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CALA Post Rehabilitation Program

Question

CALA Certified Leader: Dawn ... posed the following question: I am working with a senior who had a very serious car accident about 15 years ago, she was not expected to live, but proved them wrong. Her humerus was badly broken and a plate was put in her arm(humerus area). When she does any water work involving her arms she says her arm will ache,(this arm is also weak), she will stop working and walk around the pool. I am wondering if she should have a sling on her arm and just work the other arm for approximately 1 week. I am also thinking about a sling while she is at home or give that arm support with a pillow when she is sitting. I gave her some exercises for home--shoulder rolls forward & backwards, shoulder shrugs, hugs, and keeping her shoulders in neutral position. I guess that the plate is creating some of the problems. Should I keep the exercises going for this arm to strengthen the muscles, or wait for about a week? I hope I have explained clearly enough.

Answer

Response from Charlene Kopansky, CALA Founder and President, Hons. B.Sc. Human Kinetics, B.Ed. P.H.E. & Sc., Master Trainer and International Presenter 

Response: I think it might be wise for this person to consult with their physician to see why there is so much pain in the arm area, 15 years post surgery. I think encouraging the client to listen to her body and stop exercising the affected limb if there is persistent pain, is a good idea.

Perhaps she also needs to see a physio. I can recommend Farhan Dhalla in the Health Centre, at the Fitness Institute Clinic ( 2235 Sheppard Ave East, Toronto, Ontario, M2J 5B5) Phone: 416-492-761.

Sorry to be so vague, but it sounds like she needs treatment by a physio who can prescribe specific exercises. I have forwarded your email to Connie J. and to Elizabeth Fox to see if they have other thoughts on your query (below).

You might also want to join the ATRI e-list (www.atri.org) . This is a fee service, where you can post your questions to the wide world and get responses from the wide world!

Response from Connie Jasinskas:
I agree with Charlene. I also think your client should be assessed by a competent physio who has a lot of experience with shoulder issues. From there, she will have a list of recommendations for movements to be encouraged and avoided.

Until she can have that done, she might try keeping the arm fairly still during cardio, in order to keep herself active. Gentle ROM of her arm within her comfortable range during MSE / stretch, might be OK. If she has developed neuropathic pain (ie: the structures have healed, but her body is on red alert to any movement in her affected limb) she may need some counseling about that, to help develop strategies that will help reduce her pain. She won't know whether it is neuropathic pain or not, until she is assessed.

Good luck to her and you. Cheers, Connie Jasinskas, CALA Master Trainer, M. Sc.

Response from CALA Trainer: Elizabeth Fox:
My very quick thoughts, with the very limited information available is that the lady has chronic pain. There are a variety of reasons she may have persistent pain 15 years later, and based on my caseload, chronic post-traumatic pain is really not that uncommon (I think the current figure is 20% of folks may go on to chronic pain post injury.)

So I think Charlene's advice is wise. A physio or a similar health care provider, might be the best source to recommend exercising through her pain if that is really what is needed. Otherwise she should do what she can and aim for very small incremental progressions each week or more likely every other week. As for the sling, I really can't think of a situation where I would suggest a sling in the water (other than maybe a hemiplegic shoulder, on occasion) Certainly if the arm is aching - supporting it while sitting makes good sense.

I would agree that a physio consult is likely in order, perhaps even to clarify goals - is improving the pain a reasonable goal or really is education needed about better managing the pain and this is where the pool comes in?? Certainly you can improve strength and function, which may or may not change the chronic pain. Cardiovascular exercise is also an important component of chronic pain management. Improved overall cardiovascular conditioning can also improve overall function, which still enhances quality of life, although, the arm pain may not have changed.

My thoughts for what they are worth. Hope that helps. Elizabeth Fox Physiotherapist BA(H)Kin, BScPT, MScPT

Questions
Hello to the CALA team
It was my understanding that we can encourage participants without health limitations to work at their maximum range of motion. Specifically suspended ski, referring to shoulder and hip extension. (cuing reaching to the back wall).
Today, a participant questioned why I use this cue. She has been corrected by other instructors that the hip extension in particular, should only go to 45 degrees, and that she is reaching too far back.
I explained that in my view if the other instructor had concerns it may have to do with ability to keep the body core stable, and not twisting, or that the larger ROM may cause discomfort to some participants if they are going past what is safe for them individually, or maybe that reaching too far back would compromise the power posture and create low back hyperextension.
I just want to confirm that I did not misunderstand the instructions and that it is safe for participants to work to their comfortable ROM. keeping in mind that the resistance be kept in a safe range as well as speed.
I just wanted to make sure my response was appropriate. I try to make sure that if instructors give different information to a client that I try to explain my point of view without contradicting the other instructor.
Thanks in advance for clarification with this matter.
CALA certified leader, Ontario

