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Potential Benefits of the Aquatic Exercise on Secondary Health Conditions in Adults with Cerebral Palsy

 

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Potential Benefits of the Aquatic Exercise on

Secondary Health Conditions in Adults with Cerebral Palsy

By Michael R. Murray, SPT

brevard 3 004

Overview

Cerebral palsy (CP) is considered one of the most common physical disabilities of children, with a worldwide prevalence of 2.11 per 1,000 live births and as many as 3.1–3.6 per 1,000 8 year old children in the United States.1-4 It is estimated that over 1,000,000 children and adults currently live in the United States with CP, with those with mild to moderately severe CP having similar life expectancies to the general population.5,6 While CP is not considered a progressive disease, there is a higher prevalence of certain psychosocial and physical changes that occur in individuals with CP as they age when compared to their peers. Not all adults with CP have health problems but their underutilization of health screenings and health promotion activities as well as increased sedentary time, decreased physical activity and exercise, and chronic disease risk has been a cause for concern in the academic literature.3,4,6-23 Another reason for looking primarily at adults with CP is that much of the research is focused on children and there is an overall decrease in the utilization of health and related services once adolescent transition out of the school system into adult services which could have further health implications.6,24-26

The purpose of this paper is to present secondary health conditions associated with ageing adults with CP and then to demonstrate how aquatic therapy could be a viable option to address these concerns. The consequences of decreased physical fitness and increased sedentary time will be discussed using the academic literature. Then the impact this has on the secondary health conditions that are concerning for adults with CP will be discussed with a focus on cardiovascular, metabolic, muscular, and functional mobility deterioration. Ultimately this paper will create an argument based on the current literature that the aquatic environment has significant potential to positively affect these secondary conditions to improve the wellbeing of adults with CP.27-48 Limitations in the current research and areas for improvement will also be discussed to facilitate improved studies in the future.

 

Process and Development

Initially this project started out as a PICO question as part of the EBP II course that stated:

In adults (18 years or older) with cerebral palsy (CP), is a land-based resistance exercise program or an aquatic-based resistance exercise program more effective at improving perceived quality of life?

Upon researching this topic more it became very clear most of the research for this topic was related to children, but that there was an overall thought that this was a positive intervention for individuals with CP. After sitting down and talking with professors, classmates, and individuals with CP, I began to focus more on some of the health changes associated with adults with CP as they aged. Reviewing the literature for secondary health conditions associated with this population revealed some trends across multiple sources. The increased sedentary time, decreased physical activity, as well as cardiometabolic, musculoskeletal, and mobility implications were consistent in most studies. 3,4,6-23

The next step was to determine if the evidence for aquatic therapy could suggest positive implications on these secondary conditions. Using the information from the EBP II CAT (found below) combined with research regarding the properties of water and positive implications for similar populations, an argument could be formed to propose the potential benefits of using the aquatic environment to positively affect health outcomes in adults with CP.

Initially the goal was to create an online presentation that could be distributed to PT’s and other health care professionals. After talking to numerous PTs at CSM who work with adults with CP and/or in the aquatic environment, it became clear that a paper that could be published in an academic journal would be the more appropriate venue for this information.

 

The Paper

As mentioned previously the product is an academic paper that will be submitted to the Journal of Aquatic Physical Therapy for review in hopes of having it published in their journal. One of the requirements for the submission process is that the paper cannot be published in any other form in order to submit it for approval in the journal (http://www.aquaticpt.org/pdfs/JAPT-Author-Guidelines.pdf). As a result, the introduction above is a summary of the abstract for the paper and I’ve included a link below to the outline of the paper to help gain a better understanding of the paper’s content.

Essentially the paper will describe prevalent secondary health conditions in adults with CP, describe how this is related to sedentary time and physical activity, discussion how exercise in the aquatic environment can positively affect these areas, briefly discuss special considerations to make when developing a plan, provide some intervention ideas, and then discuss where the evidence is lacking as well as where to progress from this point in time.

 

Reflection

The process from the start of my capstone to now has taken many turns. Initially the goal was to create a visual presentation in the form of a video that could be uploaded to a website like YouTube in order to share with the most number of people. The hope was to use a visual medium to show all the information as well as intervention ideas to help people who work with adults with CP and the adults themselves to develop an exercise program. Some feedback I received from classmates was that they “knew” aquatic therapy was “good” but they had no idea what it really meant to do aquatic therapy. This is why giving specific, evidence based aquatic intervention ideas is important to have included in the paper as well.

After travelling to Indianapolis for CSM, I began speaking to any and every PT I could about my capstone idea and I received the same feedback every time… “Are you going to publish this?” It got me to thinking that a paper might be the better final product for this. I still wanted to include interventions based on evidence in the literature and had already done the work regarding secondary conditions, aquatic therapy for individuals with CP, as well as facilitators and barriers to exercise for individuals with CP. The paper just seemed the best option.

Writing the paper itself is a very long and painstaking process. I did the research and put useful quotes and important points into a document. From here I took this information and formed an outline of the main points I planned to make and the evidence to support those points. The outline listed below is actually the second draft of the outline, showing that this has been an evolving process all along. As I began to write, I found that each statement I made was backed up by multiple sources. So including the appropriate sources for the statement almost takes more time then writing the sentences themselves.

