THEHALLIWICK CONCEPPARTI

ABSTRACT JamesMcMillan developed the Halliwick Concept over50 yearsago. Initially, the Halliwick Concept wasdeveloped as an instructional strategy (called theTen-Point Program) fo teaching swimming to children with disabilities. Soonafterthe inoduction o theTen-Point (at the Program Halliwick School for Crippled Girlsin London), the teaching stafbegan to positive notice change in the physical and emoiional behaviors of the children. The changes in behavior wereattributed to a unique philosophy teaching/learning anda psycho-sensory motorlearning program thatis enhanced by hydrodynamics. Recognizing the therapeutc effects o the Ten-Point Program, McMillan and his colleagues adapted the program as a therapeutic intervention called WaterSpeciic Therapy or th Logic Approach to Therapy in Water. Key words: Halliwick Concept, Ten-Point Program, WaterSpecific Therapy, Aquatic Rehabilitation

INTRODUCTION James McMillan (19131994) first conceivedof the Halliwick Concept as a strategyto teach swimming to individuals with disabilities.The conceptuses fluid mechanicsto enablestudents to achieve stability and controlled 13 movement in the water.'0, McMillan called the conceptthe Ten-PointProgram and in 1950, introduced it at the Halliwick School for Crippled Girls in London. The therapeuticvalue of the Halliwick Conceptwas quickly noted. In fact, the esults we{e remarkable! Within weeks,not only did the childrenleam to swim but they also demonstrated improvement in head balance, trunk stability, breath control and self-esteem. McMillan and his colleagues loundedrheAssociation of Swimming Therapy and over

the next thirteen years continued developing the concept. Although their intentions were recreational, the therapeuticimpact ofthe program was evident. In 1963, McMillan was asked to teach thc Halliwick Concept at the medical center in Bad Ragaz, Switzerland.' McMillan continued advancingthe Halliwick Concept for the next twelve years. The Ten-Point Program continued to impressthe medical staff at Bad Ragaz and he was hired (1975-1979) as the project leader to extend the Halliwick Ten-Point Program as Water Specific Therapy (also known as the Logic Approach to Exercise in Water). (fIOTE: McMillan also redesignedaspects of the Bad Ragaz Ring Concept (BRRM) to attendto the ergonomic needsof those using BRRM). Today, after over fifty

years of developmentand implementation,the Halliwick Concept is one oflhe most important strategies in aquatic therapy,especially in neurology '' This article and pediatrics.i x 3, will addressthe therapeuticaspects of Halliwick both as an instructional technique and therapeuiicintervention. IIALLIWICK: THE PHILOSOPHY The goal of the Halliwick Concept is to enablethe participant to achievemaximum independence both in the water and on land. Towardsthat end, McMillan createda teaching philosophy and structue that would facilitate and encourage self-reliance. The developmentof the philosophyand structure was interdisciplinary.Following a Geneml SystemsTheory approach, McMillan worked with

AUTHORS: JohanLambeck PT,Director, . Tel/Fax+3124 gs82192 The Halliwick-Hydrotherapy lnstitute, Akkersleep 32,6581VN,4 l\ralden, Netherlands . wwwha'iwick.net Lambeck.hydro @reeler.nl FranCotey Slanat, PhD,Director, Therapeutic Recreation Program, School of AlliedHealth Professions, University o Wisconsin-Milwaukee PO Box413,Enderis . fax 414-906-3929 . stanat@uwm.edu Hall949,Milwaukee, . !1/ww.uwm.edu Wl 53201. voice414-229-4778

I ue loumal ol Aqualc Phystcal I heraDv. Vol. 8 \o. 2 . Fall 2000

professionals ffom otherfields (e.g.alliedhealth professionals and teachers) to apply information from kinesiology, pathology, psychology anddidactics to a wate enviroment. The result wasa teaching philosophy anda psycho-sensory motorleaming programthatwould become the basisfor theTen-Point Program Thephilosophical notions and concepts that arethe underpimings of the Halliwick (Figure1) werepresented Concept at a conference on the Halliwick Concept in 1986at the University of Nijmegenin theNetherlands.' McMillan believed that everyone is a swimmerand that swimming is a means to independence (not the goal). An essential skill in becoming a swimmer is balance. Balance is dependent uponbody shapeand density. A swimmer, especially onewith neurological impairments, may require assistance to establish and maintain balance.Only a one-toonehelpershould providethis suppoft. Floatation devices are neverusedbecause they encourage dependence which may significantly impair the goal of independence. Finally,becoming a swimmer requires active paticipation andis mosteffective rn groups. IALLIWICK: THE MOTOR LEARNING PROCESS The goalof Halliwick is independence and is demonstrated

ascontrolled movement.Whenin the water,balance requires adaptation to the mechanical changes in the environment. The adaptations arethe resultof a psycho-sensory motorleaming process. This is a process that enables the individualto leam how to maintain balance in an unstable environment. Once (stability)is established, balance movementcanbe iniiiated and controlled. McMillan understood the relationship between balance and movement.He realized that in order for children with neurological impairments (e.g., problems with coordination, comprehension, perception and./or pain) to leam to swim (iniiate and conhol movement),they must fust leamto balance.Establishing and maintainingbalancewas not simple,andoftenimpossible, for the children. His response wasto develop manualassistance techniques (handlingtechniques) that would enablethe students to leamcontrolof rotational pattems. Based on his observations, McMillan suggested that therewas a relationship between fluid mechanicaleffectsand adaptive bodymechanics related to inertia, which in manycases, coincided with I'primitivereflexes.', McMillan accepted the notionof "primitivereflexes" while others were embracingdifferent views of motorlearning (e.g.,Bobath).

