THE HALLIWICK CONCEPÏ PART IABSTRACTJames McMillan developed the Halliwick Concept over 50 years ago.Initially, the Halliwick Concept was developed as an instructional strategy(called the Ten-Point Program) foÍ teaching swimming to children withdisabilities. Soon after the inÍoduction oÍ the Ten-Point Program (at theHalliwick School for Crippled Girls in London), the teaching staÍf began tonotice positive change in the physical and emoiional behaviors of thechildren. The changes in behavior were attributed to a uniqueteaching/learning philosophy and a psycho-sensory motor learningprogram that is enhanced by hydrodynamics. Recognizing thetherapeutÍc effects oÍ the Ten-Point Program, McMillan and hiscolleagues adapted the program as a therapeutic intervention calledWater SpeciÍic Therapy or thê Logic Approach to Therapy in Water.

Key words: Halliwick Concept, Ten-Point Program, Water SpecificTherapy, Aquatic Rehabilitation

INTRODUCTIONJames McMillan (1913-

1994) first conceived of theHalliwick Concept as a strategy toteach swimming to individualswith disabilities. The concept usesfluid mechanics to enable studentsto achieve stability and controlledmovement in the water.'0, 13

McMillan called the concept theTen-Point Program and in 1950,introduced it at the HalliwickSchool for Crippled Girls inLondon. The therapeutic value ofthe Halliwick Concept was quicklynoted. In fact, the Íesults we{eremarkable! Within weeks, notonly did the children leam to swimbut they also demonstratedimprovement in head balance,trunk stability, breath control andself-esteem.

McMillan and hiscolleagues lounded rhe Associationof Swimming Therapy and over

the next thirteen years continueddeveloping the concept. Althoughtheir intentions were recreational,the therapeutic impact oftheprogram was evident. In 1963,McMillan was asked to teach thcHalliwick Concept at the medicalcenter in Bad Ragaz, Switzerland.'�McMillan continued advancing theHalliwick Concept for the nexttwelve years. The Ten-PointProgram continued to impress themedical staff at Bad Ragaz and hewas hired (1975-1979) as theproject leader to extend theHalliwick Ten-Point Program asWater Specific Therapy (alsoknown as the Logic Approach toExercise in Water). (fIOTE:McMillan also redesigned aspectsof the Bad Ragaz Ring Concept(BRRM) to attend to theergonomic needs of those usingBRRM).

Today, after over fifty

years of development andimplementation, the HalliwickConcept is one oflhe mostimportant strategies in aquatictherapy, especially in neurologyand pediatrics.i x 3, '' This articlewill address the therapeutic aspectsof Halliwick both as aninstructional technique andtherapeuiic intervention.

IIALLIWICK:THE PHILOSOPHY

The goal of the HalliwickConcept is to enable theparticipant to achieve maximumindependence both in the waterand on land. Towards that end,McMillan created a teachingphilosophy and structue thatwould facilitate and encourageself-reliance. The development ofthe philosophy and structure wasinterdisciplinary. Following aGeneml Systems Theory approach,McMillan worked with

AUTHORS:Johan Lambeck PT, Director, The Halliwick-Hydrotherapy lnstitute, Akkersleep 32,6581 VN,4 l\ralden, Netherlands . Tel/Fax +31 24 gs82192Lambeck.hydro @Íreeler.nl . wwwhaÍ'iwick.net

Fran CotÍey Slanat, PhD, Director, Therapeutic Recreation Program, School of Allied Health Professions, University oÍ Wisconsin-MilwaukeePO Box 413, Enderis Hall 949, Milwaukee, Wl 53201 . voice 414-229-4778 . fax 414-906-3929 . Ístanat@uwm.edu . !1/ww.uwm.edu

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

professionals ffom other fields(e.g. allied health professionalsand teachers) to apply informationfrom kinesiology, pathology,psychology and didactics to awateÍ enviroÍment. The resultwas a teaching philosophy and apsycho-sensory motor leamingprogram that would become thebasis for the Ten-Point Program

The philosophical notionsand concepts that are theunderpimings of the HalliwickConcept (Figure 1) were presentedat a conference on the HalliwickConcept in 1986 at the Universityof Nijmegen in the Netherlands.'McMillan believed that everyoneis a swimmer and that swimmingis a means to independence (notthe goal). An essential skill inbecoming a swimmer is balance.Balance is dependent upon bodyshape and density. A swimmer,especially one with neurologicalimpairments, may requireassistance to establish andmaintain balance. Only a one-to-one helper should provide thissuppoft. Floatation devices arenever used because theyencourage dependence which maysignificantly impair the goal ofindependence. Finally, becominga swimmer requires activepaÍticipation and is most effectivern groups.

ÍIALLIWICK: THE MOTORLEARNING PROCESS

The goal of Halliwick isindependence and is demonstrated

as controlled movement. When inthe water, balance requiresadaptation to the mechanicalchanges in the environment. Theadaptations are the result of apsycho-sensory motor leamingprocess. This is a process thatenables the individual to leamhow to maintain balance in anunstable environment. Oncebalance (stability) is established,movement can be iniiiated andcontrolled.

