Evidence-Based Physical Therapy (EBP) uses the best research evidence with clinical expertise and user’s preferences to produce the most appropriate and effective care. At week 43 in 2023, we had Blended Intensive program (BIP) in Finland, Kuopio Savonia University of Applied Science about EBP. This BIP program opened with welcome words of the president of The European Network of Physiotherapy in Higher Education (ENPHE) and followed with the basis of EBP and teachers who highlighted the main challenges at different Physical Therapy fields week 43 in 2023 we had Blended Intensive program (BIP) in Finland, Kuopio Savonia University of applied science. More than 40 physiotherapy students and 7 teachers from three universities (Savonia University of Applied Sciences, Finland, Universidade da Coruña, Spain, and Charles University Prague, actively participated this week and shared experiential group dynamics and social activities. Students worked together and wrote articles devoted to the following themes: Evidence Based in McKenzie, back pain, spinal cord injuries, aquatic therapy, ergonomics at work, Nordic walking, sport injuries, sport and young adults: Prevention of sport injuries and children with disabilities. In the following you can consult the works presented by the students on each topic.

Introduction into aquatic therapy and cerebral palsy

Aquatic therapy (hydrotherapy) in general is any therapy based on use of water for the treatment of patients. It is an old method used widely to support functional ability and treat health conditions. Utilizing water in different forms, durations, and at various temperatures can have diverse effects on the various physiological systems of the human body. According to the literature hydrotherapy can be used to improve immunity, restore pain, improve cardiovascular and respiratory function. It can also help with treatment of fatigue, obesity, stress, and anxiety. (Bairaktaridou et al. 2021.) Because water reduces the overall load of the musculoskeletal system, even individuals with an elevated risk of falling or joint pain can benefit from hydrotherapy (Mooventhan & Nivethitha 2014).

Cerebral palsy, also called as CP, is a term used to refer to non-progressive motor conditions (Ballington & Naidoo 2018; Akinola et al. 2019.) Bax (2005) has defined CP as a group of disorders. These disorders can cause limitations in activity, movement, and posture. These disturbances occur in the developing fatal or infant brain. (Bax 2005.) Depending on the severity of CP, it can have great effects on child’s life and their functional ability. The main features of CP are abnormal gross and fine motor function which result to abnormal motor control, imbalance between muscle agonists and antagonists as well as abnormal muscle tone. Due to these motor problems, reduced muscle elasticity, reduced joint range of motion as well as disturbed bone and joint development can occur. These then again can cause difficulties with daily activities such as walking, feeding, and swallowing, speech articulation and participation in society. (Akinola et al. 2019.)

The most common therapeutic exercises that are used in the rehabilitation with CP, are land-based exercises. These exercises could be e.g., stretching and balance training. Despite the effectiveness of land-based therapy, there have been some reports about challenges that have appeared during their usage, e.g., pain during stretching. (Akinola et al. 2019.) According to one study there is limited information on the effectiveness of water therapy, but based on that review, it is nevertheless a feasible form of exercise for children with CP (Roostaei 2016).

Aquatic Therapy in children with CP: Research Overview

The aim of this study was to investigate different hydrotherapy methods in children with spastic diplegia CP and its effect on their GMFCS performance levels and to define the effect of water therapy on the improvement of different areas of ICF. The findings revealed that water therapy combined with other traditional rehabilitation methods, produced positive effects in all areas of the ICF. Water therapy can be used for children and young people with spastic diplegia cerebral palsy, but the exercises should be chosen according to the patient’s physical and cognitive state. However, the studies on the ICF sub-area are limited and further studies are needed. (Khalaji et al. 2017.)

The study from Ballington and Naidoo (2018) concentrated on determine the carry-over effect of an aquatic-based programme on land in children with CP. The study found that aquatic therapy had a significant effect on gross motor function scores. When comparing to the control group, motor function increased following the intervention. The study was randomised into intervention and control groups. In total there were 10 children (5 + 5) between 8-12 years who were diagnosed with CP with GMFCS score of between 1 and 3, but no other medical conditions. Due to small group the study was made to be a cross-over design. Intervention group had two sessions per week and one session lasted 30 minutes, total of 16 sessions (8 weeks). The intervention was based on Halliwick Concept which took 20-min of one session. The sessions started with a 5-min warm up and ended with 5-min cool down. Control group continued with normal activities. The study was pretest-post-test, which means that tests were made before and after intervention. (Ballington & Naidoo 2018.)

