effects of aquatic exercise on upper extremity function and postural control … · 2019-06-28 ·...

Effects of Aquatic Exercise on Upper

Extremity Function and Postural Control

During Reaching in Children

With Cerebral Palsy

Yongjin Jeon

The Graduate School

Yonsei University

Department of Physical Therapy

Effects of Aquatic Exercise on Upper

Extremity Function and Postural Control

During Reaching in Children

With Cerebral Palsy

A Dissertation

Submitted to the Department of Physical Therapy

and the Graduate School of Yonsei University

in partial fulfillment of the

requirements for the degree of

Doctor of Philosophy

Yongjin Jeon

June 2013

This certifies that the doctoral dissertation of

Yongjin Jeon is approved

Thesis supervisor: Hyeson Jeon

Chunghwi Yi

Ohyun Kwon

Hunseok Cynn

Duckwon Oh

The Graduate School

Yonsei University

June 2013

Acknowledgements

I would like to thank all the people who supported me continuously throughout the

process of preparing and completing this research paper. Despite the difficulty

experienced during the research programs, participating children and their family

members have been kind and patient enough to take part in this research. I send my

sincere hope for their physical recovery and health.

A special gratitude I give to Professor Hye-Seon Jeon, my excellent supervisor, who

provided constant guidance and encouragement to complete this paper. She has led

me to the right path during the process of this research and contributed ideas on

problem solving while maintaining positive attitude. Warm care and considerate

comments were provided during her time during the postgraduate course. Her

teachings would be milestone for my career as a physiotherapist. Furthermore I would

also like to acknowledge with much appreciation the crucial role of Professor

Chunghwi Yi who has helped me explore academic issues thoroughly from

undergraduate to postgraduate course. I believe his contribution on analyzing the

research result and supplementing the weaknesses of my research has improved the

quality of this paper overall. A special thanks goes to professor Ohyun Kwon, who

provided encouragement and support based on the professional thoughts which

motivated me for developmental directions and future for physiotherapy. I would also

like to express my appreciation to profession Heonseock Cynn, who has offered acute

insights and professional advice for smooth progression of research from the

beginning to the end. In addition, I would like to express my gratitude to Professor

Duckwon Oh, who reviewed my research process as well as results and suggested

various approach methods to problems caused during the research. I also thank

Professor Sanghyun Cho and Professor Seunghyun You who helped me improve in

terms of attaining professional knowledge and ability.

I am highly indebted to my colleagues for supporting me to achieve PhD degree

while working, as well as colleagues who provided more than enough help and

encouragement during my postgraduate course.

Last but not the least, my thanks and appreciations go my family members and my

wife’s family who have embraced me with love. I would like to express thanks and

love to my wife who has continuously encouraged me as well as my daughter, Yebin

and son, Youngjun who have showed affection and love throughout my study. I would

try my best to develop myself to higher stance, not contenting with my present. Thank

you.

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Table of Contents

List of Figure ············································································· iii

List of Tables ············································································· iv

Abstract ··················································································· v

Introduction ·············································································· 1

Method ···················································································· 10

1. Participants ··········································································· 10

2. Experimental Design ································································ 12

3. Outcome Measures ·································································· 13

3.1 Clinical Measurements ························································· 13

3.1.1 Box and Block Test ·························································· 13

3.1.2 Bruininks-Oseretsky Test of Motor Proficiency ·························· 14

3.1.3 Pediatric Reaching Test ······················································ 15

3.2 Experimental Apparatus ························································· 16

3.2.1 3-D Motions Analysis ························································ 16

3.2.2 Experimental Procedure for reaching ······································ 18

4. Intervention ·········································································· 20

4.1 Preparation Exercise Before the Treatment ··································· 21

4.2 Lateral Movement of the Trunk and Upper Limbs ··························· 21

4.3 Anterior and Posterior Movement of the Trunk and Upper Limbs ········· 22

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4.4 Cross Movement of the Trunk and Upper Limbs ····························· 22

5. Statistical Analysis ·································································· 23

Results ···················································································· 24

1. Clinical Measurement Score ······················································· 24

1.1 Box and Block Test and Transferring Pennies of Bruininks-Oseretsky Test

····························································································· 24

1.2 Pediatric Reaching Test ·························································· 28

2. 3-D Motion Analysis ······························································· 29

2.1 Anterior target ···································································· 29

2.2 Medial target ······································································ 30

2.3 Lateral target ······································································ 31

Discussion ················································································ 32

Conclusion ··············································································· 40

References ················································································ 41

Abstract in Korean ······································································· 54

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List of Figure

Figure 1. Experimental setup for reaching test ······································· 19

Figure 2. Post hoc analysis of BBT scores at the pre-intervention, post-intervention,

and retention ································································ 26

Figure 3. Post hoc analysis of transferring pennies scores of the BOT at the pre-

intervention, post-intervention, and retention ··························· 27

- iv -

List of Tables

Table 1. General characteristics of participants ······································ 11

Table 2. Clinical measurements score after intervention ···························· 25

Table 3. Dominant side PRT performance after intervention ······················· 28

Table 4. Target location on the anterior ··············································· 29

Table 5. Target location on the medial ·················································· 30

Table 6. Target location on the lateral ················································· 31

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ABSTRACT

Effects of Aquatic Exercise on Upper Extremity

Function and Postural Control During Reaching

in Children With Cerebral Palsy

Yongjin Jeon

Dept. of Physical Therapy

The Graduate School

Yonsei University

The purpose of this study was to examine the effects of aquatic exercise on upper

extremity function and postural control during reaching in children with cerebral

palsy (CP). We evaluated changes in clinical measures and 3-D motion analysis

following aquatic exercise.

Ten participants (eight males and two females) with spastic diplegia were recruited

to this study. This present study used a single group pre-post design. The aquatic

exercise program consisted of five modified movements that were selected from the

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Halliwick 10-point program to enhance upper extremity and trunk movements. The

participants attended treatment two times a week for 6 weeks, averaging 35 minutes

each session. All participants were tested before and after the 6 week treatment

periods. The Box and Block Test (BBT), transferring pennies in the Bruininks-

Oseretsky Test (BOT), and pediatric reaching test (PRT) scores were used as clinical

measures. A 3-D motion analysis system was used to collect and analyze kinematic

data including movement time (MT), velocity of hand movements (HV), straightness

ratio (SR), and number of movement units (MUs). Participants performed a reach-

and-return task while maintaining a seated posture on a chair. A target was placed at

eye level at a distance of 120% of arm’s length in three directions (anterior, medial,

and lateral). To compare the changes of participants before and after aquatic exercise

program, statistical analysis was performed via non-parametric tests.