Answer
You are absolutely correct. While maintaining the power posture, with a stabilized core and all the other goodies you mentioned, keeping in mind zone of comfort, we are recommending that participants find their comfortable range of motion and work within it.
Generally speaking the population has underdeveloped the hip extension phase of movement, thus injuries happen with slips and falls or during activities that require good flexibility at the hip joint.
I can only see that limitation being appropriate for certain clients, who would have learned through experience that they need to control their ROM in hip extension, as it might exacerbate an existing problem or a problem that flares up when they do hip extension. Usually it is a case of not maintaining core stabilization with level pelvis....
Hope that answers your question. I am assuming you were talking about a regular class! 
Charlene Kopansky

Question:
Carpal Tunnel Syndrome: I have someone with Carpal Tunnel Syndrome in my aquafitness class, is there anything I should not have her do in the water? Her doctor said not to do any punching motions. 

Answer  by Connie Jasinskas:
First, consider the “Scope of Practice” guidelines (from the CALA Healing Waters course): 
* Do no harm: whatever exercises you give her, they should not increase her pain or worsen her condition
* Do not alter prescriptions assigned to your client by the medical community (without communication between yourself and the person who prescribed the treatment, with the client's permission for such communication). Her MD has said, "no punching motions", and that is to be respected.
* Do not prescribe: I would ask the client what she has been told she CAN do / SHOULD do to improve her condition. If she has no idea, perhaps she should see a physiotherapist / osteopath / rheumatologist / chiropractor in order to determine what her best course of action is.
* Until comprehensive medical advice regarding movement prescription / contraindication is available, I would suggest the following:
1. Focus on functional posture throughout all movements / while stabilizing: scapular set; proper cervical alignment with ears over shoulders; neutral pelvis, stabilized by transverse abdominals, pelvic floor and multifidus.
2. Have her maintain a functional, neutral, pain free position of her wrists throughout all gross-motor activities. Just maintaining her wrists well-aligned while doing other activities in the water, she will receive a mild training stimulus to the wrist stabilizers. If she has trouble doing this, she may need the wrists braced while exercising in the water (something she can investigate with her medical team). NOTE: Specific exercises for the wrists should be prescribed by her medical team.

Question:
Aqua Running:
I want to know if there is a difference between Aqua Running and Aquajogging. Is Aqua Running more specific? I know that "to jog" and "to run" are very different, but, in the water, these differences may seem superfluous.

Answer by Charlene Kopansky:
When I co-wrote the resource and training manual for this specialty course, the team of writers decided that both joggers and runners would benefit from the training effects of exercising in water. To avoid minimizing the market, we decided to include both 'names' in the manual. When training in deep water, zero impact, the biomechanics of running and jogging are very similar. There is no ground reaction force when running in deep water hence the actual running form is modified to suit the aquatic environment. The good news is that the specificity of training remains high, from water to land. If on the other hand, one is training in chest or shoulder deep water, there is impact involved and this affects the biomechanics of water running and aqua jogging. Get into deep water, with an appropriate flotation belt and try simulating the jogging action and the running action. How does it feel? What changes did you make to the biomechanics of your movements? Try the same experiment in chest deep water. Try running at a race pace, what happens to the landing phase of your movement?

Question from Sheila :
I have a degree in Kinesiology. I have never heard of double positive muscle activation. Could you explain more about it?

Answer from Charlene CALA Founder and President:
Thanks for reading the articles on our web site. I also have a degree – Honours Biological Science with my major in Human Kinetics and a degree in Education. The double positive muscle activation refers to the following: When immersed to shoulder depth: performing knee extension and flexion: the quads will activate concentrically during the knee extension phase; the hamstrings will activate concentrically during the knee flexion. This is due to the fact that the 'location of the load changes' - water is all around the body, you are constantly pushing and pulling it (multidirectional resistance). The 'nickname' for concentric muscle action is positive muscle activation. The nickname for eccentric is negative muscle action. The lack of soreness is because of the balanced work: double concentric or double positive. While the quads are working concentrically, on knee extension, the hams are releasing - getting a fresh blood supply - so the lack of eccentric is the same as saying double concentric or double positive. Just a different way of saying the same thing. During our CALA Foundation Course, we do discuss the lack of eccentric muscle work during most movements in water.

