The Effects of Aquatic Resistive Exercise on Adults with Cerebral Palsy

The Effects of Aquatic Resistive Exercise on Adults with Cerebral Palsy

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Background:

As the younger sibling of someone with an intellectual and developmental disability, I have naturally been plugged into the world of those with special needs all my life. Volunteering at weekend-long camps and Special Olympics throughout my childhood complemented my experience in supporting my brother at home and in the community. Because of this, it made sense to think that I was equipped to help others overcome their mental and physical challenges, bringing me to physical therapy school and more specifically Carolina’s front door.

Fast forward to the spring of 2019, I was given the opportunity to implement an exercise program for a 17 year-old with cerebral palsy (CP). I met him at a local gym and pool one or two times per week, with the goal of stretching and strengthening his affected side. In following Dr. Debbie Thorpe’s instruction, our sessions included a variety of aquatic exercises, ranging from walking in shallow and deep water to flutter kicking and swimming. So when she approached me about publishing a similar program, Adults with Cerebral Palsy Training to Increase Overall Wellness (ACT NOW), I could not have thought of a more fitting topic to pursue in my third and final year.

Statement of Need:

There is a gap in the physical therapy community regarding aquatic resistive exercise in adults with CP, making it an underdeveloped area of research. Cerebral palsy is a neurologic disorder of childhood, and therefore, past research efforts have been devoted to young subjects. However, most children with mild to moderately severe CP survive into adulthood, with more than 500,000 people in the United States living with its effects.^1-3 They have impairments in muscle tone and strength, range of motion, cardiorespiratory endurance, cognition, communication, and balance and coordination that create a cycle of physical inactivity, thereby predisposing them to a host of secondary conditions as they age.^4,5

Exercise prescription for individuals with CP references activities at moderate-to-vigorous intensities,⁶ but gravity serves as a barrier to movement in both ambulators and non-ambulators with this condition. Water-based interventions overcome this limitation, as the unique properties of water allow for higher-intensity exercise in a gravity-minimized environment.⁷ Researchers have documented the success of aquatic exercise in children with CP, finding improvements in spasticity, walking endurance, gait and balance, quality of life, and gross motor function.^8-11 Duplication of a longitudinal, repeated measures aquatic intervention in an older-aged sample has provided information about its feasibility and effect on outcome measures, such as lean muscle mass and strength. The dissemination of this data to healthcare professionals can be used to further develop the intervention design, with the overarching goal of improving the health and fitness of adults with CP.

Purpose:

The purpose of this capstone project was to communicate evidence to researchers, physical therapists, and other service providers by writing a sufficient draft of a manuscript for publication in an academic journal. This was accomplished by working alongside Dr. Thorpe, who directed the supporting study at the University of North Carolina at Chapel Hill, to conduct a thorough review of the literature and compile all results into an article currently titled “The Effects of Aquatic Resistive Exercise on Adults with Cerebral Palsy.” Her research investigated the feasibility and effects of aquatic resistive exercise on body mass index, lean muscle mass, bone mineral density, health-related quality of life, physical activity level, pain, gross motor function, and strength in a sample of adults classified across Gross Motor Function Classification System (GMFCS) levels, providing insight into avenues for long-term management of CP.

While drafting a manuscript, my personal learning objectives were as follows:

• To improve my scientific writing skills when reporting quasi-experimental research.
• To meet all formal and informal deadlines set within the scope of PHYT 854, Capstone Project, and meetings with my project advisor, Dr. Debbie Thorpe.
• To become skilled in secondary data analysis using the SPSS Statistics software package.
• To draw conclusions related to clinical practice from a previously recorded data set.

Products:

Evidence table: A review of the literature was needed to collect background information about the research topics: impairments and comorbidities of individuals with CP, accepted interventions for their treatment, and evidence-based support for aquatic exercise. Resources published between 2010 and 2020 were derived from database searches and outlined in terms of their purpose, design, subjects, measurements, results, and strengths and limitations.

Manuscript and associated tables: The manuscript was written at a level meant for academic interpretation, with sections for the background, methods, results, and discussion of the research study. Five tables and one supplemental table were designed to complement the document with details about the assessment schedule for experimental and control groups, structure of aquatic exercise sessions, descriptive characteristics at baseline, and changes in variables.

After reading the aforementioned products, the audience will be able to:

• Recognize the need for adult-specific studies in CP research.
• Explain why the development of secondary conditions in children and adults with CP is of concern.
• List the benefits of aquatic-based intervention for individuals across GMFCS levels.
• Describe the effects of aquatic resistive exercise on outcome measures of interest in adults with CP.

Evaluation:

Feedback was obtained from my project advisor, Dr. Thorpe, and committee members, Emily Paul and Jennifer Newman, via email over the past six months. Dr. Thorpe joined me in biweekly Zoom meetings to discuss the nuts and bolts of the project as we progressed through each section, while Emily and Jennifer edited the evidence table and manuscript for grammar and content in January, February, and April.

