Swim England’s 2016 research highlighted a significant need for aquatics-based GP Referral offerings; health professionals said they would have, on average, three people each month to refer to aquatics, with some suggesting they would refer up to 50 a month. Ninety-two per cent also said they would recommend self-referral if it were available.

The benefits are clear to see. The properties of water, particularly buoyancy and resistance, make exercise accessible to people who may struggle to exercise effectively on land, where bearing one’s own weight could cause significant discomfort. The water’s natural buoyancy supports a person’s weight, reducing the amount of stress that’s placed on joints, enabling them to exercise more efficiently and with less pain.

But how does delivery of aquatic activity for health differ from an aqua-aerobics class, and how is it uniquely positioned to help people with specific health issues? HCM investigates

All buoyed up
Aquatic activity for health should be specifically tailored for people who suffer with pain, have a disability or are weakened due to injury. Aquatic activity has proven value in helping with conditions including back pain, fibromyalgia, osteoarthritis, rheumatoid arthritis, hip and knee replacement (both pre and post-surgery), other musculoskeletal conditions, including amputees and people who have had a stroke.

It’s also ideal for people with mental health issues, such as anxiety and/or depression, and perfectly suited for conditions where overheating is a symptom, including the menopause and pregnancy.

However, Swim England’s research found there was a lack of specific training for fitness professionals, with 84 per cent of leisure operators expressing a need for an aquatic element to GP referral courses.

In answer to the research, Swim England worked with its partner, the Institute of Swimming, and the Aquatic Therapy Association of Chartered Physiotherapists to develop an aquatic exercise qualification for GP referral instructors to upskill the sector.

New qualification
Following a Swim England Water Wellbeing pilot scheme, the Aquatic Activity for Health qualification (AAFH) was launched in April 2018, and has since been taken up by over 100 instructors.

Rebecca Cox, managing director at Institute of Swimming says: “Aquatic rehabilitation is uniquely positioned to offer physical activity that is accessible to all. Our Aquatic Activity course is a bolt-on qualification that builds on the Level 3 GP Exercise Referral qualification, bridging the gap between dry and water-based exercise. Once qualified, instructors can create tailor made exercise plans for referral patients; this isn’t an aquafit class, the highly knowledgeable instructors assess a person’s individual needs and develop a customised exercise programme for them.

“Suitable for a range of mild to moderate health conditions, the qualification allows fitness professionals to take land-based fitness knowledge and skills into aquatic environments, making best use of available space in pools and supporting people to get the best outcomes in terms of their health.”

Sarah Cox is a chartered physiotherapist who specialises in rehabilitation and aquatic physiotherapy, and one of Swim England’s approved tutors for the two-day, face-to-face qualification. She explains: “The qualification’s challenging content focuses on teaching instructors to understand the principles of exercising in water, and what happens to the human body in water. The aim is to allow instructors to take referral customers from being a ‘patient’ to being an active participant. Standing upright in water alone has a physiological effect on the body that increases cardiac output, so the water helps with fitness before tailored movements and exercises are even introduced.”

The Institute of Swimming’s Level three Aquatic Activity for Health qualification is suitable for instructors already holding a Level three exercise referral qualification or for physiotherapists who want an introduction to water.

Taking the plunge
Active Nation’s Bitterne Leisure Centre in Southampton took part in Swim England’s Water Wellbeing pilot. Karen Tillyer, health and wellbeing lead for Active Nation says: “There are a lot of people who cannot exercise dry side because they can’t weight bear or their movements aren’t symmetrical – they may have had a stroke, so they’re prone to falling. When I saw there was an opportunity to bring functional exercise into the water I just thought, why wouldn’t you? There are a lot of people who need to be moving more, and currently can’t, and this gives them the opportunity to be physically active.

“We design a customised exercise plan for each of our referral patients, so even though you might have half a dozen people in the water at one time, all appearing to do the same thing, everyone is actually doing something completely different, which has been uniquely tailored for them.”

One of Active Nation’s aqua-referral patients, Paul, says: “Since I was a child I’ve had a long term, chronic back condition called Ankylosing Spondylitis. This effects my spine and gradually fuses it if I don’t keep active. The sessions at Bitterne Leisure are fantastic. Since starting the aqua functional training I’ve managed to reduce the drugs I’m taking. With a back condition, at the end of the day you get tired and the pain kicks in, so it’s very difficult to get to sleep. By doing these exercises I can get a good night’s sleep and at the same time reduce my drugs, it’s a winner all round. The staff are great and informed and the exercises build up too, so you are gradually growing your confidence.”

