Anyone working with the geriatric population these days is concerned with falls. Most of the patients I see in a skilled nursing facility are there because of a fall and a subsequent injury. My patients there are at risk of falling again and  their families are  worried and concerned about their safety.

Therapists usually approach fall prevention by looking at hazards in the environment, and working to increase patient's leg strength and balance. I believe water exercise has great potential for fall prevention and and has been overlooked.This is partly because, except for therapists who are trained as aquatic therapists, water exercise is seen as the purview of water exercise instructors, not therapists.

But any activity that improves function can be a therapeutic one. And therapists are vastly qualified to evaluate clients and recommend specific exercises, while identifying exercises that would violate medical precautions, (e.g. hip replacement patients).

I teach a class at the Shoreline YMCA called Prevent Falls with Water Exercise. The class was based on the Golden Waves work of Mary Sanders, PhD at the University of Nevada, but I have adapted it to stress leg strength and balance activities specifically to reduce the risks of falls.

Structure of the class
My classes run for an eight week or two-month period. I test students at the beginning for static standing balance, dynamic balance, fitness (8' Get Up and Go Test), and upper extremity ROM, at the shoulder. I also take a medical history, checking for conditions that would contraindicate certain exercises, (e.g. spinal stenosis, hip surgery) and ask the participants  to identify their goals. Generally, people want to get stronger, feel better, and be less fearful of falling.

At the end of eight weeks, I do post testing and share the results with the students. Participants know they feel better, but objective data is very reinforcing!

Class routine
The class meets weekly. We start by checking our position in standing.  We work to maintain a functional posture that is neither too flexed nor extended at the lumbar spine. We warm up, walking forwards and backwards, then sideways, sculling with hands, for balance. Students wear nylon web gloves, to provide increased resistance, but also to provide stability when sculling at the sides. This helps when we are doing activities standing on one leg.

Next we do joint ROM, going from upper extremity, (shoulders, elbows) to lower extremity, (hips, knees and ankles). Flexibility in all of these joints contribute to stability of the body as a whole, and can help when ones loses one's balance. For instance, good ROM in the ankle contributes to being able to take a step to right yourself if you have  a loss of balance.

We then work on what I feel is most critical: standing balance. The most obvious advantage of working in the pool shows itself here. The students do a variety of movement activities, which call for them to suddenly stop, against the current of the water, on one leg. With few exceptions, everyone can do this, although they would NOT be able to do so safely, on dry land.

An interval of gentle cardio follows, and participants are carefully instructed to move at their own level of comfort. I ask participants if they can talk, which is the test for keeping a safe level of activity.

Next, I lead participants in a series of hand and UE ROM activities using NerfÒ Balls.  One popular balance activity is to toss a ball in a circle, while the participants are standing on one leg. People enjoy this, especially when there is more than one ball being tossed.

Finally, the class cools down and debriefs. I ask if they have any questions or concerns.

I typically hear comments like:

"This was so fun, the hour just went by like that!"

"It was like playing!"

"It was enjoyable, and felt good."

It is clear to me that an activity must be enjoyable for people to continue to choose to participate. And people need to be educated regarding the need to choose an activity that will help reduce the chances of falling.

A recent study at the University of Washington found that most people at risk for falling do not seek resources to do something about it. The local Emergency Response Service found that, on following up with people they'd helped after a fall in their homes, less than 10% were pursuing treatment or activity to reduce the likelihood of another fall. In fact, most people tended to restrict their activity, instead!

Anything that helps motivate people to pursue fall prevention should be considered.

Some of the people in my current group have been with me since I started this program in the summer of 2009. They enjoy seeing their friends as well as exercising. As an OT, I'm convinced that the social interaction of a group is a huge reinforcer to many people for continuing with a therapeutic activity.

One of the best advocates for the benefits of water exercise in general is Bruce Becker, MD, and former head of Rehab at St. Luke's Rehabilitation Institute, in Spokane, Washington.

Dr. Becker, who authored the chapter on Biophysioloical Aspects of Hydrotherapy in second edition of Comprehensive Aquatic Therapy, states that merely being submerged in water has a beneficial effect. The pressure of the water drives the blood towards the heart, which raises the blood pressure. The body, in an attempt to achieve homeostasis, makes the kidneys get rid of fluid, which is why you feel the need to go to the bathroom after you've been in the water after a while! But the other effect of the water pressure is to increase the stroke volume of the heart, so that slightly more blood gets moved out, on each beat. In essence, being mostly submerged causes a mild exercise effect in the body, without any physical effort.

In addition, pressure on the lungs causes a respiratory stress that leads to greater respiratory fitness. Becker comments that many elite athletes these days include deep water running in their workouts, deliberately to improve cardio-pulmonary fitness. I find that when I educate my students in this area, they are even more likely to continue in the pool.

Clearly, water exercise offers many benefits. But, with the resistance of the water strengthening legs, and with the ability to safely challenge balance in the turbulence of the water environment, it needs to be seen as the modality of the future, for fall prevention.

I'm really excited about the potential of water exercise for fall prevention, and I want others to share in this with me.

Jeanne Shepard is an OT near Seattle, Washington, and currently teaches Prevent Falls with Water Exercise at the Dale Turner YMCA, She works at Shoreline Health and Rehab Center.