Aquatic Therapy:

An evaluation of rehabilitative aquatic conditioning as a treatment tool for pediatric disabilities.

Amelia Pousson

Acknowledgments

Many thanks are offered to The Gudelsky Swim Program, the Jewish Community Center of Greater Washington, and most especially to Grace Deely and Lee Fisher for their kind tutelage and help.

Abstract

Aquatic therapy is a viable treatment tool for the rehabilitation and physical therapy of the current special-needs pediatric population. Despite its unfortunate past association with faddish 'cures,' aquatic therapy, when unbiasedly evaluated, can be seen to have significant benefits for children with disabilities. Aquatic therapy provides an environment in which the myriad dangers of inactivity can be either subverted or avoided altogether. These dangers of inactivity can include not only the expected effects, such as a loss of muscle tone, but also can affect skeletal stability, cardiac health, and even self-esteem. Yet, having acknowledged the dangers of inactivity, the question remains of how to involve the pediatric patient in a exercise regimen. The success of any program of pediatric rehabilitation depends in large part upon this involvement the treatment regimen. In this role hydrotherapy excels, often seeming more like a sort of play to children thus making them more willing to participate. The success of the participation levels with aquatic therapy is rivaled only by the success that it has as a physiological treatment. The physiological benefits are equivalent or superior to those which would be gained in a standard exercise program, and include elements of aerobic, flexibility and resistance training. At the Gudelsky Swim Program, an evaluation of the success of aquatic therapy in a real-world treatment environment can be made. The benefits for both of the children studied are undeniable, although certainly much more striking for one of the children. Yet this is only a confirmation of the fact that the success of aquatic therapy, as with any type of therapy, depends largely on the individual and their situation at the time. Even with the recognition of the fact that aquatic therapy succeeds better with certain children, the benefits that it has for all pediatric therapy programs are undeniable.

The benefits of aquatic conditioning and therapy for the handicapped pediatric population are significant. Hydrotherapy, aquatic exercise, or swim therapy are all names for a technique that deserves thoughtful consideration in the treatment schedules of youngsters with disabilities. The physiological benefits (as well as psychological benefits) apply to children whose conditions might range from Cerebral Palsy to Juvenile Rheumatoid Arthritis to Autism. However, children are obviously not all alike, therefore the vagaries of their special needs must also be kept in mind in constructing an aquatic therapy program. Even though some youngsters benefit more from rehabilitation in the water than others, everyone can gain something from it. This near universal gain that is obtained by water therapy is one of the primary driving forces behind increased consideration of it as a technique for pediatric rehabilitation. The buoyant nature of water, combined with it's usefulness as a medium for aerobic, flexibility and resistance training and the fact that training in water often seems more like play to youngsters than "traditional" therapy methods (making them more willing to participate) make possibly the best medium for pediatric rehabilitation.

Lack of exercise in youngsters is a problem that should be addressed for all youth, however, is of critical importance for the special needs youth population. Although regular exercise and/or physical therapy is obviously of critical importance to the health of any person, the health of special needs youth has an even greater link with their physical fitness. However, for those children with a disability, the tedious, or even grim nature in which the exercises are presented, or the overly clinical atmosphere that pervades the physical therapy can lead the youngster to neglect or even cease entirely the exercises that maintain their health. It is important to consider exercise for children as not only a health maintenance procedure, but as a fun activity, or else the benefits to the health of the child will not be gained, because the exercises will go undone. If the health is neglected in the critical formative years, obesity, cardiovascular diseases and many other diseases and/or impediments can impact severely on the health of the individual as they age, thus maintaining physical activity is a crucial goal for the youth special needs population.

