Effect of hydrotherapy on Lower Body Strength and Balance among Elderly women

Abstract

Background: Improvement of health conditions, increasing life expectancy worldwide have brought about a proportional increase in the older population. Nowadays, falls are one of the largest public health problems among elderly people due to the high morbidity, mortality and costs for the family and society. Postural instability is one of the main factors that limit older individuals' daily activities, and falling is the most harmful consequence of this process, thus, The purpose of this study was to evaluate the impact of a structured aquatic exercise program on the static and dynamic balance of elderly women.
Methods: This was a prospective randomized clinical study in which the variables were assessed before and after the training program. Thirty-six elderly people were evaluated using static and dynamic balance tests. The participants were randomized into two groups: aquatic exercise group, and control group. The exercise groups underwent an aquatic exercise program that consisted of 40-minute sessions twice a week for 12 weeks. The data were analyzed statistically using the t- test for comparisons between the groups before and after the intervention.
Results: hydrotherapy training diminished total fat mass compared with control group (P= 0.011). Likewise, increased total fat free mass was found in experimental group compared with control group (P= 0.009). The program significantly increased static, dynamic balance and Lower Body Strength (respectively: p= 0.01, p=0.001, p=0.001) in the evaluation tests after the training program.
Conclusions: The water-based exercise program provided a significant improvement in static, dynamic balance and lower body strength among community-dwelling elderly people. Conclusively, the findings from this study have implications for health promotion strategies in healthy elders and suggest the need to develop fall prevention programs using hydrotherapy in the community setting so that health cost can be decreased and quality of life in older people can be improved. Our study concludes that aquatic practice may hence be an important therapeutic tool to improve effective factors of balance in elderly.
Key words: aquatic exercise; Balance, elderly.

Full text

Correspondence: Morteza Taheri, Ph.D., Assistant Professor, Department of
Physical Education, Faculty of Social Science, Imam Khomeini University
International, Qazvin, IRAN, Tel: +98 9124070721, Email:
taheri_morteza@yahoo.com
EFFECT OF HYDROTHERAPY ON LOWER BODY STRENGTH AND
BALANCE AMONG ELDERLY WOMEN
MORTEZA TAHERI
Department of Physical Education, Faculty of Social Science, Imam Khomeini University
International, Qazvin, IRAN.
Email: taheri_morteza@yahoo.com
How to cite this article: Taheri, M. (December, 2015). Effect of hydrotherapy on
lower body strength and balance among elderly women. Journal of Physical
Education Research, Volume 2, Issue IV, 19-26.
Received: November 12, 2015 Accepted: December 22, 2015
ABSTRACT
Falling is one of the most epidemic problems related to aging process. To prevent falls,
the preventive strategies including appropriate physical activity programs can be
effective in falling prevention. The purpose of this study was to investigate the effect of
hydrotherapy on lower body strength and balance among elderly women. Thirty-six
elderly people were randomly divided into two groups including experimental and
control groups. Experimental group participated in an aquatic exercise program that
consisted of 40-minute sessions twice a week for 12 weeks while control group had no
plan of exercise. Statistical analysis using t-test was used to analyze the data (p<0.05).
Hydrotherapy training diminished total Fat mass (FM) compared with control group.
Likewise, increased total fat free mass (FFM) was found in experimental group
compared with control group. It was also suggested that static, dynamic balance and
lower body strength were significantly improved after the exercise intervention. It was
concluded that water-based exercises can be used as an important preventive strategy
to improve effective factors of balance in elderly.
Keywords: Aquatic exercise, balance, elderly, elderly people.
1. INTRODUCTION
There have always been some important challenges related to health conditions in
the older population including how to increase physical fitness, life expectancy.
Nowadays, Falls is a major public health problem among elderly people as they
can cause the irreversible health, social, physical and psychological consequences,
and a large healthcare costs (Alikhajeh, Hosseini, & Moghaddam, 2012). Postural
instability caused by visual deficits, Muscle weakness, psychotropic drugs,
Journal of Physical Education Research, Volume 2, Issue IV, December 2015, pp.19-26
ISSN: Print-2394 4048, Online-2394 4056, IBI Factor: 4.29

