There is a quality of peace and calm when you duck your head under the still, early-morning waters of an empty swimming pool. A cocoon develops naturally around you, with the light and sound of the outside world finding only distorted reality in this quiet place. The sound of your heartbeat, the introspection that occurs and the warmth and safety of the water all lend themselves to a surreal sense of being. Imagine taking those nurturing qualities the water bears and combining them with a specific exercise program, all in hopes of strengthening the body, the mind and the heart of breast cancer patients.

That was exactly the thinking of Mary Essert, a water safety instructor for more than 50 years and a breast cancer survivor.

It was water that Essert turned to for comfort and therapy two weeks after her modified radical mastectomy in 1982. Being in the water after such trauma to her body facilitated the recovery tremendously. “As soon as the incision was clear I was back in the water and doing exercise,” she said. “My doctors were always supportive.” Even though it might have appeared to be non-traditional rehabilitation, she said she never had the feeling they thought it was a bad idea.

Benefits of a Water Program

Exercise in a pool is inherently different than on land because of the water’s properties. “It offers buoyancy and upthrust,” Essert said. “Water supports us, assists movement and causes resistance, which is when strengthening occurs.” She said the effect of hydrostatic pressure in the water reduces any edema or swelling — even if you’re just sitting on the steps in the pool. “It’s like a mini-massage all the time...that’s why water work is so beneficial for people with lymphedema.” So what are the reasons why water offers such a valuable avenue of rehabilitation. “We can use the water with all its magnificent ramifications and powers. The water assists and supports, and enables movements you might not be able to do otherwise.”

As part of an exercise regimen, Essert said the water fitness program she teaches works to decrease body fat, increase lean body mass, increase cardiovascular fitness, increase range of motion (especially with the chest and shoulders), prevent lymphedema, decrease stress, and strengthen the shoulders, back and chest muscles. Treatment goals include reducing the pain and creating a sense of “whole” body again. One of the often overlooked elements to a water fitness program is the ability to interact with others and find support in the comradery.

Essert found support when she reaped the benefits of her own professional efforts after the cancer diagnosis. Having developed a water fitness program in the late ’70s for the Duchess County New York YMCA, which catered to people with disabilities, Essert joined one of her own groups when her incision had healed. “I was involved with people a lot worse off than me. I would go every morning and do my own exercise and then see people with real disabilities. It puts things in perspective for you,” she said. “For me, the support system, and simply the whole perspective, was really important.” It was so important to her, in fact, it became a central theme of what would later become a targeted exercise program.

After a year of chemotherapy, Essert’s oncologist encouraged her to develop specific exercise programs for women with mastectomies. “That was the beginning for me,” she said of her presence working with breast cancer patients.

Program Protocol

The protocol for the water fitness class for breast cancer patients (and any cancer patient for that matter) includes a 45-minute to one-hour class. “If someone comes who’s not feeling well, we shorten the class for them,” she said. She encourages students to come two to three times a week, for about six months. “What we hope happens is the person either stays with water fitness or goes back to whatever physical activity they were doing.”

Essert recommends a water temperature below 85 degrees for the breast cancer patient. When she incorporates Watsu or Jahara (another warm water bodywork using a flotation device) into her one-on-one sessions with breast cancer patients, Essert likes the water temperature to be 92–96 degrees — a temperature too warm for someone with lymphedema.

The breast cancer water program is structured like many water programs, but there is a significant focus on strengthening the chest, shoulder and back muscles. A typical class might include a 10-minute thermal warm-up that involves walking in waist- to chest-deep water and utilizing a variety of progressive hand/arm movements. Concentration is given to basic breathing throughout. Students will next work through a variety of stretches, jogging and/or walking within the pool, with a dedicated focus on the traumatized muscles. Stretching and cool-down include external and internal rotation, shoulder flexion and abduction, followed by lower body stretches. The classes end with a focus on centering and mindfulness, asking each participant to release the stresses of their day.

A new student could begin aquatic therapy as soon as her drains are out and the wound is healed over. “Communication with a health care professional is important before beginning any new exercise regime,” Essert cautioned. Because a cancer patient may be “deconditioned” after the surgery, Essert recommends starting slowly. “I use a two to three times per week class format and people may stay in the water from 30 minutes to one hour.”

More Than the Physical

When Essert first joined one of her own classes as a participant, it was the fatigue from the disease and the therapy that was bothering her most. “My range of motion was good and so was my strength and endurance. Fatigue was the principle problem I faced.” For others, it’s just being in public again with their changed bodies.

Essert vividly remembers talking to one potential student about joining the class, but the woman was terrified of her own body. “She said she couldn’t possibly wear a swimsuit,” Essert recalled. “When I suggested shorts and a t-shirt, the woman told me it had been a year since her surgery and she hadn’t yet looked in a mirror to see herself. This is extreme, but this is a real story.”

Today, after more than five decades serving the public in a fitness role, Essert now teaches the teachers. Her next breast cancer workshops include the Aquatic Therapy Symposium in August and the 2001 Aquatic Therapy Speciality Institute Conference in October. Essert reminds therapists there is much more going on in breast cancer classes than just physical rehabilitation. “The people I train often have very little experience with the emotional stuff,” she said, yet it’s a critical piece of the puzzle.

“Body image and self esteem must be considered by the instructor,” Essert said.

“Because I believe in the whole person approach — body, mind and spirit — I know that the whole person is affected by denial, pain, fear, restricted range of motion, fatigue, loneliness and depression, which accompany breast cancer.” She reminds us of a supernova subtlety: “One faces one’s own death.” In the midst of this chaos of physical and emotional states, Essert said intervention is vital. “Aquatic therapy and exercise can be the instrument of that intervention skillfully facilitated by a knowledgeable instructor or therapist.”

Taking into consideration the massage therapist’s scope of practice, Essert recommends a team approach to treatment. “A massage therapist can work with a physical therapist, an occupational therapist, an aquatic therapist, a physician, etc. We must wear the hat for which we are licensed or certified.” Essert also points out that referral lists are a critical tool for this kind of work.

Essert summed up a therapist’s role this way: “May we as practitioners of our own field be there for our breast cancer client — to listen and to give compassion as we wait for stumbling blocks to become stepping stones.”

For more information on Mary Essert or her video, Breast Cancer Water Fitness, e-mail messert@mindspring.com or visit www.mindspring.com/~messert.