Title€¦ · region during water immersion is caused by hydrost atic pressure, which subsequently...

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Title:

A comparison of the effects of different water exercise programs on balance ability in elderly

people

Authors:

Koichi KANEDA1, Daisuke SATO1, Hitoshi WAKABAYASHI2, Atsuko HANAI3, Takeo

NOMURA1

1) Graduate School of Comprehensive Human Science, University of Tsukuba, Japan

2) Faculty of Design, Kyushu University, Japan

3) Sports Science Program, Department of Liberal Studies, Hokusho college, Japan

Authors and Information:

Koichi KANEDA

Affiliation: Doctoral Program in Health and Sport Sciences, University of Tsukuba, Japan

Mailing address: Doctoral Program in Health and Sport Sciences, University of Tsukuba, 1-1-1

Tennoudai, Tsukuba-city, Ibaraki, 305-8574, Japan

of 35 Journal of Aging and Physical Activity (c) Human Kinetics, Inc.

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Phone number: +81-298-53-6338, Fax number: +81-298-53-6338

E-mail address: [email protected]

Daisuke SATO

Affiliation: Doctoral Program in Health and Sport Sciences, University of Tsukuba, Japan


Tennoudai, Tsukuba-city, Ibaraki, 305-8574, Japan



Hitoshi WAKABAYASHI

Affiliation: Faculty of Design, Kyushu University, Japan

Mailing address: 4-9-1, Shiobaru, Minami-ku, Fukuoka-city, Fukuoka, 815-8540, Japan



of 35Journal of Aging and Physical Activity (c) Human Kinetics, Inc.

3

Atsuko HANAI

Affiliation: Sports Science Program, Department of Liberal Studies, Hokusho college, Japan

Mailing address: Sports Science Program, Department of Liberal Studies, Hokusho college, 23

Bunkyodai, Ebetsu, Hokkaido, 069-8511, Japan



Takeo NOMURA

Affiliation: Institute of Health and Sport Sciences, University of Tsukuba, Japan

Mailing address: Institute of Health and Sport Sciences, University of Tsukuba, 1-1-1 Tennoudai,

Tsukuba-city, Ibaraki, 305-8574, Japan



Running head:

Water exercise and balance ability in elderly


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Corresponding author:

Koichi KANEDA


Tennoudai, Tsukuba, Ibaraki, 305-8574, Japan




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ABSTRACT

This study compared the effects of two types of water exercise programs on balance ability in

elderly. Thirty healthy elderly persons (60.7 ± 4.1 years) were randomly assigned to a deep-water

running exercise (DWRE, n = 15) group or a normal water exercise (NWE, n = 15) group. The

subjects completed a twice-weekly water exercise intervention for 12-week. Exercise sessions

comprised a 10-min warm-up on land, a 20-min water-walking exercise, a 30-min water exercise

while separated into NWE and DWRE, a 10-min rest on land, and a 10-min recreation and

relaxation in water. Postural-sway distance and tandem-walking time were decreased significantly

in DWRE. Postural sway area was decreased significantly in NWE. In both groups, simple

reaction times were significantly decreased. The findings of this study show that a water exercise

program including deep-water running exercise is much better than normal water exercise for

improving dynamic balance ability in elderly.

Key Words: Water exercise intervention, Deep-water running, Dynamic balance, Static balance,

Elderly persons


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TEXT

Introduction:

Falls involving elderly people pose a serious problem in an aging society as they cause bone

fractures and reduce physical activities in daily life because of the attendant fear of further falls

(Vellas et al., 1987). The main factor in falls among elderly people is the decline of physical

functions with age: muscle strength, aerobic capacity, joint flexibility, and balance ability

(Edelberg, 2001). The fear of falling limits daily activities, which in turn further decreases

physical functions. Balance ability is an important function which prevents falls because it is

associated with postural control (Woollacott, 1993). Nelson et al. (2004) showed that balance

improvement and balance training are crucial in fall prevention. Balance ability is widely

acknowledged to decline with age; it is markedly lower in persons who are 60 years old or older

(American Geriatric Society, 2001). Therefore, exercises to improve balance ability are important

to prevent, or at least forestall, the decline in physical functions and consequential falls.

