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.
If you start to fall, you have only milliseconds to react. Will your ankle muscles contract to correct your balance? Will your hip muscles contract to shift your center of gravity to neutral? Will you take rapid steps in the direction of the fall? As you get older, you may notice that you are a little slower to react than you once were. Slower reaction time increases your risk of falling. The good news is that it’s never too late to improve your reaction time. Two things you can do are: train for power, and practice reacting to an unpredictable command.
Train for Power. As we get older we lose power faster than we lose strength. Strength and power are not the same thing. Strength is how much force your muscles can produce; strength is lifting a heavy bag of groceries out of the trunk. Power is how quickly you can produce force; power is catching yourself when you trip, or stepping off a curb in time. Fast twitch muscle fibers are responsible for quick, powerful movement. With age, these are the first to be lost unless we give the body a reason to hold on to them. When you move with real effort or with speed in your water fitness class, you are calling on those fast, powerful muscle fibers. It may be tempting to take it easy in class, going through the motions while chatting with your neighbor. But if you want to strengthen those fast twitch muscles so that you can react to a potential fall situation, you need to push yourself. If you only cruise along comfortably, those powerful fibers are never called into action, and you slowly lose them. The beauty of water is that the faster you push against it, the more it pushes back, so it challenges you exactly as hard as you choose to work, and never any harder. Ease off and the resistance melts away instantly. Because the water supports your body, you can put real effort into your movement without jarring your joints. You can train for power with confidence. Pushing yourself means you are working, breathing a little harder, muscles engaged. Think short bursts of effort, then ease off and recover (intervals). You are moving with purpose and a little speed, not comfortably cruising or just going through the motions. Click on Cross-Country Ski for a short video that demonstrates pushing against the water by increasing range of motion, increasing speed, adding elevation, adding power, or adding rotation. Each variable is performed in deep water for 4 counts.
Practice Reacting to an Unpredictable Command. You need your instructor to help with this one. Events that lead to a fall are not predictable. In your water fitness class your instructor normally lets you know what is coming and gives you time to switch to the next exercise. Usually you perform that exercise for a sufficient amount of time so that you feel comfortable with it. When your instructor uses the Unpredictable Command technique, the movements are atypical and the change to the next move is rapid fire. When I use the technique, I do not have a specific script, but instead I make it up on the spot, so that it is always unpredictable. A sequence might look something like this: knee lift with the right leg, push the left hand forward, put the right hand on your hip, push the left hand forward and side, look over your right shoulder, press your palms together and look forward, jog with both feet, turn to your left, take 3 steps left and one step right, swing the left leg forward and back while making fists and stretching the fingers, make a fist with one hand and stretch the fingers with the opposite hand, go into a cross-country ski and clap one hand at a time, turn to your right and travel backward. You get the idea. Physical activity that combines movement with decision-making and coordination, requires balance, timing, and problem-solving. It challenges both the body and the brain simultaneously. So the next time you are in a crowd and someone steps in front of you unexpectedly, or you are walking the dog and he decides to chase after that squirrel, or you stub your toe on a change in elevation in the sidewalk, your reaction time may be just a little quicker.
See you in the pool!
Chris Alexander
Resources: Marietta Mehanni, “Why It Pays to Push Yourself,” 2026. David Ogden, The Unpredictable Command Technique, 2001. Ruth Sova, “Never Too Old to Train the Brain,” 2026, Ruth Sova, Balance and Fall Prevention, 2026.
Once you get your Medicare card your doctor will start asking if you have fallen in the past 6 months. And with good reason. Over 14 million, or one in four, older adults report falling every year, according to the CDC. Falls are the leading cause of injury and death among adults 65 and older. But falls are preventable. Here are 3 things you can do to improve your balance:
Understand your body’s balance systems
Practice seated stability
Practice standing balance
Understand your body’s balance systems. Your ability to maintain balance depends on three sensory systems, the visual system, the vestibular system, and the proprioceptive system. The visual system is your eyes telling you where you are in relation to your environment. The vestibular system is located in your inner ears, and it tells your brain about your head’s position in three-dimensional space. The proprioceptive system consists of specialized receptors throughout your body, and they detect what your muscles and joints are doing and sense pressure in the soles of your feet. When any of these systems are compromised, the other systems must take up the slack.