All clinical measures, which included BBT, transferring pennies of BOT, and PRT,

were significantly increased after treatment (p<0.05). 3-D motion analysis, except for

the return MT of all directions and the MUs of the medial target, were significantly

improved after treatment (p<0.05). The children with CP showed shorter MT, faster

PV, smaller SR, and MUs. However, medial reaching involves more problems during

the reaching task and may involve trunk rotation.

The results of this study suggest that a twelve sessions of aquatic exercise were

beneficial in terms of improving upper extremity function and postural control in

children with CP. On the basis of the results of our study, we have demonstrated that

aquatic exercise, in conjunction with land-based physical therapy, may help to

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improve body function, activity, and participation in children with varying types of

physical disabilities. Further studies with greater numbers of participants and longer

treatment times, including the follow-up period, will be conducted to validate the

results of our study.

Key Words: Aquatic exercise, Cerebral palsy, Postural control, Upper extremity

function.

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Introduction

Cerebral palsy (CP) is a term commonly used to describe various forms of kinetic

damages (Nikolaos et al. 2009). The current definition of cerebral palsy is: "a group

of disorders of the development of movement and posture, causing activity limitation,

that are attributed to non-progressive disturbances that occurred in the developing

fetal or infant brain" (Bax et al. 2005). In other words, CP refers to non-progressive

syndromes that include involuntary movement and postural deficits and result from

neurological damage during delivery and abnormal growth during the prenatal period

(Shurtleff, Standeven, and Engsberg 2009). Children with CP experience movement

disorders that include spasticity, weakness, the co-activation of excessive antagonist

muscles, and increased stiffness at the joints (Näslund, Sundelin, and Hirschfeldet

2007). Neuromuscular symptoms result in poor motor control, asymmetrical

movement patterns, incoordination, and sensory disorders, leading to functional

impairment (Gage 1991). In addition, musculoskeletal problems caused by the long-

term effects of CP, such as contracture, decreased range of motion, and motion

displacement, may be one of contribution factors that make balance control difficult

and reduce functional level (Shumway-Cook et al. 2003).

“Postural control can be defined as the ability to control the body's center of mass

(COM) over the base of support without losing balance” (Westcott, and Burtner 2004).

Movement for postural control requires not only physical orientation in space for

stability but also the given task's orientation within the circumstances of the

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environment (Massion 1994). The effective defense against disturbing force as a

means of direction-specific postural adjustments is the main goal of postural control

(Hadders-Algra 2005). Direction-specificity means that the anterior displacement of

the body is accompanied by activity in the dorsal muscles; the posterior displacement

of the body is accompanied by activity in the ventral muscles (Forssberg, and

Hirschfeld 1994). In general, direction-specific postural muscular activity is possible

for children with CP, but children with severe CP, who cannot sit independently,

present a complete absence of direction-specific postural adjustments (Hadders-Algra

et al. 1999). Partial damage to direction-specificity makes it difficult to sit

independently, but this can be overcome with training (Butler 1998). Functional

activity at the second level of postural control involves fine-tuning the basic

direction-specific adjustment to environmental conditions based on experience and

multi-sensorial afferent input from the somatosensory, visual, and vestibular systems

(Carlberg, and Hadders-Algra 2005). Direction-specific postural muscle activity at a

young age has variation that is detected in recruited muscles, in the time sequence of

muscle activation, in antagonist recruitment, and in the degree of postural muscle

contraction (Hadders-Algra 2005). At this level, children with CP typically present

the cranio-caudal recruitment of postural muscles (Brogren, Hadders-Algra, and

Forssberg 1996; Nashner, Shumway-Cook, and Marin 1983), an excessive amount of

antagonistic co-contraction during perturbation experiments (Brogren, Forssberg, and

Hadders-Algra 2001; van der Heide et al. 2004; Woollacott et al. 1998), and a

reduced capacity to modulate the EMG amplitude to the specifics of the situation

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(Brogren, Forssberg, and Hadders-Algra 2001).

Active balance control has two mechanisms via which to strengthen balance:

reactive or compensatory postural adjustments (CPA) and proactive or anticipatory

postural adjustments (APA) (Aruin 2003; Massion 1998). Postural control in children

with CP has been researched via utilizing two experimental paradigms: a sudden

instability in terms of movable support-surface (Brogen et al. 2001; Nashner,

Shumway-Cook, and Marin 1983; Wollacott et al. 1998) and disturbing force caused

by voluntary movement (Hadders-Algra et al. 1999; van der Heide et al. 2004). These

two modes of control, compensatory or feed-back control and anticipatory or feed-

forward control may seem independent, but they are often combined in everyday life

(Carlberg, and Hadders-Algra 2005).

APA refers to movement that reduces the effects of a perturbation by voluntary

control, and CPA refers to reactive responses to postural perturbation (Bigongiari et al.

2011). The control mechanism for the reaction to unexpected external postural

turbulence is CPA, whereas the control mechanism for an action towards predictable

internal postural adjustment is APA (Westcott, and Burtner 2004). Nashner carried

out the first experiment that investigated individual reactions to balance control by

using a movable platform (Burtner et al. 2007). The paradigm used regarding CPA is

to place a child on a moveable platform and translate the platform forward and

backward to induce external perturbations (Nashner 1976). This type of control was

termed reactive balance control to differentiate it from stable postural balance while

standing still (Burtner et al. 2007). The causes of inadequate postural control are

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impaired muscle recruitment patterns, delayed onset time, and the frequent co-

activation of antagonist muscles (Westcott, and Burtner 2004).

Impaired postural control in children with CP creates difficulty in organizing CPA

and APA (Girolami, Shiratori, and Aruin 2011). Perturbation studies have suggested

that the children with CP have disordered muscle activation, such as cephalo-caudal

muscle activation, simultaneous activation of the ventral muscles, and excessive co-

contraction for sitting postural control (Brogren, Gadders-Algra, and Forssberg 1998).