McMillan understood therelationship between balance andmovement. He realized that inorder for children withneurological impairments (e. g.,problems with coordination,comprehension, perception and./orpain) to leam to swim (iniÍiate andconhol movement), they must fustleam to balance. Establishing andmaintaining balance was notsimple, and often impossible, forthe children. His response was todevelop manual assistancetechniques (handling techniques)that would enable the students toleam control of rotational pattems.Based on his observations,McMillan suggested that there wasa relationship between fluidmechanical effects and adaptivebody mechanics related to inertia,which in many cases, coincidedwith I'primitive reflexes.',McMillan accepted the notion of"primitive reflexes" while otherswere embracing different views ofmotor learning (e.g., Bobath).

It was not until later thatneurophysiology understood thesignifi cance of handlingtechniques as exteroceptive cuesor plasticity. Similarly- it iswidely accepted that the physicalpropenies of any environment area ma1or constraint to balance andthat individuals show adaptivemotor behavior (e.g., widening thebase of support, using hand forsuppon and stiffening the body inorder to stabilize the center ofgravity).'� These adaptive motorbehaviors (also referred to asshess behaviors) are consistentwith McMillan's notion of"primitive reflexes."7HALLIWICK: CONSIDERING

TWO UNTQITEHYDRODYNAMICS

FACTORSExteroceptive cues

(plasticity) and adaptive motorbehavior in the presence ofhydrodynamic elements resulted ina psycho-sensory motor leamingpro$am that is the HalliwickConcept. Thehydrodynamicelements generally accepted asinfluential in aquatic therapy alsoplay an importani role inHalliwick. In Halliwick, however,the most important fluidmechanical effect is commonlyreferred to as "metacentric

effects." Metacenter is a navalarchitectural term used to describethe point around which the forcependulum of gravity and buoyancyrotate. Both forces are equallyimportant and influential withsmall changes in either gravity orbuoyancy causing imbalance. Theshape, density and (a)symmetry ofa body will influence themetacenter (equilibrium). Inwatet balance occurs when a bodymakes necessary adjustments tocause the forces of gravity andbuoyancy to be equal and directlyopposite of each other. Wlenthese forces are not equal and co-linear, the body will become

Everyone is a swimmert

Swimming is a means to independence, not a goal in itself.

Balance depends maidy on body shape and densiry

Proper suppofts are essential.

Most activities require a l-to-1 attendance/supporl.

Floatation aids are never used.

The student participates actively in all activities.

Most activities take place in groups.

Figure 1: The Halliwick Philosophy

unstable causing it to rotate toreach balance. The body usesautomatic reactions to balance andstabilize posture, based on laws ofinertia (increase of a rotationalradius slows down velocity). Incases where loss ofbalance cannotbe coordinated well, the body usespattems based on "primitive

reÍlexes" such as the (a.lsymmetrictonic neck reactions and the tonclabyrinthine reactions.a'" Thesereactions coincide with the ineniapatterns and can block unwantedrotation, especially around themidline, to stabilize posture.McMillan allowed these reactions,to some extent, to create midlineslmmetry as a starting point forcooÍdinated rotational control.

McMillan also consideredthe commonly held views onbuoyancy. Of specific interest tohim, however, was the efficacy ofweightlessness. He believed thatpostural "...tone is influenced byproprioceptive input stimulated bygravitational forces. In otherwords, tone is a function ofweight" 4 rr which has beenconfrrmed by others.r'3 6,r' r5 Whena person is immersed in the water,proprio- ceptive input iscompromised and posnual tone isreduced. Tactile information isenhanced and "the system" mayrely on primitive reflexes or lesscoordinated motor behavior tomonitor and control movementand posture in an environmentwith altered sources of feedback.McMillan also noted that theeffect of weightlessness on tonereduction was present regardlessof water temperature. He wasoften heard saying "there is nosuch thing as cold water."?

HALLIWICK: THE TEN-POINT PROGRÁM

The Ten-Point Program isa motor learning sequence thatfocuses on postural control toteach swimming. Ten successivesteps lead students to experience

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

and master (control) in a vadety ofmovement pattems, with theoutcome being a functionalswiÍnming stroke. The threephases (originally four) ofthe Ten-Point Program (Figure 2) representan effective method for leachingswimming to both individuals whoare able-bodied and those with adisability.

The three phases includemental adaptation, balance controland movement. The purpose,goals, strategy and therapeuticoutcome for each ofthese phaseswill be described.Mental Adaotation

Mental adaptationincludes mental adjustment anddisengagement. It encompassesadjustment to the propeÉies of

hands or the pelvic girdle.Support is never provided at thehead since it is most critical tobalancing. Gradually, support iswithdrawn. This withdrawal iscalled disengagement.

Disengagement is themost important job of theinskuctor. When given too muchsupport, the student will not bechallenged to balance. Whenthere is too little support, shessreactions may occur that interferewith the desired outcome variabler(Figure 3). The desired outcomesresult from feedback that thestudent receives aboutimprovements. This feedback cancome only from proper\suppoÍed experiences that enablethe student to pmctice and master

Ten Points Phases

1. Mental Adjustment and Disengagement Mental Adaptation (Adjustment)

2. Saglttal Rotation (Control)

3. VeÍical Rotation (Control)

4. Lateral Rotation (Control)

5. Combined Rotation (Control)

6. Upthrust / Mental Inversion

7. Balance in Stillness

8. Turbulent Gliding

Balanca Conhol

9. Simple progression

10. Basic Halliwick MovementMovement

'water: buoyancy, flow, and waves,as well as the gradual decrease ofsupport by the instructor duringactivities in upright positions. Animportant paÍt of mentaladjustÍnent is breath control.Breath control focuses onexpimtion in order to preventinhaling or swallowing water.Breath control also facilitatesforward movement of the headwhich is essential for balancingactivities in water. Early in mentaladaptation, support is givenstaÍing at the shoulder girdle and(depending on student needs andabilities) changing to either the

variables

the skills.Disengagement is a

continuous process of changingsupports and using hydrodynamicelements to increase diffrculty andchallenge stability (Figure 4).

