Fall prevention through Halliwick: practical implementations

Johan Lambeck PT www.halliwick.net

Contents
Reasons for loosing balance / falling Human balancing strategies Fall prevention programmes Aquatic therapy: its role in fall prevention Halliwick and applications:
Halliwick Ai Chi The obstacle course

Epidemiology
1.1 million osteoporotic fractures annually in the US, 70% spine and 20% hips (USA 2001) 12.000 femoral neck fractures annually in Switzerland. Costs: 600 Mio CHF per year (2004) Falls account for 90% of hip and 50% of vertebral fractures 30 % of persons older than 65 fall at least once a year; in the 80 90 year old category, falls increase to 45 % once a year. Rubinstein cs, 1988

Falling
Represents a failure to meet intrinsic and extrinsic demands of mobility in a specific environment 45% fall because of dizziness, muscle weakness, confusion, stiffness, etc 39% fall because of slippery surface, poor lighting, loose objects and other extrinsic factors Rijken H, 2003

Intrinsic factors Falls are correlated with:

Muscle strength of the legs, e.g.:
Tibialis Anterior, Soleus and Gastrocnemius, Quadriceps Vastus Medialis

Range of Motion legs and lumbar spine

70% has ROM limitations lumbar spine

Walking, turning, walking stairs: unipedal activities Rising from chairs

Lord 1994

LE strength and falls

Elderly with weak quadriceps have increased fall risk ( max. 7.5 more compared to normal strength). Elderly with weak Tibialis Anterior increase their chance of falling with 4.5 times
Takazawa, 2003

Quadriceps and falling

Cent & Visser, 2003

N=16, mean age = 74 y, 2 random groups Experimental group: quadriceps exercises 8 weeks, 3 times/week Test: Tinetti/POMA, Holten diagram > increase in strength coincided with increase in Tinetti/POMA score

Prevent this!

Simmons & Hansen, 1997

Balance strategies non-intentional movements

Reactive/correction unexpected loss Ankle/hip strategies Insecurity strategy Stumble strategies
Sideways, backward Forward

Predictive/preparation expected prevention, static mechanisms. - static mechanisms:

- stiffening joints - increase base of sup.

= Supporting and balance reactions

Counter-weight, dynamic reactions that accompany intentional movements

Guccione cs 2001, Bronstein cs 2004, Pijnappels 2005

Intentional movements
- initiation (go/stop) - maintain weight-b during a task - limits of reaching with concentric/ecc activity - unipedal weight (= stance on 1 leg)

FICSIT land program

Interventions that include balance training significantly reduces falls Balance training is also important to become aware of the limits of stability
Frailty and Injuries: Cooperative Studies of Intervention Techniques, Province, 1995 and Takazawa 2003

Training programme
Balance incl single stance activities Isokinetic muscle strengthening for hip knee and ankle Tai Chi Obstacle course Flexibility/strength exercises on a mat Standing up from a mat
Judge 1993
K. Mead 1996, H.Rijken 2004

Tai Chi
TC is performed with varying degrees of concentric and eccentric contractions. TC does not improve measures of postural stability in older objects, it promotes confidence ( fear of falling questionnaire) Fall risk is reduced by 47.5%
Wolf SL et al. J Am Geriatric Soc, 1996 and Physical Therapy, 1997 Lan C, et al. Med Sci Sports Exerc, 1997.

Aquatic Therapy
Can aquatic therapy be used in a fall prevention programme?

Balance outcomes
adapted from Geytenbeek, 2002
Author Thorpe, 2000 Muhlenkamp, 2000 Suomi, 2000 Morris, 1996 Lord, 1993 Simmons, 1996 Johnston, 2002 Maginnis, 1999 Douris, 2003 Smulders, 2005 effect Positive ss Positive ss Positive ss Positive Positive ss Positive ss Positive positive Positive ss Positive ss patients CP case Elderly RA and OA CVA Elderly Elderly Parkinson Elderly Elderly Elderly test Functional reach POMA Postural sway F. Reach Body sway F. reach Berg Berg, TUG Berg ABC

Research example 1
Lord et al, 1993 older people with mild disabilities, n = 13 9 weeks, 1/wk aquatic therapy, 1 hour Outcome:
ss decrease of postural sway compared to controls, and Quad strength increased

Lord: program
Various arm/leg movements: stance 1 leg Reaching activities to limit of single leg stance in various directions Marching, side stepping, walk backward Arm exercises with metacentric effects Arm exercises with floaters Games: jumping, hopping, ball relays