Practice seated stability. Improving your balance starts with sitting in neutral. Sit on a chair with feet flat on the floor, hip-width apart. Tilt your pelvis forward and back to find neutral. Tilt your pelvis side to side to find neutral. Place your hands on the side of your waist and your tongue behind the top front teeth. Inhale and exhale slowly, feeling your belly expand and then draw upward. This is diaphragmatic breathing. It improves core stability. You want to be able to hold this neutral position for up to 90 seconds at a time. Next shift your weight to your sitting bone on one side and hold for a few seconds,. Return to center, then shift to the other side. Shift your weight forward, leaning from your hips, and hold for a few seconds. Return to center then lean backward. Practice reaching one arm forward, to the side, straight overhead, and across the midline, all with minimal trunk movement. Closing your eyes, lifting one foot, swinging your arms, turning your head, and extending one leg are all challenges for seated stability. Try doing these challenges in the pool, seated on a noodle like a swing.
Practice standing balance. Stand facing a counter, feet shoulder width apart with weight evenly distributed on both feet, your knees slightly bent, your spine in neutral, and your gaze looking forward at eye level. Stand with both hands lightly touching the counter. Progress to fingertips barely touching, one hand touching, fingertips on one hand touching, then finally hands hovering near the counter. When you can do that, practice standing away from the counter, but near enough for safety, with feet hip-width apart. Progress to feet together with inner ankles touching, then a semi-tandem stance with one heel beside the arch of the opposite foot, and finally a tandem stance with the back foot’s toes touching the heel of the front foot. The goal is to hold the position for 20-30 seconds without losing balance. The next stage is single-leg standing. Stand beside a counter with both hands touching the counter and lift one foot 2-3 inches off the ground. Progress to standing on one foot with one hand on the counter, then one finger touching the counter, and finally no support. Train your balance systems by closing your eyes, tilting your head or balancing on varied surfaces, such as foam, grass or carpet. Take your balance practice to the pool, where buoyancy reduces fear of falling, viscosity slows movement for better control, and turbulence creates continuous balance challenges. Stand in the previous foot positions near the pool wall. Progress to standing on one foot with the eyes closed, then walking with high knees, heel-to-toe, in multiple directions, and backward. Practice weight shifting, reaching in multiple directions, and reaching while standing on one leg.
Your ability to stand on one foot for 10 seconds is a snapshot of your body’s integrated health. If you are unable to do so, you are at 84% risk of death from any cause over the next 7 years. The good news is that balance is trainable at any age. This article only skims the surface of what to do to improve your balance. Start where you are now and progress from there. For more information see Ruth Sova’s books Find Your Balance for individuals, or Balance and Fall Prevention for aquatic professionals.
Even before you begin to exercise, the water has an effect on your body. The hydrostatic pressure acts like a compression sleeve, reducing the stress on your heart and blood vessels. Circulation increases and blood vessels relax. That means your heart is able to pump more blood with each heart beat. Your resting heart rate slows down; so does your exercise heart rate. That is why your heart rate is lower when you exercise in the pool than when you exercise on land, even though you you are working just as hard. Your blood pressure decreases, and this effect may last for some time after you get out of the pool.
Circulation increases through all of your organs. This includes the kidneys which work more efficiently, increasing the production of urine. That is why you may have the urge to head to the locker room right after your workout. Circulation through the lungs increases too, which enables the blood vessels to deliver oxygen to the working muscles more efficiently. At the same time the water pressure against your chest strengthens the muscles you use to inhale and exhale. Circulation increases through the brain, providing nutrients that help with brain health.
Water conducts heat away from the body, When you enter an 84 degree multipurpose pool, you feel cool because the water temperature is lower than your body temperature. It doesn’t take long for most people to warm up once they start moving. With the water conducting your body heat away, you will likely feel more comfortable during your exercise session than if you were exercising on land. If you are one of those who continue to feel chilled, wearing a long sleeved top such as the ones sold by Hydro-Fit can help with that.
