Aquatic Exercise Programming

for People with Multiple Sclerosis

MATERIALS FOR AQUATIC EXERCISE INSTRUCTORS
Edited by Deborah P. Hertz, MPH, National Director, Medical programs Clinical Programs Department
National MS Society, New York, NY. 212-476-0468.

Contributors: Helen Tilden, RN, National MS Society, Georgia Chapter Clinical Advisory Committee and National MS
Society, Special Project Consultant

Miranda Mirsec MA, CES, National MS Society Southern California Chapter Programs Manager,
Physical Health and Recreation

Brian Hutchinson, MS PT, President, Heuga Center and National MS Society Clinical Consultant

December 2003

The Professional Resource Center

The Professional Resource Center (PRC) of the Clinical Programs Department supports the work of
health professionals by providing a range of library and literature search services, as well as information
and consultation about the disease and its management, insurance and long-term care issues, and the
Society’s professional education opportunities.

For more information:

• Toll-free number: 1-866-MS-TREAT (1-866-678-7328)
• Email: [email protected], [email protected]
• Professional website: nationalMSsociety.org/For-Professionals/Clinical-Care

Acknowledgements
This manual has developed over time thanks to the efforts of many Society chapter staff and volunteers.

Connie Divine, TRS, Patricia Finlay, McSP/PT and Helen Tilden, RN, of the Georgia Chapter, developed an aquatics manual
in 1993 that was subsequently adopted as a national model.

The vision for the new format came from Denise Nowak, RD (certified by the American Council on Exercise) and Miranda
Mirsec, MA, CES of the Southern California Chapter.

A special thanks is also due to Amy Brown (Mid South Chapter ), Suzanne Carrone (Gateway Area Chapter), Connie Nesbary
(Michigan Chapter), and Jo-Ellen Zembruski (New York City Chapter) for their input.

Brian Hutchinson, MS, PT, National MS Society Clinical Consultant and Nancy Holland, EdD, RN, MSCN, Vice President,
Clinical Programs Department reviewed this manual.

Front cover photo: Robert, diagnosed in 1990

© 2016 National Multiple Sclerosis Society.

Contents
Aquatic Programming for People with MS................................................................................................. 2
Why Water Works?!?...........................................................................................................................................................2
Aquatic Programs for People with MS.........................................................................................................................2
Benefits and Considerations of an Aquatic Program.............................................................................................2
Focus on Function.................................................................................................................................................................3
Strategies for Adapting Movement............................................................................................................... 3
Using the Physical Properties of Water.......................................................................................................................3
Considering Functional Levels........................................................................................................................................4
Body Mechanics.....................................................................................................................................................................4
Impact Options for Aquatic Exercise............................................................................................................................5
Use of Equipment..................................................................................................................................................................6
General Exercise Principles..............................................................................................................................................8
Exercises for People with MS.......................................................................................................................... 8
Marching/Alternating Knee Lifts...................................................................................................................................9
Side Steps..............................................................................................................................................................................10
Static Hamstring Stretch.................................................................................................................................................10
Active Chest Stretch..........................................................................................................................................................11
Trunk Twists—Spinal Rotation...................................................................................................................................11
Leg/Hamstring Curl..........................................................................................................................................................11
Walking..................................................................................................................................................................................11
Pelvic Tilts.............................................................................................................................................................................12
Cross Country Ski...............................................................................................................................................................12
Rocking Horse.....................................................................................................................................................................12
Straight Leg Walk...............................................................................................................................................................13
Side Tilt/Lateral Weight Shift.......................................................................................................................................14
Additional Exercise Options..........................................................................................................................................15
Class Structure and Cueing............................................................................................................................20
Lesson Planning................................................................................................................................................23
Cueing...................................................................................................................................................................24
Music.....................................................................................................................................................................24
Pool Safety and the Environment................................................................................................................24
A National Multiple Sclerosis Society Aquatic Program......................................................................26
Objectives..............................................................................................................................................................................26
Aquatic Programming for People with MS
W H Y WAT E R WO R K S ?!? with MS provides an opportunity to maintain
Water is a very inviting exercise environment mobility, prevent secondary symptoms of
for many people with MS. Cool water MS, maintain or improve flexibility, maximize
temperatures—80-84 degrees Fahrenheit— muscle strength, and maintain or increase
helps to keep core body temperatures low, endurance potential.
reducing the chances of overheating. As
mentioned in Intro to MS for Fitness and The recommended pool temperature for an
Wellness Professionals, overheating can cause aquatics program for people with MS is 80–84
temporary worsening of MS symptoms. degrees.

The natural properties of water—including B E N E F I T S A N D C O N S I D E R AT I O N S

buoyancy or weightlessness combined with O F A N AQUAT I C P RO G R A M
resistance—create an excellent environment From Report of the Surgeon General, United
for movement and exercise. Participants can States Department of Health and Human
learn to use the properties of water to best Services, (1996), “People with disabilities
meet their specific exercise/fitness needs. are less likely to engage in regular moderate
Likewise exercise in a pool offers stability and activity than people without disabilities, yet
support to practice functional activities such as they have similar needs to promote their health
ambulation. Water often provides support many and prevent unnecessary disease.” The report
people with MS need to stand and maintain also recommends “community based programs
balance for exercises that would otherwise be to meet the needs of persons with disabilities.”
too difficult on land. A community based aquatic exercise program
is an excellent way to add activity, strengthen
AQUAT I C P RO G R A M S the cardiovascular system, reduce body fat, and
FOR PEOPLE WITH MS decrease stress.
The purpose of an aquatic recreational program
is socialization and exercise, and is intended Water offers benefits such as:
to meet goals such as increased function and • Less energy expenditure required for
sense of well-being. The aquatic class is not movements
intended to be a “hands on” treatment or
therapy. A recreational program is designed
• Increased muscle strength due to use of
water resistance
to offer people with MS with varying levels of
disability or activity limitations an opportunity • Opportunity to practice balance and
to participate, including individuals who use coordination (with more ease than on land)
assistive devices. The class is taught in shallow • Relaxing effects of buoyancy on the skeletal
water in a group setting with an emphasis on structure and increased ease of walking in
fun and independence. Benefits will vary from water due to buoyancy
individual to individual.
• Protection from falls (“soft” landing)
An aquatic program can include aerobic • Opportunity to weight bear on the lower
exercise, strengthening, balance training, and extremities
stretching in addition to a warm-up and cool-
down. Recreation is diversion, rest, relaxation, • Increased circulation
entertainment, exercise, play and hopefully, • A cool exercise environment which can
enjoyable. The aquatic program for people increase endurance with activity

National MS Society Aquatic Exercise Programming for People with MS | 2

Possible considerations may include:
• Loss of balance due to upward thrust of
Strategies for
buoyancy, use of foam equipment or deep
water.
Adapting Movement
• Fatigue and muscle weakness if water Components of exercise design to be considered
temperature is too warm when developing a multiple sclerosis aquatic
• Effects of incontinence class include:

• Skin breakdown • Water properties

• Decreased opportunity for full weight • Functional levels defined in the Intro to MS
bearing for Fitness and Wellness Professionals

• Fear of water • Body mechanics­—minor and subtle changes

to hand position, body alignment and body
FOCUS ON FUNCTION composition, alter movement intensity
by maximizing or minimizing the effect of
In general, most movement is beneficial for water properties
individuals living with MS. As you focus on
developing programs for people with MS, • Impact options—water is an excellent
consider movements that address functional medium for exercise because of the reduced
activities. gravitational forces experienced by the body
when partially submerged. This produces
Contributing factors include: a lower impact alternative to land-based
exercises
• Weakness
• Equipment
• Spasticity/Spasms
• Lack of coordination Remember that symptoms of MS are different
for each individual and may change daily or
• Balance difficulties
weekly. Be sure to discuss potential adaptations
• Tremors of a movement with participants, and always
• Fatigue remind them to consult with their physician if
symptoms change.
• Pain
USING THE PHYSICAL
A focus on function in the pool means P RO P E RT I E S O F WAT E R
choosing exercises/activities with the goal of
improving coordination, flexibility, balance, Familiarity with the physical properties of
muscle strength, endurance, and possibly water can help instructors create exercise
cardiovascular fitness. Exercises in these sessions that are safe, challenging and
areas can improve functional mobility such interesting.
as transfers, gait and stair climbing. Most
importantly, the activities need to be engaging.

