Szucs (2007) Halliwick and traumatic brain injury

The primary goal of the therapy described in this article is the improvementof abilities related to self sufficiency in patients with centralnervous system damage. Self sufficiency is based on the ability toperform functions that are impossible without balance and posturalcontrol.Water was chosen as the medium of rehabilitation. Its variouseffects on the body can create such opportunities that cannot betaken advantage of on land, in the absence of the medium. Additionally,during the adaptation to the new environment, due to motorlearning, open skills may develop.The subject of my article is the assessment of the applicabilityand effectiveness of the Halliwick concept in patients with centralnervous system damage, by keeping track of trunk control, reflectedby balance and function.

University of Sciences, Szeged, Hungary
Faculty of Health Scie nces and Social Studies
Department of Physiotherapy

Application of Halliwick Method on
Patients with Central Nervous System Disability with Examination of
Functional Balance, Independence and Postural Assessment Scale

Thesis
abbreviated version
20072008

Sz cs-Balzs, Zsuzsanna
physiotherapist

Consultant:
Katona, Enik
somatic educator
educator of swimming in rehabilitation
National Institute for Medical Rehabilitation

Table of Contents
1 Introduction ................................................................................ 1
2 Hypothesis .................................................................................. 2
2.1 Posing Questions .................................................................. 2
3 Subjects and Methods ................................................................. 3
3.1 Introduction of Patients General Description ...................... 3
3.2 Methods................................................................................ 3
3.3 Instruments .......................................................................... 4
3.4 Specific Case Description ............ .......................................... 4
3.5 Observation in Water ............................................................ 6
3.6 Application of the Ten Point Programme ................................ 6
4 Results ..................................................................................... 10
5 Discussion ................................................................................ 13
6 Conclusion ................................................................................ 16
7 References ................................................................................ 17
8 Appendix Additional Photos .................................................... 20

Application Of Halliwick Method On Patients ...
1
1 Introduction
The primary goal of the therapy desc ribed in this article is the im-
provement of abilities related to self sufficiency in patients with cen-
tral nervous system damage. Self sufficiency is based on the ability to
perform functions that are impossi ble without balance and postural
control. Water was chosen as the medium of rehabilitation. Its various
effects on the body can create su ch opportunities that cannot be
taken advantage of on land, in the absence of the medium. Addition-
ally, during the adaptation to the new environment, due to motor
learning, open skills may develop.
The subject of my article is the assessment of the applicability
and effectiveness of the Halliwick concept in patients with central
nervous system damage, by keeping track of trunk control, reflected
by balance and function.

Szcs-Balzs, Zsuzsanna University of Sciences, Szeged
2
2 Hypothesis
Stroke is the primary cause of chronic disability of adults, but few
studies examine the motor activity of the trunk in affected subjects
Marcucci, 2007. The assessment of trunk rose my interest mainly
because, through reestablishment of postural control, the normalisa-
tion of trunk muscle tone and the restoration of muscle balance, i.e.
proximal stability, provide the base for all distal movements.
Our goal is the fastest possible achievement of self sufficiency
and independence, safe sitting and standing, and the promotion of
change between these postures.
Mobilisation is fundamental in post-stroke rehabilitation, espe-
cially restoration of function . The base of function is the restoration of
appropriate proximal stability, i.e. the coordinated static and dynamic
functional ability to control the shoulder girdle, pelvis, and trunk
Kovcs, 2003.
In recognition of these facts we decided to assess patients by
measurement of activities of daily living (ADL), balance and trunk con-
trol.
We assume that self sufficiency and associated skills (Barthel-
Index; BI and Functional Independence Measure; FIM) improve the
same way as trunk control (Postura l Assessment Scale for Stroke Pa-
tients, items 1 and 69; PASS-TC) and functional balance (Functional
Reach Test; FRT), and the control data show improving trend com-
pared to the data collected before the beginning of therapy.
2.1 Posing Questions
Do our results, including Halliwick method in the therapy, com-
pare to the results of international literature Ching-Lin Hsieh,
2002; Benaim, 1999 that foun d significant improvement of
PASS-TC in the early post-stroke period, in strong correlation
with FIM values Ching-Lin Hsieh, 2002?
Will the patients achieve results in the normal interval of FRT?
How will it relate to function?
Do the PASS values show changes even one year after stroke?
What are these changes like? Do they change as significantly as
in the early post-stroke period?
How do the two ADL scales, FIM and BI, relate to each other?

