Christine Alexander is the author of 2 books on water exercise each published by Human Kinetics.
Water Fitness Progressions (2019) was written for water fitness instructors and aquatic personal trainers. It describes how to use periodization to help class participants and clients progress in their level of fitness. It contains lesson plans that illustrate how to progressively increase intensity for both cardiorespiratory endurance and strength training.
Water Fitness Lesson Plans and Choreography (2011) was written for water fitness instructors. It has 36 class ideas for shallow water exercise and 36 class ideas for deep water exercise. Individuals may find the exercise descriptions and photos useful for building a personal exercise routine.
Just getting in the pool lowers blood pressure for most people. The hydrostatic pressure of the water pushes blood out to the extremities, increasing stroke volume and cardiac output, while at the same time lowering the heart rate. Immersion offloads the joints, making movement more comfortable. When joints are submerged in water, they have a greater range of motion. Water also offers resistance, requiring the exerciser to apply more force to their movements. The resistance is in all directions, which promotes muscle balance. Since the water is a dynamic resistant force, the more force that is applied, the more resistance the water offers. Pool temperatures are typically 12-18 degrees cooler than body temperature, and water conducts heat away from the body, so exercisers remain cool and comfortable during exertion. Buoyancy creates a feeling of weightlessness, which is perceived as fun by most exercisers. All of these benefits apply no matter what exercise format you are using.
There is a misconception that exercise in water does not burn as many calories as exercise on land. Of course, the number of calories burned depends on many things including how hard the exerciser works, but given the same amount of effort, an exerciser will burn a comparable number of calories in water as on land, and sometimes even more. Dennis Dolny, Ph.D. reports his research on burning calories through water exercise in the Water Immersion Works guidebook, which can be downloaded on the PlayCore website. The Mayo Clinic also lists an estimated number of calories burned for various activities, and water aerobics compares favorably to other forms of exercise.
Water exercise is usually discounted as an acceptable form of exercise for people with osteoporosis because buoyancy reduces the impact compared to land based exercise. But research on water exercise and osteoporosis is ongoing and has found that shallow water exercise can slow the rate of bone loss and improve bone mineral density. Recommended exercises include jumping/rebounding, strength training and using power or force against the water’s resistance. In addition, the research has noted outcomes of improved strength, flexibility, balance and adherence. The best exercise is the one you can stick with! For more information, see Lori Sherlock’s article in AEA’s first quarter 2024 issue of Leader Tools.
Shallow water is the perfect place to work on balance. People who have fallen are often afraid of falling again and they limit balancing activities on land to minimize the risk of falling, further decreasing functionality. But in the pool, the hydrostatic pressure and buoyancy of the water is supportive, reducing the fear of falling. At the same time, water constantly moves, destabilizing movement and requiring multiple adjustments to maintain balance. Good exercises for improving balance are weight shifting, gait training, postural strength training, use of various foot positions, and one-legged movements. If there are muscle imbalances, these can also be addressed in the pool. For more information, check out the Water Exercise Coach blog post and video.
Finally, every type of equipment made for water fitness can be used in shallow water. That includes buoyant equipment such as noodles and foam dumbbells; drag equipment such as webbed gloves, Aqualogix bells, paddles and Aqua Ohm; resistance tubing; steps; drum sticks and more. There are options to please everyone. Shallow water exercise is definitely not just for little old ladies in shower caps!
Most of the time when we hear the word “core” we think of our abdominals. And in fact it is important to keep the abdominals and all the other muscles of the trunk strong. These muscles work together to maintain good posture and to support and move the shoulders, the back, and the hips. They are often referred to as the powerhouse of the body, stabilizing the trunk and allowing us to move our arms and legs powerfully and safely during exercise.
Beneath these core muscles are the muscles of the inner core and they have an important job to do. The brain is protected by the scull, the heart and lungs are protected by the rib cage, and the female reproductive organs are protected by the pelvic bone. But the remaining organs are protected by the inner core. The muscles of the inner core are the diaphragm at the top, the multifidus in the back, the transverse abdominis in the front, and the pelvic floor at the bottom.