Another study has also been made about the effects of hydrotherapy on the head control and movement functional ability of children with cerebral palsy aged 2 to 6 years. The study included 29 children from both sexes that were randomly divided into two groups. The study group received hydrotherapy and the control group received land-based therapy. Effects were measured with Gross Motor Function Measure (GMFM) and Vestibular Evoking Myogenic Potential (VEMP). The study suggests that hydrotherapy is an effective way to improve the head control of children with CP. It also shows that hydrotherapy is as effective as land-based therapy in supporting the movement functional ability of those children. (Mostafa et al. 2021.)

One systematic review investigated the effect of hydrotherapy on motor functions in children and young people aged 2-18 with CP disability. The GMFM meter was most commonly used to measure motor functions in various studies. The studies used water training, the Halliwick concept, Watsu (water shiatsu) and water bath therapy, and swimming training as therapy methods. The majority of the studies included in the review (64 %) showed improvement in motor function. This indicates that hydrotherapy is effective for this patient group. Studies showed that hydrotherapy was similar to conventional physical therapy in 27 % of cases. The review showed that hydrotherapy improves the motor functions of CP patients when the GMFCS levels are between I-III, compared to the conventional physiotherapy or non-intervention. More severe CP disorders need a longer time for intervention to achieve results. (Mujawar 2022.)

The Halliwick Concept

There are various different methods used in aquatic therapy and one of them is called the Halliwick Concept. It was one of the most used in the studies we found doing the research and that is why we decided to mention it in this article. The concept is based on hydrostatics, hydrodynamics, and body dynamics. Its goal is to teach swimming by encouraging independent movement and participation in water activities. The concept usually progresses in ten points, beginning with mental adjustment to water, continuing via rotations of the body around different axes of a motion (sagittal, transversal, …) and finally ending with learning the basic swimming movements. (Gresswell et al. 2010)

Positive results of Halliwick therapy came from a systematic review that evaluated the effectiveness of aquatic therapy based on the Halliwick concept in children with cerebral palsy. The review found that four out of five studies showed a significant improvement in gross motor function and aquatic skills in children with cerebral palsy where the Halliwick concept was used. The systematic review used five studies and mean sample size was 12 participants (7-24). The age of the participants was between 3 and 12 years, all of them with CP levels I to IV based on the Gross Motor Function Classification System (GMFCS), except for one study that did not specify the classification level at baseline. The session time varied between 30 and 45 minutes. The interventions were carried out during a minimum period of six weeks and a maximum of 16 with two weekly sessions. (Tapia et al. 2023)

One recent study also compared the effect of Halliwick water therapy and conventional land-based physiotherapy on gross motor skills in 3-5-year-old children with spastic cerebral palsy. The study found that both Halliwick water exercises and conventional exercises significantly improved gross motor skills. However, the estimated effect of Halliwick therapy exercises on sitting, standing, walking, running, and jumping was clinically more significant than in conventional exercises. (Hamed et al. 2023.)

Conclusion

In summary, the utilization of hydrotherapy and its various methods in the treatment of cerebral palsy (CP) presents a promising approach with several physical, emotional, and psychological benefits. The reduced musculoskeletal load in water makes it a particularly appealing option for individuals at risk of falling or experiencing joint pain.

Comparative studies have also highlighted the effectiveness of Halliwick water therapy, showing that it can lead to significant improvements in specific motor skills, such as sitting, standing, walking, running, and jumping, when compared to conventional land-based physiotherapy.

Overall, the research suggests that hydrotherapy can effectively improve motor functions in children and young people with CP, particularly for those with GMFCS levels between I and III. The frequency, duration, and session length of hydrotherapy should be carefully considered to achieve the best results. While it appears particularly beneficial for less severe CP cases, further studies are necessary to fully understand its effects and benefits for CP patients.

Fulin Stepan, Physiotherapy student, Faculty of Physical Education and Sport, Charles University, Czech Republic

Hasu Emma, Physiotherapy student, Savonia University of Applied Sciences, Kuopio, Finland

Pentti Jenni, Physiotherapy student, Savonia University of Applied Sciences, Kuopio, Finland

Syrjäniemi Kaisa, Physiotherapy student, Savonia University of Applied Sciences, Kuopio, Finland

Viitanen Sanni, Physiotherapy student, Savonia University of Applied Sciences, Kuopio, Finland

Marja Äijö, PhD, PhD, Principal lecturer of gerontology and rehabilitation, Savonia University of Applied Sciences, Finland

Mari Tuppurainen, Physiotherapy lecture, Savonia University of Applied Sciences, Kuopio, Finland

Dagmar Pavlu, Physiotherapist, Assoc. Prof. Charles University, Czech Republic

Ivana Vláčilová, Professor, Charles University, Czech Republic

Jamile Vivas Costa, PhD, MSc, PT. Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Researcher at Psychosocial intervention and functional rehabilitation group, Universidade da Coruña, Spain