Each activity or skillintroduced will require a differentamount of disengagement. Thepurpose is to teach the student tobalance in as open a kinetic chainas possible. Finally, whiledis engagement is especiallyaddressed in the fust phase of theTen-Point Program. it is utilized inall steps when new skills areintroduced.

Figure 2: The Ten-Point-Pro$am and the three phases ofthe Halliwick Concept.

Novel Skill

Vadable execution

Inaccurate; clumsy

Slow

Much co-contraction

Visual control needed

Visible postural adaptations

Stiff in performance

Controlled Skill

Consistent execution

Precise

Fast

Strooth

No visual control necessary

Invisible postural adaptations

Flexible in performance

Therapeutic outcomesduring phase one, mentaladaptation, are first evident withthe mouth-breath controlactiviÍies. Specifically, mental("vater) adjustment aids lipclosure, vocalization anddiaphragm activities. Addressinghead-trunk conhol results inreduction of hlpertonicity,disassociation, facilitation ofrighting reactions and symmetry.Finally, water adjustment activitiesinclude games that enable practiceand haining of functionalbehaviors such as walking,iumping and tuÍring.s, 14Balance Control

Phase two, baladce

control, includes balanceÍestoration on a variety of axes,mental inversion (upthÍust),"balance in stillness" and tubulentgliding. Balance control is theability to independently maintainor to change a position in thewater Initially, control will beineffrcient, with large(unnecessary) peripheralmovements. The client must leama fine degree of automatic andcentralized balance control toprcvent unwanted movements andto achieve eÍhcient posfuralconhol. In the first step in thisphase, the student leams to control(restore) sagittal, vertical, lateraland combined rotation to establish

postural control. Sagittal rotationis done in an upright position andis a bending from left to right ortransferring weight. Verticalrotation is aÍound the transverseaxis with the clients moving fromstanding to supine to standingposition. Lateral rotation isaround the spine producing a 360degree roll. Combined rotation,which is a combination of theveftical and lateml rotations or thesagittal and lateral rotations, isused to teach the concept of "ro1l

out oftrouble." It is an over-rotated, forward vertical, orsideways sagittal rotation with theclient being taught to roll to aface-up position (lateral rotation).

When the client hasmastered rotation, upthÍust, ormental inversion, is introduced. Itis simply the concept thatbuoyancy will bring objects andpeople to the surface. The studentleams to submerge, and, uponsurfacing, uses one of the rotationpattems to achieve a comfoÍablebreathing position.

The first Íive steps ofbalance control require amaximum amount of movement.Gradually, as the student leams tomaster the rotational patterhs, theyare introduced to static aspects ofthe progam that will require afine degree of centralized posturalcontrol. In "balance in stillness,"clients assume a variety ofpositions, from standing tofloating. The instructor uses avariety ofvariables such asturbulence or tactile stimulation(see Figure 4) to compromise theclients' balance or stability.Mastery is when the client canachieve stillness.

When "stillness" has beenmastered and the student canmaintain body position, theinstructor introduces movement rnthe water with turbulent gliding.The student, in a supine positiorr,is passively moved through the

Figure 3: Effect of feedback and experience on changes in motor behavior (Smits,Engelsman, 1999).

Simple Equilibrium

Support at the shoulder girdle

Support at hands

Many points of support

Water depth aÍound Thl I

Large radius

Wide base

Compensating hand movements (e.g. sculling)

No (turbulent) flow around the body

No waves

No metacentric effects

Methods to Challenge Balance

Shift support caudally

ShiÍï support centrally

Less/no points of supporl

Water depth above Th11

Reduction of radius

Small base

No hand movements

Flow around the body

Waves

Metacentric effects

Figure 4: Methods to increase difficulty during disengagement

Photo 1: Sagittal Rotation Control: working onrighting reactions and lengthening ofthe trunk.

Photo 2: Vertical Rotation Control: exercisingsymmetry and selectivity during graded extension.

water by the instructor who walksbackward, dragging the client in thewake produced. The instructor mayalso produce manual turbulence underthe clienfs shoulders. The client mustmaintain a still and balanced bodyposition without increase of radius,sculling or increase in tone. This stepallows the client to experience acentralized postuÍal control whilebeing dragged tbrough tbe water.. There are many therapeuticbenefits in phase two of the Ten-PointProgram. Sagittal rotation increasesspinal range of motion or spinalstabilization. It also aids in reachingand balancing sideways. Sagittalrotation also facilitates righting andsupporting reactions.

Vertical rotation is a kind ofdisassociated or selective extension.A1l components of this chain can beexercised including positioning of thehead on the tiunt, working on

Photo 3: Lateral Rotation Control: the veryimportart breath contol in a ploper alignment.

Photo 4: Balance in Stillness: turbulence createsÍotation and the swiÍnmer has to stabilize hios andsprne,

scapuiar depression, extension of thedorsal spine, positioning ofpelvic tilt,eccentric activity of the abdominalsand dynamic stability of the kneejoints.