Buoyancy reduces your hydrostatic weight. Movement may seem easier than on land because you feel lighter. At the same time the viscosity of water requires an increase in muscular effort to move the arms and legs. There is resistance in all directions. You have a concentric muscular contraction no matter which way you move, which improves muscular fitness. The movement of water around your body acts like a massage, so most people do not experience muscle soreness after their water workout.
Buoyancy reduces stress on the joints, which helps reduce joint pain. Deep water offloads the spine, which is helpful for someone suffering from back pain. Water pressure reduces swelling, especially in the legs and ankles. Healing may occur more rapidly due to the influx of blood flow to muscles and tissues. That is one reason why athletes often rehab from an injury in the pool.
The properties of water make aquatic exercise extremely unique. And beneficial. And fun!
See you in the pool!
Chris Alexander
Resources: AEA Aquatic Fitness Professional Manual, 2026. Becker, and A.J. Cole, Comprehensive Aquatic Therapy. 2010.
The question of whether water exercise can help improve bone mineral density has been a subject of research for at least two decades. The question arises because the buoyancy of the water decreases the effects of gravity and reduces weight bearing. A body immersed to the waist bears about 50% of its body weight. A body immersed to the chest bears approximately 25%-35% of its body weight. A body immersed to the neck bears about 10% of its body weight (Aquatic Exercise Association, Aquatic Fitness Professional Manual). Therefore, since water exercise is not effective weight bearing exercise, then it been dismissed as unlikely to be beneficial for people with osteoporosis. The problem with this line of reasoning is that it fails to take into account the other recommendation that people with low bone density also engage in strength training exercise. Bone remodeling is stimulated by muscle contractions and moderate skeletal loading. The aquatic environment provides resistance in all directions, promoting muscle strengthening and muscle balance. Leader Tools, an AEA publication for instructors who teach arthritis classes, notes that “In a systematic review and meta-analysis, Schinzel and colleagues (2023) reported statistically significant improvements in bone mineral density at key skeletal sites (both the lumbar spine and femoral neck).” Even with reduced joint loading, muscle activation and moderate skeletal stress still occur, helping to maintain and even improve bone density.
Low impact does not mean low intensity. One of the most effective ways to overload the muscles is to use acceleration, that is to push against the water’s resistance with force. Be intentional about it. Stabilize your core in good alignment, then move any upper or lower body joint through its full range of motion in any plane – sagittal, frontal or transverse – or in diagonals, pushing hard. Add more resistance with equipment. Drag equipment, such as webbed gloves, paddles and drag bells provide resistance in every direction. Foam dumbbells offer resistance, but mainly toward the pool floor. Click on the links for brief video demonstrations of each piece of equipment. Avoid exercises that cause spinal compression which may lead to fractures, such as crunches, waist twists and lateral flexion (or limit the range of motion).
It is important to note that it takes 6 months of consistent exercise to start seeing benefits. Being consistent and committed to a physical activity regimen contributes to bone health. The American College of Sports Medicine recommends at least 150 minutes of moderate exercise each week, and two or more sessions of strength training. You might wish to include other forms of exercise in your regimen, such as walking or strength training on land, both for variety and to meet these exercise recommendations.
If you have osteoporosis, a good resource for information is the Bone Buddies Osteoporosis Support Group. The General Programming page describes their programs, which include free exercise classes, monthly presentations on topics pertaining to osteoporosis, healthy eating sessions with a registered dietician, ask the pharmacist sessions, and sessions with a psychology educator. The exercise classes include tips on how to perform daily tasks without risking a fracture. All of the programs are on Zoom, so you can tune in from anywhere in the country. The Resources page includes links to Michael Lavacot’s very educational YouTube videos explaining osteoporosis and comparing medications, among other resources. The Events page has the Calendar with the dates of all the individual programs for the next year.
One of the risks for osteoporosis is age, and none of us can avoid that. It makes sense to remain active throughout your lifetime to minimize the risks and manage your low bone density if it occurs. See you in the pool!
Chris Alexander
One response to “Water Exercise and Osteoporosis”
Candace Dominick
Hi
Good pictures of us doing aerobics with the paddles.
You are a great instructor. I get a really good work out.
Thanks
Which is better? There are differences in exercising in shallow water vs. deep water, but each has its own advantages.
