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The Benefits of Aquatic Resistive Exercise for Adults with Cerebral Palsy

 

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The Benefits of Aquatic Resistive Exercise for Adults with Cerebral Palsy

Emily Elizabeth Paul, SPT, ATC

Overview

Not only children are affected by cerebral palsy (CP).1 In the United States alone, there are an estimated 500,000 adults living with CP.1 Although CP is a non-progressive neuromuscular disorder, it can cause progressive motor impairments and posture disorders throughout the lifespan that significantly impact the adult population.2–4 The life expectancy of individuals with CP can be influenced by the severity of cognitive, motor, ambulatory, and visual impairment, but is similar to that of their typically developing peers.4,5 As these individuals with CP progress into adulthood, they often develop secondary conditions such as decreased range of motion and cardiovascular endurance, muscle weakness, obesity, osteoporosis, increased muscle tone, and spasticity.1–3,5–7

With a background as a competitive swimmer, I have always loved the water. Throughout physical therapy (PT) school, I have spent a substantial amount of time treating patients in an aquatic setting and expanding my knowledge of aquatic physical therapy through clinical coursework and observation experiences. During the fall semester, I completed part of my Integrated Clinical Experience with Dr. Thorpe where I treated patients with a variety of neurological disorders, including CP. This experience helped to spark my interest in the benefits of aquatic resistive exercise for this population. The knowledge I have gained from this project and my experiences throughout school have further confirmed my passion for working with patients in an aquatic environment. I am looking forward to integrating some of this information during my final clinical which is focused on aquatics and as I begin my career as a physical therapist.

Statement of Need

Because access to care becomes increasingly difficult for adults with CP and because secondary conditions can contribute to fatigue, chronic pain, and decreased function and mobility, medical professionals need to be aware of effective interventions for this population.3,11 While there is a substantial amount of evidence regarding effective interventions for children and adolescents with CP, there is little evidence related to interventions for adults.3,8–10 The evidence that is available indicates that aquatic resistive exercise can be beneficial as a life-long fitness activity and may also help to prevent some of the secondary conditions associated with CP.3 Unfortunately, only one study has looked at the adult population and all of the available studies have small sample sizes and poor methodological rigor.3

Products

 For the development of this project, I completed a literature review relating to the benefits of aquatic resistive exercise for adults with CP. The resulting final product serves as the background section for any papers written using the data from Dr. Thorpe’s Project ACT NOW. This study was conducted in 2008 and investigated the effects of an aquatic resistive exercise program on muscle strength, musculoskeletal pain, cardio-respiratory fitness (VO2peak), gait speed, health-related quality of life, activity level, and mobility in adults with CP. To date, the data collected during this study has not been written up or published. Due to a lack of evidence on adults with CP, there is a need to publish on these results.

The background was written in accordance with the manuscript requirements for Pediatric Physical Therapy. The intended audience for this project includes other physical therapists and medical professionals who read the article and are interested in aquatic therapy and/or adults with CP or other developmental disabilities.

Self-Assessment

Completion of this project has challenged me to strive for excellence and has improved my academic writing. Throughout the writing process, I had to learn how to make my writing thorough yet concise. The biggest challenges for me in the writing process were to avoid using slang terms and to avoid rephrasing the same concept more than one in the paper. Feedback from my committee members at midterm really helped me be able to critique these areas and identify repetition. Further, because I was ahead of my timeline, I took about three weeks off of working on the background so when I returned to it, I was able to see the paper with fresh eyes. If doing this project over again, I would put a few weeks in the timeline that are dedicated as a break to allow for some time away from the project.

My project has been through about eight revisions since January. Dr. Thorpe has been a great mentor as she has challenged me to continually make revisions and to rework the material to make sure it flows well while still being professional and concise. Additionally she helped me identify key authors that must be cited in order for this product to be respected in the field. Her knowledge in this area was extremely beneficial as I reduced my number of sources in an effort to be compliant with the guidelines for publication set forth by Pediatric PT.

Other than using too many sources, I successfully adhered to the Pediatric PT guidelines for publication. My final product is versatile and can be easily revised to complement any full manuscript that is drafted from the Project ACT NOW data.

Additional Works

Throughout the past year I have chosen projects and catered my coursework to relate to the topic of aquatics and adults with CP, which has helped to broaden my knowledge of pertinent literature. A description of and links to my relevant additional works are available below.

