Dimitrijevic (2012) Gross motor function and CP

The objective of this study was to investigate the effect of an aquatic intervention on the gross motor functionand aquatic skills of children with cerebral palsy (CP). Twenty-nine children with CP, aged 5 to 14, were recruited.Fourteen children completed an aquatic intervention (EG), and 13 children served as controls (CG). Two participantsdropped out due to events (illness) unrelated to the intervention. The aquatic intervention lasted 6 weeks (2 sessions perweek at 55 minutes per session) with a follow-up period of 3 weeks. The outcome measures were the Gross MotorFunction Measure (GMFM) for motor function and the Water Orientation Test Alyn 2 (WOTA 2) for aquatic skillsassessment. A significant improvement was observed in the secondary assessment of GMFM and WOTA 2. In contrastto the aquatic skills improvement, the GMFM change was not maintained at follow-up. Our results indicate thatchildren with CP can improve gross motor function on dry land and aquatic skills with a 6-week water intervention.The intervention period was too short for sustainable improvement in dry-land motor skills after intervention (followup),but time was sufficient to achieve sustainable improvements in aquatic skills.

 

Journal of Human Kinetics volume 322012, 167-174 DOI:10.2478v10078-012-0033-5 167
Section - Aquatic Activities

1- Faculty of Medicine, Deptartment of Physical Medicine and Rehabilitation, University of Ni, Ni, Serbia. 2- Faculty of Sport and Physical Education, Deptartment of Aquatic Sports, University of Ni, Ni, Serbia. 3- Faculty of Sport and Physical Education, Deptartment of Biomedical Sciences, University of Ni, Ni, Serbia. 4- Faculty of Kinesiology and Rehabilitation Science, Department of Kinesiology, Catholic University of Leuven, Leuven, Belgium.
Authors submitted their contribution of the article to the editorial board.
Accepted for printing in Journal of Human Kinetics vol. 322012 on May 2012.
The Effect of Aquatic Intervention on the Gross Motor Function
and Aquatic Skills in Children with Cerebral Palsy
by
Lidija Dimitrijevi
1, Marko Aleksandrovi2, Dejan Madi2, Tomislav Okii2,
Dragan Radovanovi
2, Daniel Daly3
The objective of this study was to investigate the effect of an aquatic intervention on the gross motor function
and aquatic skills of children with cerebral palsy (CP). Twenty-nine children with CP, aged 5 to 14, were recruited.
Fourteen children completed an aquatic intervention (EG), and 13 children served as controls (CG). Two participants
dropped out due to events (illness) unrelated to the intervention. The aquatic intervention lasted 6 weeks (2 sessions per
week at 55 minutes per session) with a follow-up period of 3 weeks. The outcome measures weretheGross Motor
Function Measure (GMFM) for motor function and the Water Orientation Test Alyn 2 (WOTA 2) for aquatic skills
assessment. A significant improvement was observed in the secondary assessment of GMFM and WOTA 2. In contrast
to the aquatic skills improvement, the GMFM change was not maintained at follow-up. Our results indicate that
children with CP can improve gross motor function on dry land and aquatic skills with a 6-week water intervention.
The intervention period was too short for sustainable improvement in dry-land motor skills after intervention (follow-
up), but time was sufficient to achieve sustainable improvements in aquatic skills.
Key words: aquatherapy, experiment, follow up, pediatrics.

Introduction
Cerebral palsy (CP) is the most common
physical disability in childhood (Rosenbaum,
2003; Dimitrijevi et al., 2007). CP is characterised
by aberrant control of movements and positions
and is a consequence of early (pre-, peri- or
postnatal) brain damage or dysfunction. Motor
disorders in CP are the result of neurological
deficit and include neuromuscular and
musculoskeletal disorders: abnormal muscle tone,
abnormal muscle contraction (spasticity,
dyskinesia, dystonia and athetosis), bone
abnormalities (foot deformities, subluxation and
dislocation of the hip, long bone torsion strain),
balance disorders and loss of selective motor
control (Flett, 2003; Kriger, 2006).
Physical therapy (PT) plays a central role in
managing the condition by focusing on function,
movement, and optimal use of the child's
potential. PT uses physical approaches to
promote, maintain and restore physical,
psychological and social well-being (Anttila et al.,
2008). Numerous therapeutic interventions have
been used to minimise the development of
secondary problems (normalising tone, increasing
active range of motion), to improve muscle
strength and mobility, to obtain functional motor
skills and to encourage functional independence
at home, at school and in the community
(Declerck, 2010).
Aquatic intervention is one of the most
popular supplementary treatments for children

