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Functional Exercises to Improve ADLs

Functional Exercises to Improve ADLs
Kimberly Huff, MS, CSCS, CHES
August 29, 2017
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Editor’s note: This text-based course is a transcript of the webinar, Functional Exercises to Improve ADLs, presented by Kimberly Huff, MS, CSCS, CHES.  Please download the course handout and follow along to ensure understanding of the material and assist in taking the end of course exam.  

Learner Outcomes

  • The participant will be able to list three evidence based benefits of aquatic functional training.
  • The participant will be able to list three static and dynamic balance exercise that can be performed in the water and techniques to use the properties of the water to increase the challenge presented by each exercise.
  • The participant will be able to list five functional exercises that can be performed in the water and techniques to use the properties of the water to increase the intensity of each exercise.
  • The participant will be able to list three progressions of aquatic functional exercises that utilize equipment to increase the intensity of each exercise.

Introduction and Overview

I've been working in aquatic therapy and fitness since the early 1980s, so I've had the opportunity to see the field evolve. Believe it or not, when I started working in the pool there was no specialized equipment, so people were using milk jugs full of water for weight. When I was invited to present a workshop to therapists, I was excited but also nervous, and I asked myself what do I have to offer physical therapists. I usually turn to physical therapists for guidance. However, when I look back at my experiences over the years, I noticed in a lot of my roles I was often the link between the land-based fitness for therapy programs and the aquatic programs.

I've had the opportunity to work in cardiac rehab, pulmonary rehab, and orthopedic rehab. I've also worked very closely with PTs and OTs in work hardening programs (i.e., preparing people to return to work by doing functional training). Fortunately, in every setting that I have worked, we had access to a pool. Therefore, the therapists often turned to me for assistance in creating an aquatics program that would either support the land-based treatments or could represent a post-rehab home exercise program, especially for the folks that either had access to a pool or did have a home pool.

In several situations, I was also responsible for the facilities post-rehab program, which provided the patients the opportunity to continue to exercise under supervision in familiar and comfortable settings. In the last ten years, I've become more involved with professional education by presenting the review courses for ACSM and AEA and continuing education courses.

Going back to my original question of what I have to offer, I have knowledge of Functional Movement, knowledge of water, years and years of experience, and a passion for sharing my knowledge and experience with other professionals. I hope today's webinar provides you with a review of the principles of aquatic exercise and functional exercise, or if you're new to aquatic therapy, some new concepts and ideas that you can use in your practice.

Assistance with ADLs: Statistics

When I create workshops, I always start with establishing a need for the information. As such, I wanted to share some statistics with you on the number of people that require assistance with ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living). 

  • ADLs are activities needed for fundamental self-care, mainly dressing, eating, ambulating, transferring and hygiene. These five fundamentals of self-care comprise the acronym D-E-A-T-H; a morbid and yet handy mnemonic device. 
  • IADLs are tasks necessary for independent function, including cooking, cleaning, doing laundry, shopping, using the telephone, assessing means of transportation, taking medications and managing money. 

Each year, the Human Factors and Ergonomics Society publishes papers and abstracts from presentations at their Annual Meeting. The 400-plus papers in each year’s volume of the Proceedings of the Human Factors and Ergonomics Society Annual Meeting reflect the diversity of subject matter in the human factors/ergonomics field. The following data is from their paper, which included the results of a national survey of informal and formal caregivers to review ADLs and IADLs.

Overall, the study showed that 40% of adults 65 and older reported some type of functional limitation. Of that group, 96% reported requiring informal assistance. Informal care givers reported that 30% of people need assistance with three or more ADLs. These most frequently included dressing, transferring, and ambulation. The most frequent IADLs requiring assistance were running errands, transportation, and housework. Formal care givers reported 51% of people needed assistance with at least one ADL. The ADLs most frequently requiring assistance were bathing, showering, dressing or transferring. The IADL requiring the most frequent help involved assistance with housework.

Exercises to Improve Ability to Perform ADLs

What can we do? We can recommend exercise. Loss of muscle mass resulting in reductions in muscular strength and endurance (e.g., decreases in type II fibers resulting in decreases in power, decreases in flexibility, a decline in balance ability increasing the risk of falls, decline in cognitive performance) all impact functional mobility. Most research suggests that it is not the physiological changes associated with age that result in functional limitations, but rather lack of physical activity. In fact, many studies comparing fitness levels of active older adults to inactive younger people show that the active older adults show greater muscle mass, less body fat and overall are in better shape than some of the inactive younger people. It's not necessarily the physiological changes with age that are causing some of the problems; it might be inactivity.