PHYT 752-Evidence Based Practice II:

A Clinically Appraised Topic that assesses if aquatic resistive exercise is effective in improving gait speed in ambulatory adults with CP (21 years and older).

PHYT 875-Advanced Orthopedic Assessment:

My final project for this course was entitled Hip Osteoarthritis in Patients with Cerebral Palsy: Pathogenesis, Prevention, and Treatment. This paper explores one of the common secondary complications that adults with CP face and explains how hip osteoarthritis develops, how body mechanics influence it, prevention tactics, as well as numerous treatment options.

PHYT 824-Health Promotion and Wellness:

While not specific to adults with CP, the community health promotion program I designed in this class allowed me to become more familiar with aquatic resistive exercise. This program presented is a 10-week aquatic exercise course for obese adults (over age 65) with knee osteoarthritis in Orange County, NC.

Acknowledgements

The completion of this project would not have been possible without the guidance and support of my capstone project advisor, Dr. Debbie Thorpe, PT, PhD. I appreciate the significant amount of time she spent meeting with me to discuss my progress and for encouraging me to create the best product possible. Additionally, I would like to thank my committee members, Dr. Ilana Levin, PT, DPT, and Jennifer Newman, MSPT. I sincerely appreciate the time they took to review my paper and provide me with feedback. Their comments and feedback really helped strengthen my final product.

I would like to thank the University of North Carolina Division of Physical Therapy faculty members for their excellent teaching and mentorship, as well as my classmates and close friends for encouraging me throughout the past three years. Finally, I would like to thank my parents for always supporting me and emphasizing the importance of dedication to my education.

References*

 

  1. Svien LR, Berg P, Stephenson C. Issues in aging with cerebral palsy. Top Geriatr Rehabil. 2008;24(1):26-40. doi:http://dx.doi.org/10.1097/01.TGR.0000311404.24426.45.
  2. Carter DR, Tse B. The pathogenesis of osteoarthritis in cerebral palsy. Dev Med Child Neurol. 2009;51:79-83. doi:10.1111/j.1469-8749.2009.03435.x.
  3. Thorpe DE, Reily M. The Effect of an Aquatic Resistive Exercise Program on Lower Extremity Strength, Energy Expenditure, Functional Mobility, Balance and Self-Perception in an Adult with Cerebral Palsy: A Retrospective Case Report. J Aquat Phys Ther. 2000;8(2):18-24.
  4. Colver A, Fairhurst C, Pharoah POD. Cerebral palsy. Lancet. 2014;383(9924):1240-1249. doi:10.1016/S0140-6736(13)61835-8.
  5. Haak P, Lenski M, Hidecker MJC, Li M, Paneth N. Cerebral palsy and aging. Dev Med Child Neurol. 2009;51(SUPPL. 4):16-23. doi:10.1111/j.1469-8749.2009.03428.x.
  6. Fowler E, Kolobe T, Daminano D, et al. Promotion of Physical Fitness and Prevention of Seconday Conditions for Children with Cerebral Palsy: Section on Pediatrics Research Summit Proceedings. Phys Ther. 2007;87(11):1-16. doi:10.1007/s13398-014-0173-7.2.
  7. Verschuren O, Peterson MD, Balemans ACJ, Hurvitz EA. Exercise and physical activity recommendations for people with cerebral palsy. Dev Med Child Neurol. February 2016. doi:10.1111/dmcn.13053.
  8. Dodd KJ, Taylor NF, Damiano DL. A systematic review of the effectiveness of strength-training programs for people with cerebral palsy. Arch Phys Med Rehabil. 2002;83(8):1157-1164. http://www.ncbi.nlm.nih.gov/pubmed/12161840. Accessed February 26, 2016.
  9. Fragala-Pinkham MA, Smith HJ, Lombard KA, Barlow C, O’Neil ME. Aquatic aerobic exercise for children with cerebral palsy: a pilot intervention study. Physiother Theory Pract. 2014;30(2):69-78. doi:10.3109/09593985.2013.825825.
  10. Thorpe D. The role of fitness in health and disease: Status of adults with cerebral palsy. Dev Med Child Neurol. 2009;51(SUPPL. 4):52-58. doi:10.1111/j.1469-8749.2009.03433.x.
  11. Brakke R, Singh J, Sullivan W. Physical Therapy in Persons With Osteoarthritis. Pm&R. 2012;4(5):S53-S58. doi:10.1016/j.pmrj.2012.02.017.Picture available from: http://ih.constantcontact.com/fs135/1102844965205/img/321.jpg?a=1117375592639*For a comprehensive list of references, please see the complete background.