Lateral rotation faciiitatesrighting reactions between head,shoulder girdle and pelvic girdle.Obliques are very active in stabilizingthe components Íelative to oneanother. Control over lateÍal lotationis of utmost impoÍance duringswimming, walking and many otherfunctional activities.

Combined rotation has thesame benefits as mentioned aboveand is more functional working rnthree-dimensional pattems.

"Balance in stillness" (and tosome extent, turbulent gliding) isbeing used in al1 cases wherestabilization of trunk, pelvic area andlower extremities have to beaddressed. This point forms a bridge

to the'Water Specific Therapy andwill be more fully described later.Movement

Movement, which includessimple progÍession and a basicswimming movement, is the finalphase of the Ten-Point Program. Atthis point, the student is able to createeffective, efficient and skilledmovement in the water. onceturbuient gliding is mastered, clientsaÍe taught a simple progression thatenables independent movementthrough the water Whileprogressions may need to becustomized for each client (based onfrrnctional abilities, body composition.and s)Ínmefy), self-propellingmovements are usually some folm ofscu1ling. The sculling activity isgradually advanced to the Halliwickswimming movement, which is adouble-sided rowing activity withboth arms symmetrically in the supine

1 0

position.The most dramatic

therapeutic outcome from themovement phase is dynamicallytrained trunk stability. Duringswimming the student has to propeleffectively, which requires propercentral coordination andsynchronization. Swimming can alsobe regarded as a double task withautomatic components of posturalcontrol.

SUMMARYThe Halliwick concept began

as a method lor teaching swimming tochildren with physical disabilities.Fifty years of development andimplementation have enabledswimming instÍuctors to identifutherapeutic outcomes resulting fromuse of Halliwick Concepts.Recognizing the efficacy oftheHalliwick Concept as a therapeuticintervention, McMillan and otherssought to apply the mechanical effectsof water on the body to aquatictherapy. The resulting strategy isknown as Water Specific Therapy(also called the Logic Approach toTherapy in Water). The elements ofWater Specific Therapy as weil astreatment examples (case studies) willbe presented in The HalliwickConcept - Part 2.

R-EFERENCESI Bory P, Foidart M,Decquinze B, Solheid M, Pirnay F.Influence des bains chauds sur lesproprits rnusculaires des sujers sainset spastiques. Medica Physica. 1990;13 :121-124.

2 Carr J, Sheperd R.Neuro I o gíc al Rehab il itation,Optimizing Motor Performance.Oxford, Butterworth Heinemann,1998.

3 Clarys JP. Muscle tone,relaxation and activity in an aquaticenvlronment, in Lambeck J (Ed.).Proceedings Congres Halliwick in198ó. Nijmegen, Stichting NDT-

Nijmegen, 1990.

4 Cunningham J. HalliwickConcept, in Ruoti RG, Morris DM,Cole AJ (Eds.). AquaticRehab il i t at io n. Philadelphia,Lippincot, 1997.

5 Gamper UN.Was s erspezifis che B e1a)egngstheropieund Training. Stuttgart, GustavFischer Verlag, 1995.

6 Kozlovskaya IB, Aslanova IRGrigodeva LS, Kreidrich W.Experimental analysis of motoreffects of weightlessness. ZfrePhys iologis t. 1982; 25 sttppl.: 49 -52.

7 Lambeck J (Ed.).Neurophysiological Basis for ÁquaticTherapy : The o re t ical Top ic s.Spokane, Constellate, 1996.

8 Lambeck J . De Halliwickconcept, oefentherapie in water enzwemmen voor gehardicaÈten.Kwartaaluitgave NVOM. 1,997;2: 53-57.

9 MacKinnon K. An evaluationof the benefits of Halliwickswimming on a child with a mildspastic diplegia. I PCP Journal, 1997;December:30-39.

l0 Maíin J. The HalliwickConcept. Physiotherapy. I98t; à7:288-291.

| | McMillan J. The role ofWater in Rehabilitation.Fysioterapeuten. 197 7 ; 45 : 43-46, 87 -90,236-240.

12 Mitarai G, Mano I YamazakiY. Conelation between vestibularsensitization and leg musclérelaxation under weightlessnesssimulated by watet ifi:-;rrersion. AcÍaAstronautica. 1981; 8: 461-468.

13 Nicol K, Schmidt-HansbergM, McMillan J. Biomechanical

11

Principles Applied to the HalliwickConcept of Teaching Swimming toPhysically Handicapped Individuals,in Terauds J, Bedingfield EW (Eds.).Swimming III. Campaign,HumanKinetics, 1979.

14 Reid-Campion M.Hydrotherapy: Frinciples andP r acti c e. Oxford,Butterworth-Heinemann, 1997.

15 Ross IIE. How important arechanges in body weight for massperception? Á cta As tronautic a.1 9 8 1 ; 8 : 1 0 5 1 - 1 0 5 8 .

16 Smits-Engelsman BCM, TuijlALT van. Toepassing van cognitievemotorÍsche contÍole- theorieen in dekinde$rsiotherapie: het controlerenvan wijheidsgraden en beperkingen,in: Syllabus 'Leren en herleren vanmo to ri s c he v aardigheden b ijpaíienten met chronische benignep ij n'. Amercfo ort, NederlandsParamedisch Instituut, 1999.