Improvements have been observed during treatments that include external

movement activities such as the use of a platform, computer-generated saddle

movement, and the use of a rocker platform, which were conducted to develop the

children's postural adjustment (Butler 1998; Kuczyński, and Słonka 1999; Shumway-

Cook et al. 2003). COPDA (Coping and caring for infants with neurological

dysfunction - a family centred programme) (Blauw-Hospers et al. 2007), which is

based on the principles of motor development obtained via research, compared the

effects of early postural adjustment and found that it was more effective than

traditional pediatric physical therapy, which is referred to as NeuroDevelopment

Treatment (NDT) (de Graaf-Peters et al. 2007). A number of treatments using

adaptive seating devices, ankle foot orthoses, and NDT are being applied to children

with CP in an attempt to develop their postural adjustment; however, research on such

treatments is not enough to support their effectiveness at this stage (Harris, and

Roxborough 2005).

Activities such as reaching and grasping are the important basics of upper

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extremity multi-joint movement in daily life. Previous researchers have found that

children with CP are disturbed by dysfunctional postural control during the activity of

reaching (van der Heide et al. 2004). According to the systemic theory of motor

control, specific neural and musculoskeletal subsystems play a role in adjusting the

coordination of multi-joint movements. The velocity profile of the preprogrammed

normal reaching motion using more than one joint is a smooth bell shape, and the

trajectory is nearly a straight line (Näslund, Sundelin, and Hirschfeld 2007). It has

been found that the quality of reaching, or postural control performance, is influenced

by pelvis position during the initiation stage and is related to the stabilization of the

head and pelvis, as well as the movability of the trunk, during the action of reaching

(van der Heide et al. 2005).

Children with CP express different recruitment orders and the activation of postural

muscle at different latencies, as well as higher levels of antagonistic co-activation,

than typically developed children (van der Heide et al. 2005). Clinical research has

shown that children with CP presented improvement when given a postural support

while maintaining a sitting or standing posture (Woollacott et al. 2005). However,

only a small number of research results indicate postural adjustment during voluntary

reaching in children with CP (Hadders-Algra et al. 2007).

Children with spastic diplegic CP, who have increased muscle tone, paresis, and

involuntary motor control due to severe damage to their bodies, often to a lower body

part, experience difficulty in maintaining a balanced upright posture due to the

unstable condition of their high-centered masses and small base of support (Bobath,

- 6 -

and Bobath 1975). The goals of current CP interventions are improving kinematic

characteristics, allowing independent control and efficiency of movement,

maximizing function, preventing or minimizing secondary musculoskeletal

dysfunctions, and reinforcing motor control ability from increased endurance level

(Thorpe, Reilly, and Case 2005). Traditionally, aerobic exercise or muscle

strengthening activities have been considered to be contraindications for people with

CP due to concern that such exercises may increase the level of muscle tone, decrease

range of motion, and deteriorate overall function. Issues regarding the safety of

muscle strengthening through consistent resistance in children with CP have been

disproved by recent research that found no loss of range of motion or increase in

spasticity (Rogers et al. 2008). This suggests a rationale for developing a new

therapeutic direction in the treatment of children with CP.

Generally, aquatic exercise has been used to improve postural adjustment, range of

motion, social adaptation, and acceptance of environmental influence by utilizing the

characteristics of water, which is either supportive of or resistant to the movement

(Thorpe, Reilly, and Case 2005). Buoyancy, resistance, and hydrostatic pressure

provide the participant and therapist with a safer atmosphere for therapeutic activities

intended to improve muscle strength, balance, and technical skills (Fragala-Pinkham

et al. 2009). Aquatic exercise is known to be an effective intervention to reduce

spasticity, improve cardiorespiratory function, enhance the range of joint movement,

and increase motivation, self-perception and self-esteem (Nikolaos et al. 2009). Such

treatments in water are appropriate for children with CP because the exercise reduce

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the negative influence on postural control and excessive joint loading (Kelly, and

Darrah 2005).

The benefits of aquatic exercise for children with CP include buoyancy, which

allows movement in water despite the difficulty of moving against gravity; the high

viscosity of water, which works as a form of gradual resistance or excessive strength

in any range of movement; its relatively quicker heat transfer than oxygen, which

reduces spasticity and other involuntary motions; and hydrostatic pressure, which

stimulates the lungs and other inner organs, as well as pressure in the respiratory

muscles, exteroceptors, and proprioceptors (Hutzler et al. 1998). Therefore, reaching

actions would improve if aquatic exercise is beneficial for postural control. Despite

the fact that aquatic exercise is one of the most popular alternative treatment methods

for children with CP, there are few research results regarding its effectiveness (Getz,

Hutzler, and Vermeer 2006).

Postural control refers to the ability to control the body's COM over the base of

support (Horak 1992). Good postural control while reaching in various directions and

maintaining balance is essential in everyday life. Children with CP generally have

problems with postural control while maintaining a balanced upright posture

stemming from higher COM and small base of support (Bobath, and Bobath 1975).

An individual requires control of his or her balanced posture while reaching out in

various directions and to various distances without losing balance. The coordination

of the head, trunk and arms has great importance in performing activities in everyday

life (Sveistrup et al. 2008). Reaching and movement control depend on appropriate

- 8 -

postural control (Bertenthal, and Von Hofsten 1998). Many research projects show

that head and upper trunk control is initiated before the activity of reaching (Spencer

et al. 2000). Typically developing children require no coordination of the trunk during

reaching activity. However, in children with CP, there is a link between trunk

movement and reaching activity. It is assumed that their arms, hands and trunk are

held together during reaching in an attempt to support precise hand movement

(Carlberg, and Hadders-Algra 2005). Thus, there is a link between reaching activity

and postural control. The coordination of postural control and upper limb control lead

to the right hand moving towards a target while the balance of the body maintained

(Ju, You, and Cherng 2010). However, there are only a few studies on the relationship

between postural adjustment and hand movement in a sitting posture for children with

diplegic CP (Ju, Hwang, and Cherng 2012). The purpose of this study was to examine

the effects of aquatic exercise on upper extremity function and postural control during

reaching in children with CP.

Postural control in a sitting posture may present improvements due to aquatic

exercise. Therefore, we fabricated the following four hypotheses:

1. The number of blocks in the Box and Block Test will increase after aquatic

exercise.

