HTML Fulltext

Effects of a Hydrotherapy on Flexibility and Muscular Strength in Elderly Men

Yaser Alikhajeh1, Amir Shahriyar Ariamanesh2*, Nasser Mohamad Rahimi3, Kazem Noroozi3

1 Islamic Azad University, Mashhad, Iran
2 Mashhad Medical University, Mashhad, Iran
3 Ferdowsi University of Mashhad, Mashhad, Iran

* Corresponding Author

Vol 2, Num 1, January 2015




Introduction:We designed this study to evaluate the effect of a hydrotherapy program on flexibility and muscle strength among sedentary elderly men.

Materials and Methods:The participants were 28 healthy sedentary elderly men aged between 64 and 84 years (14 in the experimental group and 14 in the control group). Muscle strength before and after the program was assessed by means of test 30- Second Chair stand and Flexibility assessed by means of chair sit – and – reach test. The program consisted of 36 one-hour sessions over a consecutive 12-week period. The physical exercises were organized in seven levels of difficulty that were selected to obtain gains in flexibility and muscle strength. Therefore, there were between and within group analyses using independent t-test.

Results:Hydrotherapy promoted significant increases in the elderly men's muscle strength, as assessed using the test30- Second Chair stand (p< 0.001) and the chair sit – and – reach test (p< 0.001).

Conclusion:The proposed hydrotherapy program was efficient in improving flexibility and partially effective in improving muscle strength among the early elderly women who took part in the study. Our results are compatible with the findings from similar studies carried out on the ground.

Keyword:Hydrotherapy; Elderly men; Aquatic exercises; Flexibility; Muscle strength




The aging process may be understood as a set of unfavorable structural and functional alterations of an organism, which progressively accumulates, specifically due to advancing age. These modifications interfere with the performance of motor skills, making the individual's adaptation to the environment difficult, and initiating changes of both a social and psychological nature.(10) The loss of muscular strength in the muscular-skeletal system starts from 25 to 30 years of age, and occurs due to various factors(1,21): Simultaneous decreases in flexibility of all joints.

The lack of flexibility and muscular strength losses in elders affect balance; results inpoor posture and functional performance; increases the risk of falling and respiratory problems; decreases the speed of walking; and makes daily living activities difficult. Consequently, the maintenance or gain of flexibility and muscular strength is an important aim for the control of elderly people's health. Physical training programs may diminish the effects of the immobility cycle: of falls, pains, and fears.(6) It is agreed upon that musculature should be strengthened in a harmonious manner from optimized joint mobility, and that, in order to prevent aging dysfunctions, the most appropriate solution is a program of low impact to moderate the intensity exercises over a long period.(11)

Hydrotherapy is a physical therapy resource that utilizes the physical, physiological, and kinesiological effects that occur from the body's immersion in a heated pool as an auxiliary resource for the rehabilitation or prevention of functional alterations. Physical properties and the heated water perform important roles for the improvement and maintenance of joint range of movement, muscular tension reduction, and relaxation.(4)

Decreases of joint impact during physical activities induced by flotation cause reductions in pain sensitivity, decrease the compression on the painful articulations, and bring about greater freedom of movement and decreases of painful spasms. The effects of flotation aid the movement of rigid articulations in wider ranges with minimal increases in pain.(18) The strengthening exercises with submerged patients are based on the physical principals of hydrostatics, which allow the generation of constant multi-dimensional resistance to the movements. This resistance increases proportionally while the strength is exerted, generating a minimal overload of the articulations.(3)

Based on what was demonstrated above and on the importance of exploring this subject, this study had the objective to assess the effects of a hydrotherapy program developed for flexibility and muscular strength gains in previously sedentary, early elderly men.

Materials and Methods

This was a quasi-experimental before/after study. The participants were 28 healthy sedentary elderly men aged between 64 and 84 years, 14 elderly men in the experimental group (75.79 ± 4.04 years) and 14 elderly men in the control group (70 ± 13.30 years). The volunteers were recruited by means of posters in the association itself, and subsequently selected in accordance with the inclusion and exclusion criteria. The inclusion criteria were: over 64 years of age, independence in walking, independence in activities of daily living, the absence of medical contraindications for exercise, cardiological and dermatological medical certificate, 90% participation in the treatment, and signature of the free and informed consent statement.

