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Aquatic Therapy for Treatment of persons with Cerebral Palsy

Posted on Aug 04 2020
Posted by: Dr Brinda Merchant

As the adage goes“Thousands have lived without love, not one without water”. Importance of water is subconscious knowledge, which we are born with. Man has known and utilized therapeutic benefits of water for thousands of years. Swimming is one of the oldest forms of exercises known to man. 10,000-year-old rock paintings of people swimming were found in the Cave of Swimmers near Wadi Sura in southwestern Egypt.

The earliest known use of water for aquatic therapy or aqua therapy was by Swiss monks who used thermal water to treat those who had problems related to movement. Aquatic therapy or hydrotherapy as it was known then was used as a treatment mode for soldiers fighting the world war two. President Roosevelt of United States experienced the magic of aquatic therapy for pain and paralysis, resulting from poliomyelitis.

With passing years Aquatic Therapy, previously known as Hydrotherapy has evolved in terms of techniques and application. Today this method of treatment stands on a firm foundation of scientific evidence, and positive effects have been reported by patients and members of medical fraternity. It is widely used for treatment of various movement related disorders, caused by neurological concerns in both adults and children .

Aquatic therapy is used worldwide for as an integral part of treatment in children with Cerebral Palsy. It is amongst the forms of therapy, proven to benefit children with Cerebral Palsy.

Cerebral palsy (CP) is a group of disorders that affects a person’s ability to move and maintain balance and posture. CP is caused by abnormal brain development or damage to the developing brain that affects a person’s ability to control his or her movements.

Persons with Cerebral Palsy usually have gross motor and fine motor developmental delay. They may have poor posture, balance, co-ordination and may face difficulties in walking. Arm and hand function may be affected. There may face concerns with feeding and speech. Many have associated problems like vision concerns, hearing concerns, and epilepsy.

Children with Cerebral palsy undergo aggressive therapy for gaining maximum functional independence. In severe cases, therapy is given for enhancing quality of life and care-giving ease.They may undergo medical and surgical procedures like BOTOX ,muscle and bone surgeries ,for optimizing posture and movement.

Therapies may broadly include physiotherapy, occupational therapy, speech therapy and cognitive therapy.Advanced therapy options which may accelerate and enhance progress include aquatic therapy and robotics.

American Physical Therapy Association defines aquatic therapy or aquatic physical therapy (APT) as “the evidence-based and skilled practice of physical therapy in an aquatic environment by a physical therapist.” Aquatic Therapy includes “treatment, rehabilitation, prevention, health, wellness, and fitness of the patient/client population in an aquatic environment with or without the use of assistive, adaptive, orthotic, protective, or supportive devices and equipment.”

A question may arise in your minds “Why not swimming,why aquatic therapy”. While swimming is one of the best forms of exercise to improve stamina, it is an activity which takes place primarily in horizontal position.Whereas aquatic therapy/aqua therapy is geared at improving vertical functions like standing and walking.

Foundation of aquatic therapy is based on utilization of physical properties of water so that person may achieve improvement in vertical functioning.With aquatic therapy we aim at improving mobility,muscle strength,stamina,posture and overall movement.Improvements achieved are then translated into functional carryover, with appropriate combination of land based therapy.

Four cornerstones of Aquatic Therapy are buoyancy,viscosity, hydrostatic pressure and therapeutic warmth. These are properties innate to water, which are used by therapists for improving movement function in persons with Cerebral Palsy.

Buoyancy is the upward thrust provided by water. It is a force opposite gravity. Buoyancy helps a body float in water. When we are immersed in water, it helps off load our body weight, hereby making us feel lighter. When immersed upto chest depth, body weight is off loaded by 75 percent which effectively means that only 25 percent of body weight is experienced. The benefits of buoyancy for persons with Cerebral palsy are numerous, including decreased joint compression forces and lesser stress on connective tissues. Buoyancy supports weak muscles, flexibility and range of motion is greater, and helps strengthen muscles when working in a direction opposite buoyancy. For therapists, it increases ease of handling.

Viscosity is the resistance of a fluid medium. It is a measure of the frictional resistance caused by forces between molecules of liquid. Anequal amount of resistance towhile moving in any direction while inside water due to viscosity. So while the body feels lighter because of buoyancy, resistance is still provided by water to movements, which aids strengthening. More the force exerted by body,more is the resistance, which makes strengthening possible without using additional weights.

Benefits of resistance of movement due to viscosity include improved muscle strength and tone,and improved heart and lung function. Resistance of water will especially assist patients with Cerebral Palsy due to dampening of involuntary movements.

Simply walking in water provides ten times more resistance than walking on land due to the viscosity of water. This means that even by doing simple movements, patients can experience deep exercise, building muscle and increasing muscle control more quickly and effectively, all without placing undue stress on their joints.

Hydrostatic Pressure is pressure exerted by water on immersed body. It is proportionate to depth of immersion.Hydrostatic pressure and buoyancy act together to provide support to the body. Hydrostatic pressure has different effects on a person’s nervous system, cardiovascular system, renal system and respiratory system. Constant sensory input is provided by exertion of pressure and through water resistance. This aids in overall sensory processing. The weight of the water on chest provides resistance to the respiratory muscles and forces air out of the lungs, improving the inhalation muscles and assisting with exhalation. Blood flow to kidney increases. There is an improvement in circulation.