168 The Effect of Aquatic Intervention in Children with Cerebral Palsy.
Journal of Human Kinetics volume 322012 http:www.johk.pl

with neuro-motor impairments, particularly
children with CP (Getz, 2006). The intervention
may provide safe and beneficial alternative low-
impact exercise for children with disabilities
(Fragala-Pinkham et al., 2008), but there is a lack
of evidence-based studies documenting the effects
(Declerck, 2010).
Water is an equalising medium; its gravity-
minimising nature reduces compressive joint
forces, providing a better exercise environment
for patients with arthritis, back pain, osteoporosis,
or other medical conditions that may restrict
physical training on land (Takeshima et al., 2002).
Adapted aquatic exercises have been particularly
recommended as a part of physical activity
programs for children with CP. The buoyant
nature of water provides persons with CP patients
the opportunity to feel their body free from the
constraints they experience on land (Getz et al.,
2007; Kelly and Darrah, 2005). Water-based
activity aids in the relief of pain and muscle
spasms, maintenance or increases of range of
motion, strengthening of weak muscles, re-
education of paralysed muscles, improvement of
circulation, lung function, and speech as well as
aiding in the maintenance and improvement of
balance, coordination and posture (Cole and
Becker, 2004).
These characteristics may allow children
with CP to exercise in water with more freedom
than on land. Weight relief and ease of movement
allows safe movement exploration, strengthening
and functional activity training with a reduced
level of joint loading and impact, providing a
gentler environment for children who experience
persistent abnormal loading (Kelly and Darrah,
2005; Cole and Becker, 2004). In addition, aquatic
physical activities are important for the teaching-
learning process and might promote greater
independence, better manual ability and, as a
consequence, increase social participation by
individuals with CP (Aidar et al., 2007).
The purpose of this study was to
investigate the effect of an aquatic intervention on
the gross motor function and aquatic skills of
children with CP.
Matherial and Methods
Participants
Children with CP aged 5 to 14 years were
recruited for the study through MD practitioners

from the University Clinical Centre Physical
Medicine and Rehabilitation Clinic Paediatric
Department and the City Society of CP (Ni,
Serbia). All children met the following inclusion
criteria: (1) age between 5 and 14 years, (2) ability
to understand instructions, (3) no medical contra-
indications, (4) no botulinum toxin treatment or
surgery in the preceding three months and (5)
written parental approval.
An invitation letter was distributed through
paediatric physiotherapists across the cities of
Ni, Prokuplje, Meroina and Aleksinac, the
University Clinical Centre Physical Medicine and
Rehabilitation Clinic Paediatric Department and
the City Society of (Ni, Serbia).
A telephone interview was conducted with
34 children who met the inclusion criteria and
showed an interest in participation. Five children
refused to participate because of lack of time,
transportation difficulties, or a time-consuming
school program. Twenty-nine children agreed to
participate, completed the baseline measures and
were randomly divided in two groups. Fourteen
children completed the aquatic intervention (EG),
and 13 children completed all measurements but
only participated as the no-interventioncontrol
group (CG). After starting the intervention, 2
children had to stop due to illness (Figure 1).
All parents and children had the
procedures explained to them and were asked to
provide informed consent prior to data collection.
The study was conducted in accordance with the
Helsinki Declaration of 1975, as revised in 2000
(World Medical Association Declaration of
Helsinki, 2000).
Measures
Descriptive measures and characteristics,
such as age, gender, body weight, length, type of
CP and the expanded and revised Gross Motor
Function Classification Scale level (GMFCS), were
recorded for all study participants. GMFCS scores
were used to determine the childs present
abilities and limitations in gross motor function.
This classification system has been shown to be
valid (Palisano et al., 2008, Bodkin et al., 2003).
The primary outcome measures were the
Gross Motor Function Measure 88 (GMFM-88) for
motor function and the Water Orientation Test
Alyn 2 (WOTA2) for aquatic skills assessment.
Gross Motor Function Measure88 (GMFM-88)
The GMFM-88 is a standardised 88-item