The exclusion criteria were: urinary or fecal incontinence, renal insufficiency, open wounds, contagious skin diseases, infectious diseases, catheters, vascular thrombi, cardiac insufficiency, uncontrolled arterial pressure, dyspnea upon minimal effort, use of psychotropic drugs (benzodiazepi-nes), or participation in any other physical activity or physical therapy program.(22)


The materials consisted of the following: a questionnaire for interview, the test 30- Second Chair stand, the chair sit–and–reach test (8,16), a chronometer (Sport Timer), two chairs of 45 cm in height (one of them with arms), swimming pool measuring 7.5 by 11.1 meters, with a sloping bottom with the depth going from 0.8 to 1.2 meters, and with a mean temperature of 30ºC.


The subjects' evaluation occurred at two distinct moments, before and after interventions which were performed in the morning by the same properly trained investigator.

Flexibility Assessment

Chair-sit-and-reach was a method used to measure the capability of the participants for general lower body flexibility. Rikle and Jones (15) suggested this method of functional flexibility testing for older people. The participants sat on a chair with their legs extended with feet together. The participants then reached forward for their toes as far as they could reach while the examiner measured the distance between the finger tips and toe tips. This procedure was repeated three times, and the mean of the three scores was recorded.

The rationale for selecting the sit-and-reach test as a measure of lower body flexibility assessment is that flexibility decreases with age and can play a role in fall-related injuries.

Muscular Strength Evaluation

The thirty seconds sit-and-stand measure was used to assess lower body muscular strength and endurance. Participants started the test seated in the examination chair waiting for the starting signal from the examiner to prompt the commencement of the test. This involved standing straight up without the use of their hands (crossed over their chest) and sat down with their full buttocks on the chair; This procedure was repeated for 30 seconds.(8,15)

The number of correct completed movement patterns was recorded as the score achieved for this component. During execution of the test, the researcher assistant supported the chair by holding it in place. This was to ensure that the participant did not bump the chair out of the way while performing the exercise. The researcher assistant also made sure that the participant did not stumble or miss-judge the chair during testing by guiding the participant into the chair and out of the chair.

The scales were applied before the treatment (pre-test) and after 12 weeks (post-test 12) of hydrotherapy. The arterial pressure (AP) was measured before and after the treatment sessions, with the aim of checking the individuals' conditions for performing the aquatic activities, without statistical intentions. The study lasted 12 weeks, with one-hour sessions, three times a week. The hydrotherapy program was carried out with seven elderly men per group and included adaptation to the aquatic environment, hydrokinesio­therapy and inclusion of aquatic exercises from other studies (7,13,19) that were run to challenge balance. Each session was divided into three phases: the aquatic environment adaptation phase, the stretching phase, and a phase for strengthening exercises. The intensity was low to moderate, with constant intensity, frequency, and speed, for 12 weeks. Each series was performed continuously and during the time of each one, there was a one-minute rest.

Statistical Analyses

For comparisons over the course of time for the measurable variables, the Student t test was performes for paired data, by means of comparing scores or times after the treatment, with corresponding results for the same individuals from the preceding evaluation.(2) The data have been shown as mean differences and standard deviations of the difference. Statistical significance was set at the (p<0.05) level of probability. All analyses were conducted using the Statistical Package for Social Sciences (ver.19).


Hydrotherapy promoted significant increases in the elderly men's muscle strength, as assessed using the test 30- Second Chair stand (p< 0.001) flexibility, and the chair sit–and–reach test (p< 0.001)(Tales 1and2).

