Atlas›Domain X · Body, movement, breath & physical›Guide 176
Guide X-176

Aquatic physiotherapy (Halliwick, Bad Ragaz ring method)

James McMillan, Davies, Egger1949London, England; Bad Ragaz, Switzerland
A 21 · L 64 · M 1528 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the Halliwick Concept and its Ten-Point Programme as set out by Johan Lambeck and Urs Gamper in the chapter "The Halliwick Concept" (in Comprehensive Aquatic Therapy), checked against the Halliwick Association of Swimming Therapy (Halliwick AST, UK) description; the Bad Ragaz Ring Method (BRRM) as set out by Urs Gamper and Johan Lambeck in the chapter "The Bad Ragaz Ring Method" in the same book. Where Halliwick AST groups the ten points differently, both versions are noted.

What it is. Aquatic physiotherapy is physiotherapy delivered in a warm therapy pool. Halliwick and the Bad Ragaz Ring Method are two of its named methods. They are physical rehabilitation and swimming-teaching methods, not psychotherapies. This guide is written for a psychotherapist: it describes the methods as their developers and professional bodies publish them, says who delivers them, and sets out the psychotherapist's own role (when to suggest it, preparing clients, collaborating, integrating the experience, spotting adverse effects). A psychotherapist does not deliver hands-on aquatic physiotherapy unless they are also a qualified physiotherapist with aquatic training. [source: Lambeck & Gamper; Gamper & Lambeck; ATACP] [synthesis: the scope statement for psychotherapists]

Halliwick. James McMillan MBE (1913–1994; spelled "MacMillan" on the Halliwick AST page) was a voluntary swim coach. Around 1949–1950 he worked with pupils of the Halliwick School for Crippled Girls in Southgate, London, aiming to help them become independent in water and join the local community. [uncertain: sources give 1949 (Maes & Gresswell) and 1950 (Lambeck & Gamper)] The work grew into swimming clubs (the Halliwick Penguin Swimming Club, 1951) and the Association of Swimming Therapy (1952), now Halliwick AST. From 1974, at the invitation of Dr W. Zinn at the Bad Ragaz medical centre in Switzerland, McMillan led a project that produced Water Specific Therapy (WST), Halliwick's therapy extension. In the structure Lambeck and Gamper describe, the Halliwick Foundation holds the trademark. Under it sit the International Halliwick Association (IHA), which covers swimming and clubs, and the International Halliwick Therapy Network, which covers therapy. [source: Lambeck & Gamper; Halliwick AST; Maes & Gresswell]

Core idea of change (Halliwick). The person becomes independent in water by learning to lose balance and regain it. They learn this through the physics of water (buoyancy, turbulence, rotation), through motor learning, and through gradual "disengagement" of the helper's physical and visual support. Halliwick AST describes the concept as covering physical, psychological and social development. [source: Lambeck & Gamper; Halliwick AST]

Bad Ragaz Ring Method. Physiotherapists in Bad Ragaz, Switzerland developed BRRM. Davies published it in 1967 and Egger expanded it in 1990. It is a one-to-one, resistive strengthening and mobilising method based on proprioceptive neuromuscular facilitation (PNF; Kabat, Knott and Voss). The person floats on their back, supported by rings or floats at the neck, hips and sometimes the limbs. The therapist stands in the water as the fixed point and guides or resists movement patterns. Core idea of change (BRRM): resistance from the therapist's hands and from water drag strengthens and mobilises, and other techniques reduce pain and tone. The authors say BRRM works at the level of body function, is used mostly early in rehabilitation, and should be combined with activity-focused approaches such as Halliwick. [source: Gamper & Lambeck]

Who delivers it and how they are credentialed.

  • UK: aquatic physiotherapy is delivered by physiotherapists, with support from non-qualified staff. The Aquatic Therapy Association of Chartered Physiotherapists (ATACP) is a professional network of the Chartered Society of Physiotherapy. It publishes the ATACP Guidance on Aquatic Physiotherapy 2021 (paid for non-members), covering competence routes, service organisation and which patients should not enter the pool. [source: ATACP] "Physiotherapist" is a protected title in the UK, and practising physiotherapy requires registration with the Health and Care Professions Council (HCPC) by law. [source: CSP, Regulation of physiotherapy]
  • Halliwick swimming: taught by Halliwick instructors and volunteer helpers trained through Halliwick AST courses (Foundation Course, Halliwick Instructor's Certificate, Advanced Courses, Lecturer route) or IHA-listed lecturers. Halliwick therapy (WST) is delivered by therapists. [source: Halliwick AST; Lambeck & Gamper]
  • USA: the APTA Academy of Aquatic Physical Therapy (founded 1992) runs an Aquatic Physical Therapy Clinical Competency Certificate, open only to licensed physical therapists and physical therapist assistants. It is a certificate of completion, not a board certification. [source: APTA Academy of Aquatic Physical Therapy]
  • BRRM: demands a high level of skill, precise knowledge of the concept and a refined gripping technique, so in practice it means a trained physiotherapist. A volunteer partner may assist only if they know the pattern, resistance and technique. [source: Gamper & Lambeck]

Evidence status. A Cochrane review (Bartels and colleagues, 2016; 13 trials, 1,190 participants) found small, short-term, clinically relevant benefits of aquatic exercise for pain, disability and quality of life in knee and hip osteoarthritis. The evidence was moderate certainty and no serious adverse events were linked to the exercise. For Halliwick, the trials Lambeck and Gamper cite (in stroke balance and children with neuromotor impairment) are small, some uncontrolled. They report the English AST skills assessment has never been tested for reliability or validity, whereas the Water Orientation Test Alyn (WOTA 1 and 2) has reported reliability and validity. The BRRM chapter cites mainly textbooks and older literature. No source presents these methods as treatments for any disease. Their aims are function, participation, comfort and swimming independence. [source: Cochrane CD005523; Lambeck & Gamper; Gamper & Lambeck]

2. Framework

Halliwick: three learning stages and the Ten-Point Programme. Lambeck and Gamper describe three stages of motor learning. They present the ten points as a guideline rather than a fixed sequence: earlier points can be prerequisites for later ones, and points overlap. [source: Lambeck & Gamper; Maes & Gresswell]