Everyoneis a swimmert Swimming is a meansto independence, not a goal in itself. Balancedepends maidy on body shapeand densiry Propersuppoftsare essential. Most activities requirea l-to-1 attendance/supporl. Floatation aidsareneverused. The student participates actively in all activities. Most activities takeplacein groups. Figure1: The Halliwick Philosophy

It was not until later that neurophysiology understood the significance of handling techniquesas exteroceptive cues or plasticity. Similarlyit is widely accepted that the physical propenies of anyenvironment are a ma1or constraint to balance and that individuals showadaptive motorbehavior (e.g.,wideningthe baseof support,using handfor supponandstiffeningthebody in orderto stabilize the center of gravity).' These adaptive motor behaviors(alsoreferredto as shess behaviors) areconsistent with McMillan'snotionof "primitivereflexes."7 HALLIWICK: CONSIDERING TWO UNTQITE HYDRODYNAMICS FACTORS Exteroceptivecues (plasticity) and adaptivemotor behavior in the presence of hydrodynamicelements resultedin a psycho-sensory motorleaming pro$am that is the Halliwick Concept.Thehydrodynamic elements generally accepted as influential in aquatictherapyalso play an importani role in Halliwick. In Halliwick, however, the most important fluid mechanical effectis commonly referredto as "metacentric effects."Metacenter is a naval architecturalterm usedto describe the point aroundwhich the force pendulumof gravity and buoyancy rotate. Both forcesare equally importantand influential with small changes in either gravity or buoyancy causing imbalance. The shape,density and (a)symmetryof a bodywill influence the metacenter (equilibrium). In watet balance occurs whena body makesnecessary adjustments to causethe forcesof gravity and buoyancyto be equal and directly opposite of eachother. Wlen theseforcesarenot equalandcolinear,the bodywill become

unstablecausingit to rotateto reachbalance.The bodyuses automatic reactions to balance and posture, stabilize based on lawsof inertia(increase of a rotational radiusslowsdownvelocity). In cases wherelossofbalancecannot be coordinated well, thebodyuses pattems based on "primitive relexes" suchasthe(a.lsymmetric tonic neckreactions andthe tonc labyrinthine reactions.a'" These reactions coincidewith the inenia patterns andcanblock unwanted rotation,especially around the midline,to stabilize posture. McMillan allowedthese reactions, to someextent, to create midline slmmetry as a startingpoint for coodinated rotational control. McMillan alsoconsidered the commonly held viewson buoyancy. Of specific interestto him, however,was the efficacy of weightlessness. He believed that postural "...tone is influenced by proprioceptiveinput stimulatedby gravitationalforces. In other words,toneis a functionof weight"4 rr which hasbeen 6,r'r5 When confrrmed by others.r'3 a personis immersed in the water, proprio- ceptiveinput is compromised andposnual toneis reduced. Tactile information is enhanced and "the system"may rely on primitive reflexes or less coordinated motorbehavior to monitor and control movement and posturein an environment with altered sources of feedback. McMillan also notedthat the effectof weightlessness on tone reduction waspresent regardless of watertemperature. He was often heardsaying "thereis no suchthing ascold water."? HALLIWICK: THE TENPOINT PROGRM The Ten-Point Program is a motor learningsequence that focuses on postural controlto teachswimming. Tensuccessive steps leadstudents to experience

(control)in a vadetyof andmaster movementpattems,with the outcomebeing a functional swinming stroke. The three phases (originallyfour) ofthe TenPoint Program(Figure 2) represent an effective method for leaching swimmingto both individuals who areable-bodied andthosewith a disability. The threephases include mental adaptation, balancecontrol andmovement.The purpose, goals,strategyand therapeutic outcome for eachofthesephases will be described. Mental Adaotation Mental adaptation includes mentaladjustment and disengagement. It encompasses adjustment to the propeies of
Ten Points
2. Saglttal Rotation (Control) 3. Veical Rotation (Control) 4. Lateral Rotation (Control) 5. Combined Rotation (Control) 6. Upthrust / Mental Inversion 7. Balance in Stillness 8. Turbulent Gliding

hands or thepelvic girdle. Supportis neverprovidedat the headsinceit is mostcriticalto balancing. Gradually,supportis withdrawn. This withdrawal is calleddisengagement. Disengagement is the job of the mostimportant inskuctor.When given too much support, the student will not be challenged to balance.When thereis too little support, shess reactionsmay occur that interfere with the desired outcome variabler variables (Figure3). The desired outcomes result from feedbackthat the studentreceivesabout improvements. This feedback can comeonly from proper\ suppoed experiences that enable the studentto pmcticeand master
Phases

1. Mental Adjustment and Disengagement Mental Adaptation(Adjustment)

Balanca Conhol

9. Simpleprogression 10.BasicHalliwick Movement

Movement

Figure2: TheTen-Point-Pro$am andthe threephases ofthe Halliwick Concept.