Many exercises are conducted to prevent the decline of balance ability among elderly people

(Gauchard, Jeandel, Tessier & Perrin, 1999; Wong et al., 2001). Water exercises such as water

walking and water aerobic exercises are effective exercises used in fitness programs for health


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improvement in elderly people or in rehabilitation programs for people with disabilities (Foley,

Halbert, Hewitt & Crotty, 2003; Ruoti, Troup & Berger, 1994). In water, buoyancy acts against the

body to reduce the vertical load at the joints; furthermore, water resistance necessitates that

subjects exert greater force than in air (Miyoshi et al., 2004). With regard to influences on

cardiovascular responses, the central shift in blood volume from lower limbs to the thoracic

region during water immersion is caused by hydrostatic pressure, which subsequently increases

cardiac output and stroke volume (Arborelius, Ballidin, Lilja & Lundgren, 1972). Other

advantages include a low risk of falling and the consequent lack of fear of falling during water

exercise (Devereux, Robertson & Briffa, 2005).

Suomi & Koceja (2000) described the positive effects of the Arthritis Foundation Aquatic

Program on balance ability in people with rheumatoid arthritis. Simmons & Hansen (1996)

conducted water exercises such as walking, marching, sidestepping, kicking, and twisting in

healthy elderly subjects which thereby improved their balance ability. However, few studies have

investigated the effects of different types of water exercise on balance ability. Clarification on the

effects of water exercise type and of these interventions in elderly persons is important to assess

water exercise programs which are intended to improve balance in elderly persons. Although


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previous reports have shown the benefits of water exercise, as described above, deep-water

running with feet separated from the swimming pool bottom is a specific form of exercise in water.

The advantages of this type of exercise include a reduction in impact stress on lower limb joints

and positive effects on aerobic fitness (Reilly, Dowzer & Cable, 2003). Deep-water running is

widely used by athletes in endurance training and by elderly persons in fitness training

(Svedenhag & Seger, 1992; Broman et al., 2006). Moening, Scheidt, Shepardson & Davies (1993)

described deep-water running as an open kinetic chain, in contrast to a closed kinetic chain such

as water-walking. For that reason, deep-water running might be more unstable than water-walking.

It was hypothesized that deep-water running was more beneficial for the maintenance of balance

ability than water-walking.

This study was designed to investigate the effects of a water exercise program, which included

deep-water running in comparison to normal water exercise which mainly consisted of

water-walking. The program was especially designed to improve balance ability in elderly

subjects. We evaluated the static and dynamic balance ability following the 12-week water

exercise intervention.


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Methods

Subjects. For this single-blind, interventional study, 49 community-dwelling elderly volunteers

were recruited. All subjects completed author-administered medical examinations and

questionnaires related to their physical activity. Volunteers were excluded from the study if they

reported any problems such as orthopedic diseases of the lower extremities. Subjects with

circulatory diseases obtained their physician’s permission to participate in the study; the results

from these subjects were included in the experimental data. Low-attendance participants in the

water exercise sessions (attendance rate < 50%) were excluded from the experimental data. Some

participants did not have post-performance test results due to illness or work commitments.

Results from a total of 30 elderly subjects (4 men, 26 women) are included in this report. A flow

chart of the participants is shown in Figure 1. The subjects were instructed not to change their

usual lifestyle during the study. All subjects were informed of the purposes, experimental

procedures, and risks of the study and subsequently gave their informed written consent to

participate. The Ethics Committee of the Institute of Health and Sports Sciences at the University

of Tsukuba approved this study.

Exercise Protocol. The water exercise intervention was undertaken twice weekly for 12 weeks.


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The subjects were assigned to a normal water exercise (NWE) group or a deep-water running

exercise (DWRE) group based on pre-performance test data, to ensure that there were no

differences between the two groups prior to the intervention. Exercise sessions were divided into a

10-min warm-up on land, a 20-min water-walking exercise, a 30-min water exercise either NWE

or DWRE, a 10-min rest on land, and a 10-min recreation and relaxation in water. Figure 2 shows

the schedule of a water exercise session. NWE participants performed forward walking, backward

walking, side walking, kicking, knee up, twisting, and other water-walking exercises similar to the

20-min water-walking exercise protocol. DWRE participants performed running exercises

without their feet touching the bottom of the pool using a flotation device, which was called

deep-water running (Reilly, Dowzer & Cable, 2003). The water exercise program was conducted

at a public indoor swimming pool, which had a water depth of 1.1–1.3 m and the water

temperature was 30°C throughout the 12-week period.

