In the framework of evidence based clinical practice (EBCP), external evidence (the articles) should support the decision to choose for aquatic therapy instead of therapy on land. ECBP has two other domains that are equally important: patient preference and therapist competence. Clinical competence of an aquatic therapist is achieved by up-to-date – post-graduate – education. This is what the Association International Aquatic Therapy Faculty (IATF) offers, teaching various concepts with elements that are in part related to competence profiles of aquatic physical therapists.. Therapeutic goals are derived from the International Classification of Functioning, Disability and Health (ICF) by the WHO, 2001: symptom instead of disease related.
- Water Specific Therapy
- Bad Ragaz Ring Method
- Clinical Ai Chi
- Aquatic motor-cognitive therapy
- Passive manual handling
Water Specific Therapy
Water Specific Therapy (WST) – previously known as Halliwick-therapy - is THE aquatic therapy concept worldwide, included in more than 60 published research articles, see at halliwick.net/en/literature/articles . WST covers virtually all neuromusculoskeletal ICF-goals including one of the most important topics in rehabilitation: from muscle strengthening, increasing range of motion, decreasing pain to postural control, core stability, agility and fall prevention. WST can be used to evoke subtle muscle contractions that are unable to generate on land. WST is applied from pediatrics to geriatrics and has been taught in over 55 countries.
It is an aquatic therapy with elements of the Halliwick 10 point-programme swimming method that are used as pretraining for exercises that use the fluidmechanical properties of water: flow conditions (turbulence), waves of transmission and metacentric effects (using the change of gravity and buoyancy induced torques). A clinical question in WST could be: “can metacentric effects be used to train central stability in an ataxic patient”?
WST was developed by a team of physiotherapists in Switzerland in the early seventies, supporting James McMillan in his efforts to develop Halliwick towards a “Halliwick-Therapy”. The development still continues, following contemporary issues in health care. Examples are executive functions, muscle power training or modifying neuroinflammation.
WST = motor learning in water to be used on land whereas Halliwick = motor learning in water to be used in water
Halliwick originally is a swimming concept, developed by the late engineer in fluidmechanics James McMillan MBE. In 1949, he and his wife started to include disabled girls from the Halliwick-school in London in sessions of the swimming club in which he acted as a volunteer swimming teacher. It was obvious that the biggest problems the girls encountered was a lack of postural control. He knew how to use fluidmechanics in order to ease the problem and progressively train the girls. The approach soon became more structured and developed into the famous Ten-Point-Programme. Main focus is teaching rotational control: the practical approach to postural problems in 3 dimensions around the 3 axes (sagittal, transversal and longitudinal) and a combination (diagonal). A clinical question could be: “how can we adapt the transversal rotation control for a child with a hemiplegia”?
The classroom teacher observed changes within a few weeks: better trunk-, head- and mouth control as well as an increased self-esteem. The swimming method seemed to have therapeutic potential, especially because all rotation controls are related to trunk (core) activity, also a key focus for postural control on land.
Halliwick is practiced all over the world at the moment. Especially children with neuromotor deficits can benefit enormously, given the many publications in the area. The Ten-Points are a basis for other activities like adapted swimming, a specific swimming competition, game circuits or scuba diving. Halliwick games are a perfect basis for aquatic gamification (play + exercise at the same time).
Bad Ragaz Ring Method (BRRM)
Around 1955, physiotherapists in the German city Wildbad started resistance exercise in the pool with patients in a supine position. Supported by a neck collar and car tubes around the pelvis and the ankles (when necessary). This method was quickly used in Bad Ragaz, where three-dimensional patterns of proprioceptive neuromuscular facilitation (PNF) were included in the early sixties. This was the start of a long history of adaptations to the state of art in aquatic PNF. The key element is the activation of muscles in (myofascial) chains as a preparation for functional activities in water and on land. Recently, principles of muscular fine tuning, PNF techniques (like combination of antagonists) and training physiology have been included. Also concepts like functional kinetics and core stabilization are a part of contemporary BRRM, and applied to working with neurologic, orthopedic and rheumatic populations. See www.badragazringmethod.org
Examples of contemporary topics that are included in the course are:
- Reversals of antagonists: Reversals increase strength much more than contractions in one direction
- Combination of isotonics: the eccentric component is very important to balance inflammation reactions in e.g. the muscle envelope
- proprioceptive discrimination training in an environment in which pain is "under the radar", in order to influence neuro-inflammation; e.g. in low back pain
- three-dimensional movements are essential to a proper mechanotransduction, using fascia properties
- tensegrity of intramuscular fascia can be trained by smooth variable contractions and add to fascia resilience
A clinical question in BRRM could be: “which bilateral reciprocal leg pattern and technique could be used for a patient who had a surgery for a herniated disc L4/L5 about 3 months ago and still experiences motor weakness at L5. How does the technique look like in order to specifically strengthen the segment-indicating muscle in the foot?”