  • Stage 1, Mental adjustment. Goal: the person responds automatically, independently and appropriately to water and to the new situation. Breath control is the key skill.
  • Stage 2, Balance control. Goal: the person keeps or changes position in a controlled way. Early on they may use large, peripheral compensating movements. These should become fine, automatic and centralised.
  • Stage 3, Movement. Goal: effective, efficient, directed skilled movement (propulsion, swimming).
  • The ten points (Lambeck & Gamper naming): (1) Mental adjustment; (2) Sagittal rotation control; (3) Transversal rotation control; (4) Longitudinal rotation control; (5) Combined rotation control; (6) Upthrust, also called mental inversion; (7) Balance in stillness; (8) Turbulent gliding; (9) Simple progression; (10) Basic movement. Each is described in Section 4.
  • Halliwick AST grouping: points 1–2 are mental adjustment (breath control, relaxation) and disengagement (becoming independent), which the swimmer meets again with every new skill; points 3–6 are control of rotations; points 7–9 are upthrust, balance and turbulent gliding; point 10 is propulsion (a basic stroke). The two versions differ in where disengagement and upthrust sit. This guide follows the Lambeck and Gamper numbering. [source: Halliwick AST; Lambeck & Gamper] [uncertain: exact mapping of points to stages in Lambeck and Gamper's table]
  • WST: Lambeck and Gamper describe points 1–6 as the foundation for Water Specific Therapy. WST uses the same water mechanics to work on body-function impairments in adults with orthopaedic, rheumatological and neurological conditions, with a strong emphasis on core stability. [source: Lambeck & Gamper]

Format. Halliwick swimming runs as club sessions: each swimmer has one helper, and pairs work within a larger group using games and music. Halliwick therapy runs as individual or small-group sessions with a physiotherapist. Lambeck and Gamper give a worked stroke example in which relaxation is followed by Halliwick work and then swimming, but the session length and frequency in it are one clinician's plan, not a protocol. This guide gives no session count, duration or frequency. These are set by the treating physiotherapist. [source: Halliwick AST; Lambeck & Gamper]

BRRM structure. BRRM is not staged. Its parts are client education, Halliwick mental adjustment where needed (lying on the back in water can cause discomfort, breathing difficulty or strong balance reactions), and then PNF-derived patterns for the arms, legs and trunk. Difficulty is progressed along named dimensions. It is one-to-one and, the authors say, not suited to aquatic fitness groups. [source: Gamper & Lambeck]

Criteria for moving on.

  • Halliwick: the helper's support is withdrawn as the swimmer shows they can control a rotation or position independently. Difficulty is varied through water depth, foot support, attention demands, speed, arm use, rhythm and range of movement. Lambeck and Gamper list being able to stand up independently as a priority, because being unable to do so is a major source of fear. Progress in AST clubs is marked with skill badges, and WOTA is a validated alternative for measuring water skills. [source: Lambeck & Gamper]
  • BRRM: the therapist progresses only when the person controls the current level. [source: Gamper & Lambeck]
  • For the psychotherapist: pool readiness is the physiotherapist's decision after screening (Section 4). The psychotherapist's own criterion is whether the client can tolerate being held, floated and close to water, and can signal "stop". [synthesis]

3. Guiding principles

  • Independence is the goal (Halliwick). Practical meaning: success is the person doing it without help, not the helper doing it well. [source: Lambeck & Gamper; Halliwick AST]
  • Disengagement. Practical meaning: support, physical and visual, is withdrawn step by step and never more than needed. Halliwick AST describes this as adjustable, minimal support until the swimmer is fully independent. [source: Halliwick AST; Lambeck & Gamper]
  • Losing balance is part of learning. Practical meaning: being willing to lose balance and able to regain it is the core skill, and water lets people "dare to make errors". [source: Lambeck & Gamper]
  • Breath control first. Practical meaning: the person learns to blow out or hum whenever the mouth or nose nears the water, which keeps water out of the airway, before any other skill is asked of them. [source: Lambeck & Gamper; Maes & Gresswell]
  • Physics, not flotation aids (classical Halliwick). Practical meaning: swimmers find their own balance rather than relying on armbands or collars. Lambeck and Gamper note that flotation devices may be used for more severely affected clients. [source: Halliwick AST; Lambeck & Gamper]
  • Problem-solving, individualised selection. Practical meaning: the therapist analyses what this person can and cannot do and picks the points or WST exercises to match. Maes and Gresswell say there is no standard sequence for cerebral palsy. [source: Lambeck & Gamper; Maes & Gresswell]
  • Carry-over to land and to life (ICF). Practical meaning: pool goals link to function and participation, such as balance when walking, social contact and joining a club. [source: Lambeck & Gamper; Maes & Gresswell; Halliwick AST]
  • Group, games and music (Halliwick). Practical meaning: learning is social and enjoyable. Pairs work within a group and peers motivate each other. [source: Halliwick AST]
  • Clear communication between swimmer and helper. Practical meaning: the swimmer takes part in their own learning, so instructions are short and the swimmer's signals are watched. [source: Halliwick AST]
  • Physical contact is integral but bounded (Halliwick AST policy). Practical meaning: holds are flat-handed, kept minimal and placed at the pelvis, shoulders, elbows, forearms or hands. Fingers stay non-intrusive. Any non-standard support needs the swimmer's permission first. [source: Halliwick AST Policy on Physical Contact]
  • The therapist is the stable fixed point (BRRM). Practical meaning: the therapist's stance and grip set the quality of the work, and the person's whole floating body responds to every movement. [source: Gamper & Lambeck]
  • Resistance matched to the person (BRRM). Practical meaning: water drag rises with speed, so resistance partly regulates itself. The therapist adapts hand resistance to the person's force. [source: Gamper & Lambeck]
  • Consent before and during touch; the right to stop. Practical meaning: every hold is explained and agreed, the person can stop at any moment, and a stop is honoured at once. [source: Halliwick AST Policy on Physical Contact; USABP Code VIII] [synthesis: applying the USABP touch provisions to aquatic work]
  • Never sexual touch. Practical meaning: no genital or sexual contact of any kind. Holds near the pelvis are clinical, flat-handed and explained in advance. [source: USABP Code VIII; Halliwick AST Policy on Physical Contact]
  • Safety before skill. Practical meaning: no pool entry without screening, an emergency procedure and appropriate supervision. [source: South Tees hydrotherapy referral form; ATACP] [synthesis]