5 Responses to “The Benefits of Aquatic Resistive Exercise for Adults with Cerebral Palsy”

  1. Emily Paul

    Hi Katie,
    I am glad you enjoyed reading my material. As far as equipment that I like to use, I mentioned above that I like to use noodles, bar bells, kick boards, hydrotone bells and boots, floatation belts, neck floats, flippers, and ankle weights. As far as techniques that I like, it is difficult to chose just one. Anything that involves using the buoyancy of the water for strengthening is one of my go to exercises. I also like this because the turbulence of the water really challenges a person’s core strength. Also, for stretching, I like having a patient float on the surface of the water (with a noodle and neck float). This can be challenging for patients who aren’t very comfortable in the water, but as you establish trust with the patient, this becomes much more feasible.

    If you ever have any more specific questions, please feel free to contact me.

    Emily

    Reply

  2. Debbie Thorpe

    Hi Emily
    Fantastic job on this manuscript Introduction!! All the meetings and editorial suggestions paid off. You have a very concise, comprehensive Introduction that will kick off several of my aquatic intervention articles from the study!! I really enjoyed working with you . Your writing improved before out eyes!! I appreciate your organization and responsibility to deadlines. It was a pleasure to work with you….look for your name in print, hopefully soon:)

    Debbie

    Reply

  3. Emily Paul

    Hi Marian,
    Thanks for your comments! It is possible to have too many sources which was also news to me since I feel like I commonly read articles with over 100 sources. However, for Pediatric PT, only 30 sources are allowed for an entire manuscript. I kept my number of references to about 28 (after making cuts) because it is clear that more sources will need to be integrated in the rest of the background.
    In response to your question about equipment and costs, there isn’t any required equipment, but noodles, bar bells, kick boards, hydrotone bells and boots, floatation belts, and ankle weights are some common pieces of equipment that are often available at public pools or fitness centers. These products aren’t terribly expensive, but the chlorine from the water can cause them to deteriorate quickly. In order to help them last longer, I would recommend that they be washed off with cold water after each session. Yet, because of the properties of water, a person is able to complete aquatic resistive exercise without equipment. However, this can make it difficult to progress after a certain point.
    As far as cost for the patient, aquatic therapy can be expensive if not covered by insurance. A lot of clinics that are at fitness facilities will often offer membership discounts for PT patients after they are discharged. But I would say that for patients to benefit from aquatic resistive exercise, they need to exercise regularly. This can be quite a time commitment especiall for patients with mobility impairments because it takes then longer to get in and out of the water,

    Reply

  4. Katie Sly

    Hi Emily,
    I enjoyed reviewing the background you prepared for potential publication with Dr. Thorpe’s research. I hope that she can include this in a publication in the near future.

    Your background information was an especially helpful review of the properties of water and how these properties may be utilized in rehabilitation. Additionally, your coursework over the past year has thoroughly explored aquatic therapy and CP.

    In your background review, you mentioned the benefits of stretching, strengthening, and functional activities in the water for people with CP. Are there any particular techniques that you find are very useful in practice and/or is there any equipment that seems to be especially helpful?

    Again, great work! Your capstone project was very informative!
    Thanks,
    Katie Sly

    Reply

  5. Marian Thomas

    Emily –

    I enjoyed reading your background information (you had too many sources? I have not heard of such a thing!). Your paper succinctly described how the properties of water could directly help the impairments associated with CP. It also brought to mind two symptoms I typically do not associate with this disease – pain and depression. Aquatic resistive exercise sounds like a great tool for these patients to stay active and prevent the comorbidities that occur commonly with this disease.

    Hopefully Dr. Thorpe’s research can provide a starting point for exercise prescription for the adult population with CP. It would be a great resource for as an outpatient PT who would like to get their patient involved in an independent program in the local community.

    This may be a more logistical question, but what type of equipment does the patient need to complete resistive exercise and what is the associated cost? Do pools typically have this type of equipment, or would the patient have to buy it for themselves? Or is there a way to perform these exercises without equipment? Just wondering what type of investment the patient may need to make!

    Great work!

    Marian

    Reply

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