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Laws and properties include: Be sure to discuss specific limitations with each
• Buoyancy versus gravity student. In addition, involve participants when
modifications of exercises are necessary so that
• Inertia they can adapt a movement to best meet their
• Resistance needs.
• Leverage B O DY M E C H A N I C S
• Action and reaction Body mechanics can be a useful strategy for
• Hydrostatic pressure adapting movement. Minor and subtle changes
to hand positions, body alignment and length
• Surface tension of body levers changes movement intensity by
• Drag maximizing or minimizing the effect of water
• Turbulent flow properties. Additionally, the impact body
composition has on movement execution can
• Speed, power and force assist instructors to make effective movement
• Temperature choices and adaptation.

Here are examples of how to use water HAND POSITIONS:

properties to maximize pool activities: • Fist—hand(s) clenched to form a fist
• Change the surface area and speed • Webbed—fingers spread apart and
of movement extended
• Change the depth of water altering weight • Clawed—fingers flexed in claw fashion but
bearing properties not clenched as a fist
• Vary impact levels • Sliced—fingers together and moving hand
• Enlarge a movement, using the property in “chopping” movement
of buoyancy to support the lever
B O DY A L I G N M E N T
• Change the planes of movement
Neutral spine is keeping the vertebral spine
• Travel in its natural alignment with normal curves in
the cervical and lumbar areas. The importance
CONSIDERING of maintaining torso control and proper body
FUNCTIONAL LEVELS alignment is noticeable with new participants
When designing a session keep in mind the who haven’t made the adjustment from
three levels of ability (defined in the Intro to movement in a gravity-based environment
MS for Fitness and Wellness Professionals) to a buoyancy-based environment. Adjusting
to better meet the needs of all your students/ to a new center of gravity (from hip area to
clients. Movements can be altered to match the lung area) is sometimes difficult for new
abilities of individuals. For example individuals participants. Instructors can help participants
interested in improving sit to stand transfers by encouraging them to maintain a neutral
may concentrate more on lower extremity spine. As participants become more skilled,
strengthening and stretching exercises. changing planes can challenge torso control.

Remember, symptoms of MS are different for Posture is more difficult in water if the depth
each individual and may change daily or weekly. is above the navel toward the mid-chest area.

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The upward thrust of buoyancy creates an B O DY C O M P O S I T I O N
instability and improper foot placement. Bring The ratio of lean body mass to fat body mass
the class to a more shallow area of the pool to affects buoyancy and therefore can affect the
permit control, alignment, and foot strike. The intensity of executing a movement. Someone
shallow water affords cooling, protection from with a high percentage of body fat easily floats
falls, and body awareness. while a more muscular individual would sink.
A person with limited strength and/or who is
Proper standing alignment: less lean may have more difficulty controlling
• Feet parallel, slightly apart with weight buoyancy and buoyancy equipment. Teaching
evenly distributed on the heels, outside body mechanics as a means of movement
borders, and balls of the feet adaptation enables participants to increase or
decrease movement intensity. Here are some
• Knees soft and relaxed
examples:
• Hips are tucked, slight posterior pelvic tilt
• “Place hands in a webbed position to
• The abdomen is flat increase surface area, which increases
• Chest is high with rib cage lifted movement resistance.”

• Shoulders are level, with shoulder • “Keep knees extended while walking to
blades flat increase resistance.”

• Head is centered over trunk with chin • Offer support/buoyancy equipment to assist
slightly retracted and ears over shoulder individuals experiencing difficulty because
of low body fat composition.
• Arms are relaxed with palms facing the
sides of the body I M PAC T O P T I O N S
• Spine is in neutral position, meaning when F O R AQUAT I C E X E RC I S E
viewed from the side there is an anterior Water is an excellent medium for exercise
cervical curve or lordosis, followed by a because of the reduced gravitational forces
posterior thoracic curve or kyphosis and a experienced when partially submerged. This
lumbar lordosis provides a lower impact alternative to land-
based activities. Impact forces can be modified
LEVERS even further in water. Keep in mind that some
Our body consists of levers. Bones act as lever individuals will adapt to increasing the intensity
arms and joints function as fulcrums of these of water exercises but may not physically be
levers. An extended arm can be used in water able to increase the impact.
exercise to increase resistance--the longer the
lever the greater the surface area. The opposite REBOUND
is true if the desire is to decrease resistance, a Rebounding is standing in an upright position
shortened lever or flexed elbow joint created and pushing off from the pool bottom. It is a
less demand on the shoulder than an extended common movement used in aquatic programs
elbow joint. It is understandable why taller because it is most similar to land-based activities.
people, with longer limbs, find it more difficult
to move through water than someone with G RO U N D E D / N E U T R A L
shorter limbs. Keep in mind that longer lever
movements integrated into a class format The grounded or neutral position involves
require more time to execute. flexing at the hips and knees to lower the body
to a position where the shoulders are a few
inches above the water’s surface. This level

National MS Society Aquatic Exercise Programming for People with MS | 5

of impact is also seen with standing upright correctly is essential. Improper use can decrease
activities without the bounce/rebound in the effectiveness and possibly cause injury.
movement. The feet will still contact the pool
bottom but without the jumping force. This The types of equipment that may be useful
allows the reduced impact benefit of exercising in your classes are:
at chest depth without compromising control • Buoyant/floatation equipment
of movement.
• Gravity (weighted) equipment
SUSPENDED • Drag equipment
The suspended position involves flexing at the • Rubberized equipment
hips and knees to lower the body to a position
where the shoulders are at the water’s surface Considerations:
while keeping the feet elevated from the pool
bottom for several counts. This simulates • Home-made or make-shift devices such
deep-water exercise in the shallow area of the as milk jugs are inappropriate and unsafe.
pool. Suspended position requires increased Be sure to use equipment that is designed
involvement of the upper body musculature for pool use and inspect each piece before
to maintain the suspended position, and may every class to ensure there are no missing or
not be comfortable for non-swimmers. To take broken parts.
advantage of this level, without the upper body • Extra buoyancy and resistance of some
strength requirements, buoyancy equipment equipment has the risk of increasing fatigue
can be used. and loss of balance.
• Recognize muscle weakness and the
Impact Option Positions deconditioned state of participants. Weak
• Rebound position: places the most impact on muscles tire quickly and are inefficient.
the body. Therefore, do not use equipment until
• Grounded/ neutral position: places some a participant is familiar with his/her
impact on the body. personal level of fatigability and balance
in the pool. It may take several classes to
• Suspended position: does not place any
acclimate to the upward thrust of buoyancy,
impact on the body.
the extra buoyancy of foam equipment,
and the intensity that equipment adds to
the program. Ask participants to practice
U S E O F E QU I P M E N T
movements without equipment until they
Equipment is not needed to conduct an effective understand how it should “feel”, then add
program. However, floatation devices such as equipment.
noodles, bar bells or kickboards will assist with
balance when walking and will add interest and • Devices used to assist buoyancy, resistance,
variety to the class. Safety of participants is, of or floatation are not intended as life saving
course, the most important consideration. devices.
• Lifts, steps, or chairs for pool entry are
An important first step in selecting the available through major pool suppliers.
appropriate aquatic exercise equipment is to Assistive devices such as shower chairs
determine the needs of the participants. Next, or reaching sticks for the locker room are
determine which type of equipment will best available locally in many areas (check the
meet these needs. Once you have made an yellow pages under medical equipment or
equipment selection, knowing how to use it durable medical equipment.)

