Topics in Geriatric Rehabilitation Vol. 26, No. 2, pp. 104–119 Copyright c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins to Improve Balance Dysfunction in Older Adults David M. Morris, PT, PhD

Balance dysfunction and falls-related injuries represent serious public health issues, resulting in great expense and human suffering. The physical problems leading to balance dysfunction in- clude musculoskeletal-related structural limitations, diminished sensory capabilities, motor co- ordination deficits, and loss of anticipatory control mechanisms. The water has been described as an effective environment for addressing balance dysfunction through both rehabilitation and fitness activities. This article describes the underlying physical problems leading to balance dys- function, provides a rationale for using aquatic therapy to positively influence balance control, and presents evidence to support the use of aquatic therapy for the management of balance dysfunction. Key words: aquatic exercise, balance, falls, older adults

ALANCE, or postural control, can be de- tem changes that accompany the normal ag- Bscribed as the ability to control one’s ing process (eg, vision loss, joint changes) can body position in space for the dual purposes be detrimental to balance skills. These prob- of stability and orientation.1 A person’s bal- lems can be compounded by medical condi- ance is not regulated by a single system but tions that are more prevalent with older adults emerges from the interaction of many body (eg, stroke, Parkinson disease, and vestibular systems. These systems include musculoskele- dysfunction). tal factors (eg, joint range of motion [ROM], Several authors have described typical muscle tone, muscle strength), sensory fac- changes in the musculoskeletal systems of tors (eg, ability to accurately perceive and re- older adults.2–6 One such musculoskeletal spond to visual, vestibular, and somatosensory change is abnormal alignment of the body input), and neuromuscular strategies (eg, us- over its base of support (BOS). Disturbed ing appropriate postural strategies in a timely body alignment can be brought about by such and effective manner) and anticipatory con- problems as range-of-motion limitations (eg, trol (eg, pretuning sensory and motor systems hip flexion contractures) or uneven weight in expectation of postural demands based on distribution in sitting, standing, or walking previous experience and learning). Figure 1 (eg, when after a stroke, a person shifts his provides a conceptual model of how these or her weight away from his or her more af- systems must work in unison for the control fected leg when walking). Changes in muscle of balance and posture. Balance dysfunction structure and function can also result in ab- arises when changes to 1 or more of these normal musculoskeletal system function. For systems limit an individual’s ability to control example, spastic muscles have a low thresh- his or her body position in space. The sys- old to stretch and respond in an exaggerated fashion to perturbations. Also, weak muscles may respond to a perturbation too slowly or Author Affiliation: Department of , with inadequate force to prevent a fall. University of Alabama at Birmingham, A variety of sensory system problems can Birmingham. lead to balance dysfunction in older adults.7,8 Corresponding Author: David M. Morris, PT, PhD, De- In normal situations, an individual relies on partment of Physical Therapy, University of Alabama at Birmingham, 1530 3rd Ave S, Birmingham AL 35294 an interaction between visual, somatosensory, ([email protected]). and vestibular input to coordinate balance

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Balance dysfunction in older adults has also been linked to the loss of anticipatory con- trol, or an inability to activate postural ad- justments in advance of potentially destabi- lizing voluntary movements.9,10 For example, when lifting an object in front of the body, one must stabilize the body with key extensor musculature in advance of lifting or he or she will fall backward. Persons with neuromuscu- lar problems like stroke and Parkinson disease are particularly prone to experiencing these deficits. Since balance emerges from multiple sys- tems, the underlying cause for one person’s Figure 1. Conceptual model for major systems balance dysfunction can be dramatically dif- contributing to balance control. ferent from the cause for another person. Therefore, each person must be examined for the specific cause of his or her balance prob- responses. At times, the loss of one of these lems and interventions should be tailored to sensations can be compensated for with heav- address his or her specific needs. ier reliance on one or both of the remain- Balance dysfunction results in a variety of ing sensory systems. However, if the remain- mobility disorders; the most significant of ing sensory systems are already compromised, which is falls. More than one-third of adults the ability to compensate may be inadequate older than 65 years fall each year in the United to prevent a fall. At other times, a person States.11,12 Among older adults, falls are the may be unable to integrate conflicting sensory leading cause of injury and deaths and the information to produce an effective postural most common cause of nonfatal injuries and response. hospital injuries for trauma.13 In 2000, direct Motor control research has identified medical costs for fatal falls totaled $179 mil- stereotypical postural reactions to specific lion and $19 billion for nonfatal injuries.14 types of external challenges.1 For example, Even fallers who are not injured are likely to when external forces move the body to sway develop a fear of falling and may limit their ac- forward, it often recovers using an ankle strat- tivities resulting in reduced mobility and phys- egy that is characterized by activation of the ical fitness, increasing their risks for future gastrocnemius muscles, then the hamstring falls.15 Consequently, balance dysfunction and muscles, and then the paraspinal muscles. In falls are significant societal challenges result- order for this postural synergy to prevent a fall ing in great expense and human suffering. forward, the appropriate muscles must acti- Older adults can take several steps to re- vate at the right time, in the correct sequence, duce and/or prevent balance dysfunction and and with the appropriate force. Older adults falls including reducing environmental haz- often encounter difficulties in recruiting the ards, adjusting medications (with appropriate appropriate postural responses to a task or en- medical supervision) to reduce negative side vironmental demand.8 Neuromuscular strat- effects, and exercise. Aquatic therapy (AT) has egy problems that lead to balance dysfunction been suggested as safe and effective approach include recruiting muscles out of sequence, to improving balance and postural control a delayed response in recruiting a muscle or using a variety of hydrodynamic principles. group of muscles, cocontraction of antagonist The purpose of this article is to describe (1) muscles, and problems scaling the amplitude the rationale for using AT for improving bal- of a muscle response. ance, (2) AT techniques that hold promise for