Diaphragm. A weakness in the diaphragm can lead to reflux. Diaphragmatic breathing strengthens the diaphragm. To practice diaphragmatic breathing, sit comfortably in a chair with the shoulders relaxed. Place one hand on your chest and the other hand just below your rib cage. Breathe in slowly through your nose so that the stomach moves out against your hand while the hand on your chest remains as still as possible. To exhale, tighten your stomach muscles so that your stomach moves back in while the hand on your chest remains as still as possible. Another way to make sure you are breathing diaphragmatically is to put the tip of your tongue on the roof of your mouth just behind your front teeth. This stimulates your vagus nerve ending, which is involved in the regulation of breathing, and causes diaphragmatic breathing. Practice diaphragmatic breathing in the pool. Breathing against the resistance of the water by submerging the chest strengthens the muscles of respiration. Deep water exercise is great for this because the chest is continually submerged. If you are teaching a shallow water class, it is a good idea to include exercises in the neutral position (Level II) or suspended (Level III) so that participants’ chests will be submerged for part of the class. For more information on diaphragmatic breathing see the article from the Cleveland Clinic.
Multifidus. A weakness in the multifidus can lead to slipped discs. Some exercises to strengthen the multifidus are:
Bird dog. Get on your hands and knees, brace your core, lift one leg in back and the opposite arm in front.
Superman. Lie face down on a mat with your arms extended in front of you. Simultaneously lift your arms, chest and legs off the mat. Hold for a few seconds.
Side plank. Lie on your side with the elbow directly beneath your shoulder and your legs stacked. Lift your hips off the ground and hold for 20-30 seconds.
Another great way to strengthen the muscles of the back is to travel backwards in the pool. For more information on the multifidus see the article from Bret G. Ball, M.D., PhD. with Rose City Spine Surgery in Portland, Oregon.
Transverse abdominis. A weakness in the transverse abdominis can lead to a hernia. Some exercises to strengthen the transverse abdominis are:
Toe taps. Lie on your back with your arms to the side and knees bent in tabletop position (knees bent at a 90-degree angle and shins parallel to the ground). Keep your knees bent and lower one foot to tap the toes on the ground.
Bird dog. Get on your hands and knees, brace your core, lift one leg in back and the opposite arm in front.
Plank. Start in a pushup position with your elbows and forearms at your side and your palms facing down. Raise your torso off the ground and hold the position for as long as you can.
In the pool, you can do a plank holding a noodle or foam dumbbells with the hands directly below the shoulders. For more information on the transverse abdominis, see the article from Healthline.
Pelvic floor. A weakness in the pelvic floor can lead to incontinence. Women are more likely than men to suffer from incontinence. However, in men sometimes an enlarged prostate exerts pressure on the urinary tract, controlling the flow of urine, and the the pelvic floor becomes weak. If the prostate is surgically removed, men will have a more serious issue with incontinence. Therefore both men and women are encouraged to include pelvic floor exercises in their fitness routine. A good exercise to strengthen the pelvic floor is Kegels. To perform Kegels correctly, lift the pelvic floor and then gently draw in the transverse abdominis. There should be no change in your breathing, and your upper abdominals should remain relaxed. Perform the exercise gently and slowly. How long to hold the core contraction depends on the type of incontinence you are having a problem with (or wish to avoid). Stress incontinence is leaking when sneezing, coughing, etc. For this do 10 quick pelvic floor lifts 2 or 3 times a day. Urge incontinence is leaking on the way to the bathroom. For this do a maximum of 10 repetitions at a time, hold the contraction for 10 seconds at most, and take a 30-second break in between contractions. Kegels can be performed standing, sitting or lying down. You can include them in your water fitness class while standing or try sitting on a noodle like a bicycle. Cue to lift the pelvic floor off the noodle. My resource for this information comes from Marietta Mehanni, the pelvic floor ambassador in Australia, who presented a workshop entitled “Aquacise Your Pelvic Floor” in Dallas on October 5, 2019. Bridges and squats can also help strengthen the pelvic floor. For more information on pelvic floor exercises, see the article from Medical News Today. Some of my participants have thanked me for including them in my classes.
The hand is truly amazing! There are 27 bones in the hand. There are 15 muscles in the forearm that control the movements of the hands and fingers. We can turn the palms down and up, flex and extend the wrist, wave the wrist side to side, flex and extend the fingers, pull the fingers apart and bring them together, circle the thumb, and don’t forget the movement of the opposable thumb. Most of the things that we do with the hands require the strength of several muscles doing various movements simultaneously.
We probably think less often about our feet than we do about our hands, but the foot is amazing too. There are 26 bones in the foot. There are 29 muscles associated with the foot: 10 originate outside the foot but cross the ankle joint to act on the foot, and 19 muscles are inside the foot. All of these muscles work as a team. The ligaments in the ankle, which attach the bones together, contain receptors that give feedback to the brain about where the body is in space. We can dorsiflex the foot (pull the foot up toward the shin) and plantarflex the foot (point the toes). Inversion of the foot means rolling to the outside edge of the foot; eversion means rolling to the inside edge of the foot. We can lift the toes or curl the toes down. One of the most important things our feet do is transmit force both toward and away from the ground in weight bearing activities.