National MS Society Aquatic Exercise Programming for People with MS | 6

 • Equipment made from latex material should Disadvantages:
be carefully considered due to potential 1. Tend to be bulky
problems with latex allergies/sensitivity
2. Difficult to store
Prior to using any equipment, it is important 3. Can cause overload injuries on joints
to evaluate the following, to determine and muscles
appropriateness:
• Establish intended use/application G R AV I T Y ( W E I G H T E D )
E QU I P M E N T
• Rate effectiveness
Weights use different muscle groups than those
• Assess for correct body mechanics with worked with buoyancy equipment.
and without use of equipment
With weighted equipment, all movements
• Identify contraindications/risks toward the bottom of the pool are “assisted”
(musculoskeletal injury) and all movements toward the pool’s surface
• Determine benefits are “resisted”.

• Identify limitations (cost, availability, Types of weighted equipment

ability level)
• Ankle weights
BU OYA N T / F LOTAT I O N • Medicine balls
E QU I P M E N T
Buoyancy works in the opposite direction of Advantages:
gravity. Buoyancy/flotation equipment reduces 1. Offers an opportunity to work on
the effects of gravity on the body and assists weight bearing
with floatation. The tendency of this equipment 2. Can add variety to program
is to rise to the surface of the water, therefore
any movement toward the surface of the water 3. Reasonably inexpensive and easy to store
is “assisted” and any movement toward the
bottom is “resisted”. Disadvantages:
1. Difficult to transport
Types of buoyancy/flotation equipment:
2. Difficult to recover when dropped in pool
• Floatation belts/ankle floats
• Noodles, rods Recommendations:
• Foam dumbbells • Make sure the weighted equipment will hold
up well in water
• Balls
• Use of ankle weights during aerobic exercise
• Kickboards is not recommended due to the increase of
potential injury to muscles and joints
Advantages:
1. Adaptable to most fitness levels D R AG E QU I P M E N T
2. Lightweight Drag equipment can be very useful in a water
environment. The shape of equipment, velocity
3. Relatively low expense
or speed of movement, turbulence and water
depth affect the amount of resistance that can
be achieved during water exercise.

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Types of drag equipment: G E N E R A L E X E RC I S E P R I N C I P L E S
• Webbed gloves It is important to keep general exercise
• Drag parachutes principles in mind when recommending aquatic
exercises for people with multiple sclerosis as
• Hand held paddles, bells, and boards it is common to see diverse ability levels among
• Water boots people with MS. Likewise, ability levels may
• Shoes change from session to session depending upon
a number of factors. However, there are some
Advantages: general principles to keep in mind:
1. Can be used in nearly all directions • Breathing—Encourage normal breathing
during exercises. Holding one’s breath
2. Adaptable to most fitness levels
should be discouraged.
3. Lightweight and easy to transport
• Posture—It is important to encourage
proper postural alignment during activities
Disadvantages:
to avoid undue musculoskeletal stress.
1. Requires more knowledge of water skills
by the instructor • Positioning—Have participants use their
stronger side for support – a pool wall is
2. Can place adverse stress on joints and fine when initially learning the exercise.
muscles if inappropriately used
• Listen to what the body is saying—It is
RU B B E R I Z E D E QU I P M E N T important to listen to the signals the body
is sending to avoid fatigue. Exercising to the
Rubberized equipment is designed as circular point of fatigue is NOT recommended. Stop
bands or tubing cut to a desired length. before becoming tired and progress slowly.
Different tensions are available, varied by
width or thickness of the band or tube. This
equipment can be beneficial for strength
building or out of the water.
Exercises for
Types of rubberized equipment:
People with MS
• Bands The following exercises are examples of many
• Tubing activities that can be beneficial to people
living with MS. By combining exercises and
• Balls
integrating movement strategies (e.g., changes
Advantages: in movement direction and speed, body
positioning and use of equipment) an instructor
1. Inexpensive
can develop an effective, challenging and
2. Easy to transport and use motivational format for the class.
3. Adds variety to exercise program
The exercises noted address flexibility, strength,
Disadvantages: endurance, balance, coordination and overall
functional mobility. People with MS may require
1. Short life span of equipment
additional attention in one area based on their
2. May adversely affect proper body condition. However, a well rounded program
mechanics will include a variety of categories of exercise.
3. Potential allergies to latex materials—
explore latex substitutes

National MS Society Aquatic Exercise Programming for People with MS | 8

 Level 2
NOTE: Fatigue, weakness or other symptoms
may increase with over activity or heat and • Start with feet firmly planted and weight
may change daily, weekly, or suddenly (during evenly distributed in chest deep (nipple line)
class) with no apparent cause. Be prepared to water level, use pool wall for support and lift
make changes in the midst of class to address one knee up at a time, returning to starting
the situation of the day. Participants should position and repeating on other side
leave the class feeling refreshed, with a sense of
well-being and accomplishment. Do not work
• Lift knee up to create a 90 degree angle
them to exhaustion. People need to be reminded (or less) in the hips
each class that if they experience any increase in • If unable to lift knee, bend or soften knees
symptoms either due to pool temperature or the one at a time
exercises, they need to seek reevaluation.
• Hands are active (holding onto wall) yet
relaxed (not overly gripping)
M A RC H I N G / A LT E R N AT I N G
KNEE LIFTS
• Body alignment is in neutral
Level 1 • If individual experiences paralysis in one
leg, s/he can actively assist with one hand to
• While in chest deep (nipple line) water lift their knee up
level, march (alternating knee lifts) traveling
forward using arms in opposition of knees Level 3
• Knees come up to create an 80–90 degree • If individual can weight bear and can bend
angle in the hips both knees, start by facing wall and bend
• Hands are in a fist, webbed, claw or knees while holding onto wall with both
sliced position hands as if sitting back into a chair (squats).
• Foot placement focus is on heels • If unable to weight bear, start seated utilizing
pool steps or grounded pool equipment,
• Body alignment is in neutral or slightly horizontally suspended on a floatation mat
forward flexed at the hip (maintaining or suspended vertically with a floatation
head and shoulders in alignment, no more belt. Bend or soften knees one at a time,
than 10 degrees forward flexion at the hips alternating from left to right or vice versa.
and abdominals are contracted to support
lower back) • If unable to bend knees voluntarily, try to
actively assist legs by placing hands behind
TIP: If an individual needs balance support thighs to bend and lift knees.
have him/her march along the pool wall or use
• Pay close attention to ankle mobility and
a floatation piece of equipment (noodle, comfy
if possible encourage participant to dorsi
log, etc.) in front of his/her body for support.
Discourage leaning on equipment or wall—it is and plantarflex foot. Dorsiflexion while
only to be used when needed. lifting/bending knee, planter flexion while
returning to starting position.
Increase or decrease distance and speed
according to the individual’s goal and ability.
Use of pool equipment can also be added to TIP: Variation—use an aqua step. Step over or on
increase intensity. For example a floatation belt and off the step to build balance and strength.
can be used to walk suspended and speed can Some individuals will require assistance, due
be increased to turn marching into jogging. to balance, range of motion and strength
Equipment usage, direction change and increase limitations. In group settings, it is recommended
in speed can also add variety to this exercise and that individuals with needs bring an assistant to
increase intensity. class with them.