All in the mind
Active Luton operates a ‘Total Wellbeing Luton Scheme’, including Hydra Health, which can be accessed by GP or self-referral and has proved successful in getting people with long term conditions, injuries and mobility problems active through water sessions.

Matthew, 33, is bi-polar and suffers from an anxiety disorder which caused him to become agoraphobic. He was shut away in his home day after day, with little or no contact with the outside world and was referred to the scheme after a routine appointment with his GP.

Matthew says: “I was in a very bad place, both mentally and physically. My GP diagnosed me with type two diabetes, high blood pressure and high cholesterol – and this was when my referral was made. I was inspired to try the Hydro Health scheme as I used to scuba dive and thought it would remind me of this. I can now walk to the supermarket, my range of movement has improved and I’ve dropped 25kg. My diabetes, blood pressure and cholesterol are within the normal range. My mental health has also vastly improved. These classes mean the world to me.”

Making waves
Other operators offering a variety of health-related aqua programmes include Trafford Leisure, which launched its Water Wellness Class in April 2019 at its Altrincham Leisure Centre. Trafford Leisure’s Swim Well manager, Lee Pickford, says: “What’s so fantastic about aquatic activity is that participants don’t need to be able to swim to get benefit from the class. The exercises are performed in a very controlled environment, so they feel safe and not out of their depth. Our customers tell us how liberating coming to the pool is. It’s also very sociable. Since the launch we regularly have over 30 people in the class, all with a variety of health conditions including diabetes, knee injuries and even a gentleman with a broken back. It really is the missing piece to our referral fitness offerings.”

Altrincham Leisure Centre also holds weekly pregnancy aquatic physiotherapy and midwife-lead pre-natal classes, run by Sarah Hill, women’s health physiotherapist at the Pennine Care NHS Foundation Trust. The drop-in sessions, part funded by the NHS, are designed for women from 14 weeks pregnant to full gestational term. Anyone can join, but local midwives particularly recommend them for pregnancy related pain.

Hill says: “The sessions are extremely rewarding and the highlight of my week. They’re really beneficial for both the pregnant women and their babies. Pregnancy puts a lot of additional stress on a woman’s body, and many women suffer with pelvic girdle pain, sciatica and aches in the upper back, lower back and ribs, as well as the swelling in hands or feet and water retention.”

The classes concentrate on muscle strength, flexibility, cardiovascular fitness and pelvic floor exercises. Tailored to each woman’s bespoke needs, the exercises can help reduce gestational diabetes, improve ease of labour, flexibility, movement and sleep, and help prevent pregnancy-related constipation.

Hill continues: “The classes have a positive influence on the women. During pregnancy a woman’s body changes a lot. This can affect concentration, energy levels, physical ability and an individual’s confidence. We’ve worked hard to create a safe and judgement-free space, where women can enjoy a structured class and feel confident in the water and in a swim suit. There’s a lot of work in pairs and groups to help build friendships and create a social peer network. Another exciting outcome is the women intending to bring their babies to swimming lessons once they’re born, reinforcing the belief that exercise and aquatic fitness is beneficial at every stage of one’s life.”

All equal in the pool
Oldham Community Leisure (OCL) has been running three Aqua 4 Health circuit-based sessions a week across its sites since September 2018; designed for those new to exercise and those returning to exercise after a break. They are also suitable for people with long term medical conditions and for people that have come to OCL through the Oldham Exercise Referral Scheme or the Reach Exercise Referral scheme through their GP or other medical professional.

Jason Bailey, health and wellbeing officer at OCL says: “As participants have a variety of health and movement complications, we restrict the size of classes to ensure everyone is given sufficient guidance. What’s really positive is the number of men, particularly men over 60, that have taken these sessions. Our traditional aqua-aerobic classes are dominated by women, whereas Aqua 4 Health engages both men and women equally. We’ve also found Aqua 4 Health to be a gateway to swimming, which is fantastic.”

Ali Noyce, health and wellbeing manager at Swim England concludes: “It’s vitally important that the pool isn’t seen as off limits to anyone, and so it’s encouraging to see leisure operators embracing a positive and inclusive culture around poolside activity. From running disability sessions or pool time for people with dementia and their carers, to keeping changing rooms clean and welcoming, having trained staff to use hoists and providing towel hooks at the pool side, we must remove barriers, both physical and mental, to people accessing water, as being in water just makes you feel better.”