Therapy pools are usually temperature controlled, temperature being in the range of 31degree Celsius to 32.5 degree Celsius .Immersion in warm water causes our body to relax, soft tissue is more pliant and muscle spasm reduces there is considerable pain relief,and range of movement improves.

Some benefits of aquatic therapy in Cerebral palsy may be illustrated bythese cases.

Ameya, 3 year old male child with level 3 GMFCS with Spastic Diplegic kind of Cerebral Palsyunderwent treatment at AquaCentric Therapy .He was undergoing aquatic therapy in combination with land based therapy for achieving standing balance and walking independence. Aquatic Therapy was incorporated as part of his treatment regimen to strengthen hismuscles and improve his movement control. Water was a fun environment for him to exercise in.He is highly motivated for therapy inside water, and therapy can easily be achieved in a playful and pain free manner. According to therapist and parents child was extremely compliantfor therapy,which in turn was very helpful to facilitate correct movement.Some of the exercise strategies, used during this therapy included:

  • Water specific Therapy, based on Halliwick’s 10 point program
  • Activities to encourage weight bearing on pool training platform
  • Strengthening activities using water toys in standing and prone
  • Activities to strengthen the core muscles, which can be effectively managed in water

Vikram ,35 year old male, GMFCS level 1chef by occupationhas Spastic Diplegia, presented with pain in ankles while walking and difficulty walking due to pain. He also had difficulty with prolonged standing.He underwent 30 sessions of aquatic therapy. His treatment programme was inclusive of core and lower limb strengthening and various aqua based walking activities. Gentle joint mobilization and muscle releases were also incorporated.He experienced considerable pain relief due to offloading of joints .Additionally warm water contributed to reduction in muscle spasm. Increased overall comfort was experienced, and the client could exercise for strengthening in muscles using a vast array of techniques. Treatment for him included:

  • Bad Ragaz Ring method for strengthening
  • Aqua-Pilates
  • Strength training with various props such as dumbbells and foam rollers
  • Exercise based games for functional balance and mobility

Aquatic therapy is beneficial for persons of all ages and abilities, having Cerebral Palsy. Knowing how to swim is not necessary for undergoing Aquatic Therapy. However medical clearance is necessary prior to beginning therapy. This form of therapy is not suitable for persons with untreated,uncontrolled epilepsy,those with active infections/infectious diseases,severe skin problems,fever etc.(list not exhaustive)

Therapy begins with a thorough land based assessment .Therapy plan is formed keeping in mind client goals .An appropriate combination of land based and aquatic therapy sessions is suggested,so that both aquatic therapy compliments land based therapy and goals.

Aquatic Therapy at our centers is conducted in indoor,temperature controlled therapy pools. Pool hygiene is given highest consideration,with pools being outfitted with UV,Ozone and glass bead filters. Water ph is maintained at 7-7.5 which is as good as drinking water.Chlorine levels are minimal,maintained at 0.5-1 PPM.

Aquatic therapy interventions for persons with Cerebral Palsy comprise of techniques which utilize physical properties of water. These include Water Specific Therapy (WST), Bad Ragaz Ring Method (BRRM) and Aquatic Strengthening. Play is an integral part of all treatment sessions for children, making therapy enjoyable and functionally meaningful.

An important factor for deriving functional benefits is having skilled paediatric and neuro-physiotherapists,specially trained in aquatic therapy, design a treatment programme customized as per individual’s functional ability and limitations.

Depending on individual needs, frequency of session may be 2-5 times a week with session duration of 45 minutes.

Aquatic therapy equipment comprises of water dumbbells, foam rollers, resistance band, boards, floatation vests, neck collars, pelvis rings ,snorkels and most importantly various pool toys.

Specialized equipment used in accordance with age and ability include:

  • Electronic pool hoist: Persons with cerebral palsy may frequently have mobility issues that which make entry and exit difficult .Electronic pool hoists are used to facilitate entry and exit, making pool safe accessible for persons of all ages and abilities, eliminating need for ladders or steps.
  • Underwater Treadmill: Invaluable for gait training, underwater treadmill allows individuals to practice walking patterns which mimic land patterns. The speed of the underwater treadmill changes in small increments allowing persons to safely progress at their own speed.
  •  Height adjustable drop in platforms: These are sturdy, on slip surfaces above level of pool floor. Sitting based exercises and other strategies of water specific therapy (WST) are facilitated using pool platforms
  • Underwater stationary cycle: These are designed for improvement of cardiovascular endurance.

In COVID times, therapies would be conducted based on recommendations listed and followed by apex organizations of Aquatic Therapy like IATF (International Aquatic Therapy Faculty) and IOAPT. Strict SOPs would be followed, in keeping with national and state norms so that therapy is a safe and beneficial experience for our clients. To get more information, you are welcome to address your queries on contact number provided.

References-:

1.https://www.cdc.gov/ncbddd/cp/facts.html#:~:text=Cerebral%20palsy%20(CP)%20is%20a,problems%20with%20using%20the%20muscles.

2.https://www.naric.com/?q=en/FAQ/what-aquatic-therapy

3.https://www.rainbowrehab.com/introduction-aquatic-therapy/

4.https://cerebralpalsygroup.com/treatment/therapy/aqua-therapy/

5. https://www.hydroworx.com/research-education/additional-resources/cerebral-palsy-aquatic-therapy/