Montserrat Fernández Pereira, MSc, PT.  Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Physiotherapist at Spinal Cord Injury Unit, A Coruña Hospital (CHUAC), Spain

Verónica Robles García, PhD, MSc, PT, OT. Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Researcher at the Neuroscience and motor control group, Universidade da Coruña and Biomedical Institute of A Coruña, Spain

Resources:

Akinola, Bolarinwa Isaac, Gbiri, Caleb Ademola & Odebiyi, Daniel Oluwafemi 2019. Effect of a 10-Week Aquatic Exercise Training Program on Gross Motor Function in Children With Spastic Cerebral Palsy. Global Pediatric Health (6):1–7. https://doi.org/10.1177/2333794X19857378. Referred 24.10.2023.

Bairaktaridou A, Lytras D, Kottaras A, Iakovidis P, Chatziprodromidou P, Moutaftsis K 2021. The effect of hydrotherapy on the functioning and quality of life of children and young adults with cerebral palsy. International Journal of Advanced Research in Medicine 3(2) 2-24 https://doi.org/10.22271/27069567.2021.v3.i2a.211. Referred 24.10.2023.

Ballington, Samantha J. & Naidoo, Rowena 2018. The carry-over effect of an aquatic-based intervention in children with cerebral palsy. African Journal of Disability. 7 (0) a361. https://doi.org/10.4102/ajod.v7i0.361. Referred 24.10.2023.

Bax, Martin, Goldstein, Murray, Rosenbaum, Peter, Leviton, Alan, Paneth, Nigel, Dan, Bernard, Jacobsson, Bo & Damiano, Diane 2005. Proposed definition and classification of cerebral palsy. Development Medicine and Child Neurology 47 (8), 571-576. https://doi.org/10.1111/j.1469-8749.2005.tb01195.x.Referred 24.10.2023.

Gresswell A, Ní Mhuirí A, Fons Knudsen B, Maes J, Koprowski Garcia M, Hadar-Frumer M, Gutierrez Bassas M. THE HALLIWICK CONCEPT 2010 International Halliwick Association (IHA) Education and Research Committee 2010, http://www.halliwick.org.uk/publications-2/the-halliwick-story/

Hamed, Somaia A., ElMeligie, Mohamed Magdy & Kentiba, Efrem 2023. The effects of Halliwick aquatic exercises on gross motor function of children aged from 3 to 5 years with spastic cerebral palsy. Pedagogy of Physical Culture and Sports 27 (1): 24-31. 10.15561/26649837.2023.0103. Referred 25.10.2023.

Khalaji, Masoud, Kalantari, Minoo, Shafiee, Zahra & Hosseini, Mohammad Ali 2017. The effect of hydrotherapy on health of cerebral palsy patients: an integrative review. Iranian Rehabilitation Journal 15(2), 173-180. Referred 24.10.2023.

Mooventhan A, Nivethitha L 2014. Scientific evidence-based effects of hydrotherapy on various systems of the body. North American Journal of Medical Sciences, 6(5), 199-209,

Mostafa, Ahmed Mohamed Ahmed, El-Negmy, Emam Hassan, El-Maksoud, Gehan Mosaad Abd, AbdAl-Ghaffar AbdAl-Rahman, Mohamed, Srour, Amr Ahmed Othman 2021. Effect of aquatic therapy on head control in cerebral palsy children. Curr Pediatr; 25 (11): 1142-114. https://www.researchgate.net/publication/357958832_Effect_of_aquatic_therapy_on_head_control_in_cerebral_palsy_children. Referred 25.10.2023.

Mujawar, Muskaan Mahamadhanif 2022. A Systematic review of the effects of aquatic therapy on motor functions in children with cerebral palsy. Reabilitacijos mokslai: slauga, kineziterapija, ergoterapija 2 (27), 51–67. https://doi.org/10.33607/rmske.v2i27.1262. Referred 24.10.2023.

Roostaei, Meysam, Baharlouei, Hamzeh, Hamidreza, Azadi & Fragala-Pinkham, Maria A. 2016. Effects of Aquatic Intervention on Gross Motor Skills in Children with Cerebral Palsy: A Systematic Review. Physical & Occupational Therapy in Pediatrics 37 (5): 1-20. 10.1080/01942638.2016.1247938. Referred 24.10.2023.

Tapia C, Constanzo J, González V & Barría R. M.  (20 Sep 2023): The Effectiveness of Aquatic Therapy Based on the Halliwick Concept in Children with Cerebral Palsy: A Systematic Review, Developmental Neurorehabilitation 1-6 https://doi.org/10.1080/17518423.2023.2259986