VOL. 26, NO. 2/APRIL–JUNE 2010 105 MORRIS improving balance, and (3) evidence support- ditional resources and the summary provided ing the use of AT for managing balance dys- in Table 1. function. This discussion will address balance dysfunction caused by a variety of pathologi- Musculoskeletal systems cal conditions (eg, stroke, Parkinson disease, osteoporosis), as well as resulting from the Buoyancy provides support to a client’s normal aging process. The article will address body and allows for easy handling and posi- AT interventions applied in the healthcare set- tioning by the therapist so that a variety of ting (eg, skilled rehabilitation) and in the com- passive stretching activities can be used to im- munity (eg, fitness programs). prove flexibility and joint ROM. This buoyant support also provides assistance to the client’s active movements to promote active stretch- RATIONALE FOR USING AQUATIC ing for the same purposes. Muscle strength- THERAPY TO IMPROVE BALANCE ening can be effectively achieved using a variety of water properties and therapeutic The physical properties of water, includ- strategies. The graded assistance to active ing buoyancy, turbulence, viscosity, hydro- movement provided by buoyancy can be ap- static pressure, and thermal influence, can be plied to strength training for individuals who applied to the interventions directed at im- are unable to perform such activities on land. proving balance dysfunction.15–18 In this sec- Once stronger, the properties of turbulence tion, each major system underlying balance and viscosity can be used to promote more control will be addressed in relation to how vigorous isotonic strengthening to body parts these physical properties of water can poten- moving through the water. Combined with tially be applied during AT activities. An in- the therapist’s ability to support and position depth discussion of this topic is beyond the the client, this more vigorous resistance can scope of this article. The scope of this chap- be used for the dual purpose of facilitating ter does not include a detailed explanation of movement patterns and strengthening body these concepts. The reader should review ad- movements as is done during the Bad Ragaz

Table 1. Hydrodynamic principles and interaction with balance and postural control training

Hydrodynamic principles Balance and postural control training

Hydrostatic pressure Assist with muscular contraction Input into proprioceptors and joint mechanoreceptors Equal resistance in all planes—ideal isokinetic “machine” Diminish discomfort perception Edema reduction systemically and locally (lymphedema, joint inflammation) Buoyancy Reduction in gravity allowing greater recruitment time, motor planning, integration of body awareness Assistive or resistive force to assist with increasing range of motion, strengthening, endurance training, power activities Viscosity: challenge to balance and Greater resistance than air dependent on rate of movement, postural control surface area, length of lever arm Turbulence: challenge to balance and Turbulent flow—competing currents postural control Laminar flow—same-direction currents Temperature: facilitates or inhibits Cooler: stimulation to increase muscle readiness to work, muscle tone decrease inflammation Warmer: relaxation, tone reduction

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Ring Method (BRRM) (see the following text). Neuromuscular strategies Using the same properties described earlier, Muscle recruitment is enabled in the AT techniques can also be used to provide ef- aquatic environment because the buoyant fective core strengthening that could poten- support of the water slows the movement and tially influence the client’s ability to withstand allows increased time for recruitment of an ap- perturbations from external forces. Viscosity propriate postural response. If an appropriate can slow movements and allow a patient to response is not produced, the buoyant sup- adjust to perturbations before the client falls. port will assist to prevent a fall and potential This allows clients to perform activities that injury. In addition, muscle timing is facilitated they would be fearful to try on land and could with the additional sensory cues provided by be applied to more aggressive movements like the water’s viscosity. This increased ability to those used in power strength training (eg, ver- address timing of agonist and antagonist mus- tical jumping, stepping onto a step). cle firing makes the aquatic environment a Sensory systems positive venue in which to train people with neuromuscular difficulties. A variety of sensory afferent systems can Buoyancy provides a natural unloading be activated using the physical properties of to use body-weight-supported gait training. water. Buoyant support allows clients to as- Currently, an increasing use of body-weight- sume upright postures for activation of joint supported treadmill training is employed to fa- receptors in the spine and lower extremities cilitate innate neuromuscular stepping strate- during functional training. Viscosity and tur- gies or central pattern generators.22–25 The bulent drag can provide resistance to move- aquatic environment provides this unloading ments, which in turn stimulate muscle re- to facilitate stepping patterns without harness ceptors. Hydrostatic pressure and turbulence intrusion and allows movement in all planes can also stimulate cutaneous receptors. This with unloaded support. Practitioners vary the can be enhanced by using jets of water or amount of unloading by altering the water eddy currents. Finally, vestibular system in- depth for the needs of each client. put can be influenced by passive movements Turbulence can be used by the therapist to applied by the therapist (eg, ) or dur- support patient’s balance by assisting move- ing the clients’ functional activities (eg, water ments and/or by reducing the need for bal- walking). ance strategies. This is achieved by using a Another potential sensory-affecting tool, laminar flow or water currents moving in the temperature, depends on the client’s physi- same direction of the desired motion. Turbu- 19–21 ologic state. If our client with reduced lence can also be used to challenge patients’ awareness of the body in space also displays balance, resist movement, and/or increase the decreased tone in trunk and extremity mus- need for postural strategies. This is achieved culature, a cooler pool temperature could by using turbulent flow or water currents be used to increase tone. But if the client flowing in an opposing direction to the de- presents with increased tone that interferes sired motion. with function, an initial watsu series in a warmer pool would be an effective use of temperature to assist in increasing functional Anticipatory mechanisms abilities and decreasing tone. Nociception, au- One rehabilitation training category that is tonomic response, and readiness to contract highly linked to the preceding neuromuscular muscle tissue can all be directly affected by strategies area is the support that the aquatic water temperature. Cooler water stimulates environment offers to clients who are address- muscle readiness to work and decreases in- ing anticipatory mechanisms. Particularly for flammation, whereas warmer water facilitates initial training in speed-amplitude relations relaxation and tone reduction. for people with balance issues, the aquatic