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SIDE STEPS S TAT I C H A M S T R I N G S T R E TC H
Levels 1 and 2 Level 1
• While in chest deep (nipple line) water level, • While gently holding onto wall with one
take a step to the right or left side while hand, reach under knee with the other and
keeping legs straight (knees soft). Repeat gently straighten leg.
several times then change directions. • Maintain body alignment in neutral.
• Arms move like wings (as the leg move (Encourage participants to lengthen spine to
out to the side the arms move up toward maintain alignment and to not hold breath.)
the surface of water then back to sides of • Hold position for 5–30 seconds and then
body when legs are together). Hands are in repeat on other side.
clawed, webbed or slice position.
• Toes face forward (frontal plane). Level 2
• While facing wall gently hold onto to it for
TIP: To increase intensity, increase range of balance with both hands.
motion, speed and change direction after a few
repetitions. If individual needs balance support • Standing upright with body in neutral
have him/her move along pool wall or use a alignment place the heel of one foot in front
flotation piece of equipment (noodle, comfy approximately 10 inches in front of the
log, etc.) to hold in front of body for support. other foot.
Discourage leaning on equipment or wall—it is be
used only as needed. • Gently bend knee of supporting leg as if
sitting back into a chair behind you while
maintain other leg straight.
Level 3
• Lift toes up (dorsiflexion).
• While in chest deep (nipple line) water level,
stand next to wall hold on with one hand, • Hold for 5–30 seconds and then repeat on
lift leg to the side (abduction in horizontal other side.
plane), return to starting position and then
repeat on other side. Optional-free arm can Level 3
follow leg movement according to ability. If • While seated on pool steps or grounded
more stability/support is needed face wall pool equipment lengthen one or both legs in
and hold on with both hands. front of body.
• Hand(s) are active (holding onto wall) yet • Dorsiflex foot toward body.
relaxed (not overly gripping).
• Slowly bend forward from the hips. Do not
• Body alignment is in neutral. allow spine to round forward as you reach
• If participant is unable to weight bear toward toes.
but has voluntary movement of lower • Body alignment is slight forward flexed at
extremities this movement can be done the hip maintaining neck and shoulders in
vertically suspended utilizing a floatation alignment. No more than 10 degrees flexion
belt or horizontally suspended using a at the hips and abdominals are contracted to
floatation mat. Both legs can be done at the support lower back.
same time or one at a time.
• If participant is unable to voluntarily move TIP: If hamstrings are tight, bends knees slightly.
lower extremities focus is placed on upper If spasticity or tremors occur, stop and rest;
resume activity when comfortable to do so.
extremities and or focus on trunk mobility
and control while seated or suspended.
National MS Society Aquatic Exercise Programming for People with MS | 10
AC T I V E C H E S T S T R E TC H • Make sure to twist at the waist and not only
Level 1 at your neck or hips.

• While walking reach hands forward then • If standing, keep knees soft and shoulders
open to sides as if doing the breast stroke. relaxed.

• As arms move to side squeeze shoulder TIP: Variation—Level 1: This can be done while
blades together. walking (see Walking Twist on page 18.)
• Lift sternum and maintain spine in neutral
alignment and shoulders down.
LEG/HAMSTRING CURL
• Focus is placed on moving shoulder joint Levels 1 and 2
through a full range of motion (horizontal
abduction). • Bend knee and lift foot behind body toward
buttocks.
Levels 2 and 3 • Alternating from left to right and vise versa.
• While standing in place or seated reach • Maintain neutral spinal alignment (do not
hands forward then open to sides as if doing hyperextend back).
the breast stroke.
• As arms move to side squeeze shoulder TIP: To increase intensity one can increase
blades together. speed, add rebound impact option and/or travel.
To decrease intensity, stand in place, decrease
• Lift sternum and maintain spine in neutral speed and maintain grounded impact option.
alignment and shoulders down.
• Focus is placed on moving shoulder joint Level 3
through a full range of motion (horizontal
• While vertically suspended, bend knee and
abduction).
lift foot behind body toward buttocks.
TIP: If balance problems do not allow participant
If participant does not have voluntary
to maintain an active range of motion, this
movement of lower extremities, strengthen
movement can be done as a static stretch by
reaching both hands behind body and holding gluteals (buttocks) by contracting, holding
position. Wall (if standing face away from the contraction and releasing (see gluteal sets in
wall) or seat can assist in maintaining posture. chart below).

TIP: If balance difficulties exist, keep participant

T RU N K T W I S T S — S P I N A L ROTAT I O N near wall with assistant.
All Levels
• Stand with feet shoulder width apart WA L K I N G
(seated­—Level 3)
Levels 1 and 2
• If possible, shoulders are below water
surface. • Start with feet firmly grounded, weight
evenly distributed and spine in neutral
• Hands are extended out to each side at alignment.
shoulder height.
• Take a step forward as arms naturally swing
• Rotate slowly from one side to the other in opposition.
while looking over each shoulder.

National MS Society Aquatic Exercise Programming for People with MS | 11

 • Focus on heel-toe-heel placement of foot • Place arms opposite of legs one in front of
• Exaggerate push off and knee flexion stage/ the body the other in back of body (left arm
motion of walking. forward, right leg back and vise versa).
• Quickly switch leg and arm positions
TIP: Use buoyancy (flotation) and drag and repeat.
equipment to increase and decrease resistance • Maintain spine in neutral alignment.
and balance demands. Individuals with balance
problems may need to first practice near a wall
TIP: Use hand variation and flotation equipment
and/or march in place.
to modify intensity. To increase intensity bend
and extend knees (combination flexion and
Level 3 extension of knees) - this can be done in rebound
or suspended (with flotation equipment).
• If weight bearing is possible, start by
Another variation involves keeping legs extended
standing facing wall. and use of a pendulum motion while suspended.
• Place feet slightly forward.
• While gently holding onto wall, bend Level 3
knees and sit back as if sitting back into an
imaginary chair. • While seated move arm and leg (knee
flexion and extension) in opposition (right
• Return to starting position and repeat. leg forward, left hand forward and vise
versa).
If individual cannot weight bear, start by
working on weight shifting/transfer skills and • If individual does not have voluntary
ankle dorsiflexion and plantarflexion. control of lower extremities, focus on upper
extremities. If one side of body (arm and
leg) is paralyzed, then focus on side that has
P E LV I C T I LT S
voluntary movement control (arm forward
All Levels as leg goes back).
• Place back against wall and press small
(lumbar spine) area of back against wall. RO C K I N G H O R S E
Make sure you are low enough in the water Level 1
that shoulders are below water.
• Rock/shift body weight forward onto the
• Keep head and shoulders in alignment. right leg while lifting the left heel up behind
• Hold pelvic tilt (posterior tilt) for a few the body.
seconds, release and repeat. • Rock/shift body weight backward onto the
• Then press tail bone back against wall as the left leg while lifting the right knee up in
top of your hipbone tilts forward creating a front of the body.
slight anterior tilt and the small of the back • Maintain spine in neutral alignment
comes away from wall. Do not over extend throughout entire movement, never arch/
back into position that causes pain. hyperextend the lower back.
• Counter balance weight of body by moving
C RO S S C O U N T RY S K I
the arms back (scoop/push water back) as
Levels 1 and 2 you shift weight forward and vice versa.
• Stand with one leg forward, the other leg • Repeat with left leg forward.
behind (approximately 2–3 feet apart).