One thing we should do to take care of our hands is to wash them frequently. Plain soap and water washes away the viruses that cause the common cold, flu, COVID, and RSV. Remember to wash for 20 seconds, including between the fingers, the fingernails and the tops of the hands. Using hand cream will help prevent the skin from drying out. Some problems that may cause hand pain include arthritis, carpal tunnel syndrome, ganglion cysts, tendonitis, and trigger finger. For more information on these problems and treatments for them, check out the article on hands from John Hopkins Medicine. The pool is a great place to exercise the hands because the hands are constantly underwater, and therefore resisted. The Arthritis Foundation has a list of exercises for the wrists and fingers:
Hand and wrist wave – elbows are near the waist with the thumbs up, wave the hands side to side
Wrist stretch – the arms are near the surface of the water with palms together, then bring the hands toward the chest with fingertips pointing up.
Wrist rotation – circle the wrists
Finger curl – make a fist and extend the fingers
Cat’s claw – bend the fingers at the middle joint to simulate a cat’s claw
Piano – bend and straighten the fingers as if playing a piano
Finger O – touch the thumb to the tip of each finger
Finger walk – slide one finger at a time toward the thumb
Finger spread – spread the fingers apart and move them back together
Finger lift – rest the palms on the thighs and lift the thumbs and then the fingers one at a time
Thumb bend – touch the thumb to the base of each finger
You can also shake out the hands to release tension and help relax the muscles of the hands. Even though these exercises come from the Arthritis Foundation, they are beneficial to include in any water fitness class.
Some problems that may cause foot and ankle pain include heel spurs, corns, bunions, hammertoes, ankle sprains, fractures, planar fasciitis, Achilles tendon injuries and diabetes. For more information on these problems and treatments for them check out the article on feet from John Hopkins Medicine. Some exercises to do in the pool for the ankles and feet from the Arthritis Foundation are:
Point and flex the foot
Heel-toe lift – rock back on your heels then rise onto the toes
Ankle circles – or write your name with your foot
Ankle in/ankle out – roll the foot in to tap the big toe on the floor then roll it out to tap the little toe on the floor
Toe curl – lift the toes off the floor then curl the toes as if picking up a pencil
You can also walk on your toes and on your heels. Put one foot on the toes of the opposite foot and try to lift the the toes of the bottom foot.
Avoid gripping dumbbells with the wrists not in neutral. Avoid too much rebounding for the feet.
In addition to doing exercises for the hands and feet, there are some cautions for your water fitness class. Grip strength is important, but you want to be sure to relax the grip between sets with foam dumbbells. It’s a good idea to stretch the fingers or wiggle them or do one of the hand exercises above before beginning another set. Holding the dumbbells with the wrists extended can aggravate carpal tunnel syndrome. Be sure to keep the wrists in neutral, which avoids excessive strain and fatigue in the hands and wrists. To protect the feet, avoid excessive rebounding. When you tell your class to start jogging, they will automatically rebound. If you do not vary the impact forces, your class could easily rebound for 50 minutes. Include exercises in the neutral position with the hips and knees bent and the shoulders below the surface of the water (Level II), suspended exercises (Level III) and grounded exercises keeping one foot on the pool floor. When you do rebound, teach how to land. Landing toe-ball-heel will diffuse the shock. When landing toe-ball-heel, the heel barely makes contact with the pool floor before lifting off again, so do not cue to keep the heels down. Avoid repetitive impact on the ball of the foot because the metatarsal fat pad on the bottom of the foot frequently degenerates in women over 50. Offer modifications to jumping and rebounding for those who have plantar fasciitis. Aqua shoes are recommended because they can help protect the feet. Deep water exercise is best for anyone recovering from an ankle sprain.
Resource: Pauline Ivens, MS and Catherine Holder, PT, Do No Harm, 2011
You use both your hands and your feet constantly, so take good care of them. See you in the pool!