'water:buoyancy,flow, and waves, aswell asthe gradualdecrease of supportby the instructor during activities in uprightpositions. An importantpat of mental adjustnentis breathcontrol. Breathcontrolfocuses on expimtion in order to prevent inhaling or swallowing water. Breathcontrolalsofacilitates forward movementof the head which is essential for balancing activities in water.Early in mental adaptation, support is given girdle and staing at the shoulder (dependingon studentneedsand abilities)changing to eitherthe

the skills. Disengagement is a process continuous of changing supportsand using hydrodynamic elements to increasediffrculty and stability(Figure4). challenge Each activity or skill introducedwill requirea different amountof disengagement. The purpose is to teachthe student to balancein as opena kinetic chain aspossible.Finally,while disengagement is especially of the addressed in the fust phase Ten-Point Program. it is utilizedin all steps whennew skillsare introduced.

. Vol. 8 No. 2 . Fall 2000 Tbe Joumal ofAquatic Physical TberaDy

Novel Skill Vadable execution Inaccurate; clumsy Slow Much co-contraction Visual control needed Visible postural adaptations Stiff in performance

ControlledSkill Consistent execution Precise Fast Strooth No visualcontrolnecessary Invisiblepostural adaptations Flexiblein performance

Figure 3: Effect of feedbackand experienceon changesin motor behavior (Smits, Engelsman,1999).

Simple Equilibrium Support at the shoulder girdle Support at hands Many points of support Water depth aound Thl I Large radius Wide base

Methodsto Challenge Balance Shift support caudally Shi support centrally Less/no pointsof supporl Waterdepthabove Th11 Reductionof radius Smallbase

Compensatinghand movements(e.g. sculling) No handmovements No (turbulent) flow around the body No waves No metacentric effects

Flow aroundthe body Waves Metacentriceffects

Figure 4: Methods to increasedifficulty during disengagement

Therapeutic outcomes during phaseone,mental adaptation, arefirst evidentwith the mouth-breath control activiies.Specifically, mental ("vater)adjustmentaids lip closure, vocalization and diaphragm activities.Addressing head-trunk conholresultsin reduction of hlpertonicity, disassociation, facilitationof righting reactionsand symmetry. Finally, water adjustment activities include games that enable practice andhaining of functional behaviors suchaswalking, 14 iumpingandturing.s, Balance Control Phase two, baladce

control,includes balance estorationon a variety of axes, mental inversion(upthust), "balance in stillness" andtubulent gliding. Balance controlis the ability to independently maintain or to change a positionin the water Initially, controlwill be ineffrcient, with large (unnecessary) peripheral movements. The clientmustleam a fine degreeof automaticand centralized balance controlto prcvent unwantedmovementsand to achieve ehcientposfural conhol. In the first stepin this phase, the student leamsto control (restore) sagittal, vertical,lateral andcombined rotationto establish

postural control.Sagittal rotation is donein an uprightpositionand is a bendingfrom left to right or transferringweight. Vertical rotationis aoundthe transverse axiswith the clientsmovingfrom standingto supineto standing position. Lateralrotationis around the spineproducing a 360 degree roll. Combined rotation, which is a combination of the veftical and lateml rotationsor the sagittal andlateralrotations, is usedto teachthe concept of "ro1l out oftrouble." It is an overrotated, forwardvertical,or sideways sagittal rotationwith the clientbeingtaughtto roll to a face-up position(lateral rotation). When the client has mastered rotation,upthust,or mentalinversion, is introduced. It is simply the conceptthat buoyancywill bring objectsand peopleto the surface.The student leamsto submerge, and,upon surfacing,usesone of the rotation pattems to achieve a comfoable position. breathing The first ive stepsof balance controlrequirea maximumamount of movement. Gradually,as the studentleamsto masterthe rotational patterhs,they areintroduced to staticaspects of the progam that will requirea fine degreeof centralizedpostural control. In "balance in stillness," clientsassume a varietyof positions, from standing to floating. The instructor usesa varietyofvariablessuchas turbulenceor tactile stimulation (seeFigure4) to compromise the clients'balance or stability. Masteryis whenthe clientcan achieve stillness. When "stillness" hasbeen mastered and the studentcan maintainbodyposition,the instructor introduces movement rn the water with turbulent gliding. The student, in a supine positiorr, is passively movedthroughthe

Photo1: Sagittal Rotation Control:workingon righting reactionsand lengtheningofthe trunk.

Photo 3: Lateral RotationControl: the very importart breathcontol in a ploper alignment.

Photo2: Vertical RotationControl: exercising symmetryand selectivity during gradedextension.

Photo 4: Balancein Stillness:turbulencecreates otation andthe swinmerhasto stabilizehios and sprne,

water by the instructorwho walks backward, draggingthe client in the wake produced. The instructormay also producemanualturbulenceunder the clienfs shoulders. The client must maintain a still and balanced body position without increaseof radius, scullingor increase in tone.This step allows the client to experience a centralizedpostual control while beingdragged tbroughtbewater. . There aremany therapeutic benefitsin phasetwo of the Ten-Point Program. Sagittalrotation increases spinal rangeof motion or spinal stabilization. It also aids in reaching and balancingsideways. Sagittal rotation also facilitatesrighting and supportingreactions. Vertical rotation is a kind of disassociated or selective extension. A1l components of this chain canbe exercised includingpositioning of the headon the tiunt, working on

