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Fall prevention throughHalliwick: practical
implementationsJohan Lambeck PT
www.halliwick.net
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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
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Epidemiology 1.1 million osteoporotic fractures annually in the
US, 70% spine and 20% hips (USA 2001) 12.000 femoral neck fractures annually inSwitzerland. Costs: 600 Mio CHF per year(2004)
Falls account for 90% of hip and 50% ofvertebral fractures 30 % of persons older than 65 fall at least once
a year; in the 80 90 year old category, fallsincrease to 45 % once a year. Rubinstein cs, 1988
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Falling
Represents a failure to meet intrinsic and
extrinsic demands of mobility in a specificenvironment 45% fall because of dizziness, muscle
weakness, confusion, stiffness, etc 39% fall because of slippery surface, poor
lighting, loose objects and other extrinsicfactors Rijken H, 2003
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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: unipedalactivities
Rising from chairs
Lord 1994
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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 withincrease in Tinetti/POMA score
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Prevent this!
Simmons & Hansen, 1997
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Balance strategies
non-intentional movements Reactive/correction
unexpected lossAnkle/hip strategies
Insecurity strategy
Stumble strategies Sideways, backward
Forward
= Supporting and balancereactions
Predictive/preparation
expected prevention,static mechanisms.
- static mechanisms:- stiffening joints
- increase base of sup.
Counter-weight, dynamicreactions that accompany
intentional movements
Guccione cs 2001, Bronstein cs 2004, Pijnappels 2005
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Intentional movements- initiation (go/stop)
- maintain weight-b during a task- limits of reaching with concentric/ecc
activity- unipedal weight (= stance on 1 leg)
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FICSIT land program Interventions that include balance
training significantly reduces falls
Balance training is also importantto become aware of the limits ofstability
Frailty and Injuries: Cooperative Studies of Intervention Techniques,Province, 1995 and Takazawa 2003
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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 amat
Judge 1993 K. Mead 1996, H.Rijken 2004
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Tai Chi TC is performed with varying degrees of
concentric and eccentriccontractions. 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.
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Aquatic Therapy Can aquatic therapy be used in a fall
prevention programme?
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Balance outcomesadapted from Geytenbeek, 2002
BergElderlyPositive ssDouris, 2003
Berg, TUGElderlypositiveMaginnis, 1999
F. ReachCVAPositiveMorris, 1996
Functional reachCP casePositive ssThorpe, 2000
POMAElderlyPositive ssMuhlenkamp,2000
ABCElderlyPositive ssSmulders, 2005
BergParkinsonPositiveJohnston, 2002
F. reachElderlyPositive ssSimmons, 1996
Body swayElderlyPositive ssLord, 1993
Postural swayRA and OAPositive ssSuomi, 2000
testpatientseffectAuthor
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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 tocontrols, and Quad strength increased
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Lord: program Various arm/leg movements: stance 1 leg
Reachingactivities to limit of single legstance in various directions
Marching, side stepping, walk backward Arm exercises with metacentric effects
Arm exercises with floaters
Games: jumping, hopping, ball relays
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Research example 2 Simmons & Hansen, 1996
4 groups of well elderly 1. exercise in water, - 2. sitting in water 3. exercise on land, - 4. sitting on land
5 weeks, 2/wk, 45 minutes Functional reach mainly improved in 1.
Making and correcting movement errors in asafe environment + variability of practice
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Simmons V, Hansen PD: J Gerontol A Biol Sci Med Sci1996
34.0*28.7*24.423.6
Water
exercise
Land exerciseWater sittingLand sitting
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
Effectiveness of water exercise on postural mobility in the well elderly: anexperimental study on balance enhancement
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Simmons/Hansen: program Walking forward, backward high stepping
Marching for/backward with extendedknees
Sidestepping with/without crossing legs Balance on the spot: toe/heel raises etc
Kicking in diagonals
twisting
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In water: Halliwick, Ai Chi balance and the
obstacle course focused on intentional andnon-intentional balance strategies at theICF levels of body function and activity
ICF: International Classification of Function, Disabilityand Health (WHO, 2001)
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ICF and aquatic therapy
Fitness
Ai Chi
Watsu
BRRM
Obstacles
Halliwick
ParticipationActivityBody function
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HalliwickTen-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 Halliwickpoints
Work from simple to complex: disengage inevery point Apply functionally and repeat on land
Facilitation: Trial and Error, Guiding, Automatic activity
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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
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Principles of Disengagement Change supports
Change fluidmechanical principles Change general mechanics
Change exercise physiology parameters In order to:
Progress and vary at random
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The Ten Point Program in fall
prevention Breath control
Transversal Rotation Control Upthrust / Mental Inversion
Combined Rotation Control Sagittal Rotation Control
Balance in Stillness
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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
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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. hipextensors
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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 thefloatation time
Ps: Mental Inversion is 1 step more
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Combined Rotation ControlThe combination of all rotations:
TRC and LRCSRC and LRC
preventing the prone position
Preparation for functional movements
Eg: falling and standing up
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Sagittal Rotation ControlTo go to the limits of reaching
To transfer weightWith differing bases of support
Include reaching activities
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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
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Applications In Halliwick, swimming is applied in
activities as Competition High-low / waterbasketball
In Halliwick, balance in posture and gait isapplied in: Ai Chi
The obstacle course
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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
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The obstacle course is designed to
train balance strategiesFormalized equipment:
-Wiggle board
-Balance beams
-Hurdles-Reaching pole
With cognitive double tasks, dimmed light, a tray in
front, passing each other etcK. Mead 1996, H.Rijken 2004
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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
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