Application Of Halliwick Method On Patients ...
3
3 Subjects and Methods
3.1 Introduction of Patients General Description
Four persons were involved in the st udy, without restriction on gender
and age, but only two of them could be assessed and treated due to
time factor and lack of cooperation. These two persons took part of
therapy based on Halliwick concept over 8 weeks, 245 minutes a
week. Their gender, age, height and weight were noted. Involved per-
sons were male, average of 48.5 years, 181 cm and 77.5 kg. Exclusion criteria in the selection were:
Contraindications for application of aquatic therapy
Inclusion criteria in the selection were:
Sign of acceptance statement
Stay in the institute for at least 8 weeks, or participation
in therapy at least for 8 weeks in case of outpatients.
3.2 Methods
We chose objective, trustworthy measurement methods. The meas-
urement procedures aimed trunk control and balance, embedded into
function. Data were recorded before and after therapy. The following measurement scales were used:
Functional Independence Measure Scale (FIM)
Barthel-Index (BI)
Functional Reach Test (FRT)
Postural Assessment Scale for Stroke Patients (PASS)
Additionally, the following parameters were recorded:
Duration of stay in the institute
Instruments used to facilitate mobility
Assessment of range of motion and muscle strength
The measurements and treatments were performed personally,
in a well-lit, silent, placid examination room. Several international and Hungarian studies discuss the validity
and reliability of the measurement scales. We focused on measure-
ment methods that are simple to perform yet provide exact results.
This brought us to use these four methods.
Two scales were used to assess the activities of daily living. Its
importance is the refined assessment of function with multiple points
of view. The two scales (FIM and BI) intersect and complement each
other. Putten et al. 1999 foun d that both measurement methods
have similar sensitivity and has no advantage over the other one.
FRT was found beneficial due to various factors. It is simple,
easy to implement and does not require expensive equipment. It is
also reliable Duncan, 1990, and is connected to function. The ability to compare assessment data was taken into account
as well. Results of Belgian research ers Vereeck et al., 2006 underline
a significant correlatio n among trunk performance, balance and abil-

Szcs-Balzs, Zsuzsanna University of Sciences, Szeged
4 ity to function. Correlation of FIM and trunk control is also proven by
more studies Franchignoni, 1997; Ching-Lin Hsieh, 2002. Based on
analysis of movement strategies Nagy 2002 stated that the value of
FRT is primarily influenced by the flexional and rotational movement
of the trunk and the pelvis strategy , and ankle strategy for a lesser ex-
tent.
3.3 Instruments
Halliwick therapy was performed in a pool of
water with indifferent temperature (33C) and
a depth of 113 cm.
The pool can be approached in two
ways. Since it is not sunken (outer height
130 cm) steps ( Photo 1) or a hydraulic lift can
be used by the patients. Quality of the water was strictly moni-
tored not to have high mineral content be-
cause it wouldve exerted the organs and in-
fluenced the effectiveness of the therapy. We
used water with mineral contents of 0.3 gl
Csermely, 2002. In some cases rubber treaded shoes
were used to create a fixed base of support.
3.4 Specific Case Description
Anamnesis
Peter N. is 64, was hit by a concrete beam on a building site. Current
complaints: gait and sitting are uncertain, left arm and hand are
awkward. Has no pain while being st ill, but has pain during passive
mobilisation (extension) of left extremities. Associate diseases: essential hypertension, vulgar psoriasis,
spondylosis. These diseases are hereditary. Peter currently lives in a self co ntained house that has stairs.
He lives with his family who help him much. Inside he often uses a
wheelchair as exclusive ways of movement but exercises 3060 min-
utes daily with elbow crutches.
Diagnosis
He was brought to hospital as a severely damaged polytraumatic pa-
tient on 17102006. Found right te mporal cranial fracture, and op-
posite side frontal contusion that did not increase cerebral tension.
Due to the closure of right arteria cerebris media the ischemic damage
of same-side parietal lobe. Peter also suffered symphyseolysis and left
pertrochanter fracture. He woke fr om coma on 20112006. By this
time quadriplegia has developed and he suffered from severe dyspha-
sia. He was transferred to the National Institute for Medical Rehabili-
tation (OORI) on 18122006, and returned home on 01062007. He
attends hydrotherapy 245 minutes a week as an outpatient. I joined
his therapy and performed the fi rst assessment on 28112007.