4. Intervention inventory

The inventory has three parts. Part A is the psychotherapist's own work around aquatic physiotherapy. Part B describes the Halliwick Ten-Point Programme and associated techniques as published. Part C describes the Bad Ragaz Ring Method as published. Parts B and C describe what a trained instructor or aquatic physiotherapist does, so the psychotherapist can explain it to clients and collaborate. They are not instructions for a psychotherapist to carry out in a pool. No water temperatures, session lengths, repetitions or exercise doses are given. These are set by the treating physiotherapist. [synthesis: this framing]

Part A. The psychotherapist's role

A1. Deciding when to suggest aquatic physiotherapy, and referring

  • Purpose / when to use: when a client with physical disability, a neurological or musculoskeletal condition, chronic pain or deconditioning could gain function, comfort, independence or social participation in water, or wants to learn to swim despite disability. Halliwick AST lists wellbeing, motor learning, functional independence and social skills among its therapy aims. BRRM targets strength, mobility, pain modulation and relaxation. [source: Halliwick AST; Gamper & Lambeck]
  • Steps: (1) Explore the client's goal: function, pain, confidence, swimming, or belonging to a club. (2) Match the route: a referral to aquatic physiotherapy (via GP, consultant or physiotherapist in the UK, or the ATACP/CSP "Find an Aquatic Therapist" directory) for therapy goals, or a Halliwick club for swimming and participation. (3) With consent, share relevant psychological information with the physiotherapist, such as fear of water, trauma affecting touch, dissociation or body-image distress. (4) Agree how you will communicate with each other. [source: ATACP page navigation; Halliwick AST] [synthesis: steps 1, 3 and 4]
  • Example language (illustrative): "You've said you feel stuck and heavy in your body on land. Some physiotherapists work in a warm pool, where the water takes some of your weight. Would you like to find out more, or talk with your GP or physio about a referral?"
  • Watch for: the client hearing the suggestion as a sign you are giving up on talking therapy; unrealistic expectations of cure (no source presents these methods as treatment for disease); ambivalence about being seen in swimwear. It is working when the client decides from curiosity rather than pressure.

A2. Screening conversation and medical clearance

  • Purpose / when to use: before any pool referral, so the client and the referrer know what the pool team will ask. The decision belongs to the physiotherapist and the medical team, not the psychotherapist. [synthesis]
  • What NHS screening covers. Two published NHS sources are summarised here: one hospital form (South Tees, revised 2017, citing "Guidance on good practice in aquatic physiotherapy 2015") and the national All Wales evidence-based guidance on access to hydrotherapy (Welsh Physiotherapy Advisory Group, version 3, December 2016), which sorts conditions into absolute contraindications, relative contraindications and precautions and asks for a full assessment of every patient [source: South Tees hydrotherapy referral form; WPhLAG 2016]. The two lists largely agree. They are examples of what a pool team asks, not a single UK standard, and each service applies its own current criteria.
    • Absolute contraindications on that form: acute vomiting or diarrhoea (with a symptom-free interval required); medical instability after an acute episode (for example stroke, DVT, heart attack, cardiac surgery, pulmonary embolism, severe asthma attack); proven chlorine allergy; angina at rest; breathlessness at rest; uncontrolled heart failure; and a stated upper weight limit for the pool equipment.
    • Relative contraindications: acute systemic illness or fever; skin irradiated by radiotherapy; known aneurysm; open infected wounds; poorly controlled epilepsy; unstable diabetes; oxygen dependency.
    • Precautions: fear of water; behavioural problems; urinary or faecal incontinence; controlled epilepsy; haemophilia; low blood pressure; kidney failure; widespread MRSA; poor skin integrity; pregnancy; contact lenses or conjunctivitis; hearing aids or grommets; impaired vision, sensation or hearing; invasive tubes; aspiration risk; tracheostomy.
    • Practical items: inhalers brought to every session; walking aids and weight-bearing status; pool access by steps or hoist; cultural requirements; an explanation of pool and changing-area safety and the evacuation procedure, including alarm pull cords; signature by both patient and physiotherapist.
    • What the All Wales guidance adds. Beyond the items on the South Tees form, it lists bromine as well as chlorine allergy and paroxysmal nocturnal dyspnoea among absolute contraindications; open wounds, thyroid deficiency, neutropenia and a weight above the evacuation-equipment limit among relative contraindications (to be weighed case by case); and, among precautions that may proceed with extra measures, tendency to black out, sickle cell anaemia, poor temperature regulation, fungal infections, previous autonomic dysreflexia, and boisterous, unpredictable or aggressive behaviour [source: WPhLAG 2016].
    • What a patient leaflet asks of patients. A 2025 NHS adult aquatic-therapy leaflet asks patients to cancel unless they have been free of sickness or diarrhoea for 48 hours, to tell the team if their health has changed since referral, to tell the physiotherapist if they are not a confident swimmer (being able to swim is not required), and to bring any fast-acting medicine they normally carry, such as an inhaler or angina spray [source: Sherwood Forest Hospitals leaflet PIL202508-02-HA].
    • The current ATACP Guidance on Aquatic Physiotherapy 2021 covers which patients should not enter the pool environment and special considerations for particular groups, such as people with a tracheostomy; it is free to ATACP members and paid for others. [source: ATACP] [uncertain: the 2021 guidance's own lists are not reproduced here and may differ from the South Tees and All Wales lists]
  • Steps: (1) Ask whether the client has any of the conditions above and encourage them to tell the physiotherapist. (2) Ask about medicines, alcohol use on pool days and continence, and normalise these questions. (3) Flag psychological precautions with consent: fear of water, panic, dissociation, behaviour that may put others at risk. (4) Leave clearance to the pool team. [source: South Tees form] [synthesis: steps 1–4]
  • Example language (illustrative): "The pool team will ask some detailed health questions, including about continence and epilepsy. That's routine for everyone. Is there anything you'd find hard to tell them that we could think about first?"
  • Watch for: the client minimising symptoms to be allowed in; shame about continence or weight limits; heat or breathing worries. It is working when the client goes to assessment with full information and without shame.