Clinical Ai Chi
Original Ai Chi has been developed by Jun Konno, the late owner of an aquatic fitness institute in Yokohama, Japan. Around 2000 Ai Chi quickly became popular because of it’s simplicity and effects. Ai Chi is mindful and active, including 20 continuous slow and broad movements (kata’s), accomplished without force. Ai Chi focuses on breathing, upper limb movement, trunk (mobile) stability, lower limb movement, balance and coordinated total body movements. The basis of support is gradually narrowing and challenge the centre of gravity progressively. Different protocols exist, consisting of a choice of the 20 kata’s and/or a different amount of repetitions, see e.g. at www.clinicalaichi.org
Clinical Ai Chi is adapted to the possibilities of a person with a musculoskeletal and/or neurological problem. The elements of Clinical Ai Chi should fit in a custom-made treatment programme and be the result of a clinical reasoning process. Ai Chi is a postural activity in which transfers of the centre of gravity, reaching with arms, supporting activity of legs and continuous concentric –eccentric contractions are characteristic. Most of these characteristics are related to static – and dynamic balance control and might influence motor control to prevent falling
Clinical questions could be: “can Ai Chi be adapted to facilitate hip-strategies in patients with chronic low back pain”, or “can Ai Chi be adapted to Parkinson patients in order to train medio-lateral stability”.
Aquatic motor-cognitive therapy
This is a very recent development, based on the emerging notion that movement is important for brain functioning: brain vasculature health and brain plasticity. Both moderate aerobic exercise and high intensity interval training (HIIT) increase blood flow, also in the brain. At comparable physiological intensities, brain blood flow is higher in water than on land. Higher flow velocities increase immune-metabolic activity of endothelial cells: supporting plasticity processes, e.g. related to executive functions. Executive functions are cognitive control processes, governing goal-directed motor control, especially during complex, novel or ambiguous situations. These situations can often be translated as playing/exergaming with therapeutic intentions, which also happens in enriched environments. In one sentence: the added immuno-metabolic effects of (intensive) exercise in water opens a door to include cognitive elements – especially executive functions - during motor control in complex situations. These situations often have an equilibrium component and might be difficult to achieve on land when working with patients with increased fall risk. A clinical question could be: “are you able to walk in 4 different ways, always 3 steps, and try to mix these 4 ways in as many ways as you can”? Memory and problem solving are the cognitive functions that are involved in this assignment of gait variability.
It has become clear that important effects on neuroinflammation can be achieved, which might be of utmost importance in various life-style diseases.
Passive manual handling with Aqua-T-Relax (ATR)
It is easy to handle another person in - warm – water. This has led to a huge amount of passive handling concepts like our ATR. Clients are handled with choreographic elements, which can lead to deep relaxation and happiness.
Passive manual handling can be used to make persons mindwander or daydream: activating one of the important large scale brain networks: the default mode network. Another option is to ask persons to concentrate on the movements and feel them: proprioceptive perception is used which is import in decreasing nociceptive stimuli. The clinical question then could be: “close your eyes and feel which movements your low back is making and try to interpret these as harmless”.
Manual skills can be used also without a choreography: the patients just float with flotation aids and the therapist applies manipulations from manual therapy techniques like e.g.
Kaltenborn, Mulligan, osteopathy, chiropraxy. Scientific evidence of such passive manual handling is still needs development though.
Evidence is overwhelming: cardiovascular (endurance) training in water can have the same short-term and long-term physiological adaptations as cardiovascular training on land. The aquafitness industry created a massive amount of workout variations. The principles are simple though: at least 20% of skeletal muscles have to be used for some time and in some intensity in order to create an oxygen debt: the stimulus for an increase in cardiac work.