I

The Halliwick Concept, Part llióhan tambeck .,r"*ry1. - i

, . ' . t t . ,

ABSTRACT:James McMillan developed the Hall iwick Concept over 50 years ago. In Part | (Volume 8,Number 2), the basic Ten-Point pÍogram was presented. In Part l l , expanded operationaldefinit ions and the application of Water Specific Therapy is examined.

Key Words:Halliwick Concept, Water Specific Therapy, Aquatic Rehabilitation

Editors Notê:The reader is reminded that several of the concepts and deÍinit ions usêd in this article areoutlined and described in The Hall iwick Concept - Part I. A reviêw of Part I is stronglyrecommenoèo.

Also, this presentation is an accurate interpretation oÍ James McMillan's Hall iwick Tên-Point Program as a school oJ thought; and, thereforê may not nêcessarily reflect certainviewpoints hêld by aquatic therapists practicing in the United States.

INTRODUCTIONWater Specific Therapy (WST)was founded on the mechanicaleffects of water on the body, justas the Ten Point Program (seeHalliwick Concept Part I),' butapplied for purposes of aquatictherapy.c'6) This approach is mostsuitable for adults wirh neurologic.orthopedic or rheumatologicdisorders. WST is not a group ofexercises such as the Bad RagazRing Method. Rather, it is aclinical decision making systemthat contains elements to plan,execute and assess aquatic therapyapplications.

A therapist can choose aninfinite number of options toproduce the desired outcome. Theelements of WST include:- the treatment objectives- the rotational plane- the starting positions- the exercise patterns- the treatment techniques- the modes of treatment.

Each element of the WSTwill be explained with severalcases given.

TREATMENTOBJECTIVES (TO)The purpose ol the WST is

to enable a patient to improvefunctional abilities on land.McMillan was quick to point outthat ".. .if you can do it on land,don't do it in water". (2) However,if aquatic therapy can enhance anindividual 3 functional abilities,then treatment in the water shouldbe used as an extension orcompliment to land therapy.McMillan identified sevenobjectives that he believed couldbe enÏanced with the WST. Theobjectives are to: (l) strengthenweak muscle groups (+WMG), (2)increase range of motion /stretching (+RM), (3) facilitateposture and balance reactions(FPBR), (4) increase generalphysical condition (+GPC), (5)reduce pain (-P), (6) reducespasticity (-Sp) and (7) increasemental adaptability (+IMA). Theabbreviations were used to developshort, succinct treatment plans andwill be demonstrated later.

Physiological rules onmuscle strengthening,cardiovascular training andstretching of connective tissueshould be considered in relation tothese objectives. Once anassessment has been completed

and treatment objectives identifie{the therapist selects the appropriaterotational plane, starting position,exercrse patterns, treafnenttechniques and mode of treaÍnent.

[NOTE: Facilitation of posture andbalance reactions is a very broadobjective and applicable to mostindividuals with neurologicalimpairments. Currently, therapistsusing the WST have narrowed theFPBR objective to include suchlntents as symmetry,disassociation, centralization,reciprocal motion, etceteÍa.5ROTATIONAL PATTERNS (RP)

Selection of the bestrotational plane is based on theeffect of impairment on thepatients' body shape and densiry.For example, a patient who ishemiplegic may be taught side-flexing activities produced withsagittal rotation (SR) to assist withlearning posture-righting reactionswhen in the vertical position.

The same patient mightbegin work in lateral rotation (LR)along the longitudinal axis tofacilitate posture and balancereactions when in supine. Anindividual with an endoprosthesrship with muscular instability in the

Johan Lambeck PT, Director, The Halliwick-Hydrotherapy Institute, Akkersleep 32, 6581 VM l\,1alden, Netherlands . Tel/Fax +31 24 3582092Lambeck.hydro@lreeler.nl, www.hall iwick.netFran CoÍfey Stanat, PhD, DÍector, Ïherapeutic Recreation Program, School oÍ Allied Health ProÍessions, Universjty oÍ Wisconsin-l\,4ilwaukee, PO. Box413, Enderis Hall 949, MiÍwaukee, Wl 53201 . (414\ 229-4778 voice, (414) 906-3929 Íax, fstanat@ uwm.edu, w\tuw.uwm.edu

7 Ih. Jou-ul ofÁoualic ?hvsica.l TlleraDv ' VoI. 9 No. I . Fall 2001

frontal plane might work in verticalrotation (VR) along the transverseaxis to strengthen weak musclegroups or facilitate posture andbalance reactions. see the third oasehistory. A person with severe spasticquadriplegia might work in combinedrotation (CR) along the combined axisto reduce spasticity, increase range ofmotion and enhance symmetry andextension.r

STARTING POSITIONS (SP)Starting positions are designed to

cause predetermined biomechanicaland hydrodynamic effects. The waterdepth (WD) affects standing positionsin which the patient is standing.Generally, patients standing in waterat T1 1 are neutral (N+). Patients inwater above T11 [N+) experienceincreased effects of buoyancy, arerelatively non-weight bearing, andhave reduced proprioceptive input.Balance is maintained mainly with thehead. As the water level drops belowT1 1 (N-), the patient experiencesreduced effects of buoyancy, increasedweighlbearing, and moreproprioceptive input. The lowerextÍemities have an important role inweight beadng. (See also the sectionon treatrnent techniques.)

A classic starting position mthe Halliwick Concept is the "cube"

or sitting position at N+. In Figure Ithe cube is adapted to enhance headactivity.