2. The number of transferring pennies in the Bruininks-Oseretsky Test will increase

after aquatic exercise.

3. The distance achieved in the Pediatric Reaching Test will improve after aquatic

exercise.

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4. Movement time will decrease, hand velocity will increase, the straightness ratio

will be close to 1, and the number of movement units will decrease after aquatic

exercise.

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Method

1. Participants

This study included ten child participants who were diagnosed with CP with diplegia.

They were recruited from a local rehabilitation center in Seoul, Republic of Korea.

The inclusion criteria were: (1) level Ⅱ - Ⅲ on the Gross Motor Function

Classification System (Palisano et al. 1997), (2) the ability to understand the

experimental process and methods. The exclusion criteria for the participants were: (1)

any other congenital or neurological abnormalities except for cerebral palsy, (2)

surgery within 6 months, (3) Botox injections within 3 months, (4) fear of water, (5)

dysdipsia, (6) open wounds or active infections. This study was approved by the

Yonsei University Wonju Campus Human Studies Committee; parental consent was

received prior to the research. The participants' general characteristics are shown in

Table 1.

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Table 1. General characteristics of participants

Participant Gender Age

(years) GMFCS

a

Dominant side

Primary mobility device

1 mail 9 Ⅲ right Walker

2 female 8 Ⅲ left Walker

3 mail 6 Ⅳ right Walker

4 mail 10 Ⅱ left None

5 mail 4 Ⅱ right None





10 female 4 Ⅳ right Walker aGMFCS: Gross Motor Function Classification System.

- 12 -

2. Experimental Design

The present study had a single-group pre-post design. All subjects participated in

twelve aquatic exercise sessions (35 min/twice a week, water temperature range: 34℃

- 36℃). Each participant was assessed before and after the twelve sessions of aquatic

exercise in order to examine the effects of the intervention on postural adjustment and

upper extremity function. The clinical outcome measurements were the Box and

Block Test (BBT), the Bruininks Oseretsky Test of Motor Proficiency (BOT), and the

Pediatric Reaching Test (PRT) in both the sitting and standing positions. In addition,

a Vicon 3-D Motion analysis system was used to quantify the changes in movement

time, hand velocity, straightness ratio, and number of movement unit during the

reaching-returning tasks.

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3. Outcome Measures

3.1 Clinical Measurements

In this study, the outcome measures for clinical measurements were the BBT, BOT,

and PRT.

3.1.1 Box and Block Test

The Box and Block Test, introduced by Buehler and Fuchs (1957), was completed

which is an objective tool to examine an individual's hand function and upper limb

agility as commonly used in everyday life (Trombly 1989). Wooden blocks of 2.54

㎝ and a wooden box of 53.7 ㎝ × 8.5 ㎝ × 27.5 ㎝ were used in this test. The

box is divided into two sections by a partition (18 ㎝ height) in the middle. This test

measured the number of blocks moved from one side to the other side of the wooden

box by each subject's dominant hand for 1 minute. The test-retest reliability of this

test has been reported as having a rho coefficient of 0.93 and 0.97 for the right and

left hands respectively. Inter-rater reliability was 0.99 and 1.00 for the right and left

hands respectively (Cromwell 1976).

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3.1.2 Bruininks-Oseretsky Test of Motor Proficiency

The Bruininks-Oseretsky Test of Motor Proficiency is designed to measure the fine

and gross motor skills of people aged four to twenty-one. This test enables typically

developing children, as well as those with moderate motor skill deficits, to be

assessed. The assessment is based on fine motor precision, fine motor integration,

manual dexterity, bilateral coordination, balance, running speed and agility, upper

limb coordination, and strength (Bruininks 1978). This test provides standardized

results based on gross and fine motor hand functions (Gordon et al. 2007).

Transferring pennies is included as part of upper arm agility movement in the

motor system development research by Bruininks-Oseretsky, which is designed to

examine the agility, coordination, strength/visual motor control, upper limb speed,

and dexterity of children with motor skills disorders (Flegel, and Kolobe 2002). This

experiment asked subjects to place pennies in a box with their dominant hands for 15

seconds. The average number of pennies transferred was measured over three tests.

The BOT of motor proficiency is known to be reliable and valid (Liao, Mao, and

Hwang 2001).

- 15 -

3.1.3 Pediatric Reaching Test

The pediatric reaching test is a reliable and valid method for testing children with

CP. The PRT was developed and modified from the Functional Reach Test, which

was first developed for measuring functional reach while standing in adult

populations (Bartlett, and Birmingham 2003). Due to the consideration that many

children with CP are only able to maintain the upright position while sitting, the PRT

was developed to measure the maximal reach distance of children with CP both in the

sitting and standing positions. In the full version of this test, the functional reach

distances in the three reach directions (anterior, right, and left) in both the sitting and

standing positions are summed up to yield the total PRT score. In this study, subjects

were tested only in the sitting position. The sum of the three functional reach

distances in the three reach directions while the subjects were sitting was used as the

PRT score.

- 16 -

3.2 Experimental Apparatus

3.2.1 3-D Motion Analysis

A real-time 3-D motion analysis system (Vicon MX T40S, Vicon Motion System

Ltd., UK) was utilized to obtain motion configuration data. All angle changes were

measured at a 60 ㎐ sampling rate via the use of a Vicon MX T40S. Fifteen cameras

were used to analyze subjects’ motions. One of reflective markers was attached to C7,

the T10 spinous process, the humeral head, the lateral epicondyle, the dorsal

metacarpophalangeal joint of the hand on inspecting arm, and the respective targets.

Motion data were captured while each subject performed ten reach trials toward each

target. Kinematic variables for qualifying reaching performance, which were only

related to reach-and-return motion, were used to measure movement time (MT), hand

velocity (HV), straightness ratio (SR), and the number of movement units (MUs).

Total MT is defined as the time taken to complete an action, from its initiation to its

termination and then back to the initiation point. The reach phase of the MT was

defined as the target arrival time from the starting position to the target. The return

phase of the MT was defined as the time between the frames of leave target and

return end. The stand-by (SB) phase of the MT was defined as the time spent on the

target. PV indirectly measures the amount of strength utilized in the process of

circulation between reach and return. PV indicates the maximum hand resultant

velocity value between the initiation and the termination. SR was measured via the

- 17 -

route taken by the hand between its initiation and termination point. SR represents the

straightness of the hand trajectory. The ideal SR value is 1, and smaller values

represent more straight and effective hand trajectory movements. MUs are defined as

the acceleration-deceleration of the hand marker. MUs include phases of acceleration

and deceleration. The number of MUs represents hand movement and smoothness.

