Effect of Aquatic Physiotherapeutic Interventions on Autonomic Modulation of the Heart in Children with Cerebral Palsy

The need for neurorehabilitation strategies has increased in recent years. Aquatic rehabilitation has been advocated by many researcher as a useful treatment modality for patients with neurological disorders (Sova 2012, Schoedinger, 2011, Chong et al, 2009). Specific benefits provided by the aquatic environment include weight relief and ease of movement. Also the supportive properties of water allows easy handling of patients by aquatic therapy professionals. Watsu is a form of aquatic bodywork used for deep relaxation, balancing ANS function and pain management as a passive aquatic therapy (Schoedinger 2011). Cerebral Palsy (CP) is the most common cause of severe physical disability in childhood. Watsu, relaxing water therapy, improves ANS balance (Tufekcioglu and Perlitz 2010). It is performed in warm water (around 35C.) in which a therapist gently cradles, moves and stretches a receiver in chest-deep warm water (Dull 2008, Jamison, 2009). These effects of watsu on the functional state of a person can be monitored via the change in the Autonomic Nervous System (ANS) activity. Hearth Rate Variability (HRV) is widely considered a standard noninvasive method for assessing Autonomic Nervous System (ANS) function (Task Force 1996). Heart rate variability (HRV) is the variation of beat to beat intervals, also known as R-R intervals. Tufekcioglu and Cotuk, (2009) indicated significant increase in time and frequency domain parameters of HRV during watsu. To compare the effect of watsu therapy and warm water immersion on HRV time and frequency domain parameters of children with cerebral palsy, cross over design, a clinical trial design will be conducted. Methods: The 30 children aged between 3 and 12 years old will be randomly separated into two groups to conduct watsu therapy and head out warm water immersion in two successive periods. A certified watsu therapist will be applying watsu therapy for cerebral palsy in an identical pattern throughout the periods. In the first period, 16 watsu and water immersion sessions will be performed for 30 minutes and twice a week over a period of 8 weeks for each subject. After a week of wash-out period without any therapy or water involvement the 2nd period will start with the subjects crossed over from receiving one treatment to another one. Disease status of the subjects with cerebral palsy and confirmation from their family will be collected. Blood pressure levels before and after each period will be measured. HRV parameters of all participants will be recorded 4 times at the beginning and at the end of two successive periods. Each measurement will be performed while sitting and lying down on supine position for 5 minutes. Polar RS 800 CX telemetric pulse measurer with the capability of recording the heart pulse intervals with 1ms sensitivity is the tool to record heart rate. HRV parameters will be determined by polar software. Frequency and time domain analyses will then be performed. Statistics: Repeated Measures of ANOVA (Analysis of Variance) will be used for comparisons of all measurement parameters. The effect of the watsu and head out warm water immersion will be evaluated in the cross over design analysis. Clustering models will be used to investigate and discover natural groupings within the collected data the unlikely period effect from first to second will be analyzed with Wilcoxon / Mid Rank test.