The patient basically appearsas if they are sitting at a table witharms stretched in front on the table.Hips and knees are in 90' of flexion,back is straight, feet flat on thebottom with feet and knees sligh(lyapaÍt and aÍms stretched out in frontthe entire length.

A variation is shown in Figure2: the bicycle position. This positioncan be used to facilitate head control.giving a closed chain through theshoulder girdle. The fixed points rnthe "cube" position are between feetand floor and offer less help than thebicycle when working on headbalance.

Figure 1 Cube PositionThe kneeling position is the

same as the "cube" except the patientis resting on the lcrees. In the supneor backJying position, at N+, thelumbar spine is in neutral alignment,hands at the side or apart (dependingon the amount oftrunk stability), headneutral or slightly flexed, hips inneutral flexion with legs together andfeet in dorsiflexion. The proneposition or ftont-lying position, at N+,places the lumbar and cervical spinein an extended position and is seldomused. [r the oblique position, at N+,the body is in neutral extension,angling diagonally in the water withthe feet on the bottom and with theface floating above the surface of thewater.

Figure 2 Bicycle Position

TREATMENT TECHNIQT]ES (TT)WST uses seven treatrnent

techniques to disrupt the metacentricbalance. The disruption migbt forcean individual to use inertia patterns todevelop postural control, balance andmovement. While each of these

techniques will be discussedindividually, one should understandthat each technique could producemultiple results. For example, when apatient is challenged to regain postureand balance, that individual willperform isometric and dynamicactivity udth variable resistance thatwill aid in the strengthening of weakmuscle groups. McMillan believedthat buoyancy, and the concomitantweightlessness, could lead to areduction in certain types of spasticityor hypertonicity. The reduction ofhypertonicity coupled with increasedmovement and strength of weakantagonists will enable the patient toexperience greater active range ofmotion. Al1 of the activities andhydrodynamic forces will create afavorable environment for a reductionin pain. Wldle the general purpose ofeach treatment technique will bedescribed, one should consider thebroader impact on the patieni.

The first two treatrnenttechniques are gravity dominant andupthrust dominart activities, whichinvolve using gravity or buoyancy toalter or aid patients' postural control,balance, and movement.Upthrustdominant activities (N+) will focus onhead control and open chain worlgwhile gravity dominant activities (N)involve more weight bearing andlower extremity work.

Wïen entering a pool,buoyancy is the most challengingpropelty of water to be met.Buoyancy becomes most influentialwhen the lungs become immersed, atthe level of T11 or the xyphoid. Whenwalking ftom the shallow part to thedeep end of the pool, weight bearingis lost quickly at Tl1.r At this time,posture and movement must adaptquickly as well and control v/ith thehead and upper extremities overridescontrol of the lower exlremitiesbecause contact between feet andgrorind diminishes as descdbed byBecker and Harrison.l3

' The third and fourth treatÍnenttechniques are turbulence assisied and

hrbulence resisted. ln the assistedtechnique, the therapist manuallyproduces turbulence to assist thepatient to maintain postural controland balance as well as to achievemovement. The turbulence resistedtechniques are designed to challenge apatients' ability to maintain postuÍalcontrol, balance and./or movement. Byproducing turbulence, the therapistcan work without touching the patientin order to avoid compensatoryactivity.

McMillant explanation forthe fifth treatment technique, themetacentric effect, was that "...when

a body paÍ is lifted out of the water,the body rotates to try to get that paÍofthe body back under the water."'He referred to the force-couplegravity and buoyancy by stating thatany change in the force-coupleproduces a torque and a rotation ofthe body. The therapeutic impact isthat tle patient must resist the rotationto maintain balance. (See Figure 3.)Maintaining balance requires thepatients to work in a rhythmicfashion, while performing stabilizingisometric activity of the musclescontrolling the joints of the spine andlower extremities.

The wave of transmission is atechnique used for improving posturalstability. The paiient walks throughthe water one step forward and stops.The incoming wave will push thepatient from behind. The challenge isfor the patient to hold a balancedposition until the wave has passed.

ïwo facilitation techniques arealso used i,n the WST. The first isspecific stimulation ofthe skin andcoÍmective tissue underneath. This canproduce various postures, balance andmovements, depending on the amountof stability being given. When thepatient is supported at the center ofbalance, light strokes or tapping is al1that is needed. With peripheral - firm- supports, patients may use theleverage to work in closed chains tostabilize posture. Supports at thecenter ofbalance and stimulation will

Figure 3balanceproduce balance reactions in openchains.

The second facilitationtreatment technique is transference. Itis engaging the patient in movementfirst on the unaffected side ofthebody with an attempt to perform thesame movement on the affected side.The notion is that the patient will beable to transfer leaming to theaffected side since only smallcontractions (changes in body shape)are needed to facilitate movement andfeedback of these movements. Thrsmovement has efect on a spinal level,following the principles of overflowof excitation, as in PNF. Moreover,the patient is asked to feel themovement a:rd to reproduce thatfeeling on the affected side/area. Thiswould be a kind of visualizationtechnique to facilitate a correct motorpanem.

EXERCISE PATTERNS (XP)Treatment techniques are

applied in certain exercise patterns.The exercise pattems used in the WSTcan be described as symmetrical.asymrnetrical, cross lateral or

bilateral. In symmetrical patterns,both sides of the body are performingat the same time. When only one sideof the body is performing it isasymmetrical. Cross-lateral pattemsinvolve the upper extremity on oneside and the lower extremity on theopposite side performing an activity.Finally, bilateral patterns are eitherupper or lower extremities performingin unison.