VOL. 26, NO. 2/APRIL–JUNE 2010 107 MORRIS environment allows practice without the fear lease blocked energy from soft tissue and joint of falling. For example, in the water more time articulations. In addition, these slow, rhythmi- is available to practice BOS outside the center cal rotational movements reduce hypertonic- of gravity. Clients with anticipatory problems ity through tone-inhibiting vestibular stim- may not be able to adjust quickly to changes ulation. The stretches comprise specifically in environmental conditions like a spill on the described transitions and sequences of move- floor or to reach outside the BOS to push an ment including the basic moves, head cradle elevator button. sequence, near leg over sequence, far leg over Challenging the patient to control balance sequence, and the saddle sequence.26,27 and postural control by providing initial per- The application of watsu to tight body turbations in an aquatic environment permits segments can improve flexibility. Also, when problem solving without a fall as a conse- applied using slow, rhythmic rotational move- quence. Of course, the caveat is that the ments, stimulation to the vestibular sys- client’s position in the water must be grad- tem sends inhibitory input down the lateral ually adjusted through increasingly shallow vestibulospinal tract of the spinal cord, result- water and onto land while the client performs ing in full body relaxation and muscle tone successful anticipatory motor planning. Alter- reduction. This technique is particularly help- natively, an accommodation can be made by ful when applied at the beginning of a treat- widening the BOS with an assistive device. ment session, preparing the patient to move Step length and change of direction can also in a less restricted fashion during more active be practiced without fear of falling (because portions of the treatment session. of buoyancy) in an aquatic environment. Examples of specific watsu maneuvers include near leg rotation (promoting in- AQUATIC THERAPY INTERVENTION ternal and external hip rotation), the leg APPROACHES push (promoting hip extension), and the accordion (promoting hip and trunk flexion). A number of AT techniques have been de- These activities are particularly helpful for scribed in the literature as positively influenc- addressing certain musculoskeletal-related ing factors that contribute to balance control. structural limitations (eg, range-of-motion In the following section, selected AT tech- limitations, hypertonic muscles) that lead to niques will be described and their potential balance dysfunction. Theoretically, however, for managing balance dysfunction will be dis- watsu could also have a positive influence on cussed. sensory integration disorders resulting from vestibular dysfunction by providing vestibular stimulation. Watsu Water shiatsu (watsu) was developed by Harold Dull at Harbin Hot Springs, California.26,27 Dull describes the technique Ai chi was developed by combining tech- as Zen shiatsu principles applied to people niques from Eastern-based treatment ap- floating in the water. Watsu was created as proaches of tai chi, shiatsu, watsu, and Qi a wellness technique; it was not originally in- Gong and performing them in the water.28 tended for patients with neuromuscular dis- Flexibility and core (abdominal) strengthen- orders. Rehabilitation practitioners apply the ing are the most mentioned therapeutic ben- approach to patients with a variety of physi- efits of ai chi. The approach is also said cal disorders, and reports indicate clinical suc- to promote relaxation from diaphragmatic cess. On the basis of Eastern medicine theory, (slow and deep) breathing that stimulates watsu stretches the body’s meridians (path- the parasympathetic nervous system, the por- ways of energy). Rotational movements re- tion of the nervous systems responsible for