Taheri, M. (December, 2015). Effect of hydrotherapy on lower body strength and balance among
elderly women. Journal of Physical Education Research, Volume 2, Issue IV, 19-26.
JOPER® www.joper.org JOPER 20
sensory- motor impairments, orthopedic constraints, is one of the main factors
that limit older individuals' daily activities and lead to falling in the elderly,
thereby making older adults more dependent (Gananca, Gazzola, Aratani,
Perracini, Ganança, 2006; Taheri, Taheri, & Irandoust, 2014; Perracini, & Ramos
2002; Fried, Tangen, Walston, Newman, Hirsch, Gottdiener, …. &, McBurnie,
2001; Foldvari, Clark, Laviolette, Bernstein, Kaliton, Castaneda, .…, & Singh,
2000). It has been reported in a study that elderly women have a higher
possibility for falls because of less lean body mass and muscle strength (Foldvari,
et al., 2000). A number of studies, however, have shown that with ageing both
sensory inputs and motor outputs diminish leading to alterations in the strategies
used in postural control (Hess, & Woollacott, 2005). Some examples of reduced
motor function with ageing include decreased muscular strength and an alteration
in the coordination of agonist/antagonist muscle activation patterns. There are
some limiting factors such as arthritic diseases, pain, muscle weakness, obesity
which make it difficult for elderly people to perform exercises on the ground
while the situation is completely different in an aquatic environment due to joint
overload reduction and consequently less risk of falls during the exercises (Booth,
2004). Although it seems that aquatic exercise may be an appropriate intervention
for elderly persons, little is known about its effect to improve body composition
such as fat free mass, percent body fat, muscle mass in older adults engaging
regularly in these activities. Providing aged people with healthcare services in
order to overcome their possible disabilities is of utmost important, therefore,
intervening the effective strategies for improving the quality of life in the elderly
must be taken into consideration. Since the improvement in static, dynamic
balance and lower extremities strength are effective in balance maintenance in
aged people’s, so we investigated the effect of hydrotherapy on lower body
strength and balance among elderly women. The aim of this research was to study
the effect of hydrotherapy exercises on static, dynamic balance and lower Body
Strength in the elderly women.
2. METHODS AND MATERIALS
2.1 Sample
Thirty-six healthy aged women were recruited from the health clinic of Dr.
Irandoust in Qazvin. The research procedure was given to each subject; after
acceptance, written consent was obtained. Eligibility criteria for the study
included (a) older than 65 years; (b) walking independency; (c) lack of
musculoskeletal disorders, cardiovascular disease, pulmonary impairments; (d)

Taheri, M. (December, 2015). Effect of hydrotherapy on lower body strength and balance among
elderly women. Journal of Physical Education Research, Volume 2, Issue IV, 19-26.
JOPER® www.joper.org JOPER 21
lack of cognitive impairments; and (e) physical ability to participate in the
exercise program.
2.2 Measurements
2.2.1. Timed Chair-Stand Test
Body strength of legs was measured with the Timed Chair-Stand Test (Toraman,
& Ayceman, 2005). The subjects sat as far back as possible in the chair and then
stood up from a seated position with arms folded across their chests as many
times as possible within 30 seconds. Their scores were the number of times they
stood up and sat down within 30 seconds. The mean score of two repetitions was
calculated in frequencies. In the study by Jones et al. (1999), test-retest intraclass
correlations (ICCs) of 0.84 for men and 0.92 for women indicate that the 30-
second chair stand has good stability reliability (Jones, Rikli, & Beam, 1999). In
this study, the ICC was 0.98.
2.2.2. The Timed Up and Down Stair Test
This Test is designed to measure dynamic balance (Leroux, 2005). Using an 8-in.
high stair, the elders step on and off seven times at their naturally preferred
comfortable pace. They step up with one foot and then the other and step down
with one foot followed by the other foot. One time includes both ascending and
descending the stair. The mean of two repetitions was calculated in seconds. In
the study by McCarthy and Oldham (2004), the stair test had intra tester reliability
with a high ICC statistic of 0.98 (McCarthy, & Oldham, 2004). In this study,
interrater reliability was 0.97.
2.2.3. Stork Test
This test is designed to measure static balance. The elders lift one foot up without
touching it to the support leg. The elders kept their eyes open during the test. The
mean number of seconds of two repetitions on each leg was calculated. In a study
by Gioretti, Harris, & Jette, (1998), the reliability coefficient was 0.75 for one-leg
standing. In this study, the ICC was 0.93.
2.3 Procedure
Experimental group participated in an aquatic exercise program that consisted of
40-minute sessions twice a week for 12 weeks while control group had no plan of
exercise.

Taheri, M. (December, 2015). Effect of hydrotherapy on lower body strength and balance among
elderly women. Journal of Physical Education Research, Volume 2, Issue IV, 19-26.
JOPER® www.joper.org JOPER 22
Each exercise session included three parts: water adaptation phase,
stretching phase and a phase of static and dynamic exercises for balance. The
intensity of exercise was intervened from low to moderate, around 60% of
maximum Heart Rate (controlled by Polar Electro, Kempele, Finland). The
maximum HR was calculated using Cooper’s formula (220 – age). An exercise
therapist supervised all the exercise classes. The static and dynamic balance were
respectively measured by stork and the timed up and down stair tests before and
after exercise. Pre-test and post-test of Body composition variables (BMI, PBF,
FM and FFM) were measured by ZENUS 9.9 PLUS Body Composition
Analyzer.
2.3 Statistical Analysis
The analysis of data was done by SPSS v.20 software. The t-test was used to
analyze the data (p<0.05). All variables were expressed as Mean ±SD and values
less than 0.05 were considered statistically significant.
3. RESULTS
Table 1: Effects of hydrotherapy on body composition
Variable
Experimental Group
M±SD
Control Group
M±SD
Sig.
Pre-test
Post-test
Pre-test
Post-test
Age (yr)
71.2 ±4.7
71.8±3.9
-
Height (cm)
156.2 ± 5.5
156.1± 5.4
-
Weight (kg)
59.7 ± 4.9
57.7 ± 5.3
58.9 ± 5.5
58.8 ± 5.1
0.001*
Total FM
20.7
19.2
20.6
20.5
0.011*
Total FFM
46.6
47.4
46.5
46.7
0.009*
Abbreviations: BMI, body mass index; PBF, percent body fat; FM, fat mass;
FFM, fat free mass.
*Significant difference between experimental and control groups
With regard to body composition, Aquatic Group diminished total FM compared
with control group (p = 0.011). Likewise, increased total FFM was found in
experimental group compared with control group (p = 0.009) (see table 1).
Table 2: Comparison of lower body strength and balance between the
experimental and control groups at 12 weeks of intervention