The knee joint is the largest and probably the most stressed joint in the body. It is a hinge joint that allows flexion (bending) and extension (straightening) and a slight amount of rotation side to side. The bones of the knee joint are the femur (the upper bone), the tibia (the lower bone), and the patella (the kneecap). The smaller lower leg bone, (the fibula) is not part of the knee joint. Ligaments connect the femur and tibia and hold them in place. Two menisci cover the top of the tibia and serve as shock absorbers. Knee pain can be caused by a torn ligament, fractures, a torn meniscus, knee bursitis, patellar tendonitis, a loose body in the knee, a dislocated kneecap, osteoarthritis and other causes. For more information on knee pain symptoms and causes see the article on knees from the Mayo Clinic. The most common cause of chronic knee pain is arthritis (osteoarthritis, rheumatoid arthritis or posttraumatic arthritis), A Healthline Report in 2020 says that approximately 600,000 knee replacement surgeries are performed every year in the United States.
It is not always possible to prevent knee pain, but you can reduce your risk by maintaining a healthy weight, and keeping the muscles that support the knees strong and healthy, since weak muscles are a leading cause of injury. The muscles that support the knees are the 4 muscles of the quadriceps on the front of the thighs and the 3 muscles of the hamstrings on the back of the thighs. The pool is a great place to do exercises for the quadriceps and hamstrings because the buoyancy of the water lifts and supports the body, reducing the stress on the knees. Some good exercises that can be done in the pool for the knees include quad kicks (kicks from the knee), hamstring curls, squats, and lunges. We squat every time we sit down in a chair. Squats can stress the knee if done too deeply, but that is very unlikely in the pool! Vary the squat by having the feet wide apart, hip distance apart or together. You can also have one foot forward more than the other foot. In the pool you can do one-legged squats. To activate the deep core muscles before squatting, use the Heavy Concept. Imagine that you are trying to squat but are not able to. You will feel both your abdominals and the hamstrings contract isometrically. Use the same concept to return to standing. If you imagine that you are not able to stand up, you will feel both your abdominals and quadriceps contract isometrically. For an additional challenge, do your squats standing on a noodle. Lunges can be performed forward, to the side, to the back, or diagonally.
1. & 2. Quad Kick. 3. Hamstring Curl. 4. Squat. 5. Squat on a Noodle. 6. Lunge.
In addition to strengthening the quadriceps and hamstrings, there are some cautions to help you avoid an injury in your water fitness class. Rebounding is good for the knees, but landing with the knees turning inwards causes abnormal forces through the knees. The middle of the knee should align with the second and third toes when landing from a jump. Ballistic hip abduction (cheerleader jumps) puts a lot of pressure on the outside of the knees, and knees are not designed for this stress. Don’t include this exercise in your routine. Avoid forcefully throwing the knee during a kick. Cue to press your kicks rather than power popping your kicks. Eggbeater kicks have a circular motion that puts a lot of torque on the knees. They are not recommended for a group exercise class.
1. Do Not Power Pop the Knees. 2. Eggbeater Kicks Put Torque on the Knees.
It is a good idea to stretch the quadriceps and hamstrings at the end of class. Cue the quad stretch properly: the thighs are close together and the knee points down to the floor, then lift the abdominals, press the hip forward and take the knee slightly back until a stretch is felt in the muscle. Do not cue to bring your heel to your buttocks, as this forceful end range of motion can cause a meniscus tear. A hamstring stretch can be done by lifting the knee, then extending the leg, which is easy to do with the help of the buoyancy of the water. Do not round out the back to increase the stretch. A hamstring stretch can also be done by placing the foot on the pool wall. Exercising your legs to keep your quadriceps and hamstrings strong will reduce your risk of knee problems later on.