Response from Sheila:
No, it still doesn't make any sense, are you talking cardio component or muscular component? I thought that in order to actually gain muscle strength, you must have a concentric and eccentric phase. I also do not understand the reference to a “release of muscle tension”.

Answer from Connie Jasinskas:
A “Double positive” muscle activation isn’t necessarily  the technical terminology for what happens, but it beats saying “concentric-concentric”. 
B Double positive or “concentric-concentric” muscle activation means that eccentric muscle work is reduced or absent, and therefore, DOMS is reduced or absent.
C There is a "release of muscle tension" when using the opposing muscle group. Refer to the work of Dr. Herman Kabat (mid 1950s), based on the work of Dr. Charles Sherrington. Sherrington’s Laws of muscle activation ‘Reciprocal Innervation / Inhibition”, states, ”a reflex loop mediated by the muscle spindle cell …causes one muscle to relax (be inhibited from contracting) when the opposing muscle (the antagonist) contracts. This allows movement to occur around a joint. For instance, when the quadriceps muscle contracts, the hamstring is reciprocally inhibited, thereby allowing the knee to straighten”. Source: Facilitated Stretching, R. E. McAtee, HK press 1993. If the antagonist did NOT relax when the agonist activated to cause movement, we would be constantly tearing antagonistic muscles, or be locked immobile in isometric cramps.
Re: Your statement: To actually gain muscle strength, you MUST have a concentric AND eccentric phase. This is not true, otherwise, gains in strength could not occur in the water, or with hydraulically braked exercise equipment.

Question from Janet:
There has been some controversy at our pool about hand position during a breast stroke. One person is saying that the thumbs can't be down during the pull back, they must be up, or it is not a healthy action for the shoulder. If this is so, we must have a lot of lane swimmers hurting their shoulders!

Answer from Connie:
Either move is possible for the shoulder joint, and I am not aware of any danger inherent in a 'thumbs down' breast stroke pull-back. However, in this action, the shoulder joint is medially (internally) rotated. Many people are habitually in this alignment due to working on computers and other forward- focused manual activities. It is often wise to counteract this habitual postural misalignment during physical training activities. If possible, to try to restore more functional alignment to the shoulder joints and shoulder girdle.

Question
What can be done, when participants concentrate more on conversation than they do on working out?

Answer
“I have found one solution to participants talking during class: I have told them to find a place where they have a lot of room to manoeuver. Once they know the movements, I tell them to close their eyes and concentrate on that movement and on their stability. I have found that this makes participants work harder because they are more aware of when they start to get lazy. Every so often, they can open their eyes to make sure they are not getting too close to each other and/or the edges of the pool. This technique really does make a difference. I have tried it and it works! Not everyone is closing their eyes when I ask them to. I think that with time they may get to like the challenge it offers. It may be fear of the unknown that is holding some of my participants back. My reason for using this technique for myself was to experience the session the way a blind person would. I could not believe how much harder I worked and how aware I was of every movement. Doing this exercise allows the mind to rest and as a result, tension seems to leave the body.
Why not try it yourself, then try it with your participants - the mouth stops, the mind focuses and the physical results are amazing.”

Question
Dear Connie,
I recently took the Cala Aqua Natal Course, which was very interesting, and have two questions to ask you with regards to pregnant participants. Your feedback would be greatly appreciated; I thank you in advance for your help. Kindest regards, Nadia Karawani
Is the supine (floating) position permissible in the third trimester of pregnancy, or should it be avoided? I know that on land, it should be avoided; in water is there any risk involved? 

Answer
In the water, you don’t have gravity acting on the abdomen, compressing the inferior vena cava (this is the problem on land). Therefore supine is not a concern in the water, with respect to circulation. Doing a lot of supine work, however, can cause neck strain: I do little of it— other than the occasional stretch, or “snow angels” for range of motion at the hip and shoulder.

Question
In deep water, if a pregnant participant cannot tolerate the aquatic belt, what other options can I offer her? I know that one option would be to ride a noodle; could a participant also use foam dumbbells under each arm—limiting the time to 10 minutes in order to prevent strain of the shoulder girdle joint? Is this a viable option, or would it be better to use the pool wall?

