Using a co-design approach to develop aquatic reactive balance training for fall prevention

This paper describes the co-design of an aquatic reactive balance training program (AquaReBal) for older adults, developed through collaborative input from end-users and clinicians to address safety barriers and enhance engagement for fall prevention.

The Gist

Imagine you are trying to teach an elderly person how to catch themselves if they trip. On dry land, this is like practicing a high-wire act without a net. It's scary, it hurts your joints, and the fear of falling often stops people from trying.

This paper is about a team of researchers who decided to move that "high-wire act" into a swimming pool. They call their new program AquaReBal (Aquatic Reactive Balance Training). But here's the twist: they didn't just design it in a lab and hand it to the seniors. Instead, they built the program with the seniors, treating them like co-pilots rather than just passengers.

Here is the story of how they did it, explained simply:

1. The Problem: The "Scary" Balance Training

Falling is a huge problem for older adults. Scientists know that practicing how to react when you lose your balance (like when you slip on ice) is the best way to prevent falls. But doing this on land is tough.

• The Fear: It feels dangerous.
• The Pain: It can hurt your knees and hips.
• The Gear: You have to wear a heavy harness that feels like a straitjacket.

2. The Solution: The "Water Trampoline"

The team realized that water is like a magical safety net.

• Buoyancy: Water holds you up, so if you slip, you don't hit the floor hard. It's like falling onto a trampoline instead of concrete.
• Resistance: The water pushes back, making your muscles work harder without hurting your joints.
• Comfort: It feels softer and less jarring than a hard floor.

3. The Method: "Cooking Together" (Co-Design)

Usually, researchers cook up a recipe and tell people to eat it. This team decided to cook with the diners. They used a Co-Design approach. Think of it like a group cooking class where the people who will actually eat the meal get to pick the ingredients, taste the sauce, and tell the chef if it needs more salt.

The Team:

• The Chefs: Researchers, physical therapists, and experts in water therapy.
• The Diners: Three older women (the "partners") who had all fallen recently. They were the experts on what it feels like to be scared of falling.

4. The Process: A Journey of Tasting and Tweaking

The team went through several rounds of "tasting" and "fixing":

• Step 1: The Chat (One-on-One): The researchers talked to the three women individually. They learned that while some loved the water, others were scared of cold locker rooms or slippery floors. They also learned that the instructor is the most important person—if you like the teacher, you'll keep coming back.
• Step 2: The First Taste (Pool Session): They tried out some exercises in the pool.
  • What worked: The water felt great. It was less scary than the land.
  • What didn't work: The "hip belt" used to pull them off balance felt uncomfortable, like a tight waistband. The pool floor was hard to see, making it confusing how deep the water was.
• Step 3: The Fix-It Session: The team met again. The women said, "Hey, instead of pulling my hip with a belt, pull my whole body with a vest. It feels safer." They also asked for a "Welcome Kit" with photos of the pool and a checklist of what to bring (like flip-flops) so they wouldn't feel lost on day one.
• Step 4: The Final Recipe: The researchers took all this feedback and built the final AquaReBal program. It uses vests instead of belts, has clear markers for water depth, and focuses heavily on making the instructor friendly and supportive.

5. The Result: A Program Built for Real People

The final program isn't just a list of exercises; it's a program designed to make seniors feel safe, confident, and happy.

• Safety First: The water reduces the fear of injury.
• Social Connection: The women realized that having a fun instructor and friends makes the hard work feel like a party.
• Practicality: They created a "starter pack" with videos and photos so new participants know exactly what to expect, removing the anxiety of the unknown.

The Big Takeaway

This paper proves that when you invite the people you are trying to help into the design room, you don't just get a better product; you get a product that people actually want to use.

It's the difference between building a house with a blueprint and building a house where the future residents get to choose the paint, the door handles, and the layout. The result is a home where they feel comfortable staying, rather than a house they just have to live in.

In short: By mixing the science of balance training with the comfort of water and the wisdom of the seniors themselves, the team created a fall-prevention program that is safer, less scary, and much more fun.

Technical Summary

1. Problem Statement

Falls are a critical health issue for older adults, leading to injury, loss of independence, and increased healthcare costs. While Reactive Balance Training (RBT)—which involves intentional balance perturbations to train fall recovery—is effective on land, its adoption is limited by significant barriers:

• Fear of falling and injury.
• Joint discomfort and pain associated with land-based impact.
• Physical burden of safety harnesses used in traditional RBT.

Although aquatic environments offer theoretical advantages (buoyancy, hydrostatic pressure) to mitigate these barriers, there is a lack of evidence-based protocols for Aquatic Reactive Balance Training (AquaReBal). Furthermore, existing aquatic interventions often fail to incorporate the specific needs and preferences of older adults, limiting their accessibility and adherence.