scapuiar depression, extension of the to the'WaterSpecificTherapyand positioning dorsalspine, ofpelvic tilt, will be more fully described later. eccentricactivity of the abdominals Movement and dynamicstability of the knee Movement,which includes joints. progession simple anda basic Lateral rotation faciiitates swimming movement,is the final righting reactionsbetweenhead, phaseof the Ten-PointProgram. At shouldergirdle andpelvic girdle. this point, the studentis ableto create Obliquesarevery active in stabilizing effective,efficient and skilled the components elative to one movementin the water. once another.Control over lateal lotation turbuient gliding is mastered, clients is of utmost impoance during ae taught a simple progression that swimming,walking and many other enables independent movement functional activities. throughthe water While Combinedrotation hasthe progressions may needto be samebenefitsasmentionedabove customizedfor eachclient (basedon and is more functional working rn frrnctional abilities, bodycomposition pattems. three-dimensional s)nmefy), self-propelling .and "Balance in stillness"(andto movementsareusually somefolm of someextent,turbulent gliding) is scu1ling. The sculling activity is beingusedin al1cases gradually advanced where to the Halliwick pelvic stabilizationof trunk, areaand swimming movement,which is a lower extremitieshaveto be double-sided rowing activity with addressed. This point formsa bridge botharmssymmetrically in the supine

10

position. Themostdramatic therapeutic outcome from the phase movement is dynamically trainedtrunk stability. During swimmingthe student hasto propel effectively, which requires proper centralcoordination and synchronization. Swimmingcanalso be regarded asa doubletaskwith automatic components of postural control. SUMMARY The Halliwick concept began asa method lor teaching swimming to childrenwith physicaldisabilities. Fifty yearsof development and implementation haveenabled swimming instuctorsto identifu therapeutic outcomes resulting from useof Halliwick Concepts. Recognizing the efficacyofthe Halliwick Conceptas a therapeutic intervention, McMillan andothers sought to applythe mechanical effects of wateron thebodyto aquatic therapy. The resultingstrategy is known asWaterSpecific Therapy (alsocalledthe Logic Approach to Therapyin Water).The elements of Water SpecificTherapyasweil as treatment examples (case studies) will be presented in The Halliwick - Part2. Concept R-EFERENCES I Bory P,FoidartM, Decquinze B, Solheid M, PirnayF. Influence desbainschauds sur les proprits rnusculaires dessujers sains et spastiques. MedicaPhysica.1990; 13 :121-124. 2 Carr J, Sheperd R. NeuroIogcal Rehab il itation, OptimizingMotor Performance. Oxford, ButterworthHeinemann, 1998. 3 ClarysJP.Muscletone, relaxation andactivityin an aquatic envlronment, in Lambeck J (Ed.). Proceedings CongresHalliwick in 198. Nijmegen,Stichting NDT-

Nijmegen,1990. 4 Cunningham J. Halliwick Concept, in RuotiRG, Morris DM, ColeAJ (Eds.). Aquatic Rehab il i tation. Philadelphia, Lippincot,1997.

Principles Appliedto the Halliwick Concept of Teaching Swimmingto Physically Handicapped Individuals, in Terauds J, Bedingfield EW (Eds.). SwimmingIII. Campaign,Human Kinetics, 1979.

14 Reid-Campion M. 5 Gamper UN. Hydrotherapy:Frinciples and Was serspezifis cheBe1a)egngstheropie Pr actice. Oxford,Butterworthund Training. Stuttgart,Gustav Heinemann, 1997. Fischer Verlag,1995. 15 RossIIE. How important are 6 Kozlovskaya IB, Aslanova IR changes in bodyweightfor mass Grigodeva LS, KreidrichW. perception? cta Astronautic a. Experimental analysis of motor 1981;8:1051-1058. effectsof weightlessness. Zfre Phys iologis t. 1982;25 sttppl.: 49-52. 16 Smits-Engelsman BCM, Tuijl ALT van.Toepassing vancognitieve 7 Lambeck J (Ed.). motorsche contoletheorieen in de Neurophysiological Basis quatic kinde$rsiotherapie: het controleren for Therapy : The oretical Top ics. van wijheidsgraden en beperkingen, Spokane, Constellate, 1996. in: Syllabus'Lerenen herlerenvan motori sche vaardigheden bij 8 Lambeck J . De Halliwick paienten metchronische benigne concept, oefentherapie in wateren p ij n'. Amercfo ort, Nederlands zwemmen voor gehardicaten. Paramedisch Instituut,1999. Kwartaaluitgave NVOM. 1,997;2:5357. 9 MacKinnon K. An evaluation of the benefits of Halliwick swimmingon a child with a mild spastic diplegia. I PCPJournal, 1997; December:30-39. l0 Main J. TheHalliwick Concept. Physiotherapy. I98t; 7: 288-291. || McMillanJ. Theroleof Waterin Rehabilitation. Fysioterapeuten. 197 7; 45: 43-46,8790,236-240. 12 Mitarai G, ManoI Yamazaki Y. Conelation between vestibular sensitization andleg muscl relaxation underweightlessness simulatedby watet ifi:-;rrersion. Aca Astronautica. 1981; 8: 461-468. 13 Nicol K, Schmidt-Hansberg M, McMillan J. Biomechanical

11

The Halliwick Concept, Part ll

r"*ry1
. -i

ihantambeck .,

ABSTRACT: James McMillan developed the Halliwick Conceptover 50 yearsago. In Part | (Volume 8, pogramwas presented. Number2), the basicTen-Point In Part ll, expanded operational definitions and the application of WaterSpecific Therapyis examined. Key Words: HalliwickConcept, Water SpecificTherapy,Aquatic Rehabilitation Editors Not: The readeris reminded that severalof the concepts and deinitions usd in this article are - Part I. A reviwof Part I is strongly outlined and described in The Halliwick Concept recommenoo.