The lower the number of MUs, the smoother the movement is.

- 18 -

3.2.2 Experimental Procedure for Reaching

Reaching tests were selected to assess the quality of upper extremity and trunk

control. Like other assessments, 3-D motion data were collected while participants

performed reaching before and after the twelve sessions of aquatic exercise

intervention. In order to minimize the effect of possible confounding variables

depending on different test administrators, the same administrator conducted the test

to measure the participants' training and results. The test procedure was as follows:

The participants sat on a stool with their feet placed flat on the ground and their hip

and knee joints kept at 90 degrees. In the starting position, the shoulder of the

dominant hand was in approximately zero degrees of flexion/extension and zero

degrees of internal rotation. The elbows were to be kept at 90 degrees, and the

forearms were placed on an armrest, with the palms facing the ground. The non-

dominant hand was placed around the trunk in a relaxed manner. A target was placed

at eye level at a distance of 120% of arm’s length in three directions: (1) anterior to

the dominant hand, (2) deviated 40° laterally, and (3) deviated 40° medially from the

sagittal plane of the dominant hand (Ju, You, and Cherng 2010). An arm’s length was

defined as the distance from anterior axillary fold to the distal wrist crease. Each

reaching task was practiced several times prior to the data collection for

familiarization.

- 19 -

Figure 1. Experimental setup for reaching test.

- 20 -

4. Intervention

Aquatic exercise was undertaken in an exercise treatment area of 4 m × 3 m during

the treatment period. The aquatic exercise program consisted of five modified

movements that were selected from the Halliwick 10-point program to enhance upper

extremity and trunk movements, as explained by Lamback and Stanat (2000). The

Halliwick concept is a method that allows people with physical or learning disabilities

to participate in aquatic exercise, move independently in water, and learn swimming

via the exercise (Lambeck, and Stanat 2000). The treatment period was twelve

sessions of 35 minutes each. Swimming devices were not used, and the water

temperature remained at 35℃. The depth of water was designed to be 3-5 times that

of the thoracic vertebrae to allow the participants to have trunk control with enough

buoyancy.

- 21 -

4.1 Preparation Exercise Before the Treatment

This step is intended to allow participants to adapt to the characteristics of water,

such as buoyancy, water pressure, water resistance, and viscosity, before conducting

the aquatic exercise. It included movement in the water to relax the participants, for

example, moving the arms and legs in the water, maintaining a certain posture,

touching the water with the ear, and kicking the water with the legs. Taking a deep

breath via the mouth and blowing bubbles were conducted to accelerate respiratory

control and create a bond with the therapists. These activities lasted for 5 minutes.

4.2 Lateral Movement of the Trunk and Upper Limbs

The therapist instructed each participant to sit on his or her lap so that the water

came up to the participant’s shoulders while the participant's body was held by each

side of the pelvis to balance him or her in every direction. The participants were

asked to stretch their dominant arms as far as possible in the same direction while

balancing their bodies. This activity was repeated in the opposite direction. During

this movement, the alignment of the front and back of trunk was to be maintained,

and the arms were to move with bilateral symmetry above the surface of water. The

therapist could give little help to the participants in terms of managing smooth

movements. Overall, the movement was to be produced slowly, and this activity was

repeated for 10 minutes.

- 22 -

4.3 Anterior and Posterior Movement of the Trunk and Upper Limbs

The therapist instructed each participant to sit on his or her lap so that the water

came up to participant’s shoulders while the participant's body was held by each side

of the pelvis to balance him or her in every direction. The participants slowly lied on

the surface of water with their arms stretched towards their heads until they touched

their ears. This posture was maintained for 5 seconds. Then, the participants

attempted to sit up by moving their heads and drawing both arms forward to place the

hands on the therapist's shoulders. The movement of both arms was above the surface

of water. The overall motion was to occur slowly while the body balance was kept

symmetrical. This activity was repeated for 10 minutes.

4.4 Cross Movement of the Trunk and Upper Limbs

The therapist instructed each participant to sit on his or her lap where the water

came up to the participant’s shoulders while the participant's body was held by each

side of the pelvis to balance him or her in every direction. The participants maintained

balance while supinating both arms to maintain their bodies horizontally. They were

to grab the therapist's opposite shoulder by rotating their trunk to their preferred

direction while attempting to stay balance. This was repeated in the opposite direction.

Therapists could give little help to the participants in terms of managing smooth

movements. The overall motion was to occur slowly, and this activity was repeated

for 10 minutes.

- 23 -

5. Statistical analysis

The Statistical Package for Social Sciences (SPSS) Version 18.0 was used for

statistical analysis. The outcomes are expressed as mean ± standard deviation. In this

study, statistical analysis was performed via non-parametric testing because of the

small sample size. Differences in BOT and BBT values among pre-treatment, post-

treatment, and retention were analyzed by using a Friedman test. In addition, the PRT

and variables (movement times, hand velocity, straightness ratio, and the number of

movement unit) from the 3-D motion analysis were tested by using a Wilcoxon

signed-rank test. The significance level was established at p<0.05. When the results

appeared to be statistically significant, a post hoc test for multiple comparisons was

made with the Wilcoxon signed-rank test (Portney, and Watkins 2009).

- 24 -

Results

1. Clinical Measurement Score

1.1 Box and Block Test and Transferring Pennies of Bruininks -Oseretsky Test

The results of the clinical measurements for the BBT and transferring pennies of

BOT for pre-intervention, post-intervention, and retention are shown in Table 2. BBT

scores were significantly different among the three test sessions. The Friedman

analysis of variance revealed a statistically significant increase in BBT scores

(p<0.001), and the post hoc analysis revealed a statistically significant difference

between pre-intervention and post-intervention scores (p=0.005) and between pre-

intervention and retention scores (p=0.005).

The Friedman analysis of variance revealed a statistically significant increase in the

transferring pennies scores of the BOT (p=0.001), and post hoc analysis revealed a

statistically significant difference between the pre-intervention and post-intervention

scores (p=0.004) and between the pre-intervention and retention scores (p=0.011).