National MS Society Aquatic Exercise Programming for People with MS | 12

Level 2 S T R A I G H T L E G WA L K
• While standing next to wall place one hand Level 1
on wall gently for balance. • Walk forward or backward with
• Shift body weight forward onto right leg straight legs.
(standing leg) as left leg curls behind body. • Use extended arms in opposition.
• Use left arm in opposition, swing/reach arm • Pause in mid motion and hold leg and arms
forward as body weight shifts forward. in opposition for 2–3 seconds before taking
• Maintain spine in neutral alignment another step.
throughout entire movement, never arch/ • Lengthen spine while maintaining it in
hyperextend the lower back. neutral alignment.
• Shift body weight back as left leg lifts • Resume movement and repeat,
forward (knee lift on left leg). remembering to hold each time in
• Left arm swings/reaches back as body mid motion.
weight shifts back. • Cue “toes up and heels down.”
• Repeat sequence several times.
Level 2
• Change sides and repeat this movement
using right arm and leg, using left leg as • Start with feet together and firmly planted,
standing leg. while standing next to wall or holding a
supportive flotation piece of equipment.
Level 3 • Lift one leg straight in front of body.
• While seated or vertically suspended, rock • Pause and hold leg in mid motion for
upper body weight forward and back. 2–3 seconds before returning to starting
• Swing/reach arms in opposition (one position.
forward the other back). • Lengthen spine while maintaining it in
• Maintain spine in neutral alignment neutral alignment.
throughout entire movement. • Repeat, using other leg.
• Use wall or partner for support.
Level 3
TIP: A good way to introduce this movement • Start seated with knees and hips at a
is to teach upper body movement, lower 90 degree angle.
body movement and weight shift separately.
Participants find success in fine tuning and • Place arms at surface of water and allow
perfecting each component of this movement them to gently float.
before combining. Also in breaking down this • Close eyes and try to maintain upright
movement all levels are able to learn weight shift
position.
and arm movements together. Leg movements
can then be given as level 1 and 2 options. • Lengthen spine while maintaining it in
neutral alignment.

TIP: To increase challenge of this movement,

ask participant to lift knee, pause and hold for
2–3 seconds.

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S I D E T I LT / L AT E R A L W E I G H T S H I F T Level 3
Level 1 • While seated on pool steps or grounded
• Start in a suspended vertical position (use pool equipment, shift body weight to right
flotation belt). side of body. If possible, allow left buttock to
lift off of seat.
• Lean toward the right and reach with right
hand (just a few inches) toward pool bottom • Reach with right arm away from body as you
while leg sway slightly toward the left. lean toward right.

• Do not bend at the waist, maintain spine in • Try to maintain control of movement by
alignment (Envision a line connecting the utilizing core stabilizers, rather depending
head, shoulders, hips, knees and feet). on seat.

• Return to upright vertical position. • Return to upright vertical position.

• Repeat on left side. • Repeat on left side.
• Try to maintain control of movement by
TIP: This activity can be modified by keeping utilizing core stabilizers, rather depending
participant near wall or using an additional on seat.
floatation device (example: a noodle or water log) • Return to upright vertical position.
for added support.
• Repeat on left side.

Level 2 TIP: This activity can be modified by keeping

• Start in a grounded vertical position participant near wall or by holding onto
standing next to wall, place leg closest to floatation device (example: a noodle or water
wall 2–3 feet away from wall. log) for added support. Noodle can also be
wrapped around back of participant for balance.
• Reach hand closest to wall gently toward Encourage participant not to depend on assistive
wall as you lean toward wall. equipment.
• Allow leg farthest from wall to slightly
float apart from other leg (no more than
2 feet apart).
• Do not bend at the waist, maintain spine in
alignment (Envision a line connecting the
head, shoulders, hips, knees and feet).
• Try to maintain control of movement by
utilizing core stabilizers, rather depending
on leaning on or holding onto wall.
• Return to upright vertical position.
• Repeat on left side.

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A D D I T I O N A L E X E RC I S E O P T I O N S

EXERCISE BENEFIT ACTION CUEING/TIPS

UPPER BODY
Elbow bend Starting with arms at sides of body, Aim palm or thumb to shoulder
Elbow flexion/extension bend elbow joint, return on the way up and palm or index
Strengthens arm and improves finger down on return
flexibility in elbow joint
Side arm raises Starting with arms at sides of body, Keep thumbs forward.
Shoulder adduction and abduction raise arms to shoulder height or When raising arms overhead, turn
Strengthens shoulders lower, return palms toward sky at midway point-
then reverse on return.

Forward arm raises Starting with arms at sides of body, Keep arms in water. When moving
Shoulder elevation raise arms forward, return arms overhead use caution
Shoulder strength and flexibility breaking water surface and
remember to keep palms facing
each other.
Arms swings Swing arms forward and backwards Keep palms facing body and
Shoulder strength and flexibility by sides of body thumbs up
Arm circles With hands on shoulders, down Circle forward, then backwards.
Shoulder strength and flexibility by sides or out to shoulder level, Start with small circles then
slowly circle the arms from the enlarge.
shoulders
Overhead reach Start with hands on shoulder, Never raise arm to a point of
Shoulder strength and flexibility, slowly reach overhead discomfort
trunk
Butterflies Starting with arms by sides at For variation, turn into a swimming
Horizontal shoulder shoulder height, bring hands motion and play with hand
adduction/abduction together in front of body, return positioning
Improves strength and flexibility in
chest, back and shoulders
Shoulder rotation Holding arms at side with elbow Use hand variation to change
Shoulder strength and flexibility bent to 90 degrees, move hand resistance­—cup hands, make a fist
toward belly and then to the or spread fingers
starting position
Punching Hands in a fist, alternate arms Keep elbows soft
Strength, endurance, hand and punching. Push arms to full
wrist flexibility extension—apply hand variations.

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 EXERCISE BENEFIT ACTION CUEING/TIPS
Forearm rotations With elbows bent, face palm of Keep hands and fingers relaxed
Forearm strength and flexibility hands down then up

Wrist circles Rotate hands clockwise/counter Keep hands and fingers relaxed
Wrist strength and flexibility clockwise

Wrist flexion/extension Start with hands flat and parallel to Relax fingers and isolate
Wrist strength and flexibility the surface of the water, move hand movement at the wrist
and fingers up toward sky, then
down toward feet
Chin tucks Pull you chin back as if to make a Keep head straight—don’t look
Reduces neck fatigue double chin, then raise your neck down
Improves posture/appearance straight up as if someone was
pulling up on your hair. Release and
repeat.
Head turns Start with a chin tuck then turn Avoid lifting shoulders to meet
Improves cervical/neck flexibility your head to look over your chin. Relax shoulders.
shoulder. Return to the center and
repeat over other shoulder
Head tilts Start with a chin tuck then slowly Never roll head backwards.
Lateral flexion lower head toward right shoulder Maintain good alignment with
Improves cervical/neck flexibility as if to touch ear lobe to shoulder. head over shoulders and chin
Repeat on other side. tucked.
Shoulder rolls Roll shoulders backwards slowly Keep shoulders at chin level.
Retraction/protraction through full range of motion Do not drop head.
of scapula
Improves posture
Shoulder shrugs Lift shoulder toward back of head, Breathe normally and do not tilt
Elevation/depression of scapula then relax head from side to side when doing
Improves posture Variation: lift and depress one one shoulder at a time
shoulder at a time
Upper back stretch Rap arms around upper body and Breathe normally while rounding
Flexibility give yourself a hug shoulders.