MODE OFTREATMENT (MT)The final aspect of WST as an

aquatic therapy technique is the Modeof Treatment that considers the phaseand elements of treatment deliveryThe phases in the WST (pre-training,inhibition, facilitation, dynamic) aresimilar but not identical to the phases(mental adaptation, balance control,movement) of the Ten Point PÍogram.As can be seen in Figure 4, the pointsare organized in a slightly differentmanneÍ. The goals of each phase arealso different in that the goals of theWST are directed toward therapyoutcomes as opposed to swimmingabilities.

The elements of treaflnentdelivery include the selection ofappropriate interventions ftom thefirst five aspects (treatment objective,rotational patterns. starting positions,exercise patterns and treatÍnenttechniques) of the WST as well as theintensity of the activities chosen.Intensity can include many factorssuch as (but not limited to) amount of

Resisling rotation to maintain

Figure 4 Comparison of the Ten-Point Program and WST

9

weighrbearing, velocity, change ofradius and levers, length of time,visual control and position duringmovement. (See Figure 5.) Thedecisions regarding which aspectsand intensities to employ are based onthe phase of the program in which thepatient is participating. Each phase,point and element of the WST will beexplained.

Pre-training In order for theWST to be effective, a patient musthave achieved the first six steps oftheTen-Point-Program (see Figure 4). Aprerequisite for aquatic therapy is thatthe patient experiences comfort(mental adjustment) and independence(disengagement) in the water.Theïapists must assure that patientscan tolerate the physiological responseto immersion and hydrodyn amicfactors, exhibit comfort with water onthe face and in the ears anddemonstrate breath control. Onoe apatient has achieved mentaladjustment and disengagement, thetherapist assists the patient to mastersagittal, vertical, lateral and combinedrotation. The patient moves to one ofthe WST phases (inhibition,facilitation, dynamic) when they arerespectively able to submerge, rise tothe surface and use a rotationalpattem to achieve a comforlablebreathing position.

Inhibition Inhibition is staticposture control. Throughout thecourse of the intervention, thepatients' posture, position, shape andbase remain the same. The posturemay be sitting ("cube" position),kneeling, standing, supine or oblique.The base is the bottom or side of thepool or support ftom the therapist.Postural control is challenged with theuse of buoyancy only (gravity andupthrust dominate, N+, N-, N+).Activities in the inhibition phase canalso be used for the reduction of painor spasticity.

Facilitation Facilitation isd).namic posture control with changesoccurring in the patients' position,posture and./or shape or with changes

in the base. Examples of changingposture may be sitting to standing,supine to oblique. Examples ofchangrng the base are walking(step/stop) and bicycling. (See Figure2.) The base may be the bottom orside of the pool or support flom thetherapist. Postural control ischallenged with metacentric effects orturbulence assisted.iresisted activitieswith waves of transmission.

Dynamic The dyiamic phaseis postural control with changesoccurring both in the patients'position, posture and/or shape and thebase. An example of changingposture is jumping. Postural controlis challenged with metacentric effectsand turbulence assisted,/resisted withwaves of transmission. Figure 6 showshow modes of treatrnent can bedeveloped with respect to the

treatÍnent obj ectives.TREATMENT EXAMPLES UStr

THEWSTThe treatrnent examples will

use the succinct format devised byMcMillan. A narrative explanationdescribing all aspects of treatÍnentintervention will be presented in thcases. (See Figure 7.)

Case 1 The patient issupported manually in a supineposition, which is upt}rust dominaland therefore N*. The patient is aslto correct pelvic position and find ipain flee position of the spine; thisa symmetric activity in verticalrotation. The posture doesn't changand thus this is referred to asinldbition.

Case 2 The patient mustcontrol postuÍe in all directions (i.ecombined rotation). at the same tin

+WMG: Strengtlen weak muscle groups

+ROM: lncr€ase raoge ofmotion

FPBR: Facilitate postuÍê and balance reactionr

+GPC: IÍcÍ€ase general physical condition

-P: Reduce pain

-Sp: Reduce sfasticity

+IMA: lncrease mental adaptability

IDhibition

Inhibition

Inhibition

Inhibition

Facilitation

Facilitatiotr

Facilitation

Facilitation

Facilitation

Facilitatiotr

Facilitation

Dynamic

Dynamic

Dynamic

Dynamic

Dynamic

Dynamic

Figure 6 Development oÍ the mode of trêatment with Íespect to the treatmentobjectives

Simplc Àctivity Fxctors to incresse intênsity

Vertical positioÍr

Visual control

Many points of suppon

Water deptl around Thl I

LÀÍg€ radius

wide base

Shod leveÍ

No (tuóulent) Ílow afouÍrd the body

No metacentÍic effects

Shon duÍation

Horizonlal position

No visual conÍol

Lesvno points ofsuppoÍ

WateÍ depth .bove or below Thl l

Reduction ofradius

Small base

Long lever

Flow around the body

Metacenl c effects

Long duration

Figure 5 Factors lo increase intensity oÍ activities

1 0

L Àspecific low back

paiÍr incÍeasing with

spinal extension

2. Atheiosis: the body

shows contiluous

3. Endoprosthesis hipl

loss ofstÍength in the

fíontal plane

TO

RP

SP

WD

XP

TT

MT

-P

Veíical rotation

Supine

N+

Symmetrical

UplhÍust dominant

IDhibiÍion

FPBR

Combined rotation

Cube (open saddle)

N+

AsymmetÍical

Mêtà.êntÍic rfimrrl,rinn

+WMG

Stand (and walk)

N-

Asymmeirical

DynamicFacilitation

Figure 7 ïhree examples showing WST Elements

in order to get symmetry. Thisaslmmetric activity can best be donein an "open saddle position", usingthe impedance effects of water todampen movements. Proper use ofkeypoints (a slimulation technique)and small changes ofpostures(metacentric effects) facilitate postureand balance reactions.