Photo 1

Application Of Halliwick Method On Patients ...
5 Assessment
Peters observation from the aspect of frontal plane yielded the follow-
ing results: Left part of shoulder girdle is slightly elevated. Left shoul-
der joint is rotated inward. Elbow is in flexion, forearm in supine posi-
tion. Wrist, finger and thumb joints are in flexion. Leftward lateral
flexion of the trunk can be observed. From the aspect of sagittal plane:
Left pelvic, knee and ankle joints are in extension, the right counter-
parts are in slight flexion. The trunk is slightly flexed. During the muscle tone assessment both left extremities showed
the clasp-knife symptom, suggesting spasticity. The range of motion
on the right side was appropriate for his age, but it was incomplete on
the left side both actively and passively. The lower extremity is less
degraded than the upper one. Muscle tone reflected the same results.
Sensory assessment found surface anaesthesia at the distal end of
lower left limb.
FRT was used to assess balance. The spasticity in Peters left
arm made it impossible to assess both sides. The measured value was
18 cm. The result of FIM and BI scales reflected poor values primarily
in the movement, transport and self sufficiency categories. According
to PASS results Peter needs more or less help in execution of vertical
movements.
Peters motivation is outstanding; he is enduring, strongly coop-
erative. We set standing and confiden t gait as short term goals. Long
term goal was the total abandonment of the wheelchair and the exclu-
sive use of crutches. Additionally we aimed at the further resolution of
spasticity to improve the function of the hand. His treatment is re-
duced to hydrotherapy from 01012008 and the already set medica-
tion.

Szcs-Balzs, Zsuzsanna University of Sciences, Szeged
6
3.5 Observation in Water
What and where is anything showin g above water? Where is anything
sinking? Gamper, 1995 Peters trunk was observed in sitting
position. Active and passive mobilisation of
shoulder girdle and upper extremities was
essential part of his therapy. This was per-
formed in sitting position, fixed with a seat
belt at the pelvic girdle. This article is not
concerned about this part of the therapy
but it provided excellent opportunity to
analyse sitting position. Pelvis is fixed in
this posture and the compensation
mechanisms of lower extremities do not in-
terfere. The longitudinal axis of the trunk
deviates to the right from the symmetry
axis, his head and gaze is aligned to the
latter. The shoulder girdle is elevated, as-
sociated with slight protraction. This is
more emphasised on the right side. Right
shoulder is in neutral position. Left shoulder joint is spontaneously
positioned in flexion, abduction and internal rotation. Slight right ro-
tation of the thoracic section of the spine and left lateral flexion of
lumbar section can be observed. Left side is shortened, right side is
extended, and weight is borne on right side.
3.6 Application of the Ten Point Programme
Description of the Ten Point programme is not subject of this article.
We find it important, however, to introduce the chosen method
through case description because th e practical implementation of TPP
is a function of the patients actual mental and physical state in all
cases.
I. Mental Adjustment
Peter was not afraid of water from the beginning; he even prefers
aquatic therapy. He acquired exhaling to water confidently with ease
( Photo 3 , Photo 4). This exercise helps establish and improve trust be-
tween patient and therapeutist that is essential in the future. Peter
has extraordinary vital capacity. This gave him success in addition to
good ability to float.
II. Sagittal Rotation Control
This is the first step to establish balance control. We can use it in
therapy for active lateral flexion of the spine; it increases range of lat-
eral flexional motion and extends the trunk. We can improve balance
sideways, promote support and balance reactions and stabilise spine
sideways Barnai, 2003. Increasing the range of lateral flexional mo-
tion and extension of the trunk were important in our cases.