However, no statistically significant difference was noted between the post-

intervention and retention tests in either the BBT or the BOT (BBT p=0.356, BOT

p=0.595).

- 25 -

Table 2. Clinical measurements score after intervention (N=10)

Tests Pre-

intervention Post-

intervention Retention p

Box and Block Test (number)

19.50 ± 13.91a 30.80 ± 16.78 30.00 ± 17.26 <0.001

*

Transferring pennies (number)

8.80 ± 8.07 11.20 ± 9.29 11.01 ± 9.87 0.01*

a Mean ± standard deviation.

* Significant difference before and after intervention (p<0.05).

- 26 -

Figure 2. Post hoc analysis of BBT scores at the pre-intervention, post-intervention, and retention (

*p<0.05).

- 27 -

Figure 3. Post hoc analysis of transferring pennies scores of the BOT at the pre-

intervention, post-intervention, and retention (*p<0.05).

- 28 -

1.2 Pediatric Reaching Test

The outcomes of the PRT clinical measurement before and after the intervention

are presented in Table 3. A statistically significant increase was statistically shown

after the intervention, from 95.80 ± 36.78 ㎝ to 129.70 ± 50.29 ㎝.

Table 3. Dominant side PRT performance after intervention (N=10)

Tests Pre-

intervention Post-

intervention p

Pediatric Reaching Test

(㎝) 95.80 ± 36.78

a 129.70 ± 50.29 0.01

*

a Mean ± standard deviation.


- 29 -

2. 3-D Motion Analysis

2.1 Anterior target

The 3-D motion analysis results for the reaching performance towards the anterior

target are presented in Table 4. MT (except return), HV, SR and MUs showed

statistically significant differences during reaching performance after the intervention.

Table 4. Target location on the anterior (N=10)

Variables Pre-intervention Post-intervention p

Movement Time

Reacha 0.96 ± 0.29

i 0.74 ± 0.19 0.04

*

Returnb 0.69 ± 0.14 0.59 ± 0.89 0.17

SBc 1.15 ± 0.93 0.48 ± 0.33 0.02

*

Totald 2.76 ± 0.25 1.82 ± 0.52 0.02

*

Hand Velocity

Mean 0.32 ± 0.13 0.44 ± 0.13 0.01*

Peak1e 0.76 ± 0.19 0.97 ± 0.19 0.01

*

Peak2f 0.89 ± 0.17 1.36 ± 0.29 0.01

*

SRg 134.52 ± 17.06 117.67 ± 9.97 0.01

*

MUsh 2.37 ± 1.28 1.53 ± 0.50 0.04

*

aReach: target arrival time (㎳),

bReturn: arrival time from target to starting position,

cSB: time spent on the target,

dTotal: total movement time,

ePeak1: peak velocity from

the starting position to the target (㎳), fPeak2: peak velocity from the target to the

starting position, gSR: straightness ratio (%),

hMUs: number of movement units

(number). i Mean ± standard deviation.


- 30 -

2.2 Medial target

Table 5 presents the results of the 3-D motion analysis of reaching performance to

the medial target. The total MT, reach MT, MT for SB, all hand velocity variables,

and SR were significantly improved by intervention. However, MT for return and

MU were not significantly different between tests.

Table 5. Target location on the medial (N=10)


Movement Time

Reacha 0.99 ± 0.32

i 0.77 ± 0.19 0.04

*

Returnb 0.78 ± 0.71 0.68 ± 0.18 0.31

SBc 1.06 ± 1.02 0.45 ± 0.26 0.07

*

Totald 2.84 ± 1.96 1.90 ± 0.49 0.03

*

Hand Velocity

Mean 0.32 ± 0.99 0.43 ± 0.09 0.01*

Peak1e 0.73 ± 0.17 1.01 ± 0.19 0.01

*

Peak2f 0.87 ± 0.14 1.26 ± 0.33 0.02

*

SRg 133.07 ± 21.13 114.23 ± 6.05 0.02

*

MUsh 2.52 ± 1.12 1.92 ± 0.52 0.14











- 31 -

2.3 Lateral target

Table 6 presents the results of the 3-D motion analysis of reaching performance on

the lateral target location. Except for the return MT, all variables were improved

significantly by the intervention. HV, SR, and MUs showed statistically significant

differences in reaching performance after the intervention.

Table 6. Target location on the lateral (N=10)


Movement Time

Reacha 1.21 ± 0.59

i 0.87 ± 0.25 0.02

*

Returnb 0.68 ± 0.16 0.74 ± 0.19 0.39

SBc 1.19 ± 1.23 0.50 ± 0.35 0.01

*

Totald 3.08 ± 1.82 2.12 ± 0.59 0.01

*

Hand Velocity

Mean 0.37 ± 0.16 0.48 ± 0.18 0.01*

Peak1e 0.81 ± 0.28 1.08 ± 0.29 0.01

*

Peak2f 0.94 ± 0.25 1.29 ± 0.26 0.01

*

SRg 139.36 ± 18.99 119.58 ± 13.31 0.01

*

MUsh 2.93 ± 1.59 1.93 ± 0.63 0.03

*











- 32 -

Discussion

In this study, we examined the effect of aquatic exercise on postural control and

reaching performances in children with CP. The BBT, BOT, PRT, SR, MUs, hand

velocity, and MT of reaching tasks were assessed to demonstrate the efficacy of the

aquatic exercise. The results showed that six-week aquatic postural exercise improved

the upper extremity functions and the postural control of the children with CP. First,

the BBT scores and the number of transferring pennies in the BOT significantly

increased from the pre-intervention to the post-intervention. Furthermore, the

improvement was maintained one week after the intervention. Second, postural

control in sitting, tested using PRT scores, significantly improved after the

intervention. Third, all the kinematic variables in the reaching tasks relating to the

anterior and lateral targets significantly improved after the intervention. When

reaching to the medial target, all the kinematic data showed improvement after the

intervention. However, the return MT and MUs exhibited no statistical improvement.

As expected, the clinical measurements of hand coordination, upper extremity

dexterity, hand movement, and hand agility improved after the aquatic exercise.

Postural control skill in the sitting position also improved. Last, during the reaching

task, the speed in hand movement increased, and the MT straightness ratio to the

target decreased. The smoothness of the hand trajectory during the reaching task also

improved.