' ,.

.tt.

Also,this presentation is an accurateinterpretation o James McMillan's Halliwick TnPoint Program as a school oJthought; and, therefor may not ncessarilyreflect certain viewpoints hld by aquatic therapists practicingin the United States.

INTRODUCTION Water Specific Therapy (WST) was founded on the mechanical effects of water on the body,just as the Ten Point Program (see Halliwick ConceptPart I),' but applied for purposesof aquatic therapy.c'6)This approachis most suitable for adultswirh neurologic. orthopedic or rheumatologic disorders.WST is not a group of exercisessuch as the Bad Ragaz Ring Method. Rather, it is a clinical decision making system that containselementsto plan, executeand assess aquatictherapy applications. A therapistcan choosean infinite number of options to produce the desiredoutcome.The elementsof WST include: the treatmentobjectives the rotational plane the starting positions the exercisepatterns the treatment techniques the modes of treatment. Each element of the WST will be explained with several casesgiven. TREATMENT OBJECTIVES (TO) The purposeol the WST is

to enablea patient to improve functional abilities on land. McMillan was quick to point out that ".. .if you can do it on land, don't do it in water". (2) However, if aquatic therapy can enhance an individual 3 functional abilities, then treatmentin the water should be used as an extensionor compliment to land therapy. McMillan identified seven objectivesthat he believed could be enancedwith the WST. The objectivesare to: (l) strengthen weak muscle groups (+WMG), (2) increaserange of motion / stretching(+RM), (3) facilitate posture and balancereactions (FPBR), (4) increasegeneral physical condition (+GPC), (5) reducepain (-P), (6) reduce spasticity (-Sp) and (7) increase mental adaptability (+IMA). The abbreviationswere used to develop short, succinct treatmentplans and will be demonstrated later. Physiologicalrules on muscle strengthening, cardiovascular training and stretchingof connectivetissue should be consideredin relation to theseobjectives.Once an assessment has been completed

and treatmentobjectivesidentifie{ the therapistselectsthe appropriate rotational plane, starting position, patterns,treafnent exercrse techniquesand mode of treanent. [NOTE: Facilitation of postureand balancereactionsis a very broad objective and applicableto most individuals with neurological impairments. Currently, therapists using the WST have narrowedthe FPBR objective to include such lntents as symmetry, disassociation, centralization, reciprocal motion, etcetea.5 ROTATIONAL PATTERNS (RP) Selectionof the best rotational plane is basedon the effect of impairment on the patients' body shape and densiry. For example,a patient who is hemiplegic may be taught sideflexing activities produced with sagittal rotation (SR) to assistwith learning posture-rightingreactions when in the vertical position. The samepatient might begin work in lateral rotation (LR) along the longitudinal axis to facilitate posture and balance reactionswhen in supine. An individual with an endoprosthesrs hip with muscular instability in the

Johan Lambeck PT, Director,The Halliwick-Hydrotherapy Institute, Akkersleep32, 6581 VM l\,1alden, Netherlands. Tel/Fax +31 24 3582092 Lambeck.hydro@lreeler.nl, www.halliwick.net Fran Cofey Stanat, PhD, Dector, herapeutic RecreationProgram,School o Allied Health Proessions,Universjtyo Wisconsin-l\,4ilwaukee, PO. Box 413, EnderisHall 949, Miwaukee,Wl 53201 . (414\ 229-4778voice, (414) 906-3929 ax, fstanat@ uwm.edu,w\tuw.uwm.edu 7 ' VoI. 9 No. I . Fall 2001 Ih. Jou-ul ofoualic?hvsica.l TlleraDv

frontal plane might work in vertical rotation (VR) along the transverse axis to strengthen weakmuscle groupsor facilitate postureand balancereactions.seethe third oase history. A personwith severe spastic quadriplegiamight work in combined rotation (CR) along the combinedaxis to reducespasticity,increase rangeof motion and enhance symmetryand extension.r STARTING POSITIONS (SP) Startingpositionsaredesignedto causepredetermined biomechanical and hydrodynamiceffects. The water depth(WD) affectsstandingpositions in which the patient is standing. Generally,patientsstandingin water at T1 1 areneutral (N+). Patientsin waterabove T11 [N+) experience increased effectsof buoyancy, are relatively non-weightbearing,and havereduced proprioceptive input. Balanceis maintainedmainly with the head. As the water level dropsbelow T1 1 (N-), the patient experiences reducedeffectsof buoyancy, increased weighlbearing, and more proprioceptive input.The lower extemitieshavean importantrole in weightbeadng. (Seealsothe section on treatrnenttechniques.) A classic starting positionm the Halliwick Conceptis the "cube" or sitting position at N+. In Figure I the cubeis adapted to enhance head activity. The patientbasicallyappears as if they are sitting at a table with arms stretched in front on the table. Hips andknees arein 90' of flexion, back is straight,feet flat on the bottomwith feetandknees sligh(ly apat and ams stretched out in front the entire length. A variation is shownin Figure 2: the bicycleposition. This position can be usedto facilitate headcontrol. giving a closedchain throughthe shouldergirdle. The fixed points rn the "cube" position arebetweenfeet and floor and offer lesshelp than the bicycle when working on head balance.