As a health check before each session, blood pressure was measured in the pool lounge using a

wrist sphygmomanometer (EW284; Matsushita Electric Industrial Co. Ltd.). Using Borg’s scale

(Borg, 1973), the ratings of perceived exertion (RPE) were recorded to investigate the exercise

intensity after each session.


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Outcome Measurements. Performance tests were conducted before (pre) and after (post) the

12-week intervention. Individual characteristics (height, weight, and body mass index: BMI) were

also measured at pre. The subjects practiced each measurement before the experimental trials.

The postural sway test was conducted using a posturographic meter (Gravicoda GS-10, type-C;

Anima Co., Tokyo, Japan). Subjects stood silently on the posturographic meter staring at a point

marked on the wall (distance was 3 m forward, height was 1.5 m) with their bare feet together.

Tests were conducted for 30 s with eyes open. Postural sway distance and postural sway area were

analyzed. Postural sway tests are often used to measure static balance ability (Colledge et al.,

1994).

Tandem-walking tests were conducted. Subjects were required to walk heel-to-toe along a 10-step

line as quickly as possible without misstepping. A misstep was defined as the subject completely

stepping off the line or failing to follow a heel-to-toe pattern. The times of the two trials without

misstepping were then averaged. Tandem-walking is defined as walking with the feet in the

position of a tandem stance during the double-support phase and the rear foot is then moved to the

front. These tasks were performed to assess the postural control system with a reduced base of

support compared to those of normal standing and walking (Speers, Ashton-Miller, Schultz &


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Alexander, 1998). The tandem-walking test is often used as a measure of dynamic balance ability

(Medell & Alexander, 2000).

Reaction times were assessed using a simple reaction time paradigm, with a light as the stimulus

and depression of a switch by the foot as the response in milliseconds. Subjects underwent three

experimental trials and the results of these three trials were averaged. This method is often used in

central nervous system assessment (Lajoie & Gallagher, 2004).

For normal and maximal walking tests, subjects walked along an 11-m walkway without walking

aids. Subjects completed this walking test four times. During the first and second trials, the

subjects were asked to walk at a self-selected comfortable speed as the normal trial. During the

third and fourth trials, they were asked to walk as fast as possible without running as the maximal

trial. The time from 3 m to 8 m was measured at the subject’s waist, and the walking speeds were

calculated. The calculated speeds of the two trials were then averaged. Walking speed is often

used to assess the total fitness level of elderly people (Himann, Cunningham, Rechnitzer &

Paterson, 1995).

Test-Retest Reliability. In a pilot study of test-retest reliability for the six outcome measurements,

28 healthy elderly volunteers (61.8 ± 5.9 years) participated. The subjects attended two test


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sessions one week apart. Intraclass correlation coefficients (ICC) revealed high test-retest

reliability for postural sway distance (ICC = 0.89), tandem-walking (ICC = 0.87), reaction time

(ICC = 0.81), and 11-m maximal walking speed (ICC = 0.86). Postural sway area (ICC = 0.54)

and 11-m normal walking speed (ICC = 0.68) showed moderate reliability. The measured values

are presented in Table 1.

Statistical analyses. Measured values are presented as mean ± standard deviation (SD). The data

were analyzed using computer software (SPSS v.14; SPSS Inc.). All group comparisons were

evaluated using two-way analysis of variance (ANOVA) with Tukey’s post-hoc test for parametric

data. A paired Student’s t-test was used to evaluate differences between pre and post tests for each

group if no significant interaction was shown using two-way ANOVA. An unpaired Student’s

t-test was used to assess differences between the two groups. Wilcoxon’s Signed-Rank test was

used to assess differences between pre and post tests with non-parametric data, and a

Mann-Whitney’s U test was used for comparing differences between the two groups. Results were

considered to be statistically significant when p < 0.05.

Results


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Characteristics of the subjects. Subjects included 15 in the NWE group (13 women, 2 men), and

15 in the DWRE group (13 women, 2 men). The subjects’ characteristics are listed in Table 2. No

significant differences were found between the groups.