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arms, legs, and trunk and may use unilateral or bilateral patterns. Of the bilateral patterns, some are symmetric (both sides of the body moving in the same direction) and some are asymmetric (each side moving in a different direction). In both BRRM and PNF, the therapist gives the patient specific movement instructions (eg, “bring your right knee to your left shoul- der”)and encourages a movement progression of distal to proximal segments of the body. In BRRM, the patient is floating either prone or supine in the water with flotation support at the neck, hips, and, for some unilateral tasks, the extremities. The therapist places his or her hands on designated spots on specific seg- ments of the patient’s body while instructing the patient to move in the desired direction. The therapist thus serves as a point of stabil- ity from which the patient moves, generating resistance from the turbulent drag effects of Figure 2. Typical sequence of ai chi postures. the surrounding water. Generally, resistance to movement is encountered in every direc- tion of movement (ie, flexion and extension) calming effects (eg, reduced heart rate). Other because the body is completely surrounded therapeutic benefits include improved flex- by water. ibility, ROM, balance coordination, general Unlike PNF, in which the therapist manu- mobility, and mental alertness. Ai chi is ally applies graded resistance to the patient’s performed in shoulder-depth water and incor- movements, the BRRM allows the patient to porates deep breathing and slow, broad move- determine the amount of resistance encoun- ments of the arms, legs, and torso. The ap- tered on the basis of speed of movement and proach follows a typical sequence of postures the resulting turbulent drag of the water. Us- (see Fig 2 and progresses from simple breath- ing this method, therapists increase the diffi- ing to incorporating movements of the upper culty of the activity by placing their stabilizing extremities, then trunk, then lower extremi- hold more distally. Such strategies do not nec- ties, and finally total body movements. essarily increase the resistance to movement but do increase the complexity of the activity because the patient must control larger seg- Bad Ragaz Ring Method ments of his or her body during the move- The BRRM was developed in the 1930s ment. Only in a small portion of the patterns in Bad Ragaz, Switzerland.29,30 The technique described, does the therapist use manual re- developed through the years and was dramati- sistance to the patient’s movement. At times, cally influenced by proprioceptive neuromus- the therapist may use an overflow principle cular facilitation (PNF), a therapeutic exercise with the BRRM by stabilizing and resisting one technique. Bad Ragaz Ring Method is similar portion of the body to encourage activity in to PNF in that the therapist guides the patient another. through specific patterns of movement to in- The BRRM was designed for a variety of crease strength and ROM. Both techniques movement problems, mainly muscle strength include passive or active movements for the and active ROM. However, the technique

VOL. 26, NO. 2/APRIL–JUNE 2010 109 MORRIS can be effectively applied to the treatment creates turbulence around the patient’s body of motor coordination impairments that in- to challenge skill and subsequently reinforce clude movement sequencing and scaling that learning. are critical for the use of effective balance Using the method for swimming strategies. Like PNF, facilitation techniques instruction is ultimately therapeutic for all are used to enhance movements (eg, quick people because of the conditioning effects stretch, timing for emphasis) by increasing inherent in this form of exercise. It is par- the efficiency of the central nervous system ticularly helpful for individuals with impair- with sensory input. ment and disability secondary to neuromuscu- lar disorders. The approach can also be used Halliwick concept to influence movement problems directly, for Developed by James McMillan in the 1930s example, patients believed to be dominated at the Halliwick School for Girls in England, by extensor movement patterns may benefit the Halliwick method is based on principles of from gaining skill in vertical rotation control hydrodynamics and human development.31–35 in an anterior direction. Such a movement The original approach (Ten-Point Program) helps the patient to actively control flexor functioned as a swimming instruction tech- musculature and inhibit extensor muscula- nique, yet many of the Ten-Point Program ac- ture. Skill gained through balance-in-stillness tivities and an elaboration of it (The Logical activities may carry over and influence postu- Approach to Exercise in Water) can be applied ral stability during functional activities. to specific therapeutic intervention. In gen- eral swimming instruction, each patient is as- signed an individual instructor. This patient- Task-type training approach instructor pair becomes one of a group of A task-type training approach (TTTA) for pairs, usually consisting of 4 to 6 pairs per aquatic rehabilitation is documented for pa- group. Games are often used to teach skills tients who incur a stroke.36–39 For this arti- and reinforce the principles of the method. cle, the guidelines and principles of the TTTA In specific therapeutic intervention, however, extend to the treatment of all patients with activities are often conducted with each pa- balance dysfunction. The TTTA can best be tient individually. described as a task-oriented approach: Em- The Halliwick method, best described as phasis is placed on influencing the patient’s a neurotherapeutic facilitation rehabilitation disability by working in functional positions technique, follows a disengagement princi- with functional activities. In addition, patients ple. Therapists or instructors use activities to are encouraged to become active problem facilitate patterns of movement with careful solvers of their movement difficulties as op- consideration of the activity’s level of diffi- posed to passive recipients of manual and culty and the amount of manual guidance pro- verbal input from practitioners. Notably, the vided. Specifically, the therapist starts with TTTA is not a treatment technique but a set easy activities and guides the patient manu- of principles to guide therapists in design- ally to ensure correct execution of the move- ing treatment programs for their patients. The ment. As the patient becomes more skilled general principles are as follows: with the movement, the therapist reduces 1. Work in most shallow water toler- the amount of assistance provided (disengag- ated. The buoyant support of the wa- ing) and increases the activity’s level of dif- ter allows patients to stand indepen- ficulty. Activities are made more difficult by dently and move in a functional man- modifications in the patients’ position and the ner for the first time. Patients can therapists’ handling techniques. Finally, when actively and aggressively work to im- the patient masters the activity, the therapist prove their skill with functional tasks.