Answer
My preference would be to 'ride the noodle' if the belt is too uncomfortable. I know some women who wear the belt above the belly, and some who wear it below. The participants can ‘play’ with those options and make the best choice for themselves. Sometimes, if a client has enough body fat, she may pass the float test (float in a vertical “T” position, arms out to the sides and still, legs straight down and still). If the participant does not sink to below her chin and neck, she will not need a belt to work in the deep end. The use of dumbbells under the arms is not recommended: it impedes circulation to the hands, and can put pressure on the delicate plexus of nerves in the arm pit. If none of the above options work, and a belt is too uncomfortable, I would suggest exercising in shoulder to chest depth water until after the pregnancy is over.
Hope that helps, Connie Jasinskas, CALA Master Trainer

Question
The Pregnant Aquafitness Participant:
I have a pregnant woman in one of my water running classes and her doctor was saying to her that her maximum heart rate would be lower because she is pregnant. Do you know how to calculate maximum heart rate for a pregnant participant? Could you give me some idea of how hard she should be working?

Answer - Compliments of Connie Jasinskas, M. Sc., CALA Master Trainer:
Access the wisdom of Dr. James F. Clapp, Exercising Through Your Pregnancy, HK Publishers, 1998, p 27: “To assume you can use a standard target heart rate formula... as a satisfactory guide for assessing the safety, health effects, and training effects of any exercise regimen during pregnancy seems unwise. During pregnancy, the exercise heart rate has value only when it is continuously monitored, interpreted in the context of pregnancy, and compared with serial measures that reflect exercise intensity and physiological effect (how hard it feels, oxygen consumption, fetal heart rate response, fatigue, and so on)... In summary, no matter what her age or what stage she's at in pregnancy, how a pregnant woman feels before, during, and after a workout appears to be a better index of her health, safety, and quality of the workout than her heart rate response." From my experience, monitoring Heart Rate in the water is next to impossible unless the subject is wearing a waterproof heart rate monitor. Perceived exertion at a "somewhat hard" level is where she wants to be. As long as she has a healthy, uncomplicated pregnancy and is cool and comfortable, she can safely go up to 'hard' intervals, according to Dr. Clapp.

Question
Exercise Design for Breast Cancer:
I have several participants who are recovering from Breast Cancer treatment that involved varying degrees of tissue removal. The mobility in the upper body is affected, especially in the shoulder, upper back, arm and chest regions. What exercises would you recommend?

Answer - Compliments of Connie Jasinskas:
Any and all CALA arm movements are great, since they provide a variety of joint angles and forces for the arms and shoulder girdle. Emphasize a 'scapular-set' for all upper body exercise: roll the shoulders up then back, then down, and fix the scapulae (shoulder blades) low and centred toward the mid back. This is the strongest, most functional position for upper body work. The thing that needs to be emphasized for Breast Cancer clients is FULL range of motion of the shoulder joint, so the stretch section at the end of class could be increased if water temperature allows. Do a number of slow stretches overhead, interspersed with shoulder girdle adduction and abduction (round the shoulders & rotate the humerus inward, then pull the shoulder blades together, open the chest, and rotate the humerus outward by pointing the thumbs back). They could also be given some extra stretches to be done in the shower. An excellent one is to stand with your hip next to a wall (your feet parallel to the wall), and with a straight arm, trace a circle on the wall from your hip at the front ... all the way overhead...to your hip at the back. Standing close to the wall is more advanced, standing farther from the wall is a gentler stretch.

Question:
What kind of quad stretch do you recommend for people with knee problems? They cannot really bend the knee too much, let alone grab the ankle.

Answer:
In chest deep water, have the participant stand in a ski position (one leg forward, one back), then cue the following:
• pull forward with the arms using a unison breast stroke movement, so the body is balanced over the front leg of the ski stance,
• lean forward slightly in the torso, and bring the back foot off the pool floor,
• then, bring that same heel up toward the surface of the water. No need to hang on to the heel. Note: Buoyancy will help bring the back leg up toward the surface, stretching the hip flexors and quadriceps muscles of the back leg. 

In deep water:
• get into a ski position and hold this position,
• press front leg up toward the surface & dorsi-flex ankle (stretching hamstrings, gastrocnemius & soleus of front leg), 
• pull back knee BACK behind hip; back foot up toward surface of water, stretching quadriceps and hip flexors of the back leg,
• scull with hands and arms to maintain vertical balance. After ~10 - 15 seconds, split the stretch further (open the legs). Repeat this 2 - 3X before changing sides. Again, no need to hang on to the back foot. The knee is not in danger of any inappropriate forces.

Question
What does (I am not sure if I remember the term properly) diastasis recti mean?