Attendance and RPE. The attendance rate and averaged RPE scores during the 12-week

intervention are shown in Table 2. Attendance rates were 82.2 ± 15.0% and 76.7 ± 13.4% during a

total of twenty-four sessions, in the NWE and DWRE groups, respectively. The attendance rates

were not found to be significantly different between the groups. The average RPE scores for all

the exercise sessions over the 12-week period were 11.5 ± 1.4 and 11.5 ± 1.0, in the NWE and

DWRE groups, respectively. The RPE scores were not found to be significantly different between

the groups.

Performance tests. Performance test data of the respective groups are presented in Table 3. No

significant differences between the two groups were found in any of the characteristics studied

prior to the start of the intervention.

Following the intervention, a significant decrease in the postural sway distance was found in the

DWRE group (p < 0.05). With regard to the postural sway area, a significant decrease was found

in the NWE group (p < 0.05). A significant decrease was found in the tandem-walking time in the


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DWRE group (p < 0.05). The reaction time was significantly decreased in both groups (p < 0.05).

The 11-m normal and maximal walking speeds showed no significant differences between the

groups. No significant differences were observed in any of the measurements between the NWE

and DWRE groups following the 12-week intervention.

Discussion

To our knowledge, this is the first direct study of the effects of different water exercise programs

on balance ability in elderly persons. We established a normal water exercise (NWE) group and a

deep-water running exercise (DWRE) group, who performed this type of exercise for a 30-min

period within a 60-min water exercise program twice weekly for 12 weeks.

The results show that the postural sway area, and the reaction time were improved in the NWE

group. In the DWRE group, the postural sway distance, tandem-walking time, and reaction time

were improved. Although no differences were found between the two groups pre and post

intervention, each of the two types of water exercise improved different aspects of balance ability

assessed by the performance tests, even though the water environment was identical.

The postural sway distance, which reflects the distance of postural disturbance, and the postural


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sway area, which reflects the extent of postural disturbance, are respectively longer and larger in

elderly persons (Fujita et al., 2005). These two measurements are often used to assess static

balance ability (Colledge et al., 1994; Hageman, Leibowitz & Blanke, 1995). No assessments

have been carried out on healthy elderly persons to measure postural sway during a water exercise

intervention. The present study of healthy elderly subjects showed that the postural sway distance

was decreased in the DWRE group. This means that postural disturbance was slower and better

during static balance. However, although postural sway area was increased in the DWRE group,

indicating that postural disturbance was larger, no significant differences between the groups were

observed. These results suggest that DWRE may not improve static balance ability. In the NWE

group, postural sway area was decreased, but the post intervention value was similar to that of the

DWRE group. Rogers et al. (2002) reported reductions in lateral sway amplitude, speed of sway,

and postural sway area in elderly persons during land exercise. Improvements in lateral and

sagittal sway standard deviation, and postural sway area in women with lower extremity arthritis

were demonstrated during a water exercise intervention with the Arthritis Foundation Aquatic

Program, which consisted of 68 aquatic exercises designed to promote strength, range of motion,

and mobility for persons with arthritis (Suomi & Koceja, 2000). Results from the present study


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and from previous studies suggest that water exercise has the potential to improve postural sway

tests. However, moderate test-retest reliability in postural sway area was observed in this study.

This may indicate that these measurements are affected by physical conditions at the time of the

tests. Therefore more varied and detailed evaluation is needed to clarify the effects of a water

exercise intervention on static balance ability in healthy elderly persons.

In addition to improvement in the postural sway distance, the tandem-walking time improved only

in the DWRE group in this study. Several studies have assessed dynamic balance ability using

tandem-walking tests against static balance ability using the postural sway test (Nelson et al.,

2004; Medell & Alexander, 2000). Nelson et al. (2004) investigated the effects of a 6-month,

home-based exercise program that included strength and balance training. They reported

improvement in the 20-step tandem-walking time reflecting dynamic balance ability. Medell &

Alexander (2000) also investigated dynamic balance ability using the 10-step tandem-walking

time among different groups of women: young (21 ± 2 yr), unimpaired older (69 ± 3 yr), and

balance-impaired (more than one fall in the preceding year) older women (77 ± 6 yr). They

reported faster tandem-walking times in young (7.5 ± 1.1 s) and unimpaired older (8.5 ± 1.6 s)

women than in impaired older (17.0 ± 3.5 s) women. The values for tandem-walking times


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measured in young and unimpaired older women were similar to those in our study. The results of

the present study suggest that water exercise including deep-water running exercise is effective in

improving the dynamic balance ability of elderly people.