LOWER BODY
Gluteal sets Squeeze the buttocks tightly Maintain soft knees.
Strengthens buttocks and together. Hold, release and repeat.
lower back
Front leg lifts Lift extended straight leg up Maintain soft knees, spinal
Hip flexion forward, alternating or one at alignment and flexed foot. Avoid
Improves balance, coordination, a time hyperextension and spasticity.
and flexibility

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 EXERCISE BENEFIT ACTION CUEING/TIPS
Leg curls Lift foot towards buttocks. Maintain spinal alignment straight
Knee flexion and extension Alternating or one at a time. back. Contract abdominals by
Improves strength and flexibility of Variation: Lift right heel to left moving front hip bones upward
legs and lower back buttocks and left heel to right toward rib cage (keep chest lifted).
buttocks
Side leg lifts and cross-overs Lift extended leg out to side Maintain soft knees, spinal
Hip abduction and adduction Variation: Cross leg in front then in alignment and flexed foot to avoid
Improves balance, coordination, back of the other hyperextension and spasticity
flexibility and leg strength
Karate kicks Lift leg with a bent knee and extend Always maintain soft knees and
Improves coordination, flexibility with power. spinal alignment
and strength Variation: out to side or rear
Calf stretch Stand facing wall with one leg in Avoid hyper-extending the knee
Flexibility front of the other. Press heel down
on back leg.
Rear leg lifts Slightly lift extended leg behind Maintain spinal alignment.
Hip extension you. Alternating or one at a time. Contract abdominals by moving
Improves lower body flexibility and front hipbones upward toward rib
strength cage (keep chest lifted).

Ankle circles Make circle with foot. Repeat in Relax toes

Ankle strength and flexibility opposite direction and on opposite
side.
Ankle dorsiflexion/plantarflexion In seated position, point toes up Move foot directly up and down
Ankle strength and flexibility and then down while keeping bent and not in and out (avoid inversion
knee and eversion)
Front thigh/quad stretch While standing near wall, bend Maintain spinal alignment.
Flexibility knee and hold ankle with hand. Thigh should stay in alignment,
Extend thigh back and press front perpendicular to the pool bottom.
hip bone forward.
Jacks Starting position: Standing with Use hand variations for intensity
Double leg abduction/adduction legs together. modifications.
Improves coordination, flexibility End position: Legs apart *Using flotation/buoyancy
and strength Variation: Can be done with or equipment is recommended to
without side arm raises, and as reduce the effects of gravity on the
double cross-overs. skeletal system.

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 EXERCISE BENEFIT ACTION CUEING/TIPS
TRAVELING MOVEMENTS/WATER WALKING
Step over walk Walk forward as if stepping over an Maintain spinal alignment and
Balance, mobility, flexibility, arm object. Use swimming arms. keep focus of eyes ahead instead
and leg coordination; endurance of toward floor.

Cross-over steps With or without arms, cross Use hand variations for intensity
Balance, mobility, flexibility, arm leg over the other when taking a modification and variety
and leg coordination; endurance step
Jogging Same as alternating knee lift done Remain in upright position,
Improves stamina, coordination as a rebound move. (See page 5 maintaining spinal alignment
and strength for rebound definition)
Walking twist With elbows bent in front, lift knees Remain in upright position,
Coordination, flexibility of trunk high so that right elbow meets left maintaining spinal alignment
knee, then left elbow meets right
knee

JUMPS
Frog Jump with knees bent and out to Remain in upright position,
Strength, balance and endurance sides maintaining spinal alignment.
Avoid leaning forward.
*Using flotation/buoyancy
equipment is recommended to
reduce the effects of gravity on the
skeletal system.
Curl tuck Jump with knees bent and heels Remain in upright position,
Strength, balance and endurance toward buttocks maintaining spinal alignment.
Avoid leaning forward.
*Using flotation/buoyancy
equipment is recommended to
reduce the effects of gravity on the
skeletal system.
Knee tuck Jump with both knees together Remain in upright position,
Strength, balance and endurance and in front of body maintaining spinal alignment.
Avoid leaning forward.
*Using flotation/buoyancy
equipment is recommended to
reduce the effects of gravity on the
skeletal system.

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 EXERCISE BENEFIT ACTION CUEING/TIPS
TRUNK
Knee hugs Standing near a wall reach under Breathe normally. Relax shoulders
Balance and flexibility knee and gently bring knee up and feet.
toward chest. Use right hand for
right leg.
Variations: Use right hand for
left leg. Stand upright or release
upright position and round upper
body toward knee.
Twists-spinal rotation Feet shoulder width apart, Knees soft, move body as a unit.
Coordination, flexibility shoulders in water, twist slowly Avoid twisting spine (especially
and strength from side to side. with hop).
Wall press/modified push up Facing wall, lean forward, and hold Focus on maintaining spinal
Strengthen lower back and pelvic for 5 seconds. Return and repeat. alignment by using the
floor, improves posture muscles that support the spine
(abdominals, erector spinae and
lower back)
Suspended double side While using floatation equipment, Relax shoulders
leg extensions to support body without restricting
Stabilization, strength and movement around trunk, extend
flexibility both legs to one side while slightly
leaning toward the other side.
Alternate from left to right.

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Class Structure • New students may want the option of
observing a class from the deck the first day.
and Cueing They can decide if they will be comfortable
with the class, determine if they will be able
to get in and out of the pool, and enter the
S T RU C T U R I N G A N AQUAT I C C L A S S building from the parking lot without undue
FOR PEOPLE WITH MS fatigue.
A successful aquatic class for people with MS • Monitor new students until there is a
is founded on principles similar to those used general comfort level reached.
to teach a general aquatic class. Basics include
• Create the proper atmosphere (comfortable,
personally greeting each student, asking
friendly, noncompetitive and safe.)
about relevant physical conditions, modifying
Recommended water temperature is
movement and using equipment for various
80–84 degrees; however, some individuals
abilities and incorporating new students into an
work well in higher water temperatures.
established class. An emphasis should be placed
While each individual is unique, extremes
on greeting and understanding the students'
in temperature in either direction seem
physical conditions and goals, and structuring
to adversely affect most individuals
class appropriately, making modifications as
with MS. Talk to participants about
necessary—make sure that each participant is
temperature regulation (hydration, “chill
involved. Do not leave anybody out!
vests”, undershirts, etc.) so that they are
comfortable (not too warm or too cool)
Use a DIRECT approach during class and for
while in the water and after getting out of
lesson planning.
the water. In addition, don’t forget humidity,
• Define levels of ability (assessment) direct sunlight, and other environmental
• Increase intensity and duration gradually factors that can affect a person’s ability
to maintain appropriate core body
• Repeat cues and directions temperature.
• Encourage efficient movement patterns
GREETING
• Control (speed, range of motion, surface
area, direction, turbulence) • A positive attitude is important when
• Temperature of the water leading a class, it sets the tone for all
interactions.
B E F O R E YO U S TA RT • Be aware of any physical changes in
participants either during a class or since
• If possible talk with all students privately the last class.
before the first class to discuss goals, an
overview of the program, class structure • Familiarize students with the facility and
and format. Be clear that the class is not class format.
physical therapy, swimming lessons, or
water aerobics. (For students with fatigue, S A M P L E C L A S S S T RU C T U R E
offer suggestions to conserve energy such as An aquatic session often consists of a warm-
wearing a bathing suit under warm-up suit up, stretching/range of motion exercises for
to class so only one change is required at the flexibility, upper and lower body strengthening,
pool. Another tip is use of a backpack rather endurance activities (if tolerated), cool down,
than the standard beach or gym bag. and (optional) games.