A3. Preparing a client who is afraid of water

  • Purpose / when to use: the client is anxious about water, has a near-drowning or water-trauma history, or fears not being able to stand up. Fear of water is a listed precaution. Lambeck and Gamper identify being unable to stand up independently as a major source of fear, and Halliwick begins with mental adjustment and breath control. [source: South Tees form; Lambeck & Gamper; Maes & Gresswell]
  • Steps: (1) Map the fear: what exactly, such as face in water, losing footing, being held, being watched, or past events. (2) Explain how Halliwick starts: breath control (blowing out or humming as the mouth nears water), a helper who withdraws support only gradually, and early work on standing up. (3) Agree on a stop signal the client will use with the physiotherapist, and practise it in session. (4) If there is trauma, assess whether readiness work is needed first, for example with stabilisation and graded imagery, using your own trained methods. (5) Debrief after early pool sessions. [source: Lambeck & Gamper (step 2)] [synthesis: steps 1 and 3–5]
  • Example language (illustrative): "In this method, the first thing they teach is how to breathe out when your face gets near the water, and how to get back on your feet. Nobody expects you to swim at the start."
  • Watch for: flashbacks or dissociation at the thought of water; avoidance that hardens; pressure from family. It is working when the client can talk about water with rising, not falling, tolerance, and reports moments of trust in the pool.

A4. Preparing for touch and being held in water

  • Purpose / when to use: for every client, and especially those with trauma, a history of abuse, body-boundary difficulties or sensory sensitivity. Physical contact is central to Halliwick and BRRM: being held, floated on the back, supported at the pelvis, having the face near water. [source: Halliwick AST Policy on Physical Contact; Gamper & Lambeck]
  • What the published policy says (Halliwick AST, agreed 2018, dated April 2022): holds use flat hands; supports are at the shoulders, elbows, forearms, hands or either side of the pelvis ("hands on hips"), fingers pointing to the toes, with body contact kept minimal; a straddle support is rarely needed and requires the swimmer's permission, consultation with the chief instructor and maximum distance; joining a session means accepting standard contact; any other support needs the swimmer's permission first; swimmers or carers should be encouraged to say if a support is unacceptable. [source: Halliwick AST Policy on Physical Contact]
  • Ethics-code context: mainstream psychotherapy codes contain no explicit touch clause but all prohibit sexual contact. The USABP code requires informed consent before touch, ongoing monitoring of consent, and the client's right to refuse or end touch at any time, and states that genital or other sexual touch is always inappropriate. [source: USABP Code of Ethics VIII; BACP, UKCP, APA codes]
  • Steps: (1) Describe the holds plainly so nothing is a surprise. (2) Explore which holds or positions feel risky: lying back, being behind, pelvis contact, face near water, loss of control. (3) Encourage the client to ask the physiotherapist for explanation before each new hold, for an alternative (for example a facing hold rather than one from behind), or for a same-gender practitioner or a chaperone where the service can offer one. (4) Rehearse saying no and stopping. (5) Make clear that sexual touch is never part of any method, and how to report concerns (the service's complaints route; Halliwick AST has a complaints and grievance procedure). [source: Halliwick AST policies (holds; complaints procedure)] [synthesis: steps 2–4 and the chaperone suggestion]
  • Example language (illustrative): "The instructor will usually hold you with flat hands at the sides of your hips or at your shoulders. You can ask them to tell you before every new hold, and you can say stop at any point. Which of those would feel hardest?"
  • Watch for: freeze responses (going quiet and compliant rather than saying no); later shame or anger about touch the client "allowed"; any report of touch beyond the described holds, which should be taken seriously and the reporting route followed. It is working when the client can state their limits and reports that they were respected.
  • The psychotherapist's own boundary: a psychotherapist does not combine psychotherapy with hands-on in-water work unless their professional code allows it and they hold the aquatic training and qualification. Most talk-therapy codes require practising within competence. [source: UKCP item 23; BPS 2.3; APA 2.01] [synthesis: the application to aquatic work]

A5. Body image, changing rooms and hoist privacy

  • Purpose / when to use: for clients with body-image distress, eating disorders, visible difference, stomas, scars, continence needs, gender-identity concerns, or a need for hoist transfer. Pools require swimwear, changing and sometimes a hoist. Hoist access is a standard screening item. Halliwick AST publishes material on trans inclusion. [source: South Tees form; Halliwick AST policies page]
  • Steps: (1) Ask what feels exposing: being seen in swimwear, the walk to the pool, communal changing, being hoisted in view of others. (2) Help the client prepare questions for the service: private or accessible changing, gender of the staff who assist, who is present during transfers, cover-ups or swim shirts, and timing so the pool is quiet. (3) Plan coping for the moments of exposure. (4) Process afterwards. [synthesis] [uncertain: specific changing-room and hoist privacy standards for therapy pools were not found in the professional sources for this guide; ask the service for its policy]
  • Example language (illustrative): "It's reasonable to ask the pool team how changing works, who will help with the hoist, and whether you can wear a swim shirt. Shall we write down what you want to ask?"
  • Watch for: avoidance disguised as practical problems; disordered-eating thoughts triggered by swimwear; humiliation after a hoist transfer. It is working when the client attends and reports dignity was kept.