2. Methodology

The study employed a Participatory Action Research (PAR) framework using a co-design approach. The process followed the Guidance for Reporting Involvement of Patients and the Public 2 (GRIPP2) framework to ensure rigorous reporting of patient involvement.

• Participants:
  • Research Team: A multidisciplinary group including physiotherapists (specialized in aquatic and land-based RBT), researchers, and master's students.
  • Patient Partners: Three older adult women (aged >65) with lived experience of falls in the last year. Their backgrounds varied: some had prior RBT experience, one had regular aquatic exercise experience, and one had no prior aquatic/RBT experience but participated in fall prevention groups.
• Design Process (Iterative Phases):
  1. Information Gathering: Literature review and consultations with international aquatic therapy and RBT experts.
  2. One-on-One Meetings: Individual interviews with patient partners to understand personal barriers, fears, and motivations regarding water and balance training.
  3. Participatory Design Session 1 (PDS1): Online collaborative session to identify barriers/facilitators and brainstorm program concepts (using Miro boards).
  4. Internal Team Session 1 (ITS1): Researchers synthesized PDS1 feedback to draft a protocol for practical testing.
  5. Practical Pool Sessions: Individual trials in a pool at the Toronto Rehabilitation Institute. Partners tested specific exercises (walking, lean-and-release, perturbations) while researchers observed feasibility, safety, and comfort.
  6. Participatory Design Session 2 (PDS2): Online session to review pool session feedback, refine equipment choices, and finalize the "Introductory Package."
  7. Internal Team Session 2 (ITS2): Finalization of the AquaReBal protocol based on all accumulated data.

3. Key Contributions

• Development of the AquaReBal Protocol: A novel, evidence-informed aquatic RBT program specifically tailored for older adults.
• Co-Design Framework in Aquatic Settings: Demonstrates a successful model for integrating Patient and Public Involvement (PPI) in the development of aquatic rehabilitation interventions, an area previously underexplored.
• Identification of Critical Design Factors: The study moved beyond theoretical benefits to identify practical, user-driven requirements for aquatic balance training, such as specific equipment modifications and environmental cues.
• Creation of Participant Support Materials: Developed a comprehensive "Introductory Package" (including checklists, facility photos, and exercise videos) to reduce anxiety and logistical barriers for future participants.

4. Key Results

The co-design process yielded specific, actionable modifications to the intervention:

• Equipment Modifications:
  • Perturbation Delivery: Partners rejected the standard hip belt used in land-based RBT due to discomfort and the sensation of being pulled by a single point. They recommended a vest to distribute force across the whole body, making perturbations feel more natural and less jarring.
  • Tools: Mats were deemed effective for balance challenges, while pool noodles were found less effective.
• Environmental & Logistical Adjustments:
  • Pool Depth Visibility: Partners found the changing pool depths confusing and potentially unsafe. Recommendations included adding distinct physical markers or using pools with gradual slopes.
  • Chemical Sensitivity: Concerns regarding pool chemicals causing irritation were noted, suggesting a need for water quality monitoring or alternative facilities.
  • Privacy: The availability of private changing rooms was identified as a crucial factor for participation.
• Psychological & Social Factors:
  • Instructor Role: The relationship with the instructor was cited as the most critical factor for motivation and adherence.
  • Safety Perception: The aquatic environment significantly reduced the "jarring" sensation of land-based perturbations, lowering anxiety and increasing confidence.
  • Social Engagement: The social aspect of the group and the instructor's ability to foster connection were key motivators.
• Feedback Mechanisms: The study successfully utilized anonymous post-session surveys (scoring 4.6–4.8/5) to gauge satisfaction with the design process itself, leading to improvements in meeting tools (switching from Miro to Freeform for better usability).

5. Significance

• Clinical Relevance: The AquaReBal protocol addresses the primary barriers (fear, pain, harness burden) that prevent older adults from engaging in effective fall prevention training. By shifting to an aquatic environment, the program offers a safer, more comfortable medium for high-intensity reactive training.
• Methodological Impact: The study validates the use of co-design to create interventions that are not only scientifically sound but also acceptable and feasible for the target population. It highlights that involving end-users leads to tangible improvements in safety and user experience that researchers might overlook.
• Future Implementation: The developed "Introductory Package" and refined protocol provide a scalable model for implementing aquatic RBT in diverse clinical settings.
• Research Gap: This work fills a critical gap in the literature by moving from theoretical benefits of water therapy to a concrete, user-tested protocol for reactive balance control, paving the way for future randomized controlled trials to test its efficacy in reducing fall rates.

Conclusion: The study successfully demonstrates that a co-design approach is essential for developing complex rehabilitation interventions. The resulting AquaReBal program is a promising, user-centered solution for fall prevention that leverages the unique properties of water to overcome the limitations of traditional land-based training.