Maintaining a certain level of functional endurance doesn’t need much work, according to various norm values, e.g. those of the American College of Sports Medicine. Increasing cardiovascular fitness with classical endurance training needs at least some 20 minutes at minimum 50% of the maximal oxygen uptake (VO2max). A time-efficient way is High Intensity Interval Training (HIIT). The original program exists of 8 bouts of 20 seconds 90% VO2max with 10 seconds of rest in between the bouts: this takes 4 minutes. Cardiovascular training becomes increasingly more important in the treatment of a wide variety of diseases: not only for those that have a sedentary life-style (pain, muscle weakness, spasticity etc), but also for those that have a disease which is linked with neuroinflammation, like Alzheimer or multiple sclerosis. A pool offers the possibility to train for those that are restricted on land.
A clinical question could be: “can you find a level of exertion in which you are a little out of breath during the next jumping exercises?”.
The Association 'International Aquatic Therapy Faculty' (IATF)
The Association 'International Aquatic Therapy Faculty' (IATF),registered in Vilters, Switzerland. IATF consists of:
- The Water Specific Therapy Network, see the WSTN website
- The Bad Ragaz Ring Method® Network, see the BRRM website
- The Clinical Ai Chi Network, see the CAC website
- The Aqua-T-Relax Network
The board of IATF consists of:
- Urs Gamper, chair person
- Johan Lambeck vice-chair person
- Kurth Birri and Rosane Barroso Caetano, members
IATF is cooperating with various partners like the:
- Dutch Institute of Allied Health Care (NPI).
- Australian Physiotherapy Association Aquatic Group.
- Aquatic Therapy Association of Chartered Physiotherapists (UK).
- Spanish aquatic therapy network (Retaqua).
- ATNI: Aquatic Therapy Network of India
- Asociacion Mexicana Terapia Acuatica
WSTN uses both the Halliwick Ten-Point-Programme and Water Specific Therapy as an integrated system: Elements of Halliwick are used as a safety basis for WST, and relates this system to health problems as formulated in the International Classification of Functioning, Disability and Health (ICF, World Health Organisation 2001). See also the "course contents".
A group of mainly physiotherapists,form the faculty of the IATF. These professionals cooperate to develop a state-of-art aquatic therapy.. The group is growing and continues to develop aquatic therapy.
Members and (Senior) Lecturers
- Johan Lambeck, Senior Lecturer, Bernex, Switzerland
- Urs Gamper, Senior Lecturer, Vilters, Switzerland
- Marcel Hulselmans, Senior Lecturer WST, Bad Wildungen, Germany
- Anne Bommer, Senior Lecturer CAC/ Aqua-T-Relax, Lecturer Halliwick, Bernex, Switzerland
- Rosane Barroso. Lecturer WST,São Paulo, Brasil
- Javier Gueita, Lecturer WST, Madrid, Spain
- Conceição Graça, Member, Ovar, Portugal
- Marco Barile, Assistant Lecturer WST, Ischia, Italy
- Eliana Lopéz, Assistant Lecturer WST, Mendoza, Argentina
- Jihye Lee, Member, South-Korea (presently in living Perth)
- Gaby Wiklund, Lecturer Halliwick Ten Points, Aarau, Switzerland
- Ben Waller, Senior Lecturer BRRM, Jyväskylä, Finland
- Efthymia Vagena, Assistant Lecturer WST, Athens, Greece
- Eugenia Hernández Ruiz, Assistant Lecturer WST, Washington DC, USA
- Prashanth C.G., Assistant Lecturer WST, Doha, Qatar
- Mariana Kotzamanidou, Assistant Lecturer BRRM, Thessaloniki, Greece
- Dipti Patil, Assistant Lecturer WST, Mumbai, India
- Pei-Hsin (Patty) Ku, Assistant Lecturer Clinical Ai Chi, Taipei, Taiwan
- Félix Castellanos, Associate Member, Valencia, Spain
- Paula Geigle, Honorary Member, Asheville, USA
- Vassilios Panoutsakopoulos, Associate Member Research, Thessaloniki, Greece
- Brinda Merchant, Assistant Lecturer WST, Mumbai, India
- Sanne Lambeck, Prospective Member, Mook, Netherlands
- Mohamed Zidane, Prospective Member, Caïro, Egypt
- Oguz Gücin, Prospective Member, Izmit/Kocaeli, Türkiye
- Suraj Shukla, Prospective Member, Kudal, India