Taheri, M. (December, 2015). Effect of hydrotherapy on lower body strength and balance among
elderly women. Journal of Physical Education Research, Volume 2, Issue IV, 19-26.
JOPER® www.joper.org JOPER 23
Variables
Experimental group
M±SD
Control Group
M±SD
t
Pre-test
Post-test
Pre-test
Post-test
Lower Body
Strength
(Frequencies)
7.49±0.87
11±1.02
7.3±0.74
6.90±0.66
14.49
Static Balance (S)
5.8±0.84
7.8±0.91
4.0±0.98
4.1±0.82
3.61
Dynamic Balance (S)
17.2±5.2
12.6±2.4
15.31±2.6
15.2±2.2
-3.27
* Significant at p≤0.05
Results are reported in Tables 2. As seen, all variables including lower body
strength, static and dynamic balance were significantly improved after
hydrotherapy training.
Figure 1: The effect of hydrotherapy exercise on lower body strength
Figure 2: The effect of hydrotherapy exercise on static balance
**
0
2
4
6
8
10
12
14
Experimental
Control
Lower Body Strength
(Frequencies)
pre test
post test
*
0
2
4
6
8
10
Experimental
Control
Stattic Balance
(S)
pre test
post test

Taheri, M. (December, 2015). Effect of hydrotherapy on lower body strength and balance among
elderly women. Journal of Physical Education Research, Volume 2, Issue IV, 19-26.
JOPER® www.joper.org JOPER 24
Figure 3: The effect of hydrotherapy exercise on dynamic balance
4. DISCUSSION
The aim of this study was to investigate whether a hydrotherapy program would
be capable of improving older adults’ static, dynamic balance and lower body
strength in elderly women. We observed a significant improvement in the static,
dynamic balance and lower body strength of the older adults who did the
hydrotherapy exercises. Some studies suggested that aquatic exercises improved
the balance and reduced the risk of falls among older people (Lund, Weile,
Christensen, Rostock, Downey, Bartels, Danneskiold-Samsøe, & Bliddal, 2008;
Lord, Matters, St Georges, Thomas, Bindon, Chan, Collings, & Haren, 2006). It
was shown in this study that Total Fat mass were decreased significantly, while
Fat Free Mass was increased significantly after aquatic intervention that is
consistent with the previous studies (Bergamin, Ermolao, Tolomio, Berton, Sergi,
Zaccaria, 2013). The optimal change of body composition as shown would assist
the balance improvement of elderly (Bergamin, et al., 2013). In other words,
Simultaneous improvement in balance and lower body strength can be attributed
to decreased fat mass and increased fat free mass of subjects in experimental
group, likewise the improved neuromuscular coordination can be effective in this
result. This result emphasizes the role of muscle strength, suggesting the
hypothesis of a correlation between leg muscle density, muscle strength, and
balance, as previously suggested by MacIntyre, Rombough, & Brouwer (2010).
Although fall risk was not measured in this study, increases in movement
efficiency as measured by lower body strength, static and dynamic tests, implies
increased physical fitness of the elderly women which can be effective in fall
prevention. The positive effect of physical exercise on improvement of static and
dynamic balance in older adults has been reported by Ikezoe, Tsutou, Asakawa,
and Tsuboyama, (2005) which is consistent with our study. The effect of
hydrotherapy exercises on elderly performance depends on different factors
namely the increase in strength of subjects' lower limbs, creating neuro-muscular
**
0
5
10
15
20
Expeimental
Control
Dynamic Balance
(S)
pre test
post test

Taheri, M. (December, 2015). Effect of hydrotherapy on lower body strength and balance among
elderly women. Journal of Physical Education Research, Volume 2, Issue IV, 19-26.
JOPER® www.joper.org JOPER 25
Conformity due to exercise and the amount of pressure resulted from the effect of
exercise on performance (Hosseini, 2011). In explaining the effects of aquatic
training on balance, it can be noted that exercise in water, places more pressure on
neuromuscular systems to maintain balance. A novel approach of this manuscript
is based on considering the effective factors in fall prevention of the elderly
women, which focus on some selected exercise protocol for increasing lower
body strength, balance.
5. CONCLUSIONS
Conclusively, the findings from this study have implications for health promotion
strategies in healthy elders and suggest the need to develop fall prevention
programs using hydrotherapy in the community setting so that health cost can be
decreased and quality of life in older people can be improved.
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elderly women. Journal of Physical Education Research, Volume 2, Issue IV, 19-26.
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