A6. Children and young people: safeguarding, consent, assent and parents

  • Purpose / when to use: a child client is offered Halliwick swimming or paediatric aquatic physiotherapy. Cerebral palsy was the most common paediatric condition in the literature Lambeck and Gamper cite. [source: Lambeck & Gamper; Maes & Gresswell]
  • What sources state: Halliwick AST publishes Safe to Swim: Information for Clubs on the Protection of Vulnerable People, covering safeguarding policy and a code of good practice, Disclosure and Barring Service (DBS) checks for helpers, recognising and responding to abuse of children and vulnerable adults, and guidance on physical contact. Its contact policy encourages carers to say if a support is unacceptable. Maes and Gresswell describe parents taking part in group sessions. In hospital hydrotherapy pools, PWTAG advises against baby and toddler swimming classes because of infections including Cryptosporidium. [source: Halliwick AST Safe to Swim contents; Halliwick AST Policy on Physical Contact; Maes & Gresswell; PWTAG technical note 2012]
  • Steps: (1) Get parental or carer consent and the child's own assent, in language or signs the child understands. (2) Check the service or club has a safeguarding policy, DBS-checked staff and a named person for concerns. (3) Help the child show "stop" and "I don't like that hold", including non-verbal signs for children with limited speech. (4) Agree with parents who is in the water and who helps with changing and toileting. (5) Follow your own safeguarding duties if a concern arises. [source: Safe to Swim contents (step 2)] [synthesis: steps 1 and 3–5]
  • Example language (illustrative, to a child): "In the pool, a helper holds you like this, at your sides. If you don't like it, you can put your hand up and they will stop. Shall we practise?"
  • Watch for: distress the child cannot put into words, such as crying, stiffening or refusing the pool; parents overriding the child's refusal; any adult insisting on unsupervised changing. It is working when the child looks forward to sessions and the adults respect the child's signals.

A7. Integrating pool experience into psychotherapy

  • Purpose / when to use: the client is attending aquatic physiotherapy or a Halliwick club, and their experience of buoyancy, losing and regaining balance, being supported and then released, or joining a group bears on therapy themes such as trust, control, dependence, body ownership and belonging. [synthesis]
  • Steps: (1) Invite a description of the session in body terms. (2) Link where useful to themes already in therapy, such as letting go of a support or allowing an error. (3) Notice the client's own language about independence and achievement. (4) Avoid interpreting physical progress as psychological "proof". [synthesis]
  • Example language (illustrative): "You said that when they let go and you didn't sink, something in you settled. Where else in your life are you learning that you can be let go of and still be okay?"
  • Watch for: over-intellectualising; the pool becoming the only place the client feels capable; grief about a body that cannot do what it once did. It is working when the client brings pool experiences in spontaneously and uses them.

A8. Recognising adverse effects and passing them on

  • Purpose / when to use: at every review while the client attends. [synthesis]
  • What sources name as risks: aspiration or choking (the reason Halliwick teaches exhaling as the mouth nears water); falls and loss of standing; equilibrium reactions and breathing difficulty when lying on the back; infection (the HSE spa-pool guidance names Legionella, Pseudomonas aeruginosa folliculitis, environmental mycobacteria and gastrointestinal infections as risks in warm recreational spa-pool water, with higher risk for immunocompromised people, people with heart, lung, kidney disease or diabetes, and children); heat-related risks in pregnancy and cardiovascular disease; and, per PWTAG, infection risk to patients and staff in hospital hydrotherapy pools. [source: Lambeck & Gamper; Gamper & Lambeck; HSE HSG282; PWTAG technical note] [uncertain: HSG282 covers spa pools; how far it applies to therapy pools was not confirmed]
  • Steps: (1) Ask about fatigue, dizziness, breathlessness, rashes, ear or eye infections, gastrointestinal illness, panic, flashbacks or shame after sessions. (2) Encourage the client to report physical effects to the physiotherapist or GP. (3) With consent, tell the physiotherapist about psychological reactions. (4) Seek urgent medical help for chest pain, severe breathlessness, seizure or after any near-drowning episode. [synthesis]
  • Example language (illustrative): "How have you felt in the hours after the pool? Any rash, ear trouble, unusual tiredness, or anything emotional that came up later?"
  • Watch for: the client hiding effects so they can keep going; a delayed trauma response after a hold. It is working when issues are raised early and the care plan is adjusted.

Part B. Halliwick Concept (Ten-Point Programme and associated techniques), as published

This part describes what a Halliwick instructor or aquatic physiotherapist does. Unless marked otherwise, everything is from Lambeck and Gamper's chapter. Holds follow the Halliwick AST Policy on Physical Contact. The example language is the instructor's, given so the psychotherapist can explain sessions to clients. The words "head forward" and "blow out" are cues quoted in the chapter. All other wording is illustrative.

B1. Point 1: Mental adjustment, including breath control

  • Purpose / when to use: the starting point for everyone, revisited with each new skill. The swimmer learns to respond automatically, independently and appropriately to water. [source: Lambeck & Gamper; Halliwick AST]
  • Steps (as published): the instructor introduces water contact gradually. Breath control is taught: the swimmer exhales (blows out or hums) whenever the mouth or nose meets the water, which prevents swallowing and choking. Halliwick AST pairs this with relaxation. Maes and Gresswell describe clients with cerebral palsy who grip the therapist and hold their head and shoulders high, a land strategy that doesn't work in water. Mental adjustment helps them learn the new rules. [source: Lambeck & Gamper; Halliwick AST; Maes & Gresswell]
  • Example language: "Blow out" (cue quoted in Lambeck & Gamper). Illustrative: "Make bubbles as your chin touches the water. Good, you kept the water out."
  • Watch for: breath-holding, gripping, panic, coughing. It is working when exhaling at the water surface becomes automatic and the swimmer's grip softens. Safety note: this guide gives no breath-holding instructions. Halliwick breath control is about exhaling, not holding the breath. [synthesis: the safety note]

B2. Disengagement (withdrawing support)

  • Purpose / when to use: throughout, to move the swimmer towards independence. Halliwick AST lists it with mental adjustment as an early point. [source: Halliwick AST; Lambeck & Gamper]
  • Steps (as published): the helper starts with full, adjustable support (for example facing the swimmer, with the swimmer's hands on the helper's shoulders), then moves to elbows or forearms, then to hands only. Physical and visual support are gradually withdrawn. Lambeck and Gamper list ways to vary difficulty: water depth, foot support, attention demands, speed, use of the arms, rhythm and range of movement. [source: Halliwick AST Policy on Physical Contact; Lambeck & Gamper]
  • Example language (illustrative): "Now I'm just going to hold your hands lightly. Tell me if you want my hands back on your elbows."
  • Watch for: fear spikes as support reduces; the swimmer clinging. It is working when the swimmer accepts less support without stiffening.