A study published in The Journal Gerontology in 2001 reported that physical activity improved health-related quality of life scores on scales that include physical functioning and ability to perform ADLs. Another study (Taylor 2014) suggests that when older adults participated in exercises of sufficient intensity and frequency, there was a reduction in the risk of functional limitations by 30 to 50%. In a paper written by Mary Sanders of Nevada State University, she suggested that the need for assistance with ADLs is occurring at a younger age. I couldn't find her resource for that statement, but it doesn't surprise me since our population tends to be very inactive. In studies across the board, it is evident that increasing physical activity is the most important intervention to improve health and maintain functional independence.

The question becomes how do we get people to first participate in recommended therapy programs, and second to continue with the exercise program following discharge? Research on functional training, as well as research on behavior modification, indicates that if a person realizes the benefits of the program both physically and cognitively, they're more likely to adhere to the program. If they believe a program will be beneficial, there's a greater chance they will participate. Self-efficacy also plays a role in adherence, and this is where the water can make a huge difference. If they believe the program will be too stressful in terms of pain or energy expenditure, they may be hesitant to begin. However, in the aquatic environment, where the pain is decreased and movements are performed in a supportive environment, they may have a better self-efficacy, especially when they realize that those gains in the pool can carry over to functional movements on land.

Function-Focused Exercises

How do we design function-focused exercises? The focus is on training specific movement patterns, rather than training specific muscle groups. We want to create movements that are relevant to the specific needs of the patient. Again, everyone needs to be able to perform ADLs, but some people have additional functional needs. These needs may include job task, hobbies, or other interests that require specific movements. For example, someone may be interested in gardening but has not done so in years because of untreated back pain. It would be great if you are able to not only address their back pain, but also improve their ability to perform the movements necessary for gardening, or find a way to modify those movements so they can return to their hobby.

After you identify the activities that are necessary for their specific needs, you would break down the activities into a basic movement pattern. Consideration should be given to how the movements are stabilized, the role of static and dynamic balance, the muscular involvement, the type of muscle actions involved, and if the movement pattern can be modified, based on the patient's limitations. Lastly, how will you as a therapist progress the exercise as the patient improves or transfers to some type of post rehab program?

Programs should include physical activity, education and skill development. I read an article in the International Council on Active Aging Journal on functional training (Rogers and Page, 2005). The article suggested that there is a functional continuum that begins with the development of cardiovascular fitness, muscular strength and endurance and flexibility. However, greater improvements in functional mobility will be realized as you move up the continuum with the next level being incorporating compound movements. Not necessarily task-specific movements, but generic movement patterns such as pushing, pulling, reaching, bending, twisting, lunges and squats. The last level of the continuum is performing the skilled movements that involve the whole body. Several research studies also indicate the value of providing patients with education to help them make the connection between the exercises and activities of daily living on land. The connection between the functional movements and practical movements on land. It means that it allows the participants to make sense of the exercises. Their motivation is increased due to their desire to maintain independence. If patients believe the exercise will be beneficial in maintaining independence, it will improve their motivation to participate.

Why Aquatic Functional Training?

When recommending aquatic therapy to people that are not familiar with the water as a modality, one question we may receive is "Why should we get in the pool when we function on land?" Today, water as a modality is more readily accepted than when I started in the early 1980s, but I think there are still some skeptics. Some people are hesitant because it takes so much work to get in and out of the bathing suit, some people don't want to be seen in a bathing suit. Some people are fearful of the water, and the list of excuses can go on and on. We must be prepared with a strong list of benefits to help patients and medical providers overcome any of the perceived barriers to aquatic therapy.

Years ago, I heard a presenter at a conference say that the water provided multi-directional resistance and that exercising in the water is like standing in the middle of a huge resistance training machine. It is possible to feel resistance with every movement in the pool. This reduces the need to adjust your body position to work against gravity. It's also possible to work muscle pairs in the same movement, allowing for muscle balance. You can focus on a particular muscle group by simply adjusting the force in one direction while decreasing the force with other movements. For example, if you only wanted to work the posterior shoulder muscles during horizontal shoulder add/abduction, you could cue to instruct the patient to exert more force during horizontal abduction, and then just let the arms float forward.