- 33 -

Fine motor skill plays an important role in adjusting sensorimotor processing

through coordination, and maximizing gross motor skills in reaching tasks (Carr, and

Shepherd 2003; Shumway-Cook, and Wollacott 2007). It is important to decide on

the most appropriate measure for activity limitation and participation restrictions in

the clinical context of pediatric neurorehabilitation (Rosenbaum, and Stewart 2004).

The International Classification of Function (ICF) model provides diverse

information on upper extremity function measures. Among the clinical measurements

used in this study, BBT that measured the gross manual dexterity was utilized for

hand function check at activity and participation level (Ohrvall, Krumlinde-Sundholm,

and Eliasson 2012) while BOT assessed upper extremity coordination and functional

movement at activity level in ICF (Furze et al. 2013). Furze et al. (2013) described

the effect of aquatic exercise on children with CP in accordance with the ICF

framework and improvements on upper extremity function, temporal/spatial gait

parameters (step length, endurance, and lower extremity strength) were observed

during the aquatic treatment, focusing on cardiovascular endurance, lower extremity

muscle strengthening and functional upper extremity activities. Therefore, paying

particular attention to personal and environmental factors and a therapist’s thought

process as well as integrating every factor involved in ICF model including activity

and participation levels are the essential part of evidence and it is concluded that a

therapist should consider these in the measurement and treatment process.

A 3-D motion analysis system was utilized to observe the effects of the treatment

on movement dysfunction (Kawamura et al. 2007). This type of system provides

- 34 -

information on movement speed, maximum joint movement angle, coordination

between joints, and the extent of movement smoothness in a given space and time

frame in upper extremity functional studies (Caimmi et al. 2008; van Vliet, and

Sheridan 2007; Wu et al. 2007). This study used MT, HV, SR, and MUs as the

kinematic parameters during reaching to assess the upper extremity functional

changes and postural control improvement.

In the present study, the BBT and transferring pennies of the BOT were both

conducted to measure fine motor skill. While the BBT attempts to assess the skill

utilized in moving a material from one hand to the other, transferring pennies of BOT

seeks to measure delicate hand function using both hands. PRT was utilized to assess

the changes in postural control during the reaching activity. The effect of the aquatic

treatment was determined by comparing the pre- and post- status of the children.

Following the treatment intervention, the subjects showed improvements in fine

motor skill and hand function, as well as stabilization of the body torso for postural

control. They also exhibited improvements at the activity and participation level in

ICF through upper extremity function and postural control enhancement after the

implementation of aquatic exercise.

The 3-D motion analysis system has been frequently used in upper extremity

functional studies of the children with CP (Chang et al. 2005; Chen, and Yang 2007;

Chen et al. 2007; Coluccini et al. 2007; Ju, You, and Cherng 2010; Ju, Hwang, and

Cherng 2012; van der Heide et al. 2005). Ju, You, and Cherng (2010) reported that

MT, SR, and MUs were greater in children with CP than normally developed children.

- 35 -

In the present study, MT in reaching showed a meaningful improvement, regardless

of the direction of the target, excluding the time spent on the return movement from

the target. The mean HV also improved regardless of the direction of the target. It can

be derived from consuming more power during reaching, based on postural

stabilization and minimization of time spent on reaching the target by effectively

adjusting maximum resultant velocity (Chen, and Yang 2007). We propose that the

positive changes after the intervention would be due to the improvement in postural

control following the aquatic exercise.

The SR represents the degree of straightness of the hand trajectory during reaching.

In our study, the SR of reaching in all directions of the target decreased after the

intervention. The number of MUs takes account of similar concept to the SR. A

smaller number of MUs signifies that the performer did not require less number of

correction during the movement. Therefore, a smaller MU means a straighter

trajectory. In our study, the number of MUs decreased after the intervention. Both the

SR and the MUs data indirectly demonstrate that the motor control of the children

with CP improved and that the reaching task became closer to the pattern of

programmed automatic movement. However, the degree of change in the MUs was

not large enough to show statistical significance in the medially located target. Less

hand smoothness than anterior target was observed when given the target location on

the medial during reaching performance by children with CP.

Children with lack of postural control skill would find other motor solutions when

faced with tasks for postural control. It means that medial and lateral reaches involve

- 36 -

trunk rotation components. Such rotation requires a preparation process while

maintaining a stable balance of hand and trunk (Bortolami et al. 2008). According to

research by Ju, You, and Cherng (2010), from the perspective of motor control, trunk

rotation is more difficult, as it requires the movement of the transverse plane. Thus, it

causes additional problems with respect to the medial or lateral reach during reaching

tasks. Furthermore, to reach the medical target, midline crossing is necessary.

Therefore, reaching to the medial target can be considered a more difficult task in

terms of freedom of movement. It is proposed that the improvement in the MUs of the

children with CP did not reach the level of the other parameters due to the unstable

development of postural control and pre-control and the preparation for movement.

The aquatic exercise program, which consists of trunk flexion/extension in the sagittal

plane and trunk rotation in the transverse plane, promotes the midline crossing; would

contribute to the improvement in postural control. Therefore, it is possible that the

number of MUs will decrease if the aquatic exercise program continues for a longer

period.

Aquatic exercise, including underwater aerobic exercise, swimming skills

improvement training, water resistance activity, and underwater walking exercise, has

been clinically applied in various ways to increase the effect of rehabilitation

intervention in children with CP (Fragala-Pinkham et al. 2009; Nikolaos et al. 2009;

Retarekar, Fragala-Pinkham, and Townsend 2009; Thorpe, Reilly, and Case 2005).

Our results from the aquatic exercise conducted on children with CP improved upper

extremity function and postural adjustment. Interestingly, aquatic exercise helped to

- 37 -

maintain or strengthen the effect of the treatment as can be seen in continuous

improvements even after the treatment through certain measuring methods such as

BBT and BOT. Getz, Hutzler, and Vermeer (2006) concluded that there is evidence

of enhancing respiratory function of children with CP. However, there is limited

evidence to support the application of aquatic exercises in CP subjects in the area of

activity and participation level of ICF. Furthermore they suggested that future clinical

studies using various objective outcome measures are required to prove the

effectiveness of the aquatic programs for CP. In this study, the aquatic exercise

program was based on the Halliwick method. The program consists of five modified

movements which are selected from the Halliwick 10-point program to enhance upper

extremity and trunk movements. The positive and objective evidences from the

finding of this study support those of previous studies that examined the effectiveness

of aquatic exercise in the rehabilitation treatment of children with CP (Fragala-

Pinkham et al. 2009; Hutzler et al. 1998; Nikolaos et al. 2009; Retarekar, Fragala-

Pinkham, and Townsend 2009; Thorpe, Reilly, and Case 2005).