Photo 2

Application Of Halliwick Method On Patients ...
7 Peters motion is blocky, some selectivity could be observed only
after several exercises, manifested in the form of lateral flexion on the
non-laden, i.e. opposite side. ( Photo 5)
III. Transversal Rotation Control
We practiced transversal rotation a lot for both patients. This de-
mands acquiring a position that a ssumes significant trust towards the
terapeutist. This is the first exercise that changes vertical posture. The mo-
tion is a rotation around the tran sversal axis, i.e. lying supine from
standing or sitting, and vica versa. It facilitates straightening, makes
the fine tuning of trunk muscles possible due to continuous need for
eccentric-concentric control. Both patients had si milar difficulties. At the beginning they
started rotation from below, and they lacked the series of selective ex-
tension of spine sections, one by one. The therapy managed to achieve
starting the rotation from above and gradual extension of the spine
sections. The PASS results reflect that Peters therapy must focus on the
motion patterns of vertical movements. Peter needs a lot of external
support to perform the exercises (PASS 89).
IV. Longitudinal Rotation Control
Improved tone degrades, decreased tone improves the buoyancy of a
given body part. In Peters case (increased left-side tone) this would
result in longitudinal rotation to the left. The most important change to render the exercise more difficult
is the decrease of radius around the longitudinal axis. This was
achieved by drawing arms near the trunk, and closing lower limbs. Pe-
ter, due to the left side spasticity , did not succeed always in drawing
his left arm near his trunk, but closing the lower extremities did not
pose a problem. Some blocky motion could be obse rved in Peters rotation exer-
cises initially, but it evolved into harmonic fine motion during con-
tinuous practice. He still needs help to turn towards unaffected side.
This can be provided by the therapeu tist from the affected side at the
pelvis or at the shoulder girdle ( Photo 6). Rotation to the unaffected
side was easier when started from above. Rotation to the affected side
was performed with equal ease both from above and from below.
V. Combined Rotation Control
It is essential for inhaling and exhaling not to restrict control to a rota-
tion around a single axis, but during a complex exercise as well. Water
adequate exhaling achieved during mental adaptation plays a primary
role here. It facilitates the spatial coordination of trunk and body, and has
extraordinary functionality. This motion is the safe foundation of
changing posture and location in water.
This exercise demands serious attention and concentration
fromPeter. He often feels dizzy during these motions, and needs rela-

Szcs-Balzs, Zsuzsanna University of Sciences, Szeged
8 tively lots of external help. Continuous practice makes his motion
more and more integrated, selective.
VI. Mental Inversion
Peter experienced that he cannot stay at the bottom of the pool for an
extended period. He acknowledged the positive effect of upthrust. Con-
tinuous exhaling is important here as well, and we do not allow trials
too long because of changes in pressure conditions. Completion of the first six points assumes a great degree of in-
dependence that is a mandatory prerequisite of independent move-
ment.
VII. Balance in Stillness
We focus on balance and stability of various postures. Patients must
be able to react with central moto r control; balance reactions must
appear exclusively in the axial structure. Any change of support provokes a balance reaction from the pa-
tient. The less the change the fine r the coordination of muscle con-
traction that is necessary to maintain floating. This point is used to
make the patient feel and practice the stabilisation and balance origi-
nating from trunk, pelvis, and the hip region. Peter is affected on one side only. Due to the spasticity (on the
left side) destroyed equilibrium of the two sides of the body. Increased
tone degrades ability to float, so he would spontaneously rotate left-
ward around his longitudinal axis. Our goal is independent floating,
without help. Our primary goal for the patient is to learn how to maintain bal-
ance in an open kinetic chain.
VIII. Turbulent Gliding
This exercise is a more difficult version of point VII, i.e. we express
massive forces around the body (e.g. turbulence). Its relevance in therapy is th e preparation of dynamic trunk
balance. During the motion balance must be maintained centrally. Peter had relative ly much difficulty to perform this task the first
time. Frequent practice and developed trust and cooperation came to
a fruition of finding and, gradually, maintaining his balance in spite of
turbulences and whirlpools we created.
IX. Simple Progression
This is a symmetric movement with arms held underwater all the
time. If head and trunk control remained constant, then we would talk
about the first true swimming position. Arm movements disturb the trunks stability. This point may be
better functionally than turbulent gliding. Peter managed to maintain constant head and trunk control
during symmetric arm movements, but it did not last long, only a
couple of seconds. After having sw ayed off balance he managed to re-
establish and maintain it again for a short period.