The reaction time is reportedly a sensitive marker of central nervous system function (Lajoie &

Gallagher, 2004). Some studies have demonstrated an improvement in reaction time during

exercise intervention in elderly persons (Lajoie & Gallagher, 2004; Lord & Castell, 1994). Results

of the present study indicate that central nervous system function can be improved by water

exercise. Lord, Rogers, Howland & Fitzpatrick (1999) found that reaction time was an excellent

predictor of postural sway among elderly people. The improvements in postural sway test results

in the present study might reflect improvements in central nervous system function.

No improvements in the 11-m normal and maximal walking trials were shown in this study. Chu

et al. (2004) and Chandler, Duncan, Kochersberger & Studenski (1998) reported an association

between normal walking and lower extremity muscle strength. The maximal walking speed is

often used to assess the total fitness level of elderly persons (Nelson et al., 2004; Himann,

Cunningham, Rechnitzer & Paterson, 1988). Some studies have demonstrated that lower

extremity muscle activity is significantly higher during water-walking than during land walking


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because of water resistance (Miyoshi et al., 2004; Kaneda, Kimura, Akimoto & Kono, 2004). In

addition, the biceps femoris muscle is more highly activated by deep-water running than by

water-walking (Kaneda, Sato, Wakabayashi & Nomura, 2007). The exercise intensity achieved in

the present study was approximately 11 (Light) on Borg’s scale (Borg, 1973). With this level of

exercise intensity the subjects did not gain adequate stimulus for muscle strengthening (Nelson et

al., 2004; van Vilsteren, de Greef & Huisman, 2005).

The most important difference between the two water exercise programs used in this study was

that the feet of subjects in the DWRE group did not touch the pool floor. Moening, Scheidt,

Shepardson & Davies (1993) described deep-water running as an open kinetic chain in contrast to

a closed kinetic chain such as water-walking. For that reason, deep-water running might be more

unstable than water-walking. Kaneda et al. (2007) reported higher muscle activity in the biceps

femoris during deep-water running than during water-walking. Older people activate the

hamstrings more than younger people when attempting to enhance hip joint stabilization (Benjuya,

Melzer & Kaplanski, 2004; Laughton et al., 2003). Deep-water running would improve hip joint

stability, which affected static and dynamic balance tests in the present study. Wong et al. (2001)

reported that sensorimotor information is more important in dynamic balance tasks than in static


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balance tasks. For deep-water running, sensorimotor information may be more important than for

water-walking. This is due to the unstable position of the former exercise, which resembles that of

using a foam floor to reduce somatosensory input (Woollacott, 1993; Colledge et al., 1994). It is

likely that this affected improvement in the tandem-walking test in the DWRE group.

Gauchard, Jeandel, Tessier & Perrin (1999) reported that balance exercise (yoga or soft

gymnastics) can improve dynamic balance ability, and that aerobic exercise (swimming or

cycling) can improve muscle strength. Wolfson et al. (1996) also reported improvements in

balance ability in balance exercise groups and of muscle strength in muscle training groups.

Results of the present study show that outcomes differed according to the type of water exercise.

In the main, dynamic balance ability particularly improved as a result of DWRE. However, this

study had some limitations. Firstly, more varied and detailed evaluations in postural sway tests are

needed. Data on postural sway distance or area is insufficient to clearly interpret the effects of

water exercise on static balance ability. Secondly, the test-retest reliability was poor in postural

sway area (ICC = 0.54) and in the 11-m normal walking test (ICC = 0.68). This may indicate that

these measurements are affected by physical conditions at the time of the tests. Finally, there are

many measurements that were not conducted in this study (i.e. muscle strength, flexibility and


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aerobic capacity etc.) that might affect postural sway, tandem-walking and reaction times.

Nevertheless, it is considered that a water exercise program which includes deep-water running

exercise is effective in improving not only aerobic capacity but also balance ability, particularly

dynamic balance, in elderly people.