techniques will be discussed individually, one shouldunderstand that eachtechniquecould produce multiple results. For example,when a patient is challenged to regainposture andbalance,that individual will perform isometricand dynamic activity udth variableresistance that will aid in the strengthening of weak musclegroups. McMillan believed that buoyancy, andthe concomitant weightlessness, couldleadto a Figure 1 Cube Position reductionin certaintypes of spasticity Thekneeling positionis the or hypertonicity. The reductionof sameasthe "cube" exceptthe patient hypertonicity coupledwith increased is restingon the lcrees.In the supne movement and strengthof weak or backJying position, at N+, the antagonists will enablethe patientto lumbar spineis in neutral alignment, greateractiverangeof experience handsat the side or apart (depending motion. Al1 of the activitiesand on the amountoftrunk stability), head hydrodynamicforceswill createa neutralor slightlyflexed,hips in favorableenvironment for a reduction neutralflexion with legs togetherand in pain. Wldle the generalpurposeof feet in dorsiflexion.The prone eachtreatmenttechniquewill be position or ftont-lying position, at N+, described, one shouldconsiderthe placesthe lumbar and cervical spine broaderimpact on the patieni. in an extended position and is seldom The first two treatrnent used.[r the obliqueposition,at N+, techniques are gravity dominantand the body is in neutralextension, upthrustdominart activities,which angling diagonallyin the water with involve using gravity or buoyancyto the feet on the bottom and with the alter or aid patients'posturalcontrol, face floating abovethe surfaceof the balance,and movement.Upthrust water. dominantactivities (N+) will focus on headcontrol and open chain worlg while gravity dominantactivities(N) involve more weight bearingand lower extremity work. Wen enteringa pool, buoyancyis the most challenging propelty of water to be met. Buoyancybecomes most influential when the lungs becomeimmersed, at the level of T11 or the xyphoid.When walking ftom the shallowpart to the deepend of the pool, weight bearing is lost quicklyat Tl1.r At this time, postureand movementmust adapt Figure 2 Bicycle Position quickly aswell and control v/ith the TREATMENT TECHNIQT]ES (TT) headand upperextremitiesoverrides WST usesseventreatrnent control of the lower exlremities techniques to disrupt the metacentric because contactbetweenfeet and balance.The disruption migbt force grorind diminishesas descdbed by an individual to use inertia patternsto Beckerand Harrison.l3 developpostural control, balanceand ' The third and fourth treatnent movement. While eachof these techniquesareturbulenceassisied and

hrbulenceresisted.ln the assisted technique,the therapistmanually producesturbulenceto assistthe patient to maintainposturalcontrol andbalance aswell asto achieve movement.The turbulenceresisted techniques are designed to challengea patients'ability to maintainpostual control,balanceand./or movement. By producingturbulence,the therapist can work without touchingthe patient in order to avoid compensatory activity. McMillant explanation for the fifth treatmenttechnique,the metacentric effect,wasthat "...when a body pa is lifted out of the water, the body rotatesto try to get that pa ofthe bodybackunderthe water."' He referred to the force-couple gravity and buoyancyby statingthat any changein the force-couple producesa torqueand a rotation of the body. The therapeuticimpact is that tle patient must resistthe rotation to maintain (SeeFigure3.) balance. Maintaining balancerequiresthe patientsto work in a rhythmic fashion, while performingstabilizing isometricactivity of the muscles controlling thejoints of the spineand lower extremities. The waveof transmission is a techniqueusedfor improving postural stability.Thepaiientwalksthrough the water one stepforward and stops. The incoming wavewill pushthe patientfrom behind. The challenge is for the patientto hold a balanced position until the wavehaspassed. wo facilitation techniques are alsousedi,nthe WST. The first is specificstimulation ofthe skin and comective tissue underneath. This can producevariouspostures, balanceand movements, dependingon the amount of stability being given. When the patient is supportedat the centerof balance,light strokesor tappingis al1 that is needed. With peripheral- firm - supports, patientsmay usethe leverage to work in closed chains to stabilize posture. Supports at the centerofbalance and stimulationwill

bilateral. In symmetricalpatterns, bothsides of thebody areperforming at the sametime. When only one side of the body is performing it is asymmetrical. Cross-lateral pattems involve the upper extremity on one side and the lower extremity on the oppositeside performing an activity. Figure 3 Resisling rotation to maintain balance Finally, bilateral patternsare either upperor lowerextremities performing produce balance reactions in open in unison. chains. MODE OFTREATMENT (MT) The second facilitation The final aspectof WST as an treatmenttechniqueis transference. It aquatictherapytechniqueis the Mode is engagingthe patient in movement of Treatment that considers the phase first on the unaffectedside ofthe and elementsof treatmentdelivery body with an attemptto perform the The phases in the WST (pre-training, samemovementon the affectedside. inhibition, facilitation, dynamic)are The notion is that the patient will be similar but not identical to the phases ableto transferleaming to the (mental adaptation, balancecontrol, affected sidesinceonly small contractions (changes in body shape) movement)of the TenPoint Pogram. in Figure4, thepoints areneededto facilitate movementand As canbe seen are organized in a slightly different feedback of these movements. Thrs goals manne. The of eachphaseare movement hasefect on a spinal level, also different in that the goalsof the following the principles of overflow WST are directedtowardtherapy of excitation,as in PNF.Moreover, outcomesas opposed to swimming the patient is askedto feel the abilities. movementa:rdto reproduce that The elementsof treaflnent feeling on the affectedside/area. This delivery include the selectionof would be a kind of visualization techniqueto facilitate a correct motor appropriateinterventionsftom the first five aspects (treatmentobjective, panem. rotational patterns. positions, starting EXERCISE PATTERNS (XP) patterns exercise and treatnent Treatment techniquesare techniques)of the WST aswell asthe appliedin certain exercise patterns. The exercise pattemsusedin the WST intensity of the activities chosen. Intensity can include many factors canbe described as symmetrical. suchas (but not limited to) amountof asymrnetrical, crosslateral or

