Use of aquatic therapy can help infants and children with cerebral palsy and acquired brain injury make significant improvements in functional outcomes.
At the Kennedy Krieger Institute in Baltimore, we have found that treating pediatric patients with cerebral palsy, acquired brain injury, and some other neuromotor disorders in a therapeutic pool has numerous unique advantages. The aquatic environment is beneficial to patients because the warm water helps to relax muscles, increase range of motion, and decrease pain. The buoyancy of water minimizes the effect of gravity, makes the child feel lighter, reduces levels of impact and joint loading, and provides increased postural support.1 These factors frequently allow children with neuromotor disorders to more easily perform functional activities in the water as compared to on land. The water provides patients with 14 times the amount of somatosensory information than air.2 It is effective in stimulating the skin (in terms of temperature and tactile sensations), the vestibular system (due to turbulence and movements in the water), the visual system (reacting to the environment and monitoring the surface of the water), and the inner ear (which reacts to changes in pressure when a patient goes underwater). There are also many cardiovascular and respiratory advantages to working in an aquatic environment. “Blowing bubbles, holding the breath, and breathing out through the mouth and nose all improve respiratory function as well as oral motor control, which can aid speech and decrease drooling and feeding problems.”3 The water also provides a medium for children with neuromotor disorders to be able to move at a much faster pace than can be achieved on land, which challenges their cardiovascular system.
THE CORE OF FUNCTION
One of the most common impairments seen in children with cerebral palsy, acquired brain injury, and some other neuromuscular disorders is their difficulty activating and sustaining the postural system, particularly the abdominal obliques and deep back extensors. This has a profound impact on their ability to perform coordinated and controlled movements of their upper and lower extremities and their head and neck. These patients lack a stable base on which to initiate and control movements, which inevitably impacts nearly any functional goal they may have. In order for these children to attempt to maximize their functional mobility and environmental interactions, they tend to rely on their superficial “movement” muscles as a substitute for weak core musculature.4 Strengthening their postural muscles can therefore help to decrease compensatory movements of the extremities used for stability, improve their postural alignment, and allow them to perform more controlled movements of their extremities. The following are suggested techniques for increasing core strength:
- Have the patient straddle a noodle like a horse and provide them with trunk support only as needed. Patients can use their hands in the water to assist with balance, or progress to the more difficult task of either holding the noodle or holding their hands in the air. They can perform a bicycle kick with their lower extremities to propel themselves around the pool, or the therapist can help them to move around the pool while they work on staying upright. If patients do not maintain a proper alignment, the buoyancy of the water will tip them off balance and they will require activation of the core muscles in order to right themselves. Righting reactions can also be practiced sitting on a kickboard or raft, or trying to stay upright while wearing a small flotation belt.
- Stand with the patient facing you, with their legs straddling your trunk just above your pelvis, and with their trunk leaned back into supine. Place your hands over the lower ribs and abdominal obliques in order to improve alignment of the rib cage and to bring the abdominals into a length where they can be more easily recruited. Lower one side of your pelvis, lean the child back slightly, and ask them to reach to touch or knock a toy off of your opposite shoulder. You can assist the patient by squatting down deeper into the water as they are coming up to sitting and then stand up straighter as they go back to supine.
- Position the patient in supine with a neck flotation collar or noodle under their head/neck, a pelvic support under S2 (as needed), and floats under the knees or ankles (as needed). The therapist stands with a wide base of support at the patient’s head, reaches under the patient’s arms, and supports them at their rib cage in order to facilitate abdominals and help to anchor the lower ribs as needed. Ask the patient to try to maintain a straight streamlined position while the therapist moves them toward either side at the surface of the water. This isometric exercise is a modification of the Bad Ragaz Ring Method.5
REACH OUT FOR FUNCTION
In children with cerebral palsy and acquired brain injuries, decreased ability to activate and sustain postural trunk muscles is often compensated with overutilization of the latissimus dorsi and pectoralis muscles for stability, resulting in difficulty bringing arms forward into flexion.4 There are a variety of techniques that we use in the aquatic therapy center at Kennedy Krieger to assist patients with increasing their shoulder girdle stability and improving their ability to get their arms out in front of them to be able to play with toys, eat finger foods, or access a joystick or communication device on land.
- Swim strokes in prone with support as needed provide a great means to work on increasing thoracic extension with trunk rotation. Abdominals will be recruited with trunk rotation and when pushing the arms back down into the water. Shoulder flexion and abduction will be assisted by buoyancy when bringing the patient’s arms back up toward the surface of the water. This will assist with strengthening the deltoid muscles and lengthening of the pectoral and latissimus dorsi muscles.
- Support the patient in side lying so that their lower extremities are dissociated in order to maintain a neutral pelvis and thus a neutral trunk and neck. They can then practice reaching up overhead in a buoyancy supported position. From this position, you can also have them work on reaching across and rolling toward prone, which will also facilitate activation of the abdominal obliques.
- Position the patient in sitting or standing (with trunk support as needed) and ask them to try to use their hands to push floating toys under water. They will have to recruit their abdominals to stabilize their trunk while trying to push down squirt toys, floating foam shapes, a barbell, or a kickboard. This will also develop strength of their serratus anterior and shoulder girdle muscles. As the patient gains upper extremity strength and control, you can also ask them to stabilize their trunk while moving their arms in the water using Aqua Fins or other resistive devices.