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Acknowledgements

The support of the staff of the Swim Laboratory at the University of Tsukuba is greatly

appreciated. We also thank the 30 men and women who participated enthusiastically in this study.

This study was undertaken in cooperation with the city of Joso, Ibaraki, Japan. Brad Fast (Fastek

Ltd., Miyagi, Japan) revised the English used in this article.


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30

Figure legends:

Figure 1. Flow chart of the study participants.

Figure 2. Contents of the water exercise programs used in this study.

A normal water exercise (NWE) group and a deep-water running exercise (DWRE) group were

assessed. NWE participants performed water-walking, water resistance training using a kickboard,

and other water-walking exercises. DWRE participants performed locomotive motions, mainly

running motions, using a flotation device.


Recruited (n = 49)

Excluded (n = 3)

Randomized (n = 46)

Allocated to intervention (n = 20)Normal water exercisegroup

Allocated to intervention (n = 26)Deep-water running exercisegroup

Low attendance (n = 1)Lost post performance test (n = 4)

Low attendance (n = 6)Lost post performance test(n = 5)

Analyzed (n = 15) Analyzed (n = 15)

Figure 1. Flow chart of the participants in this study.


Figure 2. Contents of water exercise program at present study.

10

10

10

30

20

(min)Warming-up exercise on land

Walking exercise in water(Walking forward, backward,

sideways, with kicking,torso twisting and knee-ups,

etc.)

Water exerciseWater exercisein separate groupsin separate groups(NWE and DWRE)

Rest

Recreation and relaxationin water


Test (n = 28) Retest (n = 28) ICC

Postural sway distance (cm) 47.42 ± 16.51 45.02 ± 12.39 0.89

Postural sway area (cm2) 2.24 ± 1.19 1.75 ± 0.80 0.54

Tandem walking time (s) 7.8 ± 1.3 7.8 ± 2.1 0.87

Reaction time (ms) 486.8 ± 88.3 461.6 ± 48.6 0.81

11-m normal walking speed (m s-1

) 1.44 ± 0.15 1.31 ± 0.18 0.68

11-m maximal walking speed (m s-1

) 1.93 ± 0.15 2.00 ± 0.19 0.86

Values are mean ± SD.

ICC: Intraclass correlation coefficients

Table 1. Values of test-retest reliability measurements.


NWE (n = 15) DWRE (n = 15)

Age (year) 60. 5 ± 4.1 60.9 ± 4.1

Height (cm) 152.5 ± 6.6 153.2 ± 6.7

Weight (kg) 56.4 ± 8.7 61.2 ± 10.9

BMI (kg m-2) 24.2 ± 2.4 25.9 ± 3.5

Attendance (%) 82.2 ± 15.0 76.7 ± 13.4

RPE 11.5 ± 1.4 11.5 ± 1.0


There is no significant difference between the two groups.

NWE: Normal water exercise group

DWRE: Deep-water running exercise group

Table 2. Physical characteristics, attendance rate and averaged RPE score of

12 weeks.


NWE (n = 15) DWRE (n = 15) NWE (n = 15) DWRE (n = 15)

Postural sway distance (cm) 47.42 ± 16.51 45.02 ± 12.39 45.84 ± 15.38 41.24 ± 10.81 *

Postural sway area (cm2) 2.24 ± 1.19 1.75 ± 0.80 1.70 ± 0.64 * 1.84 ± 0.83

Tandem walking time (s) 7.8 ± 1.3 7.8 ± 2.1 7.3 ± 1.4 6.7 ± 1.2 *

Reaction time (ms) 486.8 ± 88.3 461.6 ± 48.6 450.1 ± 69.3 * 417.0 ± 36.9 *

11-m normal walking speed (m s-1

) 1.43 ± 0.14 1.38 ± 0.16 1.44 ± 0.18 1.40 ± 0.17

11-m maximal walking speed (m s-1

) 1.93 ± 0.15 2.00 ± 0.19 1.99 ± 0.20 2.07 ± 0.30


*: Significant difference between pre and post test, p = 0.05

NWE: Normal water exercise group

DWRE: Deep-water running exercise group

Table 3. Results of each performance test at pre and post 12 weeks.

pre post


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