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The ultimate goal is for the func- postural stability in upright positions tional improvement to carry over to are identified. Patients with neuromus- gravity-influenced land activities; there- cular disorders typically demonstrate fore, the effect of buoyant support difficulty using these strategies to main- should be systematically removed as pa- tain their balance, so they are encour- tients demonstrate skill with functional aged to relearn these maneuvers in a activities. Performance indicators, such safe but challenging environment, the as the inability to maintain an erect water. As patients move their extremi- trunk while standing or the inability ties in or above the water, their center to maintain knee extension in support- of balance is challenged. Prevention of ing lower extremities, may show that falling requires use of effective postural deeper water is better for functional ac- stability strategies. The patient is forced tivity practice. to solve problems actively to redevelop 2. Practice functional activities as a these strategies, with attention given to whole. Although some treatment pro- contracting the appropriate muscles, in grams address strengthening or stretch- the proper sequence, and with the ap- ing of specific body segments or fa- propriate force of contraction. cilitating specific movement patterns, 5. Encourage quick, reciprocal move- the TTTA encourages practice of ac- ment. Many functional activities re- tivities that are identical to or closely quire rhythmic, reciprocal movements approximate the land functional activ- along with quick movement changes ities to be improved. This principle is to maximize the use of inertial forces. based on a specificity-of-training princi- Movement in this manner ensures ple that a functional skill requires prac- smooth and efficient execution of func- tice to be learned.40 When performed tional activities. Weakness, ROM limita- as a whole, the entire functional skill tions, and other voluntary movement must be mastered, including control of deficits prevent patients with balance moving body segments and appropri- dysfunction from moving effectively in ately graded contraction of stabilizing a gravity environment; the support- body segments. ive and assistive properties of water 3. Systematically remove external stabi- dramatically increase the likelihood of lization from patients. Holding onto their doing so. Therefore, whenever the pool wall or the therapist’s man- possible, quick, reciprocal movements ual assistance may be necessary in the should be practiced (eg, marching in earlier stages of a TTTA. This exter- place, pedaling the legs while supine). nally applied stabilization should be Such practice may produce a condition- quickly removed as patients gain inde- ing effect that will positively influence pendent control over the functional ac- the impairments that constrain patients tivity. Thus, the therapist minimizes the with neuromuscular disorders to slow, patient’s dependence on outside sup- labored movements. port for functional skills. 6. Encourage active movement problem 4. Encourage stabilizing contractions in solving. Motor learning research sug- upright positions with movement of gests that healthy humans learn move- selected body segments. Vertical or ment skills better when they actively upright positions (ie, sitting, stand- participate in the learning process.41 ing) are positions of function and For example, when subjects are given should be used as much as possible. less feedback on their performance Stereotypical strategies for maintaining and are required to practice many and

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varied activities, they must become task characteristics that make a task more reliant on their own ability to more or less difficult.42 For example, critique and modify their performance, introducing intertrial variability to a leading to more active participation. task, or changing task requirements Studies of patients with neuromuscu- from trial to trial, increases the skill lar disorders have come to similar required to execute the task. A ther- conclusions. For this reason, patients apist could use this strategy when should be encouraged to critique their performing balance training with a performance and propose movement patient. While passing a ball with a solutions to their problems. Open- patient attempting to remain standing, ended questions, such as “How did the therapist could throw the ball to you do that time?” and “How can you the same spot, with the same speed improve your next attempt?” should and at the same time (no intertrial vari- be used whenever possible. When ability). Conversely, the task could be working with patients with neuromus- made more challenging by varying the cular disorders in the pool, several speed, timing, and location (with inter- factors may make the use of such prin- trial variability). ciples difficult. Many patients with neu- Another variable that could be altered romuscular disorders have difficulty within the taxonomy is the use of body sta- critiquing their performance because bility activities (eg, the patient is not required of physical (ie, sensory) and cognitive to move from one location) or body trans- (ie, perceptual) impairments. In this port activities (eg, the patient is required to case, the therapist must provide mini- move from one location to another during mal guiding feedback regarding the pa- the task execution). Using such a progres- tient’s performance. sion with balance training, the patient would 7. Gradually increase the difficulty of pass the ball from one location. Later, the pa- the task. Task characteristics can be tient would pass the ball while walking for- modified to increase or decrease the ward. Table 2 includes examples of specific challenge of a functional activity. Gen- AT activities that are in line with the TTTA tile provides a taxonomy to describe principles.

Table 2. Task-type training approach activities commonly used to improve gait dysfunction

Standing weight shift. Client stands and shifts weight from one leg to the other. Slight knee flexion should occur in the unweighted lower limb. One leg up. Client stands facing the pool wall and lifts 1 leg repeatedly. Emphasis is placed on active hip flexion and passive knee flexion. Marching. Client lifts and lowers one leg, followed immediately by the same on the other leg. Speed and coordination are emphasized. Kick back. Client stands facing the pool wall and kicks 1 leg in a posterior direction repeatedly. Emphasis is placed on hip extension with knee extension. Side kick. Client stands facing the pool wall and kicks 1 leg to the side repeatedly. Emphasis is placed on hip abduction and knee extension. Straight leg kick. Client stands with side to the pool wall and swings 1 leg forward and back repeatedly. Emphasis is placed on hip flexion and extension, with knee extension on the swinging lower limb and hip and knee extension on the stance limb. Walking with front support. Therapist stands in front of the client and provides bilateral support to the client’s upper limbs. Walking with side support. Therapist stands at the client’s side and provides unilateral support to one of the client’s upper limbs.