The buoyancy of the water takes the pressure off of the joints. Depending on the body type, a body submerged to the umbilicus will offload approximately 50% of the body weight. Submerged to the xiphoid process offloads approximately 60%, and immersion to the shoulder up to 85%. This reduction in body weight reduces joint pain with movements. Buoyancy also assists with movements towards the surface, which can improve the ability to perform that movement, as well as the range of motion. Buoyancy takes the pressure off of the joints which also relieves joint pain, while the hydrostatic pressure (the pressure of the water against the body) improves circulation and reduces edema. The viscosity, or thickness, of the water, provides resistance, but it also provides support for people that may be unstable with movements on land. The fear of falling is significantly reduced in the water. People may still be concerned about losing their balance and getting their hair wet, but they're willing to take a greater risk when they know they have the support of the water. The supportive environment of the water allows for slower movements, which gives a neuromuscular system time to relearn movement patterns and respond to changes in the movement patterns without increasing the risk of injury. Many research studies have concluded that the water provides a safe comfortable and effective alternative to land-based exercise.

Research Review

I write the research reviews for the AAE's Aqua Journal and I've presented several research-to-practice workshops at AAE's International Aquatic Fitness Conference. When I was submitting ideas for this conference, I was trying to decide between this workshop and a research review. I shared both ideas with some therapist colleagues, and they all agreed that they would fall asleep during a research review. However, I still wanted to include a couple of studies, not only to verify the benefits of aquatic training but also to look at some of the methodologies in relation to exercise design. I do think it's important to understand research so that we can confidently say that we have positive outcomes and evidence based outcomes.

Reichert et al., 2016

The first study is titled, "Continuous and Interval Training Programs Using Deep Water Running Improves Functional Fitness and Blood Pressure in Older Adults." I don't personally work in deep water, but I wanted to include the study in the event that some of you do use deep water, and that the water is cool enough to do deep water running. 

This study was aimed to investigate the effects of two deep water running (DWR) programs on functional fitness and on blood pressures. There were 36 men and women between the ages of 60 and 75, and they were randomly placed into either a continuous training group or an interval training group. Pre- and post-measurements included blood pressure, timed up and go (TUG), arm curl, chair stand, back scratch, chair sit and reach and a six-minute walk. The deep water running programs were two times a week for 28 weeks. They were 45-minute sessions and included deep water running and upper body strengthening exercises.

Results/Conclusions. The results of the tests found that there were improvements in agility and dynamic balance, upper and lower body strength improved, upper body flexibility improved, with greater improvements in lower body flexibility and cardiovascular fitness in the interval training group. They also saw improvements in systolic and diastolic blood pressure, with greater improvements in the continuous training group. As a side note, the improvements in blood pressure are typical with aquatic exercise due to the hydrostatic pressure, as well as the chronic effects of the cardiovascular exercise.

Since DWR does not allow participants to touch the bottom of the pool, researchers suggested increases in balance due to the instability created with deep water running. In addition, they saw increases in strength due to the horizontal displacement and cyclical movements of the hip and knee. Increases in lower body flexibility were also attributed to the knee and hip joint movements during DWR. 

The participants in the study were not familiar with deep water running prior to the study. If you are not familiar with deep water running, try to imagine how difficult it would be to run on a non-compliant surface. Now make that even harder by imagining running without hitting the ground. The proprioceptive mechanisms have no feedback for balance, so you have to depend on torso stability. The movements of the hip and knee can be much larger without the ground reactive forces, allowing for increases in strength development, as well as increases in range of motion. I thought it beneficial to include this study to support DWR as a possible modality, for those of you who may have access to deep water.

Kieffer et al., 2012

The next study is entitled "The Effects of a Short-Term Novel Aquatic Exercise Program on Functional Strength and Performance of Older Adults." I chose this study because they used high-intensity training and plyometrics. Both modes of training when performed in the water have been proven to increase power and functional ability in older adults, who otherwise would not be able to do this type of training on land. Now I know high intensity, warm water, and your patient population may not mix well together. This study was conducted in what the researchers called "warm water," however they didn't provide a temperature. I included the study in the event that some of you have access to cooler water and work with patients that might be able to tolerate a higher intensity.