B3. Point 2: Sagittal rotation control

  • Purpose / when to use: control of side-to-side movement around the front-to-back axis, as in reaching sideways or shifting weight. [source: Lambeck & Gamper]
  • Steps (as published): the swimmer, upright and supported, practises reaching and weight shifts to each side and controls the resulting tilt, at first with support and then with less. [source: Lambeck & Gamper]
  • Example language (illustrative): "Reach to the side for the ball, then bring yourself back to the middle."
  • Watch for: big compensating arm movements, which should become smaller and more central with learning. It is working when the swimmer can lean and come back to upright without help. [source: Lambeck & Gamper (stage 2 description)]

B4. Point 3: Transversal rotation control

  • Purpose / when to use: control of forward and backward movement, including sitting into the "chair position" and moving from upright to lying on the back and back again. Learning to stand up is a priority because being unable to is a major source of fear. [source: Lambeck & Gamper]
  • Steps (as published): the move to lying on the back is taught gradually, because it can trigger strong balance reactions. The instructor supports at the sides of the pelvis. To come back up, the swimmer is cued to bring the head forward. [source: Lambeck & Gamper; Halliwick AST Policy on Physical Contact]
  • Example language: "Head forward" (cue quoted in Lambeck & Gamper). Illustrative: "Sit back as if into a chair. I've got your sides. Now head forward and come up to standing."
  • Watch for: startle or panic when going backwards; arching. It is working when the swimmer can move between lying back and standing calmly.

B5. Point 4: Longitudinal rotation control

  • Purpose / when to use: rolling around the body's long axis, up to a full turn, back to lying on the back. Lambeck and Gamper call it a key safety skill. [source: Lambeck & Gamper]
  • Steps (as published): the helper faces the swimmer and supports at either side of the pelvis, fingers non-intrusive. Lambeck and Gamper describe support at the body's centre of balance, around the sacrum. The swimmer turns the head and body to roll and returns to lying on the back. [source: Halliwick AST Policy on Physical Contact; Lambeck & Gamper]
  • Example language (illustrative): "Turn your head and roll towards me, all the way round, and finish on your back with your face up."
  • Watch for: fear of the face going under, water in the ears (Maes and Gresswell describe this limiting the back float), disorientation. It is working when the swimmer can recover from a roll to a safe face-up position. [source: Maes & Gresswell]

B6. Point 5: Combined rotation control

  • Purpose / when to use: combining the rotations to recover from any fall or position, used to fall safely and stand up again. [source: Lambeck & Gamper]
  • Steps (as published): the swimmer practises forward and sideways rolls that combine the earlier rotations. Lambeck and Gamper say falls are taught in deep water first, then progressively in shallower water. [source: Lambeck & Gamper]
  • Example language (illustrative): "Let yourself fall to the side and find your way onto your back, then up to standing."
  • Watch for: the swimmer avoiding falls; disorientation. It is working when an unplanned loss of balance leads to a controlled recovery rather than panic.

B7. Point 6: Upthrust (mental inversion)

  • Purpose / when to use: the swimmer comes to understand and trust that water pushes them back up. Lambeck and Gamper call this fundamental to comfort and safety. [source: Lambeck & Gamper]
  • Steps (as published): the swimmer experiences being lifted by the water, for example by trying to go under and finding themselves floating back up, with breath control in place and with support as needed. [source: Lambeck & Gamper] [uncertain: the detailed activities for this point are thinly described in the chapter]
  • Example language (illustrative): "Try to sit down on the bottom and notice how the water lifts you back up."
  • Watch for: panic about going under; water up the nose if exhaling is not yet automatic. It is working when the swimmer relaxes into being lifted.

B8. Point 7: Balance in stillness

  • Purpose / when to use: the most static point. The swimmer refines a stable posture upright and lying on the back while the water or the instructor disturbs their balance. [source: Lambeck & Gamper]
  • Steps (as published): the swimmer holds still, upright or lying back. Compensating hand movements and stiffening are not allowed. The instructor creates turbulence by hand, or uses the body's natural tendency to rotate in water, to challenge balance. [source: Lambeck & Gamper]
  • Example language (illustrative): "Stay still and quiet. I'm going to make some waves. Let your body find the balance without paddling your hands."
  • Watch for: stiffening or hidden sculling. It is working when the swimmer stays balanced with small, central adjustments.

B9. Point 8: Turbulent gliding

  • Purpose / when to use: a dynamic follow-on to balance in stillness. The swimmer, lying on the back, keeps their balance while the instructor tows them through turbulence. [source: Lambeck & Gamper]
  • Steps (as published): the instructor moves the water around the swimmer to draw them along without holding them. The swimmer holds a balanced back float and does not use their arms. [source: Lambeck & Gamper]
  • Example language (illustrative): "I'm not holding you. The water is pulling you along. Just keep your balance."
  • Watch for: rotation the swimmer cannot correct; anxiety at having no contact. It is working when the swimmer glides in a stable position without being touched.

B10. Point 9: Simple progression

  • Purpose / when to use: the first self-propulsion. [source: Lambeck & Gamper]
  • Steps (as published): while keeping head and trunk control, the swimmer moves forward using small, symmetrical hand movements under the water (sculling) near the body. [source: Lambeck & Gamper]
  • Example language (illustrative): "Use your hands by your hips, small movements, and move yourself along."
  • Watch for: losing trunk or head control as the hands start working. It is working when the swimmer can move independently and stay balanced.

B11. Point 10: Basic movement (basic Halliwick stroke)

  • Purpose / when to use: an efficient basic stroke for swimmers at any level. Halliwick AST emphasises inclusion and high expectations at this point. [source: Lambeck & Gamper; Halliwick AST]
  • Steps (as published): a symmetrical arm stroke on the back, with arm recovery within a limited range out to the side, building on the earlier balance control. [source: Lambeck & Gamper]
  • Example language (illustrative): "Both arms together, out and back, and keep your head still."
  • Watch for: asymmetry pulling the swimmer into rotation. It is working when the swimmer swims a distance independently and safely.