Application Of Halliwick Method On Patients ...
9 X.
Basic Halliwick Movement
Peter did not reach this point by 01 022008 when my role in the re-
habilitation ended. Our short term goals did not include the comple-
tion of the ten point programme; we aimed the confident control of wa-
ter and the timely, exact, controlled adaptation to the effects of water.
It is, however, a valid goal and his rehabilitation continues in this
spirit.

Szcs-Balzs, Zsuzsanna University of Sciences, Szeged
10
4 Results
This section describes the results achieved. It is analysed in the func-
tion of time. Additionally, we compare our results to some internation-
ally published data. The results are the achievement of all the people
involved in the rehabilitation. Th e most important member of this
team was the patient.
Barthe l-Inde x - PTER
5 15
5
10
5 10
5 10 10 10
5 15
5
10
5 10
5 5 10 10
051015
1 2 3 4 5 6
7 8 9
10
P t e r II.P t e r I.
Chart 1 Barthel Index
FI M - PT ER
6
4 4 7
6
7
7
7
6
5 5 5
5
7
7 7 7 7
4 4 4 4 4 7 7 7
4 4 4 4 4 7
7 7 7
6
0123 4567
A
B
C DE F
G
H I
J
K
L
M
N
O P
Q R
P t e r II.P t e r I.
Chart 2 FIM
The first two charts compare the initial and control values of
FIM and BI. The values have improved. BI did not improve considera-
bly, but FIM values show an improvement to be reckoned with. Appar-
ently, according to BI Peters activities improved only in getting
undressed, while FIM shows improvement in more areas. These are
eating, movement and transport.
PASS - PT ER
3 3
3 3
2 3 3 3 3
3 3
1
3
2
1 1 1 3 3
2 2 3 3
0
0123
1
2
3
4 5 6 7
8 9
10 11
12
P t e r II.P t e r I.
Chart 3 PASS
PASS-T C - PT ER
3 3 3 3 3
3 3 3
2
2
01 23
1
6 7 8
9
P t er II.Pter I.
Chart 4 PASS-TC
Chart 3 shows initial and control values of PASS. No negative
tendencies can be observed. Peter received maximum score for five
items initially, and ten items at control assessment. He still has poten-
tial to improve in standing on affected lower limb (item 5) and pick
up a small item from the floor wh ile standing (item 12), but even
these two items have improved. It is important to emphasise that

Application Of Halliwick Method On Patients ...
11 there is an item that could not be performed at all by Peter initially,
and he could perform it, even though with considerable support.
The items of PASS that are relevant to trunk control, based on
the studies of Ching-Lin Hsieh et al 2002 are items 1 and 69. We
took these as the base of our analysis. These items are:
1. Sitting without support
6. Supine to affected side lateral
7. Supine to non-affected side lateral
8. Supine to sitting up on edge of table
9. Sitting on edge of table to supine
The maximum score for these items is 53, that is, 15 points.
Peter ( Chart 4) scored maximum for three of these elements even
at the initial assessment, but control scores are maximal for all five
items. He increased his initial score of 13 to the maximum available,
15. One year has passed after the stroke of Peter before the initial
assessment. His initial score was 67%. He scored 92% on the control
assessment. We deduce that the improvement was significant, inde-
pendently from the time of the stroke.
Chart 5 compares trunk control (PASS-TC) to functional inde-
pendence and self sufficiency (FIM, BI). Improvement can be observed
in all three scales. Peters BI improved by 5%, FIM improved by 12%,
and PASS-TC improved by 13%. The values suggest that the three
values are closely, but not linearly correlated. Of course this cannot be
a general conclusion due to the low case count. The normal interval of FRT is above 1525 cm. Both patients
achieved values than the lower boundary at the initial assessment,
but they did not reach the upper boundary, unlike at the control as-
sessment. Peters FRT improved by 50%.
A m ax im lis rtkhe z v iszony tott ke zde ti s kontroll
rtke k Pte r e se tn
100%
87%
85%
87%
75%
80%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
PASS-TC FIMBI
Pter IIPter I
Chart 5 Initial and control val-
ues compared to maximum, ADL
and PASS-TC