STAND UP FOR FUNCTION
Children with cerebral palsy and acquired brain injury frequently present with difficulty sustaining their antigravity extensor muscles. This greatly impacts their ability to push up to standing and maintain an upright position for standing or walking. Instead of utilizing the deep postural extensors and abdominals as a stabilizing foundation off which to maintain hip and knee extension using quadriceps and gluteals, they tend to instead more easily recruit hip flexors, hamstrings, and erector spinae muscles.4 The following water activities can help strengthen lower extremity antigravity extensors:
- Position the patient in supine either with a neck and float belt or with the patient’s head and trunk supported in supine on a flotation mat with their legs hanging off of the edge. The therapist holds the top and bottom of one of their feet and serves as a stable point from which the patient moves. Ask the patient to push this foot down into the therapist’s hand (activating hip and knee extensors and ankle plantar flexors) and then pull back up into the therapist’s hand (activating hip and knee flexion and ankle dorsiflexion). Their body will move away from or toward you as they complete this task. This isokinetic exercise is also a modification of the Bad Ragaz Ring Method.6
- If the patient has particularly weak gluteals and increased tightness in their hip flexors, you can position them in supported prone with their trunk over a kickboard or flotation mat (a buoyancy assisted position for hip extension) and have them practice kicking. If you tilt them down on one side, the leg closer to the water surface will be in an alignment to allow for buoyancy assisted gluteus medius function into hip abduction, extension, and external rotation.
- Walking, hopping, and jumping in the water can be fabulous for development of hip and knee extensors and ankle plantarflexors. This can help patients to learn to effectively push into the floor with their lower extremities to power up instead of relying on their upper extremities to support their body weight. Underwater treadmills can assist with pacing, and can be an alternative to using body weight-supported treadmill training on land.
SPEAK UP FOR FUNCTION
Children with cerebral palsy often have difficulty lifting their head in midline and instead lift their head asymmetrically with excessive cervical flexion and capital extension, elevated shoulder girdle, and decreased thoracic extension. Improving head control and alignment is important to maintain an open airway for efficient respiration and to achieve bilabial closure for verbal communication and swallowing. The following techniques can motivate patients to improve their head and neck alignment.
- For patients who tend to maintain neck rotation to one side: Position the patient propped in prone on forearms over a partially submerged flotation raft or kickboard. If they tend to maintain neck rotation to the left side, tilt the kickboard down toward the left so they will turn their head to the right to keep their mouth up out of the water.
- For patients with a forward head posture: Practice a chin tuck with floating in supported supine. Floating promotes an improved head alignment, including cervical extension with capital flexion.
- For patients who have difficulty with lip closure or decreased vital capacity: Practice exhalation as they submerge their lips or have them try to say words or sing songs underwater. They can also practice blowing bubbles underwater or try to blow a Ping-Pong ball across the water surface.7
The pool can serve as a motivating and fun environment for patients to work on improving a variety of common impairments, and, more importantly, to help them achieve desired functional outcomes. Swimming and performing other aquatic exercises can serve as an extremely beneficial lifelong activity for patients with neuromotor disorders to achieve and maintain a higher level of fitness. It can also provide a social outlet as they pursue aquatic opportunities in the community. Finally, the benefits of using an aquatic environment to improve freedom and control of movement can foster improvements in the child’s body image, self-esteem, and quality of life.
Emily Ledbetter Viguers, PT, DPT, C/NDT, is a physical therapist specializing in pediatric aquatic therapy, constraint-induced movement therapy, and neurodevelopmental treatment. Since 2003, she has worked in Kennedy Krieger Institute’s Fairmount Rehabilitation Programs, which provide comprehensive neurorehabilitation in a day hospital setting. Internationally recognized for improving the lives of children and adolescents with disorders and injuries of the brain and spinal cord, the Kennedy Krieger Institute in Baltimore serves more than 13,000 individuals each year through inpatient and outpatient clinics, home and community services, and school-based programs. For more information, visit www.kennedykrieger.org.
- Kelly M, Darrah J. Aquatic exercise for children with cerebral palsy. Dev Med Child Neurol. 2005;47(12):838-842.
- Styer-Acevedo J. “I can chew gum now!” A Case Study of Therapeutic Aquatics. Laguna Beach, Calif: NDTA Network. May/June 2004. www.ndta.org/network/article.php?article_id=152. Accessed June 20, 2010.
- Introduction to adapted aquatics. In: Lepore M, Gayle GW, Stevens S, eds. Adapted Aquatics Programming: A Professional Guide. 2nd ed. Champaign, Ill: Human Kinetics; 2007:3-20.
- Stamer M. Children with hypertonia. In: Posture and Movement of the Child with Cerebral Palsy. Austin, Tex: Pro-Ed Inc; 2000:63-139.
- La Tourette D, Meno J. Bad Ragaz. Aquatic Therapy Journal. January 2000:13-16.
- Morris DM. Aquatic rehabilitation for the treatment of neurologic disorders. In: Cole AJ, Becker BE, eds. Comprehensive Aquatic Therapy. 2nd ed. Philadelphia: Elsevier Inc; 2004:151-175.
- Styer-Acevedo J. Buoyancy-assisted function through therapeutic aquatics. In: Erhardt R, ed. Parent Articles about NDT. San Antonio, Tex: Communication Skill Builders; 1999.