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EVIDENCE FOR USE OF AQUATIC 12 participants were assigned to participate THERAPY FOR IMPROVING BALANCE in an aquatic exercise program lasting 60 min- utes, 3 times each week for 12 weeks. Eight A growing number of publications have de- individuals were assigned to a no treatment scribed AT interventions to manage balance control group. The water exercisers’ proto- dysfunction. In this section, these reports will col consisted of a variety of trunk and lower be considered in chronological order. extremity strengthening activities and aerobic Taylor and colleagues43 used a single-case conditioning. All participants were tested 3 ABAB study design to examine the effects of times each week regarding resting heart rate, an AT program on gait parameters for 2 indi- maximum heart rate, maximum oxygen con- ˙ viduals in the chronic phase of recovery from sumption (VO2max), body composition, and stroke. The B (treatment) phases of the study muscular endurance as assessed by work ca- included 25 minutes of water walking, 3 days pacity in the water. The water exercise group each week for 3 weeks in each phase. Partic- improved significantly on all measures except ipants walked continuously during each ses- body composition, whereas the control group sion and were verbally encouraged to nor- experienced no significant changes. The in- malize their gait symmetry. Short rest breaks vestigators concluded that nonswimming wa- (generally less than 2 minutes) were pro- ter exercise was effective for improving car- vided every 10 minutes and participants’ heart diorespiratory fitness and work capacity in rate was monitored to ensure that they safely older adults. Of most significance to this topic achieved the defined intensity level. The gait of balance control are the improvements parameters examined were velocity, cadence, observed for work capacity or muscular and stride length. Results were examined us- endurance. ing visual analysis of celeration lines and a Morrisetal45 reported findings from an 2 standard deviation band (2SDB) method; ABAB single-case design study exploring the both commonly used methods of analysis for use of an AT program for improving gait and single-case design studies. Participant 1 exhib- balance with 3 older adults (61–75 years old) ited significant improvements for all 3 gait pa- in the chronic phase of recovery from stroke rameters using the 2SDB method, and visual (more than 6 months). All participants were analysis suggested improvement for cadence independent with gait but all typically used only. Participant 2 exhibited a significant im- a straight cane, and 2 of the 3 participants provement in cadence using visual analysis used an ankle foot orthosis. Outcome mea- and the 2SDB method and a trend toward im- sures included the functional reach (FR) test provement using visual analysis for velocity and gait parameters including velocity, ca- and stride. The authors concluded that the dence, stride length, and single limb stance AT program consisting of water walking did on left and right legs. Results were analyzed produce positive effects on selected gait pa- using visual analysis and the 2SDB method de- rameters for both participants. Of note, both scribed by Taylor et al.43 An AT program was participants were relatively young (33 and 55 conducted for 3 weeks during the first treat- years of age) and both entered the study with ment phase and for 6 weeks during the sec- fairly good gait skills. Therefore, there may ond treatment phase. The treatment sessions have been a ceiling effect–influencing out- lasted for 45 minutes, 2 times a week, and come. Also, the authors noted the limitations included 5 minutes of warm-up, 10 minutes of making generalizations from single-case de- of active stretching of key lower extremity sign studies. muscle groups, 15 minutes of movement con- Ruoti et al44 examined the influence of trol activities (eg, water walking and marching an organized nonswimming aquatic exercise with a target heart rate of 70% of the partici- class on a variety of physical parameters in pants/maximum heart rate), 5 minutes of cool older adults (age 50–75 years). In their study, down, and 10 more minutes of active lower

VOL. 26, NO. 2/APRIL–JUNE 2010 113 MORRIS extremity stretching. Results revealed an land sitters who participated in supervised so- improvement in FR as assessed by visual anal- cialization activities on land. All groups met ysis but not from the 2SDB method. Gait anal- separately twice a week for 5 weeks. The ex- ysis demonstrated positive results also, yet ercises used in the water and land exercise different participants experienced benefits groups consisted of gait, balance, and lower for different gait parameters. The authors con- body strengthening activities. Outcomes were cluded that the AT program showed promise assessed using the FR test weekly during the for improving gait and balance in older adults entire intervention. At the beginning of the recovering from stroke. However, they noted trial, each group was at risk for falling (FR that data collection difficulties and the limita- < 10 in). The water exercise group signifi- tions of generalizing single-case design results cantly increased their FR scores every week of should be considered before drawing conclu- the intervention period to a final FR score of sions from this investigation. 13.4 ± 16. The land exercisers significantly in- A 1996 report by Taunton et al,46 com- creased their FR scores during the first week pared a generalized water exercise program to only for a final FR score of 11.3 ± 1.5. The a land-based exercise program for improving water- and land-sitter groups did not increase cardiorespiratory fitness, body composition, their FR scores at all during the interven- forward trunk flexion, and strength in older tion period and remained in the “at risk for women (between 65 and 75 years of age). falling”score range. The authors hypothesized Forty-one healthy, sedentary older women that exercise in water provided more oppor- were randomly assigned to either the water tunities for challenging balance and that par- or land-based exercise groups; each exercis- ticipants were more comfortable with vigor- ing 45 minutes per session, 3 times each week ously engaging in higher-level skills, resulting for 12 weeks. Outcome measures were per- in greater improvements in balance. formed prior to the treatment period, during In 2000, Suomi and Koceja48 examined treatment, and after treatment and included the effects of an AT on postural sway for measures of peak aerobic power (oxygen con- women with lower extremity osteoarthritis ˙ 48 sumption per unit time [VO2] peak), forward or rheumatoid arthritis. Twenty-four older trunk flexion, sum of skin folds, grip strength, adult women were recruited to participate in curl-ups and push-ups. Results revealed that an AT program designed to improve strength, both groups experienced significant improve- ROM, and mobility for persons with arthri- ˙ ments in VO2 peak with no significant dif- tis. Eleven of the participants were diagnosed ference between the groups. The land-based with rheumatoid arthritis and 13 were diag- group also demonstrated significant improve- nosed with osteoarthritis. The exercise group ments in the total number of curl-ups. The met 3 times a week for 6 weeks and exercised investigators concluded that both exercise for 45 minutes each session. Ten individuals protocols were equally effective in improv- with arthritis were enrolled in a no treatment ing cardiorespiratory fitness but not specific control group. The primary outcome measure enough to lead to improvements in muscular was postural sway as assessed by the 2-legged strength, flexibility, or body composition. stance test. Aquatic therapy exercise group Simmons and Hansen47 examined the ef- members experienced significant reductions fects of water exercise on postural mobility in postural sway and control group members in the healthy older adults. Fifty-two inde- experienced no changes. On the basis of their pendently living adults were recruited from a findings, the authors concluded that the AT residential retirement community. They were program was beneficial for improving balance assigned to 1 of the following 4 groups: (1) control in persons with arthritis. water exercisers, (2) land exercisers, (3) wa- Douris and colleagues49 examined differ- ter sitters who sat in the water without exer- ences in the effectiveness of land- and water- cise but with supervised socialization, and (4) based exercises for improving balance. Eleven