B12. Games, music and group activities

  • Purpose / when to use: to make learning structured, enjoyable, meaningful and social. Games were part of the Ten-Point Programme from the start. Group work fits the ICF focus on participation. [source: Halliwick AST; Lambeck & Gamper; Maes & Gresswell]
  • Steps (as published): pairs (swimmer and helper) work within a group. Activities described include a partner-supported jumping "frog", throwing balls to each other at different heights and angles to challenge balance, "bicycle" games, passing objects round a circle, and obstacle courses (balance beams, wobble boards, hurdles, reaching poles). Groups may include several clients, therapists, parents and Halliwick instructors. [source: Lambeck & Gamper; Maes & Gresswell]
  • Example language (illustrative): "Let's pass the ball round the circle. Everyone stays in their chair position."
  • Watch for: a swimmer being overwhelmed by noise or the group; social anxiety; peers being unkind (Halliwick AST has an anti-bullying policy). It is working when the swimmer joins in and the skills appear inside play. [source: Halliwick AST policies page]

B13. Water Specific Therapy (WST)

  • Purpose / when to use: Halliwick's therapy extension for impairments of body function, especially in adults with orthopaedic, rheumatological and neurological conditions. Points 1–6 serve as the groundwork. [source: Lambeck & Gamper]
  • Steps (as published): the physiotherapist uses the water's buoyancy and rotational effects to set balance challenges that call for stabilising reactions, with a strong emphasis on core stability. Lambeck and Gamper say many exercises resemble Functional Kinetics and Pilates. They give the example of a man with one-sided paralysis after stroke whose goals included righting reactions, shoulder relaxation, trunk symmetry and swimming. [source: Lambeck & Gamper]
  • Example language (illustrative): "Keep your middle steady while I move the water around you."
  • Watch for: fatigue and overload. The therapist aims to challenge without overstressing. It is working when there are gains in control that carry over to land function. [source: Lambeck & Gamper]

B14. Assessment of water skills

  • Purpose / when to use: to set goals and track progress. [source: Lambeck & Gamper]
  • Steps (as published): the English AST assessment grades Ten-Point skills with badges, but has never been tested for reliability or validity. The Water Orientation Test Alyn (WOTA 1 and WOTA 2, by Tirosh) has reported test-retest reliability, validity against the Gross Motor Function Measure, and responsiveness. WOTA 1 is simplified for children who cannot follow verbal instructions. An ICF-based activity-level assessment was in development at the time of the chapter. This guide does not reproduce the items. [source: Lambeck & Gamper]
  • Example language (illustrative, psychotherapist): "Your instructor will check skills like getting back to standing and rolling onto your back. It's about what you can do, not a pass or fail."
  • Watch for: a badge or score becoming a source of shame or perfectionism. It is working when the assessment motivates the swimmer.

Part C. Bad Ragaz Ring Method, as published

Everything in this part is from Gamper and Lambeck's chapter. It describes what a trained aquatic physiotherapist does. The chapter's dosage figures (numbers of contractions, rest intervals, session lengths) are deliberately left out. The example language is illustrative.

C1. Set-up, flotation and therapist position

  • Purpose / when to use: the basis for every BRRM pattern. Indications named in the chapter: peripheral joint problems such as osteoarthritis, inflammatory conditions such as rheumatoid arthritis and ankylosing spondylitis, chronic spinal problems, general weakness or motor-control deficits (for example after stroke or with neuropathy), and impairments after surgery or injury. [source: Gamper & Lambeck]
  • Steps (as published): the person lies on their back at the surface, supported by a neck ring (or collar) and hip ring, with extra floats as needed. The neck collar keeps the cervical spine neutral and the ears clear so instructions can be heard. Rings should not be over-inflated, as that causes instability and reduces force. The therapist stands in stable equilibrium as the fixed point, avoids unnecessary movement, and stands no deeper than about mid-trunk, because deeper water reduces stability. Before starting, the person is taught what will happen and, where needed, does Halliwick mental adjustment, because lying back can cause discomfort, breathing difficulty or balance reactions. [source: Gamper & Lambeck]
  • Example language (illustrative): "The rings will hold you. My hands will be on your feet (or knees, or hands). I'll tell you each movement before we do it, and you can stop at any time."
  • Watch for: breath-holding, startle, neck tension, anxiety at being held by the feet or legs while floating. It is working when the person floats relaxed and can follow commands.
  • Contraindications: the chapter lists no formal contraindications. Pool screening (A2) applies. [source: Gamper & Lambeck; South Tees form]

C2. Arm patterns

  • Purpose / when to use: strengthening and mobilising the shoulder girdle and arm. [source: Gamper & Lambeck]
  • Steps (as published): mostly one-arm patterns of moving away from and towards the body (abduction and adduction) combined with rotation, because flexion and extension are hard to perform lying on the back. The chapter mentions a face-down variation using a mask and snorkel. The therapist's hold provides fixation and resistance, and the person's body moves through the water around that fixed point. [source: Gamper & Lambeck]
  • Example language (illustrative): "Push your arm out to the side against my hand... and now bring it back in."
  • Watch for: pain, shoulder guarding, the trunk twisting to compensate. It is working when the movement is smooth and controlled within comfortable range.

C3. Leg patterns

  • Purpose / when to use: strengthening and mobilising the hips and knees, and indirectly the trunk. [source: Gamper & Lambeck]
  • Steps (as published): patterns with both legs moving together (bilateral symmetrical) or alternately (bilateral reciprocal), done as moving (isotonic) or holding (isometric) work, with variations of knee bending and straightening. The therapist usually holds the feet or legs. Moving the hold from closer to the trunk to further out makes the work harder. Movements start at the far end of the limb. [source: Gamper & Lambeck]
  • Example language (illustrative): "Both legs, push down and out against my hands... now pull them up and in."
  • Watch for: low-back strain, cramp, a sense of being pulled through the water. It is working when power and control improve without pain.

C4. Trunk patterns

  • Purpose / when to use: trunk strength, mobility and control. [source: Gamper & Lambeck]
  • Steps (as published): pure side-bending; bending forward or backward combined with side-bending and rotation. These are applied through the legs, the arms or the limbs on one side. [source: Gamper & Lambeck]
  • Example language (illustrative): "Bend your body sideways towards me, like a banana, and back."
  • Watch for: back pain flaring up; dizziness. It is working when the trunk moves with control and symmetry improves.