An evaluation form concerning the manuscript and associated tables was distributed to my classmates as a method of peer assessment. Questions pertained to the structure, content, health literacy, importance, and quality of materials, in addition to an open-ended field for suggested changes. This project continues to be ongoing as we work to submit the manuscript for publication in the coming months, so other students’ feedback will be considered when preparing the final draft. To date, all responders have strongly agreed with the statements in the evaluation form, including the materials being of excellent quality.

Self-Assessment:

The first-year and second-year version of myself would have shied way from a project like this. Participating in new, unfamiliar situations both personally and professionally is not something that I tend to do, especially when I lack experience. Yet, I took a chance in contacting Dr. Thorpe about this faculty-led project and have since realized how crucial it has been to my academic career.

In terms of tangible and non-tangible outcomes, I have improved my scientific writing skills, become comfortable navigating statistical analysis software, grown to be a critical thinker, and gained across-the-board knowledge about CP. I have learned to set realistic expectations that align with my educational goals, especially with the mental and physical demands of clinical education experiences. Juggling third-year coursework with a full-time job, among other obligations, has taught me about time management and dedication to deadlines, which I will take with me into the workforce post-graduation.

Perhaps most importantly, this project has opened my eyes to the tedious but necessary parts of research. I reviewed over 50 articles in preparation for the writing process, completed an in-depth analysis of 27 of them, and referenced even more articles in the manuscript itself. By the same token, Dr. Thorpe and I analyzed her data in nearly 10 different ways and even received consultation from external sources, all to ensure that the statistical tests that we performed were providing the most accurate results. The intentional nature of our actions offers a glimpse into time and effort that were poured into this project, ultimately leading to the pride and sense of accomplishment that its completion has given me.

Acknowledgements:

To Debbie Thorpe, PT, PhD, your mentorship over the past six months, and really the past three years, has been invaluable. Thank you for being open to taking a student on board while overseeing my cohort’s capstone projects and preparing for a well-deserved retirement. Your patience and willingness to virtually teach me the ropes of research during the COVID-19 pandemic has given us a student-faculty alliance, as well as a lasting friendship. I am grateful, not to mention excited, to see my name next to yours on that title page. Thank you, thank you, thank you.

To Emily Paul, PT, DPT and Jennifer Newman, MSPT, thank you for agreeing to serve on my capstone committee and for balancing your time between this endeavor, your careers, and your personal lives. Your combined expertise in aquatic physical therapy and the CP population has been an asset to Dr. Thorpe and myself, and I am appreciative of your contributions.

To the Graduating Class of 2021 and division faculty, I could not have reached this milestone without you. It has been a wild ride to say the least, but we have become better people, better friends, and better clinicians along the way. Here’s to us and the adventures that lie ahead.

References:

1. Turk MA, et al. Adults with cerebral palsy: exercise and fitness. In: Agings and Cerebral Palsy. 1997a. Washington, DC: United Cerebral Palsy.
2. Strauss D, Shavelle R. Life expectancy of adults with cerebral palsy. Dev Med Child Neurol. 1998; 40(6):369-375.
3. Crichton JU, Mackinnon M, White CP. The life-expectancy of persons with cerebral palsy. Dev Med Child Neurol. 1995;37(7):567-576.
4. Kirby RS, Wingate MS, Van Naarden Braun K, et al. Prevalence and functioning of children with cerebral palsy in four areas of the United States in 2006: a report from the Autism and Developmental Disabilities Monitoring Network. Res Dev Disabil. 2011;32(2)462-469.
5. Turk MA. Health, mortality, and wellness issues in adults with cerebral palsy. Dev Med Child Neurol. 2009;51 Suppl 4:24-29.
6. Verschuren O, Peterson MD, Balemans ACJ, Hurvitz EA. Exercise and physical activity recommendations for people with cerebral palsy. Dev Med Child Neurol. 2016;58(8):798-808.
7. Thorpe DE, Reilly MA. The effect of aquatic resistive exercise on lower extremity strength, energy expenditure, functional mobility, balance and self-perception in an adult with cerebral palsy: a retrospective case report. J Aquatic Phys Ther. 2000;8(2):18-24.
8. Lai C-J, Liu W-Y, Yang T-F, Chen C-L, Wu C-Y, Chan R-C. Pediatric aquatic therapy on motor function and enjoyment in children diagnosed with cerebral palsy of various motor severities. J Child Neurol. 2015;30(23):200-208.
9. Adar S, Dündar Ü, Demirdal ÜS, Ulaşlı AM, Toktaş H, Solak Ö. The effect of aquatic exercise on spasticity, quality of life, and motor function in cerebral palsy. Turk J Phys Med Rehabil. 2017;63(3):239-248.
10. 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):69-7.
11. Akinola BI, Gbiri CA, Odebiyi DO. Effect of a 10-week aquatic exercise training program on gross motor function in children with spastic cerebral palsy. Glob Pediatr Health. 2019;6:2333794X19857378.