114 TOPICS IN GERIATRIC REHABILITATION AQUATIC THERAPY TO IMPROVE BALANCE DYSFUNCTION older adults were enrolled as participants. tion, and mental health domains of the SF-36. Five participants were recruited from an as- There were no significant differences in pre- sisted living facility and performed lower to posttreatment changes scores on the Falls body exercises on land. Six participants Efficacy Scale for either group. The investiga- were recruited from an outpatient physical tors concluded that the intervention was ef- therapy clinic and performed lower body ex- fective for improving balance and quality of ercises in the water. Both groups participated life in older adults but not reducing fear of in 2 exercise sessions each week for 6 weeks. falling. The Berg Balance Scale (BBS) was adminis- In 2006, Lord et al,51 published a report of tered at pre- and posttreatment time intervals. a study conducted to examine the influence As evidenced by posttreatment BBS scores, of a 22-week AT program for improving physi- both groups experienced statistically signif- cal functioning in older adults. Eighty-five par- icant improvements in balance. There was ticipants were recruited to participate in the not a significant difference in change scores “Waves” group AT program for 1 hour each between groups however. The authors con- week for two 10-week sessions; with a 2-week cluded that use of land- or water-based exer- break between sessions. The AT program in- cises was equally effective in improving bal- cluded activities designed to improve partic- ance in older adults. They cited a low sample ipants’ muscle strength, muscle power, co- size and the lack of randomization as signifi- ordination, and agility. Forty-four individuals cant limitations to their study. were assigned to a control group and received Devereux and colleagues50 examined the no intervention during the study period. Out- effects of a water-based exercise and self- come measures included maximal lean in an- management program on balance, fear of terior and posterior directions, coordinated falling, and quality of life in community- stability, shoulder ROM, quadriceps strength, dwelling women 65 years and older with a di- and reaction time. Only forty-eight partici- agnosis of osteopenia or osteoporosis. Partici- pants completed the entire program; 37 par- pants included 50 women who were random- ticipants dropped out. The AT group demon- ized into an intervention or a control group. strated significant improvements in maximal The intervention group participated in a 10- lean ability, coordinated stability, and shoul- week water exercise class, 2 times weekly. der ROM but not in quadriceps strength or The exercise sessions lasted 50 minutes and reaction time. The control group did not ex- exercises were described as warm-up, stretch- perience changes in any outcome measure. ing, aerobic, strengthening, and activities to The authors noted that other investigators had improve posture, gait, vestibular function found significant strength changes in compa- and proprioceptive function. Tai chi activi- rable groups of participants. They theorized ties were also included. Members of the inter- that the infrequent number of exercise ses- vention group also participated in brief self- sions in their study (ie, only 1 time each management educational sessions addressing week) may have been insufficient to produce such topics as medications, footwear and falls strength changes. risks, and hazards. Participants in the control Tsourlou and colleagues52 published a re- group did not participate in any educational port of their examination of the effects of sessions and were not encouraged to change a 24-week AT program on muscle strength, their physical activity, activities of daily liv- flexibility, and functional mobility in healthy ing, or social habits during the study. Out- women older than 60 years. Twenty-two par- come measures included the step test, the ticipants were randomly assigned to an AT Short Form-36 questionnaire (SF-36), and the group (n = 12) or control group (n = modified Falls Efficacy Scale. Results demon- 10). Members of the AT group exercised for strated significant improvements in the step 60 minutes, 3 days each week during the test and physical function, vitality, social func- study period. The AT protocol consisted of

