Falls are a major problem in older (frail) adults, and in those persons with neuromusculoskeletal problems, leading not only to an increase of incapacity but also to an increase of morbidity and mortality. Falls account for 77% of all injury-related hospitalizations in Canada.10 Complications of falls include fractures and fear of falling (FOF) with consequent activity reduction and reduced independence, among others. When training balance on land, an individual’s performance may be diminished by a lack of confidence or a fear of falling. In an aquatic environment, the inherent viscosity of water serves as a postural support, promoting confidence and reducing the fear of falls. Aquatic therapy has the capacity to prevent deterioration and increase the quality of life within the elderly community as well as promoting and maintaining independence. A number of studies have investigated the efficacy of postural exercise programs in the aquatic environment, suggesting positive effects in older adults with coordination and balance deficits.11-15 Evidence based aquatic exercise programs that focus on balance should follow evidence from both land-based and water-based research. Programmatic description in the aquatic literature is often poor and does not always follow established land-based interventions such as using an obstacle course or performing Tai Chi in falls prevention programs. Land obstacle courses and Tai Chi are used successfully to increase balance and to reduce fall risk.16-19
Because of the similarities between Ai Chi and Tai Chi, it is tempting to refer to the results of Tai Chi research on various health status variables (keywords: stability, balance, postural control, postural sway, fall prevention). A simple search in PubMed gave 168 hits on Tai Chi AND balance (July 2010). Research outcomes mostly are positive, although the conclusion of a recent meta-analysis by Logghe et. al.20 was that currently there is insufficient evidence to conclude whether TC is effective in fall prevention, decreasing fear of falling or improving balance in people over age 50 years. Nevertheless Tai Chi is (also) recommended in various guidelines as an exercise to be included in balance training. 21-25
The Cochrane library includes 27 systematic reviews and meta-analyses with Tai Chi in the full text. A selection about neuromuscular diseases shows positive effects of Tai Chi on fall rate and risk of falling in elderly,26, 27 increase of lower extremity range of movement in patients with rheumatoid arthritis28 and a probable positive effect of Tai Chi on pain in patients with hip osteoarthritis.29
Ai Chi includes some of the variables that explain 68% of the effects of exercise on fall rate.30 The variables of the highly challenging balance exercises include movements of the centre of mass, minimized supportive use of the upper extremities and balancing with a narrow base. Also the total exercise dose should be over 50 hours of exercise. Ai Chi does not use the hands for support as long as arm movements are slow enough to not have “grip” on the water, the center of mass moves in many of the movements and also a narrow stance base is used in most of the positions. In order to make Ai Chi more challenging, the more static and stable parts could be modified or left out.
Other adaptations of Ai Chi might be included, based on falls prevention research.
Lateral stability as well as lateral stepping skills are important factors in falls prevention.31,32 Implementing this in Ai Chi could mean:
- Working in tandem and unipedal positions, using asymmetric arm movements to prevent stabilisation through the symmetrical action of arms.
- Focusing on the cross-step movements, leaving out the pivots and asking clients to maintain a position after 2 steps
- Including side stepping without crossing feet
Being able to reach over a certain distance is well documented as a predictor for balance and for the risk to fall.33 Originally, functional reach was tested in the anterior direction but more recent also lateral reach and multi-directional reach have been introduced.
Ai Chi includes slow broad arm movements and potentially could yield more effect by increasing the range of movement and at various positions including a stop of some 2 seconds in order to challenge posture at the end of the reach.
The elderly can have difficulties in stepping over obstacles because of limited knee flexion and/or limited strength in plantar flexors.34
Ai Chi: anterior weight shift might more actively start with plantar flexion of the hind limb ankle and the swing leg could be moved with more knee flexion.
Gait variability decreases with age. One reason is the decrease of rotation in the spinal joints.35 This leads to turning the whole body while looking around, consequently decreasing the security of foot contact with the floor.
Ai Chi: focus on rotations in between pelvis and thorax and ask clients go more to the end of the active range of motion. In particular include movements where the eyes follow the hands in order to incorporate and increase cervical spine rotations.
Hip strategies are used when the area of support is small like on a balance beam or when the foot musculature cannot effectively stabilize the body because of a slippery surface36 or possibly also limited contact with the floor like in water. Hip strategies are more common in elderly and clients with lower extremity involvement.
Ai Chi: focus on hip extension and hip flexion and allow lateral hip movements during the tandem stance or unipedal movements.