    Table 1: (M±SD) of the differences in elderly men control group and experimental group the program of hydrotherapy for muscles.
    Table 2: (M±SD) of the differences in elderly men before and after the program of hydrotherapy for Muscle Strength/Flexibility obtained by means of the paired sample t test for paired data


    The “fun”, the “enjoyment”, and the social aspects of water exercise are highly significant. It provides motivation for the isolated and frail elderly to be active.(17) Water is a supportive, low risk exercise environment that may reduce the likelihood of acute injury and fear of falling, while improving participation and adherence. Aquatic exercise in warm water increases blood circulation to involved joints, increases strength and range of motion to involved joints, relaxes muscles, temporarily decreases levels of pain, and increases confidence in functional ability.(20)

    Buoyancy provides support to the body weight and reduces the compression to the weight bearing joints.(12) Therefore, although water-based exercising is non-weight bearing, the added resistance to movements may be sufficient to stress the bones and therefore it leads to improvement in bone density. Strengthening of the muscles and the other tissues surrounding the joints can improve posture and joint stability. Hydrostatic pressure improves the circulation of blood around the body, and thus causing a lower working heart rate, assists in the removal of waste products, promotes more effective recovery from exercise, reduces swelling in joints, but makes it harder to breathe, if water is pressing against the rib-cage.(12)

    According to the obtained results, muscle strength and flexibility increased significantly after conducting the hydrotherapy program, according the test 30-Second Chair stand, the chair sit–and–reach test. A previous study assessed the flexibility using the same methodology in response to a program of physical exercises performed on the ground, including stretching, muscular strength, respiratory, balance and motor skills exercises, or a general exercise program.

    The study was conducted with 15 early elderly women in the experimental group and 15 participants in the control group, who were trained for four months, twice a week. The study showed improvements in experimental group's flexibility, and decreasing the average wrist-ankle distance to half of the values found on the pre-test, that is, an average decrease of 21.9 ± 4.3 m. The control group did not show significant alterations.(5)

    These results are compatible with the data of Rauchbach,(14) who studied the effects of a general exercise program (stretching, respiratory, muscular strength training, joint mobilization, balance training, and relaxation, together with walking), applied for three months, three times a week, in sessions of one hour, of 42 subjects with an average age of 64 years. The authors found a relationship between performing the proposed physical activities and improvement of the range of motion of the articulations of the upper and lower limbs. The flexibility of the lumbar spine measured during the anterior flexion of the trunk showed an average increase of 5 cm in 88.1% of the participants after training, indicating that the association of the training proposed by the author increases flexibility.

    Judge et al. (9) assessed the effects of 12 weeks of postural balance-and-strength training of the knee extensors, hip adductors, foot dorsal flexors, hip extensors, and knee flexors with muscular exercise training with 16 participants. The control group, with 15 participants, performed general stretching exercises while seated on a chair. The average age of the participants was 82.1 years. The authors found that the experimental group demonstrated increases in strength and walking velocity. This study is compatible with our findings, thus strengthening the idea that hydrotherapy programs, as well as general ground exercises, promote increases in strength and flexibility.


    The proposed program has shown it-'s efficiency in generating improvements in muscular flexibility and strength of previously sedentary early elder men, and has confirmed the clinical findings reported in most didactic books about hydrotherapy. The muscular flexibility and strength increases found are similar to those found in ground-based studies. This research contributes to the development of more detailed programs of physical exercise directed towards the elderly population, with more exercise routines. The demonstration of the effects of various programs may facilitate more adequate exercise prescriptions, for the needs of the elderly.

    Yaser Alikhajeh
    Facualy of department of Physical education and Sport Sciences, Young Researchers Club and elites, Mashhad Branch, Islamic Azad University, Mashad , Iran


    Amir Shahriyar Ariamanesh
    Orthopaedic Facualty of Mashhad Medical University, Hip and Knee Surgeon, Mashhad , Iran
    Corresponding Author


    Nasser Mohamad Rahimi
    Faculty of Physical Education and Sport Sciences, Ferdowsi University of Mashhad, Mashhad, Iran


    The authors would like to express their gratitude to elderly to participate in related field work of this research.


    Financial disclosure:
    None declared.



    1.Balfites BSH, Sargent IIF. Human physiological adaptability through the life sequence. J Gerontol: 32(4):402-10, 1977.