National MS Society Aquatic Exercise Programming for People with MS | 20

This program emphasizes the whole person. ROM exercises are designed to maintain and/
The lesson plan should reflect the emphasis on or achieve maximal joint movement. These
wellness, by including information on overall exercises can be used to improve flexibility of a
health. A group session usually lasts 30–45 specific joint and/or increase muscle strength.
minutes. It is important to move the joint through its
full range of motion. Muscles of the lower leg,
Remember: The essentials of instruction posterior thigh (i.e., hamstrings), buttocks,
are content and presentation. Content and lower back are often weak and may make
includes concepts, skills, and knowledge to walking more difficult. Select exercises to
select exercises and plan the exercise session. strengthen these muscles: hip flexors, hip
Presentation is the delivery and interaction extensors, ankle dorsiflexors, hip abductors,
with participants. trunk for flexion and extension. It is important
that a rehabilitation therapist evaluates a range
of motion impairment to ensure that the proper
TIPS:
stretching techniques are utilized.
1. Inquire about symptoms experienced since
last class. Stretching: Gentle, slow stretching may help
2. Consider adding a “mini lecture” 2–3 minutes reduce the effects of spasticity. Stretching the
about health, wellness, energy conservation following muscles—quadriceps, calves, gluteals,
tips, etc. to maintain the interest of lower back, shoulders, neck, hip adductors,
participants. An invited guest is an option, rotators of the hips, spinal extensors, and
as well. pectoral or chest muscles—will provide a
comprehensive flexibility program for most
WA R M - U P people. Some people may require specific
stretching exercises to address range of motion
This can consist of gentle, rhythmical
impairments.
movements to acclimate to the temperature of
the water and the effects of buoyancy/reduced
gravity. These can include walking, marching REPETITION
in place, and or continual upper/lower body Repetitive exercises help improve endurance
movements. and may improve problems with coordination
and performance of activities of daily living.
F L E X I B I L I T Y / R A N G E O F M OT I O N Use low weights, high repetition, if weights are
used. However, weights are not necessary and
Flexibility exercises involve two components—
may tire out the muscle rather than strengthen
joint range of motion, moving each joint through
it. The resistance of the water with changes in
it’s full range of motion, and muscle flexibility, or
speed, force, hand or leg position, and depth of
stretching the muscle.
the water will suffice to strengthen the muscles
of most participants.
Range of motion: Range of motion (ROM) is
defined as the movement at a particular joint.
The length of soft tissue structures, such as C O O L D OW N
muscle and ligaments, which surround the joint The cool down involves slower activities,
can affect movement as well as pain and joint patterns of walking, relaxation, and a return to
flexibility. the effects of gravity.

National MS Society Aquatic Exercise Programming for People with MS | 21

POINTERS • Provide opportunity for socialization to
help create support and encouragement
• Think overall wellness, not just strength or among participants.
cardiovascular fitness.
• Encourage participation by all. Modify
• Use an exercise-rest-exercise-rest or high movements or activities as needed. No
intensity-low-intensity format (H-L-H-L) one should be made to feel discouraged
to prevent fatigue and overheating. (Rest or left out.
may be an active rest and recovery, or a
relaxation). Encourage breaks as needed. • Explain exercises clearly and repeat the
Encourage participants to find their own movement during the execution to assist
comfortable intensity levels. Encourage use participants experiencing short-term
of a rate of perceived exercise (RPE) scale to memory loss or coordination issues.
monitor intensity during exercise. • Encourage the use of senses to enhance
• Use body awareness techniques to increase learning. Use images to accompany new
relaxation and postural awareness. One sensations. Ask students to articulate what
session could be used solely for relaxation they experience to encourage a sense of
("feel the water support you”, “listen to the discovery, curiosity and observation.
ripples”). • Recognize each individual as an
• Explain the rationale for choosing the adult learner, with specific abilities
exercises (e.g.; to work towards a better and restrictions. Do not impose your
gait pattern and improve balance and expectations or level of ability.
coordination). This assists participants to • Make it fun!
set realistic and functional goals.
• Vary order of activities from class to C LO S I N G A N D A F T E R C L A S S
class. Classes should be goal oriented not
• Make yourself available to students for
“routine"—and always enjoyable.
their questions.
• Emphasize the use of a flat foot when
• Avoid making any promises regarding
leading exercises for gait training (as in
results.
warm up exercises) as walking on the toes
may induce extensor spasticity in the legs.
For these exercises, use cues, “heels to the
bottom or strike with heel.” However, it is
not essential to emphasize use of a flat foot
for exercises to improve strength or balance.
• Eliminate actions that involve the
participants “hanging” on the pool wall.
A noodle is preferred to wall-handing
exercises.
• Encourage participants to exercise at their
own pace, listen to body signals, and to
make modifications as needed.

National MS Society Aquatic Exercise Programming for People with MS | 22

Lesson Planning Circuit training utilizes the equipment on
hand, and does not require a large purchase of
equipment for each person at the same time.
L E S S O N P L A N N I N G : H OW T H E Kick boards, pull buoys, bar bells, balls, gloves,
B O DY WO R K S and noodles offer a myriad of possibilities for
Evaluate the exercises you select for your a circuit. It is possible to have a circuit without
class for functional activities and wellness. equipment. Plan stations of rocking horse,
Use normal movement patterns and a range scissors, figure 8s, biceps curls, and other
of motion that will not create injury, pain, or exercises from your routine.
undue fatigue. Next, evaluate whether or not
the movement can be performed at an intensity The stations and number of stations you select
and position to permit proper body alignment depends upon the ability of your class. Use
The intensity and design of the movement laminated cards or waterproof paper with large
should produce a controlled, smooth print to describe each station.
movement without momentum as the primary
moving force. WA R M - U P : 5 M I N U T E S
• Walk forward, arms push water away
This work sheet may be useful to you in
designing a lesson plan. Think about posture, • Walk backward, arms pull water
range of motion, safety, the impact on functional toward body
activities, and the ability of your participants. • Straight leg walk, arms front to back
Head ______________________________________________ • Side step, arms scissor

Shoulders ________________________________________ C I RC U I T: 10 – 20 M I N U T E S
• Bar bells—shoulder elevation
Arms ______________________________________________
• Bar bells—shoulder rolls
Elbows ____________________________________________ • Leg/hamstrings curls
• Front leg lifts—hip flexion
Hands and wrists _______________________________
• Gluteal sets or rear leg lifts—hip extension
Spine ______________________________________________ • Bar bells—elbow flexion
Pelvis ______________________________________________ • Bar bells—elbow extension
• Pull buoy, place heel on top of strap and
Legs _______________________________________________ side leg lift

Foot and ankle ___________________________________ • Noodle, straddle and bicycle for count of 25
• Bar bells, arm crossover under water
S A M P L E L E S S O N P L A N F O R C I RC U I T • Punching
Circuit training adds interest to the class and
• Rocking horse
accommodates various ability levels at one
time. The participant selects stations within • Marching/alternative leg lifts
his/her ability or moves on if a station is too
difficult or tiring.