Ultimately I hope that this paper shows the efficacy of using the aquatic environment to help improve the lives of adults with CP, since they are often a forgotten group of people once they transition out of the school system.

 

Links:

EBP II CAT: Click Here for CAT

Capstone paper Outline: Click Here fore Outline

 

Acknowledgements

Special thanks are owed to Deborah E. Thorpe, PT, PhD; Darcy L. Cooper, PT, DPT; and Karen L. McCulloch, PT, PhD, NCS for their expertise, insight and suggestions throughout the research and writing process. Additional thanks are owed to Bess Maxwell, PhD, PT; Lauren Flynn, PT; Jim Schaeffer; Ariana Bevilacqua; and Corinne Bohling for their support and unique perspectives that helped to finalize the content of this paper. A special thank you is owed to my parents and Patricia Daly, who first sparked my passion for the water that continues to this day.

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4 Responses to “Potential Benefits of the Aquatic Exercise on Secondary Health Conditions in Adults with Cerebral Palsy”

  1. Vicki Mercer

    Hi Michael,
    Looks like you have done a great job on this project! You obviously have been very thorough in compiling and reviewing the existing evidence. Best of luck in getting your manuscript published – remember, if at first you don’t succeed, revise and resubmit!!

    Best,
    Vicki

    Reply

  2. Michael R. Murray

    Thanks Gary and Lorna,
    To speak to your comment Lorna the earlier than expect aging is across multiple areas. Obviously our body systems do not live in a vacuum and as such they have some inter-relatedness when it comes to the premature ageing. From what I can tell there is a big relationship between cardiovascular decline, metabolic dysfunction, chronic inflammatory conditions, obesity, and musculoskeletal disorders. These may have more to do with behaviors such as sedentary time and activity level but a direct cause and effect is hard to determine right now since this has been a booming area of research within the past 3-10 years. You also brought up a good point that there is a huge spectrum across which people with CP can present so explicit exercise ideas may be difficult but my hope is to share a plethora of ideas from the literature to show the efficacy of using the aquatic environment across GMFCS levels. As for specific recommendations, well, there aren’t really any except that we are not getting this adults to high enough intensity levels, so I’m using recommendations from The American College of Sports Medicine and some of the research that says that using the aquatic environment appropriately can get close to appropriate intensity levels. Thank you both for your comments and ideas!

    Reply

  3. Lorna Troost

    Hi Michael,

    First, I think your chosen topic is extremely valuable. I recently spoke to my aunt (58, with CP) who has been extremely motivated to improve her fitness and use of her involved UE. She very much wishes to improve her function, yet has a hard time getting her medical providers to consider her for therapy. I haven’t seen many neuro PTs take on adult patients with CP, and many PTs who work with teens with CP are uncomfortable working with adults, but it’s not as if this condition somehow goes away when the patient turns 18. I think this topic needs to be talked about more!
    While I’m sad I can’t read your actual paper (yet), it is terribly exciting that you’re submitting it for publishing! I found reading your outline had a large number of interesting points (though of course I look forward to reading the actual paper). I’m going to just touch on a few of them. First, I was surprised to learn that adults with CP can experience earlier age-related changes. From context, I’m assuming this is mostly referring to orthopedic changes, but does this also mean neurologic/vestibular/etc. changes as well? This is particularly interesting in light of the fact that under life expectancy, those with CP without severe conditions tend to live around as long as the general population. I suppose maybe this is because CP is such a variable condition, and includes many individuals with only mild impairments.
    I was glad to read about the sedentary time verses activity in relation to mortality. I suspect we have all heard of the various studies linking sedentary behavior and desk jobs to mortality, even in those who exercise regularly. This article is an editorial, but references much of that literature (http://annals.org/article.aspx?articleid=2091332). This is of course relevant for any population (certainly, think about how much sitting we’ve been doing in the third year!), but particularly for those with mobility impairments. I imagine creating exercise/physical activity guidelines for adults with CP is challenging at least partially because functional levels vary so significantly.
    I’m also really impressed with the visuals provided in your outline! I think they do a good job of illustrating points and adding to your discussion. Great discussion on various approaches to aquatic therapy. I found I could picture each method you were talking about, which is a rare thing with therapy descriptions! One of my big frustrations in reading literature is that protocol descriptions are generally at least decent in describing reps and sets, but sort of horrible at describing the actual interventions. How useful are studies that you can’t replicate because of insufficient description? All of this is to say great job on descriptions.
    Even just the outline contains so much useful information. I think it’s wonderful you chose this topic, since adults with CP deserve more research, and aquatic therapy is such an effective and safe modality. I look forward to reading the full paper some day! Like Gary said, please keep your classmates posted on its status.

    Lorna

    Reply

  4. Gary Johnson

    Michael, good luck getting published! It is great that you have decided to take a gap in evidence and use it for your Capstone project. Looking at your outline the charts look great and will be well recepted by us visual learners. I also like how you tie the health conditions associated with CP in with how they can be affected by aquatic therapy. That seems to be a great way to demonstrate the benefits of pool therapy. I am excited to read the final product of this paper, let me know when it’s finished!

    Reply

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