For this study, all of the participants (28 men and women, ages 65-90) were physically active. Since many previous studies compared aquatic exercise groups to control groups, the researchers in this study wanted to use physically active participants and compare the effects of an aquatic program to a traditional land-based program. Participants were randomly assigned either to a traditional exercise group or a water exercise group.

The water exercise group included what they called "multidimensional" aquatic exercises that included functional movements and plyometric exercises. The training sessions were two times a week, for 45 minutes. Pre- and post-measurements included 30-second chair stand, arm curl and a timed up and go. The aquatics training sessions included resistance training, aerobic conditioning and what they called "low level" plyometric training. The aerobic conditioning program included multi-directional movements so that they frequently changed directions. The plyometrics segment included bounding, single leg hop, skipping and vertical jumps. The aerobic portion also included water walking and jogging and various arm movements using buoyant equipment and kick boards, as well as resistance training that mimicked ADLs.

The participants were instructed to maintain a full range of motion and to work out at a rate of perceived exertion of 13 to 15 (somewhat hard/hard). The researchers define low-level plyometric exercises as a repeated series of stretch shorting cycle movements, which is a plyometric exercise, that produces less stress on the body while following the same principle of plyometrics. The low-level plyometrics were incorporated into the aerobics portion as intervals and again, the participants were encouraged to maintain an RP of 15. Note: It's important to remember that although it is called high intensity, the intensity is based on the rate of perceived exertion. It's specific to the functional level of the participant.

The land training sessions involved walking, low impact aerobics or square dancing and did not involve resistance training. The participants were asked to perform their normal workout in 45-minute sessions, three times a week to match the time of the aquatic exercise group and also to achieve their RPE of 13 to 15.  

Results/Conclusions. The results showed significant improvements in the aquatic exercise group for all measures, while the land group only improved in the chair stand. Additionally, the improvements in the chair stand for the aquatic group were significantly greater than those in the land group. Again, the researchers concluded that the participants in the aquatic exercise group were able to experience the benefits of plyometric training without experiencing increases in pain or risk of injury, due to the buoyancy of the water. This also suggests that functional improvements require more than simply training specific movement patterns; it also requires training techniques to improve power.

Sanders et al., 2013

The next study looked at the "Impact of the S.W.E.A.T. Water Fitness Method on Activities of Daily Living for Older Women." The S.W.E.A.T. water fitness method is a trademark technique for improving functional movement. I believe this technique is one that you could modify, for just about any patient level or client level. We're going to talk about the S.W.E.A.T. method in more detail in the next few minutes.

The researchers wanted to evaluate the S.W.E.A.T. method. The participants, 77 women over the age of 60, were assigned to a water exercise group. Pre- and post-measurements included static and dynamic balance, walking speeds, stride length, lower body and upper body strength, stair climbing and lower body flexibility. It was a 16-week program; sessions were three times a week for 20 to 45 minutes. The sessions included functional activities of daily living progressions, cardiovascular endurance, and muscular strength. Exercise intensity was altered using the S.W.E.A.T. method.

Results/Conclusions. The results showed improvements in all functional measurements with the greatest improvements in static balance, sit to stand, and arm curl. The researchers indicated that previous studies have identified muscular strength as a predictor for functional mobility, whereas this study suggests that power may be a predictor of the performance of activities of daily living.

The S.W.E.A.T acronym describes a method of cues that coach participants to changes in speed, surface area, impact, range of motion, and planes of movement or travel through the water. You begin with one movement (e.g., a jog), and every 10 seconds you change the movement based on the S.W.E.A.T. acronym, as follows: 

S = Changes in Surface area and Speed.

W = Changes in impact by using the Working positions of rebound (jumping), neutral (chest submerged, feet touch lightly), suspended (buoyant work performed without feet touching bottom), and extended (standing tall, feet grounded on the bottom).

E =Enlarge the movement (extending to a fuller range of motion).

A = Work Around the body or joint by changing planes (sagittal, transverse and multiplane).

T = Traveling through water forward, backward and diagonally.

I believe this methodology can be used as a guide to increase or decrease the intensity of exercise.