Due to the prevailing attitudes in prior years towards the manner in which childrens' activity programs should be structured (ie. starkly functional and clinical), many children with special needs were prone to physical inactivity, in part as a result of the unpalatability of their exercise regimes. This disuse proves quite harmful to the body, however. There are several physiological effects of disuse and physical inactivity on the body's systems including the cardiovascular system, nervous system, and the muscular/connective/skeletal systems. As noted in Basics of Exercise Physiology, after prolonged neglect the cardiovascular system shows a "higher resting heart rate, higher resting blood pressure, lower cardiac output," and decreased circulation in general (Curtis, 1981: 27). The higher resting heart rate, the higher resting blood pressure and the lower cardiac output are all indicators of heart disease, which although it is not a major concern of the pediatric population, can develop into a serious problem, even by the teenage years, if inactivity is pronounced. Decreased circulation can also be extremely hazardous for those whose limbs are secured during most of the day (such as youngsters with cerebral palsy). The nervous system also shows the effects of disuse. Not only this, but according to K. Hakkinen (Hakkinen, 1982: 44) the physiological effects that can be observed include extremely sub-optimal coordination, as well as decreased emotional state, possible depression, and lethargy. Sub-optimal coordination leads to decreased skill in movement, and lack of ability on activities requiring either accuracy, precision or balance. All of these physiological effects impact on the mental state of the youngster, resulting in lower self esteem, or even depression, and since ability to participate in activities has decreased, so does desire to participate in those selfsame activities, resulting in overall lethargy. Stone noted that (Stone, 1988: 5163) the muscular effects of this lethargy often include decreased muscle mass (atrophy), decreased strength, and increased percent body fat. The decreased muscle mass and decreased strength strongly decrease the ability to perform daily activities. This inability can result in isolation from peers, which in turn can lead to loneliness and ancillary bad habits associated with loneliness such as apathy toward any activity, or bad eating habits. These in turn, contribute to increased percent body fat, which can lead to obesity, and still further isolation from one's peers. Obesity, especially in a youngster can be the harbinger of more serious problems, including cardiovascular disease, as well as making any necessary surgeries more difficult and riskier. The effects of disuse can also be observed in the connective and skeletal systems. There is "extensive bone demineralization," commonly known as osteoporosis, decreased pliability of tendons and ligaments, contractures, and pressure sores (Stone, 1988: 5164). Although osteoporosis is primarily known as a disease of elderly persons, its causes, especially in the special needs population, can often be traced to an inactive childhood. The reduction in range of motion (ROM) that is the effect of contractures, as well as the weakness in joints that is caused by the decreased tensile strength and pliability can increase incidence of injury as well as decreasing the number of activities that can be preformed. It is clear, from the serious effects of lack of exercise on the special needs pediatric population, that it is necessary to develop a way to encourage youngsters to participate in physical exercise and therapy.

One solution to this dismal cycle of boring exercise and neglect of exercise is not only to make the exercise not only less repetitive and more interesting, but also to give it a greater impact for the amount of time that must be spent doing it. What is this mystical form of exercise that is both fun and useful? Nothing more mundane than swimming, or actually, aquatic therapy. One of the major benefits of aquatic therapy is the fact that it provides all the beneficial physiological effects of resistance, aerobic and flexibility training, in a single setting. The water provides support for the body (buoyancy), provides resistance to movement, and allows easier aerobic exercise, without impact on the fragile joints and muscles of special needs youngsters, or overheating and pain that are endemic to many exercise regimes. Most exercises that are painful for the child, or simply boring on dry land, are livened by the new area, and the children gain much greater physical benefits from the exercises. Their fitness level increases at a rate that is easy to see for both the youngster and the therapist, thus encouraging persistence in gaining a higher level of health.

Not just participation, but actual physical gains must be included in an evaluation of the usefulness of aquatic therapy as a treatment method; in short, one must ask how good aquatic therapy is at assisting achievement of an appropriate level of fitness. Fitness is the general measure for determining how physically healthy a given individual is. There are eight key aspects of fitness: flexibility, aerobic capacity, anaerobic capacity, musculoskeletal resiliency, strength, power speed and skills. All of these aspects contribute to improving the health of the bodily systems mentioned earlier. Hydrotherapy allows achievement of these objectives of fitness in a much more relaxed and less painful setting, while allowing a certain amount of therapy disguised as game-playing. The buoyancy of the water allows stretching to be preformed easier, and warm water can reduce the pain that often deters children from improving their flexibility through stretching. The tendons, ligaments and fasciae are all improved in tensile strength and elasticity by these exercises, which contributes to easier performance of daily activities and self-propulsion. Aerobic capacity is the ability of the body to preform activities for extended periods of time, and occurs when the heart rate is elevated to the "target heart rate" for twenty to sixty minutes three to five times per week. This is achieved easier in water where the water makes what are strenuous activities on land, both easier and so much more fun that most youngsters seem to hardly realize that they are working. Despite this, as White noted (White, 1995: 75), their work shows in their decreased resting heart rate and blood pressure, their greater absolute stroke volume, more efficient cardiac output and pulmonary ventilation, their increased oxygen extraction and delivery to muscles and increased circulation. In their life, this decreases the youngsters' incidence of cardiovascular disease as they age, as well as improving their endurance, thereby allowing them to experience independence more and more. Anaerobic capacity relies on muscle glycogen, and usually requires exercises that have a great deal of impact on land. But in the water, this impact is cushioned, allowing youngsters to develop this capacity without pain. Musculoskeletal resiliency (MSR) is the strength of the bones and connective tissues. As before, the fact that water provides an environment that is more 'fun', makes this type of training much more effective. For example, many of the exercises to develop MSR, which on land take the form of tedious lunges, can be replaced with chasing and reaching games in the water. The increased desire to participate in such activities leads to increased bone density and mass, increased resiliency of connective tissues and a greatly decreased incidence of injury from overuse activities. Strength is a muscle's ability to exert force. Certain devices that increase the surface area of the hands or the feet, and thereby increase resistance in water exercise have a comical enough look, and are so light (especially in contrast to the weights that are usually used in resistance training to develop strength) that children with special need see strength training as a type of play. This 'play,' however, increases their overall muscle mass (hypertrophy) and improves their ability to exert muscle tension, thereby also improving ambulatory faculties in weight bearing children, and improving their overall ability to complete day to day activities. Not only does this have an effect on the child's physical health, the sense of accomplishment generated by increased day-to day skills proficiency is not to be discounted as an important benefit. Power is the maximal strength producing capacity of an individual over a period of time, while speed is the rate of a limbs movement around a joint. Developing these two aspects of fitness is one of the more common causes of injury on land, but in the water, speed and power can be improved without this risk for the children. This leads to increased EMG response, due to the demands on the nervous system for greater velocity, improves the activation of motor units in prime movers, and increases accuracy, precision, balance and speed of movement. All of these can translate into greater self confidence for the child in their own ability to do things for themselves. Finally, skills are neuromuscular habit patterns that allow people to perform their activities with efficiency. This is one of the places that water therapy really excels. Children who are completely non weight bearing on land, may be able to actually walk in the water, while those who are in constant pain due to a condition such as severe juvenile rheumatoid arthritis, may experience such a reduction in this pain that they are able to easily do activities that are excruciatingly painful on land. For instance, the desired flexed trunk posture that allows a child to transfer from floating on their back to other positions, will also transfer over to standard therapy for a child with trunk extension, allowing them to gain better posture and more ambulatory qualities. Overall, the skills gained in 'play' in the water are so crucial, and transfer so well to other aspects of the children's life that this can truly be said to be the most important of the aspect of fitness that are gained through aquatic therapy and exercise.

