Cerebral palsy is a neuromuscular disorder affecting the lives of individuals spanning from childhood to adulthood. It is caused by the brain being damaged before it is fully developed, this usually occurs before birth (3). It is a disorder that causes changes in movement, posture, and muscle tone (9). There are many symptoms, associated with cerebral palsy, including, abnormal reflexes, rigidity, involuntary movements, and unsteady walking. These symptoms usually occur at infancy or early childhood (3).
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Aquatic therapy is a type of therapy that occurs in the pool; it has many properties that can make it more beneficial to patients than land therapy. Buoyancy in the pool reduces compression and weight bearing on the joints (9). This reduces the risk of falling in the pool, even when balance and strength are challenges for the individual on land (10). This property of the water can reduce or eliminate pain with movement. Surface tension in the pool can result in ballistic movements and torque for the joints involved, resulting in large movements with limited pain, which can be very beneficial to the patient (7). Out of several options to reduce the effects of cerebral palsy, aquatic therapy is practical for these children. It is the most practical because of spastic movements and achieving more range of motion in the pool, being able to balance better, and reducing pain while getting strength back into the joints (10). It can get the children the functioning skills they need to live a relatively typical childhood. The water is going to be a great place to reduce pain for these children while getting them the strength and functioning necessary for them (8). Research suggests that aquatic therapy can have a significant effect on overall motor function in children diagnosed with cerebral palsy.
SIGNIFICANCE OF THE PROBLEM
Cerebral palsy is the most common of all childhood disabilities. Ten thousand babies and infants are diagnosed with cerebral palsy each year. Forty percent of the cases of cerebral palsy have a severe case of it. Currently, 764,000 people in the United States are living with the symptoms of cerebral palsy (13). The cost for a family to care for a family member with cerebral palsy is detrimental. It costs a family approximately $921,000 to care for a loved one diagnosed with cerebral palsy. That number does not include out-of-pocket expenses, lost wages of the family members caring for the child, and emergency room visits (13). Many children with cerebral palsy cannot dress themselves, feed themselves, or care for themselves in any way (14). This is a huge cost on the family, who needs to have someone home at all times to care for the child or who needs to pay for extra help to take care of the child.
With aquatic therapy, these children will get more movement in joints, allowing them to do more daily activities on their own (9). This could potentially reduce the amount of time off of work for family members, or the amount of money spent on caretakers for the child. When the child can do more activities, they will eventually be able to get enough motion to play like healthy children can. This will majorly improve the quality of life for these children and will reduce the burden on them and their families.
REVIEW OF THE LITERATURE
Individual Aerobic Training
Many children diagnosed with cerebral palsy do not have much aerobic capacity when it comes to physical activity. They are unable to run around and play as much as healthy children can, so they do not have the same endurance and aerobic capacity. Aerobic capacity is a very important component of physical fitness. Aerobic capacity refers to your cardiovascular fitness. Cardiovascular fitness is vital for people, as it reflects how much oxygen is being delivered to active muscles from the blood pumped by the heart (14). This is vital for performing daily activities, the better your cardiovascular fitness the better you can do physical components of life, as you are getting more oxygen to the muscles throughout your whole body. Having a good aerobic capacity can reduce your risk for serious diseases, such as cardiovascular disease, diabetes, stroke, and many more (9).
The aquatic therapy based studies performed by Declerck, Feys, and Daly (4), Dimitrijevic et l. (5), Fragala et al. (6), and Oliveria et al. (12), included individual aerobic training to see how motor function was affected in children with cerebral palsy. These studies looked at children with mean ages ranging from 5.2 to 10.6. The children were rated on the Gross Motor Function Classification System (GMFCS) scale, ranging from I to III. The children were rated on the scale by doctors, based on being able to walk with or without assistive devices, climbing stairs with or without holding onto the railing, running, and jumping (9). While each aerobic training study varied in length, they all had four different measurements. Twice before the intervention began, once when the intervention ended, and once a while after the intervention ended (4, 5, 6, 12).
Each researcher used a different method to test the changes in aerobic capacity. Decklerck, Feys, and Daly (4) had the children walk 14 meters at a comfortable pace, Fragala et al. (6) had the children walk as fast as possible over a 25-meter course, and Dimitrijevic et al. (5) had the children do a walking test while measuring heart rate and VO2max. Oliveria et al. (12) measured aerobic capacity by testing rectus femoris activation while walking, unlike the rest who focused on physical components rather than anatomical components.
While each aerobic training study had a different duration, there were significant changes from the baseline measurements to measurements taken after the intervention ended. The children all had significant improvements in aerobic capacity. However, there was not improvement seen from the measurement when the intervention ended to the measurement a while after the intervention ended. This showed that improvement was maintained, but no more aerobic endurance was gained once the intervention ended (4, 5, 6, 12).
Individual Strength Training
Many children with cerebral palsy lack strength in their muscles. They are unable to run around and play as much as healthy children can which contributes to less muscle tone, along with if they need to be in a wheelchair when traveling long distances (9). Strength training is very important for children with cerebral palsy; as the children gain more strength and tone in their muscles, they can move better meaning they can do more for themselves and can play better with friends. Strength is a very important component for everyday functioning, so you can move your body in ways necessary to perform everyday tasks (9).
The aquatic therapy based studies performed by Adar et al. (1), Lai et al. (11), and Sharan and Rajkumar (17), included individual strength training to see how motor function was affected in children with cerebral palsy. These studies looked at children with mean ages ranging from 7.08 to 9.7. The children were rated on the GMFCS scale, ranging from I to IV. While each strength training study varied in length, they all had two different measurements. Once before the intervention began and once when the intervention ended (1, 11, 17).