C5. PNF techniques adapted to water

  • Purpose / when to use: the chapter names techniques from PNF and links them to aims. Hold-relax is used first for pain inhibition. Repeated contractions with timing for emphasis build strength. Contract-relax and hold-relax build mobility. Relaxation uses reciprocal inhibition and post-facilitation inhibition. [source: Gamper & Lambeck]
  • Techniques named: rhythmic initiation; reversal of antagonists; repeated contractions (repeated stretch); combination of isotonics; timing for emphasis; hold-relax; contract-relax. A floating body cannot use the stretch reflex to start a movement the way it can on land, so full range is often not reached and only parts of patterns are used. [source: Gamper & Lambeck]
  • Steps (descriptive): in hold-relax, for example, the person holds against the therapist's resistance and then relaxes, after which the movement is taken further. In rhythmic initiation, the movement is first guided and then becomes the person's own. [uncertain: these one-line descriptions draw on general PNF usage; the chapter names the techniques without step detail]
  • Example language (illustrative): "Hold... don't let me move you... and now let go completely."
  • Watch for: pain, breath-holding during effort, fatigue. It is working when pain eases or range and strength increase across sessions.

C6. Types of resistance and progression

  • Purpose / when to use: to match the challenge to the person's force. [source: Gamper & Lambeck]
  • Steps (as published): resistance can be isotonic (moving against resistance), isokinetic (constant speed) or isometric (holding). Because drag increases sharply with speed, resistance partly regulates itself. The chapter lists ways to progress: increase range; move the hold further out; increase speed; lengthen the lever; add techniques; add hand paddles; reduce flotation; change the surface area facing the movement. Stimuli include tactile cueing and holding, short precise verbal commands, traction and approximation, and irradiation (using strong muscle groups to recruit weaker ones). The chapter notes that strong patients limit the method, because the therapist's own strength becomes the ceiling. [source: Gamper & Lambeck]
  • Example language (illustrative): "This time faster. You'll feel the water push back harder."
  • Watch for: overload, post-session soreness or fatigue, flare-ups of inflammatory conditions. It is working when the person handles the next level without symptoms.

5. Handling problems

Most of this section is [synthesis]: the sources describe methods, not problem management in psychotherapy. Source-based points are tagged.

  • Client refuses the pool or keeps postponing. Respond: explore the specific feared element (A3), separate fear of water from body exposure (A5) and from touch (A4), and consider a visit to the pool without getting in. Respect a final "no". Land-based physiotherapy is an alternative. [synthesis]
  • Panic or a near-drowning reaction during a session. Respond: this is managed in the pool by the physiotherapist, using the service's emergency procedure. Halliwick's priorities of breath control, getting back to standing and the safe face-up position exist to reduce this risk. Afterwards, debrief in therapy, treat any trauma response, and agree with the client and physiotherapist whether to step back to mental adjustment. [source: Lambeck & Gamper; South Tees form (evacuation procedure)] [synthesis: the debrief]
  • Freeze, dissociation or flashback when held or floated on the back. Respond: tell the physiotherapist (with consent) so they can use facing holds, keep feet on the floor, give advance warning of each hold, or slow down. Halliwick AST policy allows swimmers to object to a support, and BRRM always involves lying back and being held, so it may be unsuitable for some trauma survivors until they are ready. Work on stabilisation in therapy. [source: Halliwick AST Policy on Physical Contact; Gamper & Lambeck] [synthesis]
  • Concern about inappropriate touch. Respond: take it seriously; there is no therapeutic version of sexual touch. Support the client to use the service's complaints route (for Halliwick clubs, the Halliwick AST Complaints and Grievance Procedure), the employer, or the regulator (HCPC for UK physiotherapists). Follow safeguarding procedures for children and adults at risk. [source: Halliwick AST policies page; USABP VIII] [uncertain: no reports of misconduct specific to these methods were located for this guide]
  • Body shame or eating-disorder activation. Respond: A5 planning, plus attention to whether swimwear or weight limits trigger restriction or compensation; liaise with the eating-disorder team if one is involved. [synthesis]
  • Child distressed but parent insists. Respond: centre the child's assent; explain to parents that independence in Halliwick depends on the child feeling safe; suggest a slower start or a different helper; follow safeguarding duties if there are coercion concerns. [synthesis]
  • Over-expectation ("the pool will fix my condition"). Respond: give the evidence status plainly. For knee and hip osteoarthritis, the Cochrane review found small, short-term benefits. The methods aim at function and participation, not cure. [source: Cochrane CD005523] [synthesis]
  • Non-attendance or poor adherence. Respond: explore practical barriers (transport, an ambulance requirement, changing time, fatigue, continence worries, cost) and emotional ones; liaise with the service about timing and support. [source: South Tees form (ambulance and access items)] [synthesis]
  • Infection, rash or illness after sessions. Respond: refer to GP and tell the pool team. Gastrointestinal illness means staying out of the pool until cleared, and infected wounds and widespread MRSA are listed contraindications or precautions. [source: South Tees form; HSE HSG282] [synthesis]
  • Epilepsy, cardiac or respiratory symptoms. Respond: these are medical matters. The client should not self-manage pool participation around them. Encourage disclosure to the pool team and GP. [source: South Tees form] [synthesis]
  • Rupture with the psychotherapist ("you're sending me away" or "you don't get how hard this is"). Respond: name the rupture, acknowledge the effort and exposure involved, and clarify that aquatic work adds to rather than replaces therapy. [synthesis]
  • Grief or anger about the body. Respond: when the water allows movement that is impossible on land, clients may feel joy and grief together. Make space for both, and explore what independence means to them now. [synthesis]
  • Psychotherapist tempted to join in the pool. Respond: don't combine roles unless qualified and permitted by your code. Codes require working within competence and managing boundaries and dual relationships. [source: UKCP items 8 and 23; BPS 2.3; APA 2.01 and 3.05] [synthesis]

Sources

Primary method sources

Professional bodies, safety and infection control

Evidence

Ethics codes (touch, boundaries, competence)

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