Szcs-Balzs, Zsuzsanna University of Sciences, Szeged
12
A maximlis rtkhez viszonytott kezdeti s kontroll
rtkek Pter esetn
100% 100%
87%
72%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
PASS-TC FRT
Pter IIPter I
Chart 6 Initial and control values
compared to maximum, FRT and PASS-TC
A maximlis rtkhez viszonytott kezdeti s kontroll
rtkek Pter esetn
87%
85% 100%
75% 80%
72%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
FIM BI
FRT
Pter IIPter I
Chart 7 Initial and control values
compared to maximum, FRT and
ADL
FRT control values exceeded 100%, defined as the upper bound-
ary of the normal interval (25 cm). PASS-TC, on the contrary, has an
absolute upper boundary (15 points). The two measurement methods
are consistent, since both patients reached the maximum of PASS-TC
and the upper boundary of FRTs normal interval. ( Chart 6)
Similar to PASS-TC, FRT improved in significantly higher degree
than the ADL measures. While FRT reached the maximum the ADL
functions left measureable deficiency. ( Chart 7)

Application Of Halliwick Method On Patients ...
13
5 Discussion
The ADL scales complemented each other, as assumed (
3.2 Methods).
Their scores were similar to each other ( Chart 1 and Chart 2 ). The ac-
tual abilities of the patients were not reflected in all areas. We found
its root cause in the strict conditions and restrictions of scoring. Addi-
tionally, objective data was derived from subjective scoring in many
cases (e.g. intense, moderate, slight support). PASS results yielded the following: Peters original score was 24
of 36 ( Chart 3 ), of which PASS-TC was 13 of 15 ( Chart 4). Control val-
ues show improvement, since complete PASS scored 33 of 36, and
PASS-TC scored the maximal 15 of 15. We find it important that both patients have reached the maxi-
mal score for trunk control. Additionally, PASS reached 91.6% for Pe-
ter and a similar excellent result fo r the other patient. Both patients
found the item Standing on paretic leg the most difficult. This is,
however, not surprising, since this is the hardest, most complex of the
exercises when assessing static balance. Base of support is tiny, and
the conditions demands appropriate muscle strength and coordination
alike. Both patients had tone controlling problems as well that could
not be dealt with by the end of the therapy. This is an important ex-
ercise from functional point of view. In Perrys midstance phase of gait
the same demands are necessary, i.e. bearing the full body weight on
one lower limb. This item has improv ed for Peter and stagnated for the
other patient. As a side note we add that our part of the therapy, hy-
drotherapy, did not put emphasis on this exercise. We focused on im-
provement of trunk control instead, while land therapists endeavoured
to perfect gait and the bearing of body weight. Comparisons from functional point of view were made by corre-
lating FIM and BI to PASS (see below).
Evaluating PASS-TC we can state that the possible best results
were achieved. Peters little initial deficiency can be explained by the
time of the stroke and the continuous, frequent, adequate therapy ap-
plied ( Chart 4).
Peter had problems with Supine to sitting on edge of table
(item 8) and its reverse (item 9). Both belong to the upright (vertical)
movements. They were improved prim arily during vertical rotation and
all combined movements based on that. Balance in stillness (step 7 of
the ten point programme) and turbulent gliding (step 8) created such
static and dynamic balance conditions that needed the finely harmo-
nised work of all muscle groups, including the muscles responsible for
vertical trunk movements, to maintain. Evaluating full PASS we concluded that the test qualified as
sensitive, independently from the time of the stroke. This opposes the
results published in international literature Ching-Lin Hsieh, 2002,
but this cannot be generalised, since we studied only one case where
one year had passed after stroke. Changes due to therapy were very

