As Harriet walked to the corner of the pool during her Arthritis Foundation Aquatic Program (AFAP) class she saw a pair of brand new webbed gloves lying on the side of the pool. As her fitness level had increased over the past few years of participation in the program, Harriet was looking for more of a challenge in her workout.  These webbed gloves peaked her interest. She inquisitively asked her instructor, “Sue, can I use these gloves for this exercise? Won’t it make me stronger?”

Sue was forced to reply, “Sorry Harriet, but those aren’t an approved piece of equipment for the AFAP Program.”  Harriet grumbled and headed back to her corner, frustrated that she can’t advance her level of fitness in this program, even while she is under supervision.

Situations like Harriet’s are what made the AFAP multidisciplinary committee consisting of experts in the field of exercise, therapy, aquatics and safety consider adding upper body resistance equipment, flotation and assistive devices to the Arthritis Foundation Aquatic Program.  Participating on the Arthritis Foundation’s AFAP Review and Revision committee offered both challenges and rewards. Exciting new research, information and practical knowledge regarding arthritis has grown in leaps and bounds over the past several years. Our challenge was deciding how we could apply this research to the core foundation of AFAP, while ensuring the safety of our participants and promoting good health and ease of disease symptoms.

As the committee gathered to confer about the optional use of upper body resistance equipment to the program, a lively discussion ensued. Will this harm our participants? Can they do this without worsening their arthritis? If we do it, how do we add it safely? What equipment do we recommend based on the evidence provided to us through research? Will these devices aid in symptom management?

Teaching the AFAP program for many years led the experienced instructor to believe this was not only going to be safe and beneficial, but also a welcome, refreshing change for the class participants. They would benefit both physically and mentally, as would our instructors who are always looking for new ways to refresh the AFAP movements.  Instructors were surveyed nationwide prior to the committee’s formation in regards to all areas of the existing program.  One message resounded from across the country: “Please, add equipment!” Adding equipment required much time reviewing the literature to maintain an evidence based program that would ensure safety for participants.

A pilot project was initiated that would incorporate the use of equipment to the exercises already established in the AFAP program. With full support from the facility, The William G Rohrer Center for Healthfitness at Virtua Health in Voorhees, NJ, as well as the Arthritis Foundation, we began the 13-week project using gloves, mitts and two types of arm resistance trainers.

This facility runs 14 highly successful AFAP classes weekly. Each class reaches up to 15 people and the advanced class targets up to 20. Out of approximately 200 people, we had 22 women practically jumping out of the water, eager to participate.  The requirements were simple: attendance in the AFAP program twice weekly for 3 full months prior to the study and clearance from their doctor. Their consistent attendance would ensure the participants were familiar with the class exercises and activities, and thus, could perform them with complete accuracy without the added equipment. Medical clearances were obtained, several from rheumatologists, all with no restrictions. The study had a good range of ages (61-88) and a variety of medical conditions and arthritis types, with osteoarthritis being most prevalent. 

The participants were pre-tested using the Senior Fitness Test program, a research based battery of tests to assess the major fitness parameters associated with functional mobility. The tests are based on what researchers call a “functional fitness framework”. These indicate functions required for basic and advanced activates that include walking, stair climbing, standing up from a chair, lifting/reaching, bending/kneeling and Body-Mass-Index. (Rikli, Jones 23)

The equipment used in the study ranged from mild to medium resistance. Listed in assumed resistance order, we used the following: Aqualogix yellow bell, Speedo Hydro Resistance Arm Trainer, a standard Lycra webbed glove, and the H20 Wear newly Hdeveloped “FittMitt.”  The FittMitt is oven-mitt shaped and fits over the hands of those with severe arthritis without the restriction found with individually fingered webbed gloves. Equipment was assigned to each participant during the pre-testing appointment with medical limitations taken into consideration.

The participants were filtered back into their respective classes performing the same AFAP movements as the rest of the group, but now with the use of their equipment. The equipment was added on a graduated scale of 10 minutes per class, per week, until most participants were continuously using the FittMitt and webbed glove for a full 50-minute class. Our instructors who teach the classes are seasoned, the majority having taught AFAP for over 10 years with a loyal following. The instructors maintained weekly contact, discussing each of their participants, expressing concerns and even adding more difficult equipment progressions (for example, webbed gloves to Speedo bells for specific exercises). This was done through the request of individual class members and the approval of the instructor and the pilot supervisor. The progression was not always possible due to some people’s physical limitations.

 A large component of the project was the Weekly Participant Feedback Sheet. On this sheet the participant commented on the individual piece of equipment, along with personal feelings on how her body was managing the added resistance. This was most interesting to review. The majority of participants were excited, feeling both mentally and physically challenged. Many initially expressed feeling resistance, muscle achiness and some difficulty, but that was attributed to the body’s adjustment to resistance training. Once into the 4^th week, the majority of the weekly comments were overwhelmingly positive. The initial physical discomfort disappeared except when equipment was progressed to something more difficult. We attributed this discomfort to the body’s normal reaction to added resistance in exercise.

At the end of the 13 weeks there were 16 remaining participants. It is important to note that of the 6 that dropped out, not one was due to injury or difficulty in the use of equipment. The reasons varied from other medical conditions that required treatment to membership cancellation.