Mary Sanders, who was one of the lead researchers in this study, provided another easy approach to progressing exercises in the water, called the 4 Ss. The 4 Ss to Powering Up are: stabilize, increase sizespeed up, and increase the surface area. Likewise, there are 4 Ss to powering down: slow down or stop, decrease the sizeshorten levers/work in straight planes and decrease the surface area.

ACSM 62nd Annual Meeting 2015

The next study we will look at is titled "Water Based Exercise Better for Some Functional Movement." This study is exceptional in its duration and sample size: 365 days and 350 participants. They compared water exercises to many other forms of exercise on land for an entire year. The participants were assigned to one of five groups: walking, water exercise, resistance training, Pilates, functional exercises or the control group. Pre- and post-measurements included arm curls, chair stand, timed up and go, time to get up from a lying position on the ground, trying to walk 800 meters, balance and flexibility. The intervention groups participated in 60 minutes of exercise three times a week for one year. The improvements were seen in arm curl and chair stand was greater in the group that did resistance training. The functional scores and quality of life scores improved in all of the exercise groups. The improvements in timed up and go, the timed walk, the balance, and flexibility were greater in the water exercise group.

Results/Conclusions. The researchers' findings support the use of water exercise to improve functional mobility. Although improvements in arm curl and chair stand were greatest in the resistance training group, the people that participated in the water exercise saw significantly greater improvements the timed walk, tug, balance, and flexibility.

Fisken et al., 2015

One final study that I think you will find interesting is titled "The Comparative Effects of Two Aqua Exercise Programs on Physical Function, Balance, Perceived Quality of Life in Older Adults with Osteoarthritis." I thought this was interesting because they compared an exercise class to aquatic therapy sessions. They compared the effects of the aquatic fitness program and a hydrotherapy program on strength, function balance, fear of falling and perceived quality of life.

The aquatic exercise group met two times a week for 12 weeks. Each session was 45 to 60 minutes and included aerobic and strengthening exercises. The hydrotherapy group attended a seated exercise class in 97-degree water once a week for 12 weeks. The focus was on a range of motion and relaxation. According to the researchers, a rationale for having the therapy group attend weekly class sessions was to provide the opportunity for social interactions, similar to what would be experienced in an aquatic exercise class, as research has shown a positive relationship between social interaction and functional improvements. Seated in warm water was chosen to reduce pain and stiffness from arthritis and represent a motivator to attend the class. Pre and post-measurements included the timed up and go, 15-second step tests at the stand, hand grip dynamometry, 400-meter walk, quality of life scales, fall efficacy scales, and rapid assessment of physical activity questionnaire.

Results/Conclusions. The only significant outcome measure between the two groups was that the aquatic exercise group showed a reduction in fear of falling. The aquatic exercise group did show improvements within the group in three outcome measures: the step tests, the chair stands, and the walk time. The hydrotherapy group improved their walk time, but according to their researchers, the improvement was not significant. However, what was interesting is that the hydrotherapy group improved their scores on the social domain of the quality of life scale, while the aquatic fitness group showed no improvement in the social domain. The researchers felt this could be due to the relaxing environment of the warm water pool, allowing for positive interaction with class members. 

The researchers concluded that the aquatic exercise class may be beneficial in reducing the fear of falling, however they expressed concern for the high dropout rate (10 people dropped out of the aquatic exercise group, whereas only four dropped out of the hydrotherapy group). This suggested that the aquatic exercise group may not be suitable for everyone and that the warm water option, which focuses on relaxation and range of motion, may be a more appropriate starting point for people of lower functional levels who might enjoy that versus attending an aquatics class. 

The Aquatic Environment

To begin, we will review some basic aquatic concepts and terminology for those of you that may be new to the aquatic environment. Then we will look at the equipment used in the pool, followed by aquatic muscle actions which focus on eccentric and concentric movements.