Szcs-Balzs, Zsuzsanna University of Sciences, Szeged
14 similar in both cases. Percentage-wise, control score improved by 25%
in both cases. Percentage increase of ADL values compared to PASS-TC values
yielded likewise results ( Chart 5). Scores increased in both cases, but
not in equal rate. Our assumption that BI and FIM increases linearly
with PASS-TC, did not hold. In Peters case FIM and PASS-TC im-
proved nearly the same rate, but BI improved much less. This may be
explained by the inconsequent scoring of BI that does not reckon with
marginal values.
We can conclude that our results partially match international
studies Ching-Lin Hsieh, 2002. Bo th tests scores improved, but the
rates were not similar enough to claim a close correlation.
Comparing PASS-TC and FRT results the following correlation
can be observed. Peters initial PASS-TC score was close to maximum,
thus the improvement was not so outstanding (13%). Regarding FRT
(defining 25 cm as 100%) improvement was 36% (control value of
108%, not shown by charts) and it can obviously be measured. There-
fore we concluded that, in Peters case, PASS-TC was not as sensitive
as FRT ( Chart 6).

Comparing FRT and ADL scales we can state as well that in Pe-
ters case, due to the high initial scores, the improvement that can be
measured by ADL scales is not as evident as for the other patient. FRT
has changed in the same direction but for a different degree ( Chart 7).

All in all, we can state that fu nctional balance and trunk control
improved for a greater degree than abilities used in activities of daily
living. Thus, former measures only fo recast the latter ones. Complete
PASS, on the other hand, shows an overall picture.
The changes in range of motion and muscle strength were in
positive direction in both cases. Peter had initial values deviating from
normal on the unaffected, right side in addition to the affected left side
Kapandji, 2006. The former showed changes on the proximal section
of the upper limb; range of motion improved there. On the proximal
section of the left upper limb and in the full length of the left lower
limb improvement both in muscle strength and range of motion can be
observed. Observing the trunk we saw significant changes in lateral
flexion and rotation. Former increased by 125% on right side and by
150% on left side. Rotation became equal (20) on both sides, reflect-
ing an improvement of 133% on right and 200% on left side. Flexion
and extension muscle strength was level 4 on control assessment.
This matches the initial value on right, and exceeds the initial value of
3 on left side.

The following results reflect th e harvest of our work best:
Peter spent his everyday life in his wheelchair in November
2007. In contrast, nowadays he uses the crutches more than the

Application Of Halliwick Method On Patients ...
15 wheelchair. By his own admission he climbed 5 stairs independently
up and down. On 01022008 he clim bed the pool stairs alternating
his legs. Downwards he still had problems with alternated gait. He is
able to fetch books independently fr om shelves over breast height at
home. He is able to stand in the kitchen without support and peel po-
tatoes.
The success of therapy and e ffectiveness of Halliwick concept
are best demonstrated by these results.

Szcs-Balzs, Zsuzsanna University of Sciences, Szeged
16
6 Conclusion
We studied patients with cerebrovascular insult in this article, and
treated them according to Halliwick method. We examined functional
independence, abilities of self sufficiency and balance. The objective
scales at our disposal were simple, demanded little time and low cost
to apply. Assessments were made at the times when I joined the reha-
bilitation and when I left the team. Rehabilitation of patients is con-
tinued afterwards.
Patients received comprehensive therapy. It includes medica-
tion, movement therapy and ergother apy alike. Movement therapy has
two large parts, basic and supplemen tary ones. Basic movement ther-
apy is performed on land, while the treatment is made complex and
comprehensive by the supplementary part; hydrotherapy. The Halli-
wick concept is organic part of hydrotherapy, but other, aquatic ther-
apy methods were used in addition to address specific problems. We
find it important to notice that the results achieved are not exclusively
results of our job. We were members of a rehabilitation team; therefore
the results reflect the complete work of the whole team. In my opinion we managed to improve abilities to perform func-
tions significantly, and improve some functions to skill level. We had opportunities in water th at couldnt have been estab-
lished on land. Such a condition is the lack of fixed base of support,
making it possible to easily change its size and direction, giving an
unbound instrument to the therapeu tist. By changing base of support
the aid can easily lead the patient to find and lose balance. This is the
essence of improving balance. In addition, buoyancy helped to perform
such normal movements that could not be achieved on land. This
stimulated the central nervous system with appropriate input.
I think that we aided the patients much in performing activities
of daily living, self sufficient and in dependent lifestyle, and raise their
standards of their life to a higher level.

Application Of Halliwick Method On Patients ...
17
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8 Appendix Additional Photos
Photo 3

Photo 4

Photo 5
Photo 6

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