    2. Candeloro JM, Caromano FA. Effects of a hydrotherapy program on flexibility and muscular strength in elderly women. Rev. bras. fisioter. São Carlos: 11(4):267-272, 2007.

    3. Candeloro JM, Caromano FA. Graduação da resistência ao movimento durante a imersão na água. Rev Fisioter Brasil: 5(1):73-6, 2004.

    4. Caromano FA, Candeloro JM. Fundamentos da Hidroterapia para Idosos. Arq Ciências Saúde Unipar: 5(2):187-95, 2001.

    5. Caromano FA. Efeitos do treinamento e da manutenção de dois programas de exercícios em idosos sedentários saudáveis [tese]. São Paulo: USP: 1999.

    6. Daley MJ, Spinks WL. Exercise, mobility and aging. Sports Med: 29(1):1-12, 2000.

    7. Douris P, Southard V, Varga C, Schauss W, Gennaro C, Reiss A. The effect of land and aquatic exercise on balance score in older adults. J Geriatr Phys Ther. 26(1):3-6, 2003.

    8. H. Scott Kieffer, Marie Attanasi Lehman, Danielle Veacock, and Larua Korkuchthe. Effects of a Short-Term Novel Aquatic Exercise Program on Functional Strength and Performance of Older Adults. International Journal of Exercise Science: 5(4): 321-333, 2012.

    9. Judge JO, Lindsey C, Underwood M, Winsemius D. Balance improvements in older women: effects of exercise training. Phys Ther: 73(4):254-62, 1993.

    10. Kalache A, Veras RP, Ramos LR. O envelhecimento da população mundial: um desafio novo. Rev Saúde Pública: 21(3):200-10, 1987.

    11. King AC, Taylor B, Haskell WLEffects of differing intensities and formats of 12 months of exercise training on psychological outcomes in older adults. Health Psychol; 12(4):292-300, 1993.

    12. Lawrence, D. The complete guide to exercise in wat er. 2nd ed. London. A & C Black publishers Ltd: p. 9-10, 54, 2004.

    13. Lord SR, Matters B, George RS. The effects of water exercise on physical functioning on older people. Aust J Ageing: 25(1):36-41, 2006.

    14. Rauchbach R. A atividade física para a terceira idade. Curitiba: Lovise: 1990.

    15. Rikle, R.E. & Jones, C.J. Exercise and Older Adults. In Howley, T.E. & Franks, B.D. (eds.), Health Fitness Instructor's Handbook. 4th ed. Champaign, IL: Human Kinetics, p. 300. 2003.

    16. Rikle, R.E. & Jones, C.J. Senior Fitness Test Manual. Champaign, IL: Human Kinetics 2001.

    17. Rissel, C. Water Exercises for the Frail Elderly: A Pilot Programme, The Australian Journal of Physiotherapy, vol. 33, no. 4, p. 226-232,1987.

    18. Ruoti, R.G., Troup, J.T. & Berger, R.A. 'The Effects of Non-swimming Water Exercises on Older Adults', JOSPT Research Study, vol. 19, no. 3, p.140-145, 1994.

    19. Simmons V, Hansen PD. Effectiveness of water exercise on postural mobility in the well elderly: an experimental study on balance enhancement. J Gerontol.51A: (5):M233-8, 1996.

    20. Takeshima, N., Rogers, M.E., Watanabe, E., Brechue, W.F., Okada, A., Yamada, T., Islam, M.M. and Hayano, J. Water-based exercise improves health-related aspects of fitness in older women, Medicine & Science in Sports & Exercise: vol. 34, on. 3, p. 54, 2002.

    21. Williams GN, Higgins MJ, Lewek MD. Aging skeletal muscle: physiologic changes and the effects of training. Phys Ther: 82(1):62-8, 2002.

    22. Yaser Alikhajeh ., Seyyed Reza Attarzadeh Hosseini &Amir Moghaddam. Effects of hydrotherapy in static and dynamic balance among elderly men. Procedia - Social and Behavioral Sciences: 46: p 2220 – 2224, 2012.