. Ecclestone, N.C., Tubor-Locke, D.A., Meyers Lazowski, A. (1995). Programming and evaluation insights into physical activity for special older populations. International Conference on Aging and Physical Activity, “Promoting Vitality and Wellness in Later Years”, Colorado Springs, Colorado, October 1995. Journal of Aging and Physical Activity 4, (3),424-25.
5. Emergy, C.F., & Blumental, J.A. (1990) Perceived change among participants in an exercise program for older adults. The Gerodolist, 30, 517-521.
6. Fillingim, R.B., & Blumental, J.A. (1993) Psychological effects of exercise among the elderly. In P. Seraganian (Ed.), Exercise physiology: the influence of physical exercise on psychological processes, New York: Wiley, pp. 237-254.
7. Gauvin, L., & Rejeski, J.W. (1993). The exercise-induce Feeling Inventory: development and initial validation: Journal of Sport and Exercise Psychology, 15, 403-423.
8. Judge, J.O., Underwood, M., & Gennosa, T. (1993). “Exercise to improve Gait Velocity in Older Persons” Archives of Physical Medicine and Rehabilitation, 74, 400-406
9. Lepore, M., Gayle, G.W., & Stevens, S.F. Adapted Aquatics Programming: Professional Guide. Champaign, IL: Human Kinetics, 1998, pp. 12-16.
10. Matsouka, O., Kabitsis, C., Harahousou, Y., & Trigonis, I. (2005). Mood alterations following an indoor and outdoor exercise program in healthy elderly women. Perceptual and Motor Skills, 100, 707-715.
11. McAuley, E., & Courneya, S.K. (1994). The Subjective Exercise Experiences Scale: development and initial validation. Journal of Sport & Exercise Psychology, 16, 163-177.
12. McAuley, E., & Rudolph D. (1995). Physical Activity, Aging, and Psychological Well-Being. Journal of Aging and Physical Activity, 3, 67–96.
13. Moore, K.A., & Blumental, J.A. (1998). Exercise training as an alternative treatment for depression among older adults. Alternative Therapies in Health and Medicine, 4, 48-56.
14. Morgan, K., Dollosso, H., Bassey, E.J., Ebrahim , S., & Arie, T.H.F. (1991) Customary Physical activity, psychological well-being and successful ageing. Ageing and Society, 11, 399-415.
15. Moses, J., Steptoe, A. Mathews, A., & Edwards, S. (1989) The effects of exercise training on mental well-being in the normal population: a controlled trial. Journal of Psychosomatic Research, 33, 47-61.
16. Osness, W.H., Adrian, M., Clark, B., Hoeger, W., Raab, D., & Wisnell, R. (1990). Functional fitness assessment for adults over 60 years (a field based assessment). Reston, VA: American Alliance for Health Physical Education Recreation and Dance
17. Parkatti, T., Rantanen, T., & Hartkka, K. (1994). The Effect of an Intensive Physical Activity Training Program on Functional Ability Among Frail Elderly People. Physical Activity And Health In The Elderly, Scotland.
18. Jones C.J., & Rikli R.E. (2002). Measuring functional fitness of older adults, The Journal on Active Aging, pp. 24–30.
19. Rikli, R.E., & Edwards, D.J. (1991). “Effects of a Tree-Year Exercise Program on Motor Function and Cognitive Processing in Older Women” Research Quarterly for Exercise and Sport, 62, 61-67.
20. Robert, J. J., Jones, L., & Bobo, M. (1996). The physiologic response of exercising in the water and on land with and without the X1000 Walk’N Tone Exercise Belt. Research Quarterly for Exercise & Sport, 67, 310-315.
21. Takeshima, N., Rogers, M.E., Watanabe, E., Brechue, W.F., Okada, A., Yamada, T., Islam, M.M., & Hayano., J. (2002). Water-based exercise improves health-related aspects of fitness in older women. Medicine and Science in Sports and Exercise, 33, 544-551.
22. Thomas, S., Reading, J., & Shephard, R.J. (1992). Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Canadian Journal of Sport Science, 17, 338-345.
23. Tsourlou, T., Benik, A., Dipla, K., Zafeiridis, A., & Kellis, S. (2006). The effects of a twenty-four-week aquatic training program on muscular strength performance in healthy elderly women. The Journal of Strength & Conditioning Research, 20,811-8.
24. Whitlactch, S., & Adema, R. (1996). Activities, Adaptation and Aging, 75-85.
### Corresponding Author
Department of Physical Education & Sport Sciences
University of Thrace