National MS Society Aquatic Exercise Programming for People with MS | 23

S T R E TC H / F L E X I B I L I T Y:
5 – 10 M I N U T E S Music
• Major muscle groups Music can be a great tool for motivation,
relaxation, maintaining cadence, or achieving
• Range of motion exercises the desired intensity if used appropriately.
However, whatever your reason for using music
C O O L D OW N : 5 – 10 M I N U T E S in a group setting it should always complement
• Walk patterns similar to warm-up in slower, your class and never distract or take away from
smaller ranges of motion the purpose or goals of the class. If music is
not adding benefit, and/or is making it hard to
understand cues, it is best not to use music at all.
Cueing
There are three categories of cueing, Pool Safety and
Correctional, Motivational and Transitional.
Cueing provides a signal to class participants: the Environment
• Correctional or “form” cue: to take note of
body alignment and technique. Always use S A F E T Y A RO U N D T H E P O O L
positive cues, such as “knees soft”, rather WAT E R S A F E T Y
than “don’t lock your knees”. Water adds an element of danger that is not
• Motivational cue: for encouragement and present during land activities such as falls on
reinforcement slippery decks or drowning. Keep the following
in mind:
• Transitional cue: to make a change in
tempo/rhythm, activity or direction, such • If a person cannot participate in the aquatic
as: class without assistance, s/he need to have
an aid in attendance at each class.
»» Directional “forward, back etc.”
• Have class participants use the buddy
»» Numerical “1, 2, 3, 4, etc." or
system when in the pool even if the
“4, 3, 2, 1, etc.”
lifeguard is on duty. Do not overestimate
»» Footwork “right, left, right, etc” the ability of participants or leave them in
»» Step “rock, kick, swing, etc.” water alone.

»» Rhythm “half time”, “double time” • Keep the deck clean and free of equipment
to reduce incidence of injury. Store or stack
Cues can be vocal, visual, or a combination equipment after each class.
of both. Variety in cueing is Important because • Assist participants when entering or exiting
participants are different in their learning the pool. Use volunteers if needed (not other
capabilities. participants). Be aware of individuals who
may be fatigued and need extra assistance
TIP: Remember many people with MS experience after the class.
cognitive impairment that could affect • Do not allow participants to eat or chew
concentration and/or memory. gum during class. Do not allow glass bottles
on pool deck.
• Do not leave objects floating in the pool.

National MS Society Aquatic Exercise Programming for People with MS | 24

 • Do not allow horseplay in the pool area or • Shoes may increase stability on the pool
running on the deck. deck and offer protection if participant
• Orient all participants and volunteers to has a shuffling gait, ataxia (uncoordinated
emergency protocol. Practice a safety drill movements), or decreased ankle
with the class at least once a month. dorsiflexion during gait.

• Check water temperature before each class. • Encourage participants to exercise at their
Optimum water temperature is 80–84 own pace and listen to their body for signs
degrees. Higher temperatures may cause of heat, weakness, or fatigue.
fatigue in many people with MS.
• Examine the building and parking lot for Be aware of the following symptoms that may
occur during or immediately following class:
possible hazards or handicaps.
• There should always be a lifeguard on duty • General weakness • Pain
during a class. • Fatigue • Stress or anxiety
• Blurred vision • Nausea
PA RT I C I PA N T S A F E T Y • Tremor • Rapid eye movement
Precautions to remind participants of at the • Tingling • Coordination or
beginning of each class: balance disturbance
• Slurred speech
• Rubber tips on canes and walkers lose their • Spasticity
grip on wet surfaces and can become a risk.
Remind participants to be aware of this
around the pool deck. MORE ON SAFETY
• Stress the importance of each participant
knowing his/her own limitations and to • Most exercises are performed in the shallow
exercise at his/her own pace. The class must end of the pool for safety and to decrease
not be competitive in nature. It is OK for the effects of buoyancy. This depth, at
people to take short breaks during the class approximately the navel (or somewhere
if needed. between the navel and nipple), affords ease
of movement, some weight bearing input to
• Remind participants of the difference in the brain, a cooling effect on the body, and
significant feeling between buoyancy and protection from falls.
gravity. They will feel lighter in the pool
and once they begin walking out of the pool • Some participants do not have the strength
they will need to use extra strength to walk to swim or have never learned to swim.
back to the changing rooms. Participants Identify those who can swim and those
may want to sit wrapped in a towel for a who cannot. If there is a doubt, request
few minutes and have a cool glass of water, a performance swim. This is necessary if
giving the body a chance to acclimate. you plan a deep water relaxation session.
Floatation devices are not life saving
• If at any time, a person begins having devices, therefore, do not take a person who
trouble in the water or symptoms increase, is afraid of the water or cannot swim to
suggest contacting the physician. Do not deep water.
make a judgment or give medical advice.

National MS Society Aquatic Exercise Programming for People with MS | 25

A National Multiple Sclerosis Society
Aquatic Program
OBJECTIVES
Speak to our chapter staff about potential
1. Improve socialization, decrease isolation opportunities.
2. Promote well being and improve self-
Call 1-800-344-4867 to contact the chapter in
esteem your area or visit nationalMSsociety.org.
3. Provide an atmosphere to exercise that
minimizes or prevents a rise in core body
temperature
4. Prevent symptoms secondary to MS
(i.e.: muscle atrophy, joint contractures
pressure sores)
5. Maintain or improve range of motion and
flexibility of joints
6. Maintain or increase endurance potential
7. Maximize muscle strength

National MS Society Aquatic Exercise Programming for People with MS | 26

The National Multiple Sclerosis Society (“Society”) is proud to be a source of information on multiple sclerosis
related topics. The information provided is based on professional advice, published experience, and expert
opinion, but does not constitute medical or legal advice. For specific medical advice, consult a qualified
physician. For specific legal advice, consult a qualified attorney.

The Society does not endorse products, services or manufacturers. Such names appear here solely because
they are considered helpful information. The Society assumes no liability for the recipient’s use of any product
or service mentioned. The Society does not independently verify whether the information provided by each
service provider is accurate. The Society undertakes no responsibility to verify whether the service provider is
appropriately licensed and certified and has applicable insurance coverage.

Early and ongoing treatment with an FDA-approved therapy can make a difference for people with multiple
sclerosis. Learn about your options by talking to your healthcare professional and contacting the National MS
Society at nationalMSsociety.org or 1-800-344-4867.

The Society publishes many other resources about various aspects of MS. Call 1-800-344-4867 or visit
nationalMSsociety.org/brochures.

The National MS Society mobilizes people and resources so that everyone affected by MS can live their
best lives as we stop MS in its tracks, restore what has been lost and end MS forever. To fulfill this mission,
the Society funds cutting-edge research, drives change through advocacy, facilitates professional education,
collaborates with MS organizations around the world, and provides programs and services designed to help
people with MS and their families move their lives forward.

nationalMSsociety.org
1-800-344-4867

© 2016 National MS Society. All rights reserved.