Terminology

  • Buoyancy. The upper thrust causing resistance to be felt with movements towards the bottom of the pool while movements towards the surface are assisted.
  • Hydrostatic pressure. The pressure of the water against the body. Hydrostatic pressure assists with venous return thus improving circulation and reducing edema.
  • Frontal surface area. The size of an object, body part or the body, that are presented to the attendant line of travel. Remember, larger bodies will have greater frontal surface area and it will be harder to move through the water. The size of the object refers to its final surface area. Frontal resistance is felt when the object is moved through the water.
  • Lever length. A lever is defined as the bar moving around a fixed point. The body, of course, is a system of levers. The longer the lever, the greater the muscular effort to move the body through the water. Initial movements should be shorter levers. People though will unwillingly adjust lever length to accommodate increases in intensity. Typically, as the intensity level increases, they may bend their elbows, bend their knees, to make it a little bit easier to do the exercise.
  • Inertia. The law of inertia says that an object will remain at rest unless acted on by an external force. You have to overcome inertia to stop, start or change the direction of movement. You have your own inertia in your body, but the water also has inertia that we have to overcome, when we change directions in the pool. Remember, the one study talked about multi-directional exercise so that constant change of direction has an impact on the intensity of the exercise.
  • Acceleration. The reaction of the body is directly proportional to the force applied. Adding more force or muscular effort increases the intensity of the exercise. In layman's terms, if you want to work harder in the water, you have to push harder. If you want to make it easier, don't push as hard. This is something I mentioned before with doing horizontal shoulder add/abduction. If you wanted to work the posterior muscles you would push harder going backward, but not as hard coming forward.
  • Action reaction. For every action, there is an equal and opposite reaction. If you push forward, there will be a tendency for the body to move backward and vice versa. This is why the pool is so good for stability. As you move your arms forward into that horizontal shoulder abduction your body is going to have a tendency to go backward if it's not stabilized properly.
  • Speed. The rate of travel. In the water increasing speed will increase intensity. However, it should be used with caution, as an increase in speed may also decrease the range of motion.

Equipment

In addition to using the properties of the water to increase or decrease the workload or provide assistance for support, we also have a variety of equipment options. Not knowing what type of equipment you may have available, I tried to find as many different types of equipment as I could. 

  • Buoyant equipment. Anything that floats, such as hand bars, noodles, balls, ankle and wrist cuffs. The resistance is going to be felt towards the bottom of the pool. Assuming that extension stops at neutral, shoulder extension, elbow extension, hip extension, knee extension toward the bottom of the pool. Hip and shoulder adduction would experience the overload with buoyant equipment.
  • Drag equipment. Anything that increases frontal surface area, such as paddles, various bells, gloves. You can also experience a certain amount of drag force with buoyant barbells noodles and kick boards that are pushed through the water. With drag equipment, resistance will be felt in all directions of movement. Up, down, right, left, forward or backward -- wherever you push.
  • Bands or rubberized equipment. I don't typically use bands in the water, but I did read a paper that was written again by Mary Sanders, suggesting that teaching someone to use bands in the pool will carry over to land-based exercises that could be continued outside of the pool. However, with a band, the resistance is felt away from the anchor points, similar to using a band on land, with minimal effects of the water.
  • Noodles. For buoyancy and for support. 
  • Kick boards. For drag and for support.

Aquatic Muscle Actions

Now here's where aquatic functional training requires some thought. The difference in muscle actions from land to the pool tend to be a little confusing for some people, so I thought it might be a good idea to take some time and review this information.

  • If you are in the pool, and you're moving with no equipment, all of the movements are met with resistance, so all of the muscle actions will be concentric.
  • If you are in the pool and you are using buoyancy equipment, the biomechanical stress is going to be different than it would be as if exercising on land. Only movements towards the bottom are met with resistance, so those movements would be concentric contractions, while movements towards the surface as you're trying to prevent the piece of equipment from popping up out of the water are assisted with buoyancy, and therefore would be eccentric contractions.
  • If you're using drag equipment, the drag equipment simply increases the frontal surface area. The movements again would be concentric in all directions.
  • If you are using bands, those actions would be similar to actions on land, in that the work is felt in movements away from the anchor point, followed by an eccentric contraction with movements towards the anchor point.

Functional movements require a combination of concentric and eccentric contractions or muscle actions, so the challenge is not in recreating the functional movement pattern, but in recreating the pattern with the appropriate muscle action.


kimberly huff

Kimberly Huff, MS, CSCS, CHES

Kimberly Huff, MS, CSCS, CHES has over 30 years’ experience in health and fitness. She is certified through ACSM, NSCA, AEA and ACE and is a Certified Health Education Specialist. Kim presents certification review courses and continuing education courses for ACSM and AEA, writes research reviews for the AEA AKWA Journal and is a contributing author to the AEA Arthritis Foundation Exercise and Aquatics Program.



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