Each researcher used a different method to test changes in muscular strength. Adar et al. (1) worked on strength training of the children’s knees, ankles, and feet; he tested changes in strength using the Timed Up and Go Test. Sharan and Rajkumar (17) worked on balance training to strengthen the legs of the children, Sharan used the Timed Up and Go Test, like Adar did. However, Sharan and Rajkumar (17) used another test to measure muscle strength, the Pediatric Balance Scale. Lai et al. (11) worked on strengthening the upper and lower extremities, unlike the other researchers who only focused on lower body strengthening. Lai et al. (11) tested the strength gains using the multiple scales, the Modified Ashworth Scale and the 66-item Gross Motor Function Measure.
While each strength training study had a different duration, there was a large improvement from the baseline measurement to the measurement taken when the intervention ended. The children all had significant improvements in functional strength (1, 11, 17). When taking measurements, the researchers observed decent improvements in balance. There was a slight improvement in aerobic capacity observed by all of the researchers (1, 11, 17).
Group training can be very beneficial to children. Group training creates an environment where the children can do activities together and have a support system in place. These children bond and can support each other through the difficult process of therapy (10). That can be very beneficial to children going through this process, as it can be long and can be exhausting for these children.
The aquatic therapy studies performed by Ballaz, Plamondon, and Lemay (2), Fragala, Haley, and O’Neil (7), and Ryu et al. (16), included group training to see how motor function was affected in children with cerebral palsy. These studies looked at children with mean ages ranging from 9.7 to 17.25. The children were rated on the GMFCS scale ranging from I to IV. While each group training study varied in length, each had two measurements. Once before the intervention began and once when the intervention ended (2, 7, 16).
Each researcher used a different method to test the effects of group therapy. Ballaz, Plamondon, and Lemay (2), Fragala, Haley, and O’Neil (7), and Ryu et al. (16) tested cardiorespiratory endurance and strength. Ballaz, Plamondon, and Lemay (2) measured cardiorespiratory endurance by measuring EEI and heart rate, while Fragala, Haley, and O’Neil (7) measured it by a half mile walk/run, and Ryu et al. (16) measured it by a 20-meter walk test. Ballaz, Plamondon, and Lemay (2) measured strength by using a dynamometer on the children’s quadriceps and hamstrings and Fragala, Haley, and O’Neil (7) and Ryu et al. (16) measured strength by using a chatillon dynamometer. Fragala, Haley, and O’Neil (7) measured the motor skills of the children; she did this by using the M-PEDI and FTS.
While each group training studies had a different duration, there was improvement evaluated between the two measurements. The children had a slight improvement in aerobic capacity (2, 7, 16). There were no improvements measured for balance or strength of the individuals (2, 7, 16).
Aerobic capacity improved with individual aerobic training (4, 5, 6, 12). It improved significantly with therapy that was held for multiple weeks, with sessions being held twice a week (4, 6, 5). In the study by Oliveria et al. (12), aerobic capacity only improved slightly; the largest possibility for this is because the study only lasted one day. Aerobic capacity improved moderately with individual strength training and with group training (1, 2, 7, 11, 16, 17).
Functional strength improved significantly with most studies of individual strength training (1, 17). In the strength training study by Lai at al. (11), strength only improved slightly. This is most likely because the mean attendance rate was only 88.3%, many of the kids missed therapy sessions due to upper respiratory infections. Functional strength improved moderately with individual aerobic training (4, 5, 6, 12). Functional strength showed no change with group training (7, 2, 16).
Balance improved significantly with two of the individual aerobic training studies (4, 6). Balance only slightly improved with the individual aerobic training studies conducted by Oliveira et al. (12) and Dimitrijevic et al. (5). This is likely due to the study by Oliveira et al. (12) only lasting one day and Dimitrijevic et al. (5) having solely aerobic training as the main purpose of his study. Balance improved significantly in two of the individual strength training studies (1, 17). In the study conducted by Lai et al. (11) balance was only slightly improved. This is probably due to the slightly low attendance rate. Balance was not changed in the studies performed with group therapy (2, 7, 16).
Aquatic therapy can be very beneficial in improving overall motor function in children with cerebral palsy. It can help show major improvements in aerobic capacity, functional strength, and balance (1, 2, 4, 5, 6, 7, 11, 12, 16, 17). These are all improvements that will help the child get functioning so that they are able to do more activities for themselves. It will make improvements and will help that child be able to do things such as dressing themselves, feeding themselves, and playing with friends. These children deserve to have a childhood where they can function to the best of their abilities and can play and do things children should be able to do. Aquatic therapy is one of the best methods of doing that. It gets the child function necessary, while making gaining the function fun, and is close to painless (15). It is relatively cheap compared to the amount of money the family would be spending to care for the child otherwise, that includes extra help, staying home from work, emergency room visits, which would all be decreased with aquatic therapy treatments.
Future research should be done with more children higher on the GMFCS scale, to see how well aquatic therapy helps children with more severe cases of cerebral palsy and less motor functioning from the start of the therapy sessions. Many studies done by researchers, include children with more motor functioning from the start. The children in the studies were all able to walk with or without assisting devices (5, 6, 7, 8, 12, 16).
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Future research should be done to see how aquatic therapy can help children with cerebral palsy when started early in life, around birth and infancy, to see if they can get motor function sooner and how that will affect the quality of life of these children. It would be interesting to see if more motor function is gained and if it is gained faster, when started very early in childhood. However, the exercises would all have to be done passively as the children would not be able to swim yet. Many studies performed by researchers, include children with mean ages of seven to ten (3, 5, 6, 7, 11, 16). Research should be done on children below the age of four to see how the children gain motor function back and the amount of time this takes.
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