by Dimitrijevi L. et al. 169
Editorial Committee of Journal of Human Kinetics

observational instrument developed to measure
changes in gross motor function over time. The
test was conducted as described in the GMFM-88
manual and was performed without any aids. A
percentage score was calculated for the total score
as % of the five dimensions (PTS). This measure
has been found to be reliable and valid (Russell et
al., 2002).
Water Orientation Test Alyn 2 (WOTA 2)
The aim of this evaluation is to assess the
swimmers level of adjustment and function in
water. The evaluation is based on the Halliwick
concept, with a 10-point program subdivided into
several skills. Both the swimmer and instructor
were in the water at the time of testing. In
addition to verbal instruction, the instructor
demonstrated the task to be performed. Each item
was attempted up to three times. A 4-point

ordinal scale was developed for each skill based
on the level of performance and functional
independence. When there was uncertainty as to
which score to assign, the lower of the two
possible scores was chosen. The scale has been
demonstrated to be reliable and valid (Tirosh et
al., 2008). The following measures are calculated:
mental adaptation (WMA), skills balance control
movement (WSBM) and total score (WTOT).
Procedures
The participants were enrolled in an
intensive swimming program for 6 weeks (55-
minutes session, 2 sessionsweek) in the
swimming pool of the Sports Centre air in
Ni, Serbia (water temperature 27.7C, water
depth 70 cm for a 10 m x 10 m area and 180 cm for
a 20 m x 10 m area).

Figure 1
Design and flow of participants throughout the trial

170 The Effect of Aquatic Intervention in Children with Cerebral Palsy.
Journal of Human Kinetics volume 322012 http:www.johk.pl

The main objective of the swimming
program was to improve safety and functional
independence in the water. Each participant was
taught by one instructor. The main investigator
performed the aquatic therapy with the assistance
of 3 additional instructors.
The aquatic therapy consisted of 10 minutes
of light warm-up in the water (forward and
backward walking, jumping, and other such
exercises), 40 minutes of exercise swimming
techniques (prone and back gliding from the wall;
prone and back floating; blowing bubbles; breast-
stroke, backstroke or freestyle techniques; diving
to the pool bottom) and 5 minutes of play (ball
games, chasing games, etc.)
The therapy was focused and performed
individually. To minimise the drop-out rate, the
intervention was customised to maximise
enjoyment by each individual child. Depending
on the spontaneous swimming technique
demonstrated by each child and related functional
ability, the respective child performed more
breaststroke than crawl stroke or vice versa. In
addition, some interventions focused more on
arm movements than on leg movements and vice versa. A diary was kept to record each swimming
lesson for each child separately. Thus, the goals
and progression of each child could be followed
intensively and individually, and every instructor
was able to easily continue onto the next lesson
with each child.
Analysis
Statistical processing of all parameters was
performed by calculating the mean values and
standard deviation, while statistical significance
(p 0.05) was determined by Students t-tests.
Statistical analysis was performed with SAS
version 9.1.3. All measurement were repeated at
the beginning and end of intervention and after 3
weeks of follow-up after cessation of intervention.
Results
The descriptive participant data (whole
sample, EG and CG) are presented in table 1. The
EG consisted of 14 children (10 boys and 4 girls),
and the CG was comprised of 13 children (7 boys
and 6 girls).

Table 1
Descriptive data of study participants (whole sample, experimental group and control group)
Baseline descriptor Total
EG CG
Number of participants 27
14 13
Sex
Male 17
10 7
Female 10
4 6
Age (years)
Mean (SD) 9.56 (2.37)
9.21 (2.45) 9.92 (2.32)
Weight (kg)
Mean (SD) 28.95 (9.57)
29.20 (9.48) 28.60 (10.04)
Height (m)
Mean (SD) 135.59 (12.97)
134.50 (13.26) 136.77 (13.08)
Sub - CP Type (number)
Spastic Hemiplegia 4 2 2
Spastic Diplegia 6 3 3
Spastic Quadriplegia 13 6 7
Spastic Hemiparesis 4 3 1
GMFCS
I
10 6 4
II
6 3 3
III
4 2 2
IV
2 1 1
V
5 2 3

by Dimitrijevi L. et al. 171
Editorial Committee of Journal of Human Kinetics

Table 2
GMFM % scores for baseline, 6-week and 9-week time points
Baseline 6 weeks 9 weeks
EG CG EG CG EG CG
PTS
73.53 (25.63) 65.99 (29.61) 77.92 (23.63)* 66.56 (29.84) 73.04 (27.44) 66.56 (29.84)
Mean (SD), * significant difference on 95% level between baseline and 6-week time points