Shallow Water. Nearly every pool that offers water fitness classes has shallow water, which is defined as a depth between mid-rib cage to mid-chest for most participants. This provides the benefits of both reduced impact and grounding forces that allow participants to maintain proper alignment and control. Shallow water provides resistance in every direction of submerged movement, which means both muscles in a muscle pair are trained. People who are limited because of impact concerns from land based training are able to exercise at an intensity to improve fitness. People at higher levels of fitness can train at higher intensities without experiencing increased musculoskeletal stress. Shallow water exercise burns calories comparable to land exercise. Wearing shoes provides traction and can allow for a more intense workout that burns more calories.
You can exercise at five impact levels in shallow water. Level I is performed in an upright position. Level II is performed by flexing the hips and knees to submerge the body to shoulder depth. Level III is performed without touching the pool bottom. Grounded movements are initiated in an upright position, but one foot remains in contact with the pool floor at all times. Propelled movement, or plyometrics, is jump training. People with osteoporosis can benefit from propelled movement because it involves some weight bearing. People with arthritis often find it more comfortable to exercise in water than on land because of the reduced impact.
You can train for cardiorespiratory fitness by increasing range of motion, increasing speed, and accelerating. You can train for strength by pushing against the water resistance or using equipment. You can train for core strength and balance by exercising on one foot or in other less stable positions, such as a tandem stance. Any kind of aquatic equipment can be used in shallow water. This includes buoyant equipment, such as foam dumbbells and noodles; drag equipment such as webbed gloves, Aqualogix bells, fins, paddles and Aqua Ohm; rubberized equipment such as bands and resistance tubing; aquatic steps; aqua poles; and aqua drum sticks.
Deep Water. Fewer pools have a deep end, but those that do have seen a growth in popularity of deep water classes. Deep water exercise is performed at a depth that allows the participant to remain vertical while not touching the pool floor. A flotation belt should be worn for neutral buoyancy, which allows the participant to concentrate on working against the drag properties of the water as opposed to trying to stay afloat. Participants can move freely in all three planes of motion, creating a total-body workout, muscle balance and a substantial challenge for the core muscles without impact stress to the joints. Heart rates in deep water are lower than on land or in shallow water because of heat dissipation, hydrostatic pressure and limited gravitational forces. Research shows that there is no difference in oxygen consumption in spite of the reduced heart rate. When comparing land and water exercises, similar exercises performed at the same intensity require greater caloric expenditure in deep water.
There are no impact levels in deep water because there is no impact. However you can exercise in various positions. Upright is similar to Level I. Seated, as if sitting in a chair, is similar to Level II. Elevating the body with a scull is similar to Level III. Single leg moves while keeping the other leg vertically extended is similar to Grounded movements. Accelerated moves that propel the body upward by using the limbs to apply force against the water is similar to propelled moves. In addition you can challenge the core with off-axis moves, such as leaning diagonally to the side or forward. People with osteoporosis are advised to include resistance training in their routine, and you can certainly perform that in deep water; however it is advisable to also include weight bearing exercise, such as walking, if possible. Arthritis classes are offered in the deep end for those who appreciate a completely non-impact workout.
You can train for cardiorespiratory fitness in deep water by increasing range of motion, increasing speed, and accelerating. You can train for strength by pushing against the water resistance or using equipment. Maintaining neutral alignment works the core for the entire class period. Not all kinds of aquatic equipment are appropriate for deep water. The equipment must float if you don’t want to dive down to the bottom of the pool to retrieve a piece of equipment someone dropped. Buoyant equipment, such as foam dumbbells and noodles, and drag equipment that attaches to the body, such as webbed gloves and swim fins, work well. Drag equipment that floats, such as Aqualogix bells, and rubberized equipment can also be used. Aquatic steps; aqua poles; and aqua drum sticks can only be used in shallow water.
Conclusion. It comes down to personal preference. Some people prefer to have their feet on the ground/pool floor. Some prefer the freedom of movement in the deep end. There is no right or wrong answer. For more information about shallow water and deep water exercise, see the AEA Aquatic Fitness Professional Manual. For lesson plans for both shallow and deep water see my book Water Fitness Progressions.
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