Research example 2
Simmons & Hansen, 1996 4 groups of well elderly
1. exercise in water, 3. exercise on land, - 2. sitting in water - 4. sitting on land

5 weeks, 2/wk, 45 minutes

Functional reach mainly improved in 1. Making and correcting movement errors in a safe environment + variability of practice

Simmons V, Hansen PD: J Gerontol A Biol Sci Med Sci 1996

Effectiveness of water exercise on postural mobility in the well elderly: an experimental study on balance enhancement 5 weeks 2 times per week, 45 minutes. Ntotal = 52 Elderly subjects: 80 +/- 5.8 years Measurement: Functional Reach Initially: each group at risk, FR < 25 cm

Land sitting 23.6

Water sitting 24.4

Land exercise 28.7*

Water exercise 34.0*

Simmons/Hansen: program
Walking forward, backward high stepping Marching for/backward with extended knees Sidestepping with/without crossing legs Balance on the spot: toe/heel raises etc Kicking in diagonals twisting

In water:
Halliwick, Ai Chi balance and the obstacle course focused on intentional and non-intentional balance strategies at the ICF levels of body function and activity
ICF: International Classification of Function, Disability and Health (WHO, 2001)

ICF and aquatic therapy

Body function Activity Halliwick Ai Chi Obstacles BRRM Fitness Watsu Participation

Halliwick
Ten-Point-Program and Water Specific Therapy

Be dynamic: in the middle of the pool Use hands-free Halliwick Teach falling and standing up with the Halliwick points Work from simple to complex: disengage in every point Apply functionally and repeat on land Facilitation:
Trial and Error, Guiding, Automatic activity

The Ten-Point-Program
Mental Adjustment/Dis Sagittal Rotation Control/Dis Transversal Rot Control/Dis Longitudinal Rot Control/Dis Combined Rotation Contr/Dis Upthrust/Dis Balance in Stillness/Dis Turbulent Gliding/Dis Simple Progression/Dis Basic Movement/Dis

Dynamic

Static Dynamic

Principles of Disengagement
Change supports Change fluidmechanical principles Change general mechanics Change exercise physiology parameters
In order to:

Progress and vary at random

The Ten Point Program in fall prevention

Breath control Transversal Rotation Control Upthrust / Mental Inversion Combined Rotation Control Sagittal Rotation Control Balance in Stillness

Breath control
A part of mental adjustment Oral and nasal Some 5 seconds of expiration Timing and quick reaction is important To be combined with movement = falling

Transversal Rotation Control

A control around a transversal axis of the body From stand / sit to supine, stand up again falling backward as a tree Also a basis for local endurance of e.g. hip extensors

Upthrust / Mental Inversion

To realize that its difficult to stay at the bottom of a pool One always comes to the surface again Head should be put forward during the floatation time Ps: Mental Inversion is 1 step more

Combined Rotation Control

The combination of all rotations: TRC and LRC SRC and LRC preventing the prone position Preparation for functional movements Eg: falling and standing up

Sagittal Rotation Control

To go to the limits of reaching To transfer weight With differing bases of support Include reaching activities

Balance in Stillness
To be able to keep a position during different balancing tasks No peripheral movements, good alignment and no attempts to enlarge radius, use metacentric effects or close chains Disturbing factors are: turbulence, waves and metacentric effects + others Focus: control of head and trunk around all axes

Applications
In Halliwick, swimming is applied in activities as
Competition High-low / waterbasketball

In Halliwick, balance in posture and gait is applied in:

Ai Chi The obstacle course

Ai Chi and balance

All intentional strategies
Maintain weight during a task shift weight and reach to the limits with concentric and eccentric components, unipedal stance, at least 10 sec initiation (go / stop)

Non-intentional strategies
Ankle / hip / sideward stumble strategies Counter weight strategies

The obstacle course is designed to train balance strategies

Formalized equipment: -Wiggle board -Balance beams -Hurdles -Reaching pole
With cognitive double tasks, dimmed light, a tray in front, passing each other etc K. Mead 1996, H.Rijken 2004

Task-Type training
In all of the stations of the obstacle course, functional tasks should be included
Throw a ball in a basketball bucket Wheel someone on a ball through the pool Fill a basket with water, using bags A tower of boards, push up/down Step/jump over a rope Collect material, sitting on a mat Transport bottles across the pool