Table 3
WOTA scores for baseline, 6-week and 9-week time points (only EG)
Baseline 6 weeks 9 weeks
EG CG EG CG EG CG
WMA 20.71 (10.82) NA 31.93 (9.10) ** NA 31.93 (9.10) NA
WSBM 1.79 (5.32) NA 15.57 (16.53) ** NA 15.57 (16.53) NA
WTOT 22.50 (14.25) NA 47.50 (22.51) ** NA 47.50 (22.51) NA

Mean (SD), WMA Mental adaptation, WSBM - Skills balance control movement,
WTOT Total score,
** significant difference at 99% level between baseline and 6-week time points

There was no statistically significant
differences between EG and CG in age (EG: 9.21
years 2.45, CG: 9.92 years 2.32), weight (EG:
29.20kg 9:48, CG: 28.60kg 10.04) and height (EG:
134.50cm 13:26, CG: 136.77cm 13.08). The G
consisted of 2 children with spastic hemiplegia, 3
with spastic diplegia, 6 with spastic quadriplegia
and 3 with spastic hemiparesis, whereas the CG
was made up of 2 children with spastic
hemiplegia, 3 with spastic diplegia, 7 with spastic
quadriplegia and one with spastic hemiparesis.
The EG had 6 participants with a GMFCS score of
I, 3 with GMFCS II, 2 with GMFCS III, 1 with
GMFCS IV and 2 with GMFCS V, whereas the CG
had 4 subjects with a GMFCS score of I, 3 with
GMFCS II, 2 with GMFCS III, 1 with GMFCS IV
and 3 with GMFCS V.
There was no difference in GMFM score
(post-treatment score, PTS) between the groups at
the start of the intervention (Table 2). By the
second time point, after 6 weeks of aquatic
treatment in the EG and after the same period of
time of sedentary activities in the CG, there was a
significantly different advantage for the EG. In the
second test, which took place after a 6-week
aquatic intervention, there was a statistically
significant improvement in GMFM, as measured
by the PTS, when compared with the initial score.
In addition, there was a significant improvement
in all variables related to water orientation: WMA,
WSBM and WTOT (p 0.01). In the three-week
follow-up period between the second and third
tests, there were no statistically significant
differences in PTS or WOTA scores (Table 3).
For the CG, there were no statistically
significant changes in GMFM (the CG was not
included in the aquatic exercise program)
(Table 2).
Discussion
Aquatic physical activity has strong
potential to benefit children with CP (Gerter and
Currie, 2011). Despite the fact that swimming is
one of the most frequently reported physical
activities in children and adolescent with CP
(Gerter and Currie, 2011), there is no consensus on
optimal concepts of aquatic physical activity
regarding duration of intervention period,

172 The Effect of Aquatic Intervention in Children with Cerebral Palsy.
Journal of Human Kinetics volume 322012 http:www.johk.pl

duration of a single treatment, frequency per
week of treatment, individualgroup work, water
temperature, swimming pool size and depth.
In our study, where the purpose was to
investigate the effect of an aquatic intervention on
the gross motor function and aquatic skills of
children with CP, aquatic physical activity was
performed for 6 weeks, twice a week, with a one
to one teacherparticipant ratio, in 55 min
sessions, 27.7
0C water temperature, and water
depth between 70 cm and 180cm.
The PTS GMFM value, which represents
the motor function of children with CP after 6
weeks of aquatic treatment, presented a
statistically significant improvement in the EG
compared with the initial measured value (p
0.05). This result is not consistent with those of
Getz (7) perhaps because a group treatment was
dominant. However, this result agrees with those
of Mackinnon (1997) and Troup et al. (2005), as
these interventions were individually focused.
Individualisation is important when working
with persons with a disability and especially
children with CP (Bax et al., 2005). Some studies
describe the effects of individualised aquatic
treatments that might be beneficial in ensuring
proper technique and intensity (Kelly and Darrah,
2005).
In contrast, with the CG, there were no
considerable changes in PTS value at any of the
three time points; this is not unexpected with the
sedentary lifestyle associated with many of the
children.
In the follow-up study (no aquatic
treatment), the EG PTS directly decreased, but the
difference was not statistically significant. This
result indicates that permanent involvement in
physical therapeutic activity is necessary for
children with CP to ensure that their motor
functions can be maintained at a higher level. Any
benefits from the aquatic intervention and any
other physical activity for children with CP
appears to be reduced or lost after completion of
the programme, suggesting that maintenance
programmes may need to be implemented for
long-term benefit. Each pause in physical activity
can lead to decreased motor function as a
consequence (Verschuren et al., 2007; Bania et al.,
2011).
An important aspect of this study is the fact
that it was done using feasible and practical