Case 3 The case ofthe patientwith an endoprosthesis of a hip willbe extended, since most patients dohave more than one treatmentobjective. The patient not only suffersfrom a gluteal muscular instability inthe fÍontal plane, but also has alimited extension of that hip joint andhe is afraid to bear weight againbecause of a history ofpain. Threeexamples, combining the elements ofWST in one session will be given inFigure 8.

The patient has received a hipimplant as a result of degenerativejoint disease. The treatÍnentobjectives are to increase range ofmotion, to enhance the mental abilityto bear weight and to strengthen weakmuscle groups.

The starting position is supinelying, using buoyancy to increaseROM, followed by standing with thewater depth around T1 I (relativelynon-weight-bearing with reducedproprioceptive input) to feel thatweight bearing is possible. As thepatient progresses, they will walk in awater depth below T11 (more weighf

bearing, closed chain activity andproprioceptive input).

The passive pattern isslnnmetric (buoyancy works on bothhips) and the active exercise patternswill be asymmetric because theyfocus on an asymmetric problem.

Treatment techniques are theuse of upth-rust to gravity dominance,metacentric effects, wave oftransmission and hlrbulence resisted.The way these techniques are used isindicated with the mode of treatment.In this case the patient begins withhhibition and moves via facilitationto the d)'namic phase. In thefacilitation phase, the patient willmaintain body position whilechanging the base. The patient willwalk continuously, at a constant depthat N+. As more weight bearing canbe tolerate4 the patient will walkcontinuously at N-. The patient willnot walk ffom N* to N- but stay at a

11

consistent depth. Walking in thismanner will utilize notjust buoyancyand gravity in the manner describedearlier but turbulence in the form ofdrag as well. As the patient gainsmore strength and improves balancereactions, the patient will walk in astep/stop sequence to produce a waveof transmission challenging thepatient to maintain balance. Thisactivity will also be performed atwater depths ftom N to N-. In thedynamic phase, the patient willchange both position/po sture andbase. In this case the patient wouldstart in the standing position anc..move fiom a jump/stop producing awave of transmission.

SUMMARYWorking with physical

therapists in Europe, McMillanelaborated on the principles oftheHalliwick Method to describe aspecific aquatic therapy technique:WST. This approach to aquatictherapy utilizes hydrodynamic forces,the metacentric effect, moments ofinertia and primitive reflexes toenable patients to improve functioningon a variety of levels.

The Ten-Point-Program andthe WST were originally used withindividuals with neurologicaldisorders. Today, they haveapplications for patients vr'ith manydisabilities, paÍicularly in neurology,orthopedics, pediatrics, geriatrics andbehavioral health. In addition, theHalliwick Method has been used with

EndopÍosthesis hip: limited extension ofthe hip, being afraid to bear

weight, reduced strength in the major glutei

TO

RP

SP

WD

XP

TT

MT

+ ROM

Vertical Rotation

Obl ique supine

N+

Symmetrical

Upthrust dominani

lnhibition

+ M A

Sag;ttalRotation

Stand

Metacentric

Facilitation

+ WMG

Stand and walk

N -

Dynamic

Figure I WST Development in one session

other aquatic therapy techliques (theBad Ragaz Ring Method andWatsu@)) to provide comprehensivetreatment progÍams in the water.

REFERENCES1 McMillan J. The role of Waterin Rehabilitation. Fysioterapeuten.197 7 ; 45: 43 -46, 87 -90, 236-240.

2 Cunningham J. HalliwickMethod, in Ruoti RG, Morris DM,Cole AI (Eds.). AquatícRe habilitati on. Philadelphia,Lippincot, 1997.

3 Gamper UN.Wa s s er s p ezifi s c h e B ew egu n gs t h e rap i eund Training. Stuttgart, GustavFischer Verlag, 1995.

4 Lambeck J . De Halliwickmethode, oefentherapie in water enzweírmen voor gehandicapten.Kwartaaluitgave NVOM. 1997:2: 53-57.

5 Lambeck J., Stanat R TheHalliwick Concept , Part 1. Journal ofAquatic Physical Therapy . Fall 2000 ,Vol . 8, No. 2, 6 11.

6 Paeth B. Schwimmtherapie'Halliwick-Methode' nach JamesMcMillan bei erwachsenen Patientenmit neurologischen Erkrankungen.Zei t s c hr ift f) r Kran ken gy m n a s t i k.19841'36: 100-1 12.

7 Becker BE. BiophysiologicAspects of Hydrotherapy, in BeckerBE, Cole AJ (Eds.). ComprehensiveAq uati c Th erapy. Bo ston,Butterworth-Heinemarxr, I 997.

8 Harrison RA, Hilmann M,Bulstrode S. Loading of the lowerlimb when walking partiallyimmersed: implications for clinicalpracÍice. Pltysiotherapy, 1992; 7 8:164-166.

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