Answer: by Connie
This is a separation of the rectus abdominis muscles during pregnancy. The connective tissue running between the two halves of the rectus muscles softens in response to the hormones of pregnancy (relaxin). If the abdomen is profoundly stretched, the two halves of the rectus muscle will tend to take the shortest route when the rectus abdominis muscles are activated. This means they will tend to move laterally to travel a straight line from the sternum to the pubis,and not have to work over the large expanse of the abdomen. The split can be made worse by doing aggressive abdominal work (ie: crunches on land) once the split has begun. Aqua natal exercise does not place the same forces on the rectus muscles, providing aggressive tucking actions are not performed. Therefore, it is a useful way for women who are experiencing diastasis recti to maintain core strength.

Question
In the CALA Basics Manual, Chapter 6, page 40. It says that lactic acid build up is not involved in DOMS. What is the reason for DOMS? Is it the microscopic muscle tears from repeated eccentric contractions only?

Answer: by Connie
My understanding is that the exact cause of DOMS isn't fully understood/proven, but we do know that it isn't lactic acid, because that is metabolized during recovery. The “muscle tear” theory seems one of the most likely, and it includes evidence that there is cellular swelling (lymph dealing with the injured tissues)... resulting in that “tight feeling” one gets after vigorous exercise.

Question:
What is the result of lactic acid build up in the event that active recovery was not done after vigorous exercise?

Answer: by Connie
My understanding is that the lactic acid gets metabolized anyway. Active recovery enhances circulation and the recovery process at a cellular level. Active recovery is more likely to enhance performance when it is not at the end of a workout, per se, but used as a rest interval, with more work to follow.

Question
Jennifer Oman asked a question about including stretching during the warm up phase of a class.

Answer:
Stretching at the beginning of a class, or after a warm up is not currently recommended on land. Add the thermal conductivity of water and you have an even stronger case against pausing to stretch. A pause to stretch would allow the muscles which have just been warmed up to get cold. Then trying to get the muscles to stretch seems like a juxtaposition. We all know the relationship between cold muscle tissue and the ability to stretch. Also, the energy level which is built during the warm up to motivate and focus the participants may slip if a stretch portion is added. Include 1/2 tempo* and, or 1/4 tempo full range of motion movements in the warm up along with tempo movements. During the 1/2 and 1/4 tempo, dynamic stretching can be integrated. For example, large full range of motion walking at 1/4 tempo, with a cue to keep the heel on the pool bottom for as long as possible ( within the music) before starting the next step. Encourage toe-ball-heel landing and you will have designed a dynamic stretch of the gastrocnemius and soleus muscle in the calf region. *Tempo guidelines are based on music between 118 and 126 beats per minute. A Tidal Wave - Volume I Music Tape, 90 minutes of the correct tempo, suitable for Aquafitness, step, gentle aerobics and muscle conditioning is available for purchase through CALA. 

Question
Dear Charlene: I need some advice on water depth... In each group, I always have 5 participants who are short compared to the other 20. They have a lot of trouble handling the water, which is about to their neck. If I lower the floor (it's a one level pool with a moving floor), the other 20 participants have water about to the chest, even lower for some. Last week, I adjusted the water to the shoulder level of the short people, but the tall ones didn't have enough water to work with. Moves like TARZAN and the FLASHER didn’t work for the taller people. Some participants bent their knees, and others hunched their shoulders forward in order to do the moves with their arms under the water. Neither of these alterations are safe or effective for my participants. Should I adjust to the chest of the shorter people, so that everyone can enjoy the class? Or should I maintain the level higher of water and penalize the shorter people? My-Linh Diep, CALA graduate

Answer:
Dear My-Linh: My recommendation is to keep the floor at a level where the majority of the class is armpit depth and all arm moves work well for them. Give the 5 shorter people a deep water belt. With the flotation belt they can perform the movements suspended and water depth is no longer an issue. However, you will have to offer choices for deep and chest deep movements, when leading. As you know the ‘horse’ and ‘pendulum’ moves do not work in deep water, so you will have to instruct the people who are suspended to do other moves which work in deep water like cross country ski or jumping jack. If you do not have aqua belts, then the participants can order some from H2Owear. I have found that many participants appreciate the opportunity to have their own flotation belt and feel proud to bring it to class. I hope this helps you. I like the question and believe it is a common problem with pool depth and varying heights of participants. Good luck!

Aqua Flotation Belts can be purchased through H2OWear.  http://www.h2owear.com/H2O-Wear-Flotation-Belt/productinfo/FBLT/ 

Detailed Description
Feel secure and relaxed for your deep water workout. Custom-molded, non-chafing flotation belt is designed for comfort and freedom of movement. Adjusts to fit waist sizes 28" to 60".