outcome measure in water such WOTA. This has
been missing in the past (Gerter and Currie, 2011).
The initial water orientation test with the
EG subjects indicated modest aquatic experience,
i.e., swimming experience. However, a positive
progression was evident between the first and
second treatments, as measured by water
orientation indicators (WMA, WSBM and WTOT)
after a 6-week aquatic intervention programme
(P0.01). Individual work and adaptation for each
participant positively influences movement (oh
et al., 2004).
These results match the results of a similar
study and treatment (Declerck, 2010), as well as
the results of the study of Getz (2006), where
improvement was evident in an aquatic skills
assessment, the Aquatic Independence Measure
(AIM) test, after a longer treatment (32 sessions
for 16 weeks). In addition, these results are in
agreement with the findings of Mackinnon (1997)
and Hutzler et al. (1998a, 1998b).
In the three-week follow-up period (no
aquatic treatment), there was no progression in
water orientation skills; however, the skills values
remained unchanged and did not decrease. These
results indicate that a good motor basis in water
was established for these children, which could
have positive influence on motor function, other
functional abilities and the quality of life (Anttila
et al., 2008; Declerck, 2010; Getz, 2006; Fragala-
Pinkham et al., 2008; Kelly and Darrah, 2005;
Hutzler et al., 1998a; Hutzler et al., 1998b; Ballaz
et al., 2010; Dorval et al., 1996; Chrysagis et al.,
2009). As water orientation is a skill, it will not be
forgotten after only a short time period, but motor
function will vary by the time and effort put into
the underlying skills training.
Conclusion
The present study found significant effects
following a 6-week aquatic intervention on the
gross motor function of children with CP.
Significant improvement in water skills was also
observed. The intervention period was too short
for sustainable improvement in dry-land motor
skills after intervention (follow-up), but there was
enough time to achieve sustainable improvements
in aquatic skills. Future studies with a larger
sample size and longer and more intensive
interventions are needed.
Aquatic activities not only have a

by Dimitrijevi L. et al. 173
Editorial Committee of Journal of Human Kinetics

therapeutic effect on children with CP (decreasing
muscle tonus, increasing motor function,
increasing walking efficiency, functional
abilities), but they also have a psycho-social
effect (increasing quality of life, life habits,
socialization) (Getz et al., 2007). So, in future
studies researchers should use adequate
questionnaires, tests or interviews for analysing
these types effects.
Our study also included the highest
number of participants of any other recent study
(Gerter and Currie, 2011). Nevertheless, to obtain
better information larger numbers are needed in
the future.
Acknowledgments
The authors gratefully acknowledge the children who participated in the study, swimming instructors
from Academic Swimming Club for People with Disabilities Delfin City Society of CP and entire stuff of
the University Clinical Center Physical Medicine and Rehabilitation Clinic - Paediatric Department (Ni,
Serbia) and Mr. Johan Lambeck, International Halliwick Therapy Network Senior Lecturer (Malden,
Netherlands).
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Corresponding author:
Assoc. Prof. Marko Aleksandrovi, Ph.D.
Faculty of Sport and Physical Education, University of Ni
arnojevieva 10A, 18000 Ni, Serbia
Phone: 381 18 510 900, 511 940, 511 941, ext. 105 (office)
Fax: 381 18 242 482
E-mail: marko.aleksandrovic@gmail.com

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