The overall results are as follows:

• Chair Stand (leg strength) Increase by 13%
• Arm Curl (arm strength) increased by 24%
• Sit & Reach (hamstring and lower back flexibility) increase by 7%
• Back Scratch (upper body flexibility) increase by 13%
• 8 Foot Up & Go (agility and coordination) increased by less than 1%
• BMI showed no change

The results were divided into 4-year age group increments from 61-88. All age groups made progress in four areas, with the highest increase in the arm curl category. This was expected, but still a pleasant surprise. Increase in leg strength was not anticipated, yet there were many comments from several participants that the added resistance made them more aware of the body position and posture while trying to maintain stability in the water. Standing “strong” may have contributed to this increase. Also, the increase in drag while wearing a glove on the body during the water walking movements may have also contributed to these positive results.

It was a pleasant surprise to see the increase in both upper and lower body flexibility. Using the equipment makes one acutely aware of the execution of the movement. Most of our participants have performed the same movements over and over again for many years, and thus simply become lazy in the implementation of the exercises. Refining the exercise and going for the full, strong range of motion (ROM) may have been a factor in the increase in flexibility. In other words, concentrating on an exercise really does make a difference! They seemed to enjoy the mental challenge the equipment brought to the program.

There was overall a minimal change in agility and balance. The participants themselves did express a strong feeling of improved overall trunk strength and improved balance. They certainly had to stand in a more mindful position of postural awareness in order to use the equipment correctly through a full ROM.  Therefore, the feeling of confidence coupled with improved postural awareness translated into a positive image of improved core strength and balance.

Great emphasis must be placed on the importance of knowing the participants. We never underestimated the acute observation and encouragement of each class instructor in our project. They were heavily involved, assuring that the participants they knew so well were neither “overdoing nor under-doing” the exercises.  The class instructor and participant must agree on the specific equipment added, carefully taking into consideration the diagnosis, limitations and ability of the individual. Once the decision is made, the instructor now must be even more observant of each person’s movement. During the study, we initially saw exercise movements being compromised. For example, the lack of upper body strength resulted in shortened levers, shoulder elevation and a smaller ROM. The instructor must guide the participant into the proper form, allowing for a possible slower repetition and more thoughtful movement. If necessary, the instructor should recommend less resistive equipment or a return to no equipment.

The recommended equipment must be incorporated into the program progressively. For example, for the first week of the project (or first two classes) the participant uses the glove for 10 minutes or for only a small number of repetitions for specific exercises.  The second week the participant uses the gloves for 15 minutes or for only a slightly larger number of repetitions for specific exercises.  This continues until the desired level is reached and follows the same general format recommended in the current AFAP program that does not incorporate equipment. It is important not to allow the participant to use the equipment for a full hour the first time. This sets the participant up for possible injury, disappointment and discouragement. 

Please note that adding equipment slows the movement down. The participant has to be coached to not rush the movements they had so easily performed without equipment. We saw a period of adjustment and encouraged a self-paced workout through a full ROM.  Basic understanding of each exercise and how the body reacts to the exercises, while allowing the body to form a base level of strength, is essential before participants begin a more advanced resistance workout. The instructor must be certain each participant not only performs each AFAP exercise correctly, but is able to perform the movements through the variations as indicated in the AFAP manual.

The initial addition of resistance to the exercises through all other options, such as water speed and hand position, in the correct manner should be practiced and observed during the class. Once the instructor is assured the participant has a good mastery of the movement, the idea of optional resistance can be introduced.  The AFAP instructor manual does offer a clear explanation of each exercise, including the variations to increase resistance without the use of equipment.  Those exercises that allow the option of added equipment are clearly indicated, and should be followed precisely.

As always, if there is any question on the participant’s ability to add any of the specific AFAP optional equipment, please have him/her consult with their healthcare provider. The healthcare provider is the ultimate guide for both the instructor and the participant. The criteria for equipment usage in the AFAP program are clearly and precisely explained in the newly revised 2009 manual. The current instructor, and those interested in certifying for the AFAP program, can be assured that they will be guided through the implementation of equipment in a safe and positive way.

Harriet’s story has a positive ending.  At age 84 and a retired nurse with osteoarthritis, she notes, “I feel stronger in my arms and shoulders. I have less pain, more strength in my muscles, better ROM in upper body and my balance is improving. I am greatly motivated and exhilarated after my water exercise.”

Another female participant, age 61, who suffers from Fibromyalgia, also had a positive experience using equipment as a part of the AFAP program. She states, “I feel stronger in my wrists, arms and shoulders. Using equipment has brought some newness to the program, which helped give me a fresh perspective on the exercises and gave me new-found confidence. Physically, I am stronger and I can do more! This helped me make a new discovery about my Fibromyalgia.  Because of this pilot program, I discovered that using my muscles more actually helps to relieve the pain!  Thank you for the opportunity to be in this program.”

Without Harriet’s and other inquisitive voices in our classes, we may have never uncovered the added benefits that equipment can provide our AFAP participants.  We were all very excited to see what happened in our AFAP Equipment Pilot Project. The addition of optional equipment use in the AFAP program should leave your existing classes thrilled and entice many new participants to this fun, newly revised version of AFAP.

Each AFAP instructor must be recertified in the newly updated 2009 AFAP program in order to teach it. Please go to http://www.arthritis.org/ in order to contact your local chapter concerning certification or recertification.