Resources: Ruth Sova, MS – Feet Ankle Knees Mini Session 10-06-22
Pauline Ivens, MS and Catherine Holder, PT, Do No Harm, 2011
We use our hips all the time to sit down, stand up, and walk. The hip joint is a ball-and-socket joint that allows us to move our legs and at the same time gives us the stability necessary to bear the body’s weight. Unlike the shoulder joint, the socket part of the hip joint is extremely strong and dense with surrounding ligaments to keep the head of the femur (the ball part of the hip joint) in place. You rarely hear about a hip dislocation. To watch a short video describing the anatomy of the hip joint check out the John Hopkins Medicine website. Even though our hips are designed be be weight bearing, the extra pressure on the joints does make them more likely to develop arthritis. Other potential problems include bursitis and injuries because of a fall. Problems with the hip may show up as problems with gait, that is walking. Examples of gait/hip problems include:
Reduced step length (the distance you cover when you take one step)
Reduced stride length (the distance you cover when you take two steps, one with each foot)
Reduced walking speed; a slower gait increases the risk of developing a disability
Foot angle out of the line of progression (the toes point out or in instead of forward)
Transferring body weight from side to side
Quad dominance (the thigh muscles are overactive and take over for the glutes and hamstrings during squatting, lunging, running and standing)
Gluteal Amnesia (the muscles on the back of the hip are weak and not activated during squatting, lunging and running)
Difficulty with sideways movements caused by weak hip abductors
For all of these reasons, it makes sense to do exercises that keep our hips heathy and strong. There are 22 muscles that act on the hip joint. These muscles allow the hip to flex (lift forward) and extend, abduct (lift to the side) and adduct, rotate to the midline and rotate to the side. Since the muscles that lift the leg forward (hip flexors) are strong and often tight from sitting too much, it is important to emphasize extension over flexion. Here are some exercises for your hips to include in your water fitness class:
Lunge in all directions, using a clock face
Walking in all directions
Shallow water running and deep water running
Knee-lifts (emphasize extension)
Cross-country ski with rotation
Kick forward (emphasize extension)
Kick to the side
Inner thigh lift
In addition to strengthening the muscles of the hips, there are some cautions to help you avoid an injury:
Do jumping jacks with the toes pointed out in the upright position
Ballistic Hip Abduction. These are known as cheerleader jumps, but since very few activities requires forceful hip abduction, this move is not functional. Instead do jumping jacks. Make sure that the feet are parallel so the move is hip abduction. It is okay to change foot positions when doing jacks upright, but if the toes point out when performing suspended jacks, you are changing the move to hip flexion.
Ballistic Karate Kicks. When karate kicks to the side are thrown forcefully, there can be an injury in the labrum of the hip. Cue “control and press” so that the throwing action is eliminated.
Prone Flutter Kicks. Flutter kicks strengthen the hips and legs, but prone flutter kicks while holding on to the wall compromise the hands, hyperextends the neck, hyperextends the lumbar spine, and compresses the spinal discs. Performing the exercise with foam dumbbells does not improve these issues. The neck and spine are still hyperextended, and the spinal discs are still compressed. Instead, perform flutter kicks in deep water in a vertical position with neutral postural alignment wearing a deep water belt.
Abdominal pike and spine extension
Prone to Supine Abdominal Exercises use the hips to change positions, but they require accurate cueing. Going all the way to prone involves too much spinal extension and going all the way to supine involves too much spinal flexion. I have heard this exercise called by the amusing name of Sun Tan/Superman. But using this cue encourages going supine all the way and prone all the way. I prefer to call the exercise Abdominal Pike and Spine Extension. Bring the legs forward to a 90-degree angle in front, then tuck and extend the legs diagonally back, as in the pictures above. Wear a belt to do the exercise in deep water; do not do the exercise using just foam dumbbells.
Supine Crunch does not work the abs Limit the “L” Position
Crunches are not functional, but they do work the abdominals. The problem in the water is that we are not horizontal as are crunches on land. Instead we are in a reclined sitting position with the legs close to the surface of the water. Most people pull their knees to the chest, which is repeated hip flexion with lumbar spine flexion. This compresses the front edges of the discs of the spine. Also, placing a noodle under the armpits impinges the shoulder joint and risks damaging the nerves in the arm pit. Instead work the muscles of the core in a vertical position. See the previous posts Take Care of Your Shoulders and Take Care of Your Spine.
“L” Position. This position is a long lever in hip flexion and it is difficult to hold the torso in neutral. Limit the amount of time used in this position.
Kick too high
High Kick with Compromised Posture. Some participants try to increase the intensity of a high kick by getting the toes to the surface of the water. This causes too much spinal flexion and too much hip flexion. Instead, lower the kick so that the lumbar spine does not slip into flexion. Emphasize hip extension, the downward movement of the leg.
Finally, there are some good stretches you can do in the the water for your hips. Side steps lengthen the inner thigh muscles. Forward steps lengthen the gluteal and hamstring muscles of the forward leg and stretch the hip flexors of the back leg. Slow motion walking is good for balance and coordination. Swing one leg forward and back to stretch the hip flexors. Bend the knee when the leg swings back to lengthen the quadriceps. Crossover steps lengthen the outer thigh. Hip figure 8’s are good for hip mobility. Use a range of motion that is controlled and pain free. Take care of your hips so that you can continue to sit down, stand up and walk without difficulty into your golden years..
Resources: Ruth Sova, MS – Hips Mini Session 9-22-22
Pauline Ivens, MS & Catherine Holder, PT Do No Harm 2011