The exercise in this study was not difficult for the subjects, and there was no

potential for harm during participation. Moreover, the aquatic exercise had positive

effects on the participants throughout the research, and there was full compliance with

the regime, with no dropouts. This would be due to the fact that aquatic exercise was

undertaken where the participants experienced comfort and relaxation of their body in

water and are provided with physical activity reinforcement in an environment which

is different from the land. These factors would have led to positive treatment results

- 38 -

and inducement of motivation and participation among the participants. The aquatic

exercise would be especially beneficial the children with CP whose body movements

are limited due to gravity and restrictions from physical difficulties while on land.

Therefore, aquatic activity has great potential for contributing to life-long exercise

program for children with CP.

There were inherent limitations in this study. First, a control group was not

included in this study’s design, and the sample size was relatively small. Randomized

controlled trials of children with pediatric neuromotor impairments are difficult due to

the diverse nature of these impairments (Getz, Hutzler, and Vermeer 2006).

Participants with neuromotor impairments display different characteristics, even

within the same classifications (Thorpe, Reilly, and Case 2005). For this reason, a

small group, well-designed intervention, with specific outcome variables, was

appropriate to investigate the effect of the treatment (Bower, and McLellan 1994). In

the future, this aquatic exercise program will be extended to other types of CP, to

participants with more severe symptoms, and to those with higher GMFCS levels.

Second, the reliability of the clinical measurements was not determined in this

study. However, the credibility of the clinical measurements used has been previously

established in the literature (Bartlett, and Birmingham 2003; Cromwell 1976; Liao,

Mao, and Hwang 2001). Moreover, a single well-trained and experienced researcher

collected the clinical measurements to minimize potential errors caused by using

various researchers. The inclusion of psychological outcome measures in future study

would allow the psychological effects (e.g., motivating the child and providing a

- 39 -

stimulus in a social environment) of aquatic treatment to be evaluated.

- 40 -

Conclusion

Aquatic exercise was undertaken in such a way that the participants experienced

comfort and relaxation in water. They were provided with physical activity

reinforcement in an environment that is different from the land. The results of this

study suggest that twelve sessions of aquatic exercise were beneficial in improving

upper extremity function and postural control in children with CP. Although our

results were not conclusive, there was a positive effect on upper extremity function

and postural control during reaching performance after aquatic exercise. Therefore,

aquatic activity has great potential for contributing to life-long exercise programs for

children with CP. On the basis of the results of our study, we have demonstrated that

aquatic exercise, in conjunction with land-based physical therapy, may help to

improve body function, activity, and participation in children with varying types of

physical disabilities. Further studies will be conducted to validate the results of our

study.

- 41 -

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국문 요약

수중치료가 뇌성마비 아동이 팔뻗기를 하는 동안

상지기능과 자세조절에 미치는 효과

연세대학교 대학원

물리치료학과

전 용 진

본 연구의 목적은 뇌성마비 아동이 팔뻗기(reaching)를 하는 동안 상

지기능과 자세조절에 대하여 수중치료가 미치는 효과를 알아보는 것이다.

뇌성마비 유형 중에서 하지마비를 가진 10명의 참가자(남자 8명, 여자

2명)가 연구에 참여하였다. 본 연구는 단일 집단 실험 전, 후 설계를 사용

하였다. 상지와 몸통을 강화시키는 운동을 포함하는 할리윅 10-포인트 프

로그램을 응용하여 수중치료 프로그램을 구성하였다. 참가자들은 일주일에

2회, 6주간, 각 회기 당 평균 35분 동안 참여하였다. 박스와 블록 검사,

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Bruininks-Oseretsky 검사의 동전 옮기기, 그리고 아동 팔 뻗기 검사 점수가

임상 평가도구로 이용되었고 6주 치료기간 전과 후에 측정을 하였다. 3차

원 동작분석기는 동작시간, 최고 속도, 직선 이동비율, 움직임 단위 수를

검사하였다. 참가자들은 의자에 앉은 자세에서 뻗기와 돌아오기 동작을 수

행하였다. 목표물은 팔 길이 120%의 거리와 눈 높이에 세 방향(안쪽, 앞

쪽, 바깥쪽)으로 위치시켰다. 실험 전, 후 대상자의 변화를 분석하기 위해

비모수 검정을 사용하였다.

박스와 블록 검사, Bruininks-Oseretsky 검사의 동전 옮기기, 그리고 아동

팔 뻗기 검사의 모든 점수에서 치료 후에 유의한 향상이 있었다(p<0.05).

3차원 동작분석에서는 모든 방향에서 돌아오기 움직임 시간과 안쪽 목표

물의 움직임 단위 수를 제외하고 치료 후 유의한 호전을 보였다(p<0.05).

즉 뇌성마비 아동들은 움직임 시간이 짧아졌고, 최고 속도가 빨라졌으며,

직선 이동비율과 움직임 단위 수도 감소하였다. 하지만 안쪽 목표물에서는

팔 뻗기 수행에 몸통 회전을 동반하는 어려움이 관찰되었다.

본 연구의 결과, 12회기의 수중치료가 뇌성마비 아동의 상지기능과 자세

조절에 유익함을 보여주었다. 이러한 결과를 바탕으로 지상 운동치료(land

exercise)와 수중치료를 병행하면 다양한 신체장애를 가진 아동들에게 기

능과 활동, 그리고 참여에 있어서 개선이 있을 것이다. 이후 연구에서는

실험 참여자 수, 치료시간, 그리고 치료 후 관찰기간(follow-up)을 늘려

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서 본 연구에서 얻어진 결과의 타당성을 검증할 필요가 있다.

핵심 되는 말: 뇌성마비, 상지기능, 수중치료, 자세조절.

effects of aquatic exercise on upper extremity function and postural control … · 2019-06-28 ·...

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