VOL. 26, NO. 2/APRIL–JUNE 2010 115 MORRIS aerobic and resistance components including specific perturbation exercises that target the 10 minutes of warm-up and stretching, 25 stepping response that could potentially have minutes of endurance activities with a target a positive effect in reducing falls. The pro- of 80% of heart rate maximum, 20 minutes posed water-based training program involves of upper and lower body resistance exercises use of unpredictable multidirectional pertur- with specialized equipment, and 5 minutes of bations that evoke compensatory and voli- cool down. Outcome measures included knee tional stepping responses. Concurrent cogni- flexor and extensor isometric strength (as- tive tasks during movement tasks are included sessed using a dynamometer), grip strength, and principles of physical training and ex- and 3 repetition maximum for chest press, ercise include awareness, continuity, motiva- knee extension, latissimus dorsi muscle pull- tion, overload, periodicity, progression, and down, and leg press. Body composition was specificity. The protocol is being studied in a measured using bioelectrical impedance test- prospective randomized, cross-over trial with ing, jumping performance was evaluated us- 36 community-dwelling older adults. Volun- ing the squat jump and flexibility in trunk tary step reaction times and postural stability flexion as assessed by the sit-and-reach test. using stabilogram diffusion analysis are being Finally, functional mobility was assessed us- used as outcome measures. ing the timed up-and-go test. Participants in Noh and colleagues55 conducted a random- the AT program demonstrated significant im- ized controlled trial to evaluate the effect of provements in all outcome measures, whereas an aquatic exercise protocol designed to im- the control group experienced no significant prove balance in persons with stroke. The changes in any outcome measure. A unique as- twenty-five participants were in the chronic pect of this study was use of heart rate moni- phase of recovery from stroke (more than tors during the entire AT session to ensure ap- 6 months) and could walk independently propriate exercise intensity. The investigators with or without an assistive device. They also used music to guide participants to move were assigned to receive the aquatic inter- at a certain speed and modified the exercise vention or a conventional, land-based exer- program with increased music tempo as the cise program. All interventions were con- weeks of training progressed. ducted for 1 hour, 3 times a week for 8 Roller et al,53 examined the influence of weeks. The AT program was based on prin- a water-based exercise program conducted ciples of the Halliwick and ai chi meth- at YMCA for improving Berg Balance Test ods. Two participants were supervised by scores for women older than 65 years. Thir- 1 therapist at each session and sessions in- teen women, all residents of assisted living cluded 10 minutes of warm-up activities, facilities, participated in the water exercise 20 minutes of Halliwick method activities, program for 45 minutes, 2 times weekly for 20 minutes of ai chi method activities, and 6 weeks. The program was conducted in 10 minutes of cool down activities. Pri- shallow water; was supervised by a personal mary outcome measures were the BBS and trainer; and included active ROM exercises, weight-bearing abilities as measured by ver- water walking, and using water weights for tical ground reaction force during 4 stand- strengthening. Results revealed that Berg Bal- ing tasks. Secondary measures included the ance Test scores improved significantly from Modified Motor Assessment Scale and mus- pre- to posttreatment. The authors concluded cle strength of knee and back muscula- that the water exercise program was effective ture. The participants in the aquatic exercise for improving balance in older adult women. group demonstrated significantly better im- They also recommended that the protocol be provements in the BBS, forward and back- compared to a land-based exercise program. ward weight-bearing abilities, and knee flexor Melzer and colleagues54 are currently in- strength than participants in the control vestigating a water-based program including group. There were no significant differences

116 TOPICS IN GERIATRIC REHABILITATION AQUATIC THERAPY TO IMPROVE BALANCE DYSFUNCTION in the other measures between the groups. Scale of Dizziness. All outcome measures re- The authors concluded that the aquatic inter- vealed statistically significant improvements ventions were effective in improving balance following the intervention. There was no in persons in the chronic phase of recovery association between age, time since symp- from stroke. tom onset, and use of antivertigo medication. Gabilan and colleagues56 examined the The authors concluded that the intervention therapeutic effects of aquatic exercise for was effective in reducing physical effects of persons with unilateral vestibular hypofunc- UVH regardless of age, chronicity, and use of tion (UVH). Twenty-one persons with chronic medication. dizziness (more than 3 months) from UVH were recruited to engage in 10 treatment ses- sions of 45 minutes each for 3 times each SUMMARY week. The exercise program consisted of 12 phases and was based on specialized tech- Balance dysfunction can result from the niques consistent with the Halliwick method negative effects of the aging process on mus- and BRRM. The treatment protocol also in- culoskeletal factors, sensory capabilities, pos- corporated vestibular rehabilitation princi- tural strategies, and/or anticipatory control ples of adaptation and substitution mech- skills. These problems can be compounded by anisms targeting eye-head movements and medical conditions commonly experienced coordination of sensorimotor strategies and by aging adults (eg, stroke, Parkinson disease, active body control alignment. Participants osteoporosis). The physical principles of wa- were progressed through the stages on the ter allow the application of a wide range of basis of their responses to the maneuvers therapeutic strategies to positively influence and the complexity of the exercises. Out- balance control. Mounting evidence suggests come measures employed included the Dizzi- that AT is beneficial, when applied as part of ness Handicap Inventory, Dynamic Comput- rehabilitation and/or community fitness pro- erized Posturography, and the Self-Perception grams, for improving balance control.

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