Figure 4 Comparison of the Ten-Point Program andWST

weighrbearing, velocity, changeof Simplcctivity Fxctors to incresseintnsity radius and levers,length of time, Vertical positior Horizonlal position visual control andposition during (SeeFigure5.) The movement. Visual control No visual conol decisionsregardingwhich aspects Many points of suppon Lesvno pointsofsuppo and intensitiesto employarebasedon Water deptl aroundThl I Wate depth.bove or below Thl l the phaseof the programin which the patientis participating. Eachphase, Lgradius Reduction ofradius point andelement of theWST will be wide base Smallbase explained. Shodleve Long lever Pre-training In order for the WST to be effective,a patient must No (tuulent) low afourdthe body Flow aroundthe body haveachieved the first six stepsofthe Ten-Point-Program (seeFigure 4). A No metacentic prerequisitefor aquatictherapyis that effects Metacenl c effects the patient experiences comfort Shon duation Long duration (mentaladjustment) and independence (disengagement) in the water. Figure 5 Factors lo increase intensity o activities Theapistsmust assure that patients treatnentobjectives. cantolerate the physiological response in the base. Examples of changing TREATMENT EXAMPLES UStr to immersion andhydrodyn posturemay be sitting to standing, amic THEWST factors,exhibit comfort with water on supine to oblique. Examples of The treatrnentexamples will the face and in the earsand changrng the basearewalking use the succinct format devised by demonstrate breathcontrol. Onoea (step/stop) andbicycling. (SeeFigure McMillan. A narrative explanation patient hasachieved mental 2.) Thebasemay be the bottomor describingall aspects of treatnent adjustmentand disengagement, the side of the pool or supportflom the interventionwill be presented in th therapistassists the patient to master therapist. Posturalcontrol is (See cases. Figure 7.) sagittal,vertical, lateral and combined challenged with metacentriceffectsor Case1 The patientis rotation. The patientmovesto one of turbulenceassisted.iresisted activities supported manuallyin a supine theWST phases (inhibition, with wavesof transmission. facilitation, dynamic)when they are Dynamic The dyiamic phase position, which is upt}rust dominal and thereforeN*. The patient is asl respectively able to submerge, rise to is posturalcontrol with changes to correctpelvicpositionandfind i the surfaceand usea rotational occurringboth in the patients' pattemto achieve a comforlable position, postureand/or shapeand the pain flee positionof the spine;this a symmetricactivity in vertical breathing position. base.An example of changing rotation. The posture doesn't chang Inhibition Inhibition is static postureis jumping. Posturalcontrol thus this is referredto as posturecontrol.Throughoutthe is challengedwith metacentriceffects and inldbition. courseof the intervention,the andturbulenceassisted,/resisted with Case2 The patientmust patients' posture, position,shape and wavesof transmission. Figure 6 shows postuein all directions control (i.e baseremainthe same. The posture how modesof treatrnentcanbe combinedrotation). at the sametin maybe sitting("cube"position), developed with respectto the kneeling,standing,supineor oblique. Thebaseis the bottomor sideof the +WMG: Strengtlenweak musclegroups Facilitation Dynamic pool or supportftom the therapist. Posturalcontrol is challenged +ROM: lncraseraogeofmotion with the Facilitatiotr Dynamic useof buoyancyonly (gravity and FPBR:Facilitate postuandbalance reactionr IDhibition Facilitation Dynamic upthrustdominate, N+, N-, N+). +GPC:Icase generalphysical condition Facilitation Dynamic Activities in the inhibition phasecan alsobe used for the reduction of pain -P: Reduce pain Inhibition Facilitation or spasticity. -Sp: Reduce sfasticity Inhibition Facilitatiotr Dynamic FacilitationFacilitation is +IMA: lncreasementaladaptability d).namicposturecontrol with changes Inhibition Facilitation Dynamic occurring in the patients' position, Figure 6 Development o the modeof tratment withespect to the treatment postureand./or shapeor with changes
objectives

10

L specificlow back pair inceasing with spinalextension TO RP SP WD XP TT MT -P Veical rotation Supine N+ Symmetrical Uplhust dominant IDhibiion

2. Atheiosis: thebody shows contiluous

3. Endoprosthesis hipl lossofstength in the fontal plane

FPBR Combined rotation Cube(open saddle) N+ Asymmetical

Mt.ntic rfimrrl,rinn

+WMG

Stand (and walk) NAsymmeirical

Facilitation

Dynamic

Figure 7 hree examples showing WSTElements

in order to get symmetry.This aslmmetricactivitycanbestbe done in an "opensaddle position", using the impedance effects of waterto dampen movements. Proper useof (a slimulation keypoints technique) andsmallchanges ofpostures (metacentriceffects)facilitate posture andbalance reactions. Case 3 The case ofthe patient with an endoprosthesis of a hip will be extended, sincemostpatients do havemore than one treatment objective.The patient not only suffers from a gluteal muscularinstability in the fontalplane,but alsohasa limited extensionof that hip joint and he is afraidto bearweightagain because of a historyofpain. Three examples, combining the elements of WST in onesession will begivenin Figure8. Thepatienthasreceived a hip implant as a result of degenerative joint disease. The treatnent objectives areto increase rangeof motion, to enhance the mental ability to bearweight and to strengthen weak muscle groups. The startingposition is supine lying, using buoyancyto increase ROM, followed by standingwith the waterdeptharoundT1 I (relatively non-weight-bearing with reduced proprioceptiveinput) to feel that weightbearingis possible.As the patientprogresses, theywill walk in a waterdepthbelowT11 (moreweighf

bearing, closed chain activity and proprioceptive input). The passivepattern is slnnmetric (buoyancy works on both hips) and the active exercise patterns will be asymmetricbecausethey focus on an asymmetric problem. Treatment techniques are the use of upth-rustto gravity dominance, metacentric effects, wave of transmissionand hlrbulence resisted. The way thesetechniquesare used is indicated with the mode of treatment. In this case the patient begins with hhibition and moves via facilitation to the d)'namic phase. In the facilitation phase,the patient will maintain body position while changingthe base. The patient will walk continuously, at a constant depth at N+. As more weight bearing can be tolerate4 the patient will walk continuously at N-. The patient will not walk ffom N* to N- but stay at a

consistentdepth. Walking in this manner will utilizenotjust buoyancy and gravity in the mannerdescribed earlier but turbulencein the form of drag as well. As the patient gains more strengthand improvesbalance reactions, the patientwill walk in a step/stopsequence to producea wave of transmission challenging the patientto maintain balance.This activitywill alsobe performed at water depthsftom N to N-. In the dynamicphase,the patientwill changeboth position/po stureand base. In this case the patientwould start in the standingposition anc.. move fiom a jump/stop producinga waveof transmission. SUMMARY Working with physical therapists in Europe, McMillan elaborated on the principles ofthe Halliwick Methodto describe a specific aquatictherapytechnique: WST.This approach to aquatic therapyutilizes hydrodynamicforces, the metacentriceffect, momentsof inertia and primitive reflexesto patients enable to improve functioning on a varietyof levels. The Ten-Point-Program and the WST wereoriginallyusedwith individuals with neurological disorders. Today, theyhave applicationsfor patientsvr'ithmany paicularly in neurology, disabilities, pediatrics, geriatrics orthopedics, and behavioralhealth.In addition,the Halliwick Methodhasbeenusedwith

Endoposthesis hip: limited extensionofthe hip, being afraid to bear weight, reducedstrengthin the major glutei

TO RP SP WD XP TT MT

+ ROM Vertical Rotation O b l i q u es u p i n e N+ Symmetrical Upthrust dominani lnhibition

+MA Sag;ttalRotation Stand

+ WMG

Stand and walk N-

Metacentric Facilitation Dynamic

Figure I WSTDevelopment in onesession

11

other aquatictherapytechliques (the Bad Ragaz Ring Methodand Watsu@)) to providecomprehensive treatmentprogamsin the water. REFERENCES 1 McMillan J. The role of Water in Rehabilitation.Fysioterapeuten. 197 7; 45:43-46, 87-90, 236-240. 2 Cunningham J. Halliwick Method,in Ruoti RG, Morris DM, ColeAI (Eds.).Aquatc Re habilitati on. Philadelphia, Lippincot,1997. 3 GamperUN. p ezifische Bewegu Wa ssers ngstherapi e und Training. Stuttgart,Gustav Fischer Verlag,1995. 4 Lambeck J . De Halliwick methode,oefentherapie in water en zwermenvoor gehandicapten. KwartaaluitgaveNVOM. 1997:2:5357. Lambeck 5 J.,Stanat R The Halliwick Concept , Part 1.Journalof Aquatic Physical Therapy . Fall 2000, Vol.8, No.2, 6 11. 6 PaethB. Schwimmtherapie 'Halliwick-Methode' nachJames McMillan bei erwachsenen Patienten mit neurologischen Erkrankungen. gymnasti k. Zeitschrift f) r Kranken 19841'36: 100-1 12. 7 Becker BE. Biophysiologic Aspectsof Hydrotherapy, in Becker (Eds.). BE, ColeAJ Comprehensive Aquatic Therapy.Bo ston, Butterworth-Heinemarxr, I 997. 8 Harrison RA, Hilmann M, BulstrodeS. Loading of the lower limb when walking partially immersed: implications for clinical pracice.Pltysiotherapy,1992;78: 164-166.

coMrNG TO CSM 2o,o.2...

A NEW AQUATIC PHYSICALTHERAPY

T-SHIRT

THE DESIGNIS "UNDER-WRAPS" FORNOW,BUTJOINUS AT APTI(S MEETING COMBINEDSECTIONS IN FEBRUARY 2OO2 AND SEETHE UNVEILINGOF THE NEW T-SHIRT EXHIBITBOOTH. AT THE SECTION'S
A specialdiscountwill be offeredto AquaticSectionmembers a T-Shirtat the Sectionbooth duringCSM2002. who purchase

tz