Theory is a wonderful basis for action, however, as in any scientific endeavor, it is experimentation and real life data that tells the tale. People, especially children, are not so easily manipulated as, other, more empirical experimental factors, and therefore must be observed in a more real world setting. There are many programs that provide aquatic therapy for children, and a well respected one is the Gudelsky Swim Program located at the Jewish Community Center of Greater Washington, Rockville, Maryland. This program is affiliated with the American Red Cross, which trains all of the clinicians, and with the Treatment and Learning Centers, a school for disabled children, which provides three to five physical therapists per week to observe and give assistance to the clinicians in terms of technique for helping the children achieve their goals. The program takes place one day per week, Saturday mornings between 11 and 1 PM, and is free of cost to the participants' families. There are two sessions, from eleven AM until noon, and then from noon until one PM. Each clinician works with one child for approximately an hour, and then conferences with the parent or parents about their child's progress. Every two weeks of working with a child, or oftener if it is deemed necessary, the clinician conferences with the head clinician about what objectives should be the primary ones for the next sessions and methodology for achieving these goals. To be included in the program, a child must be referred by their doctor, and with the leaders of the program, the physician and parents attempt to set a specific goal, but these goals range from "gaining play reflexes in water and desensitization to touch" to "Increased ambulatory proficiency and muscle tone". The overall goal of the program is to acquaint the children with the medium of water as a fun and healthy place to exercise early on, and for some, to provide a place to learn the basics of swimming in an atmosphere that can care for their special needs in a more professional and caring way than a standard swim program would be able to. Observations were taken of two children over a twenty-six week period, and are recorded in appendices A and B. This time period was selected because it was the duration of the 'Primary session' after which, participants in the program decided whether or not to continue.

The first child observed was T, an child with special needs that were undiagnosed as yet, but displayed features of Autism, ADHD, juvenile rheumatoid arthritis and had very low muscle tone (floppy) on her left side. An observational record was kept by this researcher during the twenty-six-week period, as a standard method of recording the results of scientific experimentation with people in real life situations, and the observational records for T can be found in Appendix A. Weeks that are skipped are ones where there was either no notable progress, or they were extremely similar to the previous week. As can be seen by the observational record, T underwent very quick progress during this twenty-six-week period. This is by no means due solely to the impact of the aquatic therapy. She had changed physical therapists about six weeks prior to joining the program, and several of her medications, including the ones intended for pain control, and the ones to mediate her emotional state, were changed. Also, the time period encompassed half of a year, which is a large time span for a child, especially one of her age, and many of the developments could be due, in part, to the natural development that comes with age. Yet despite these mitigating factors, T clearly one of the major success stories of aquatic therapy, having overcome an initial fear of the water, to become a child well on their way to swimming proficiency. The day that she walked for the first time in the pool was an emotional one. In the three years in which I was a volunteer and observer in the Gudelsky Swim program, T is one of very few that have made so much progress, so quickly. Much more often, what is seen is slow progress. Another reason why T. was able to progress so quickly is the fact that she was recommended by her doctor for a set of symptoms that water does a lot to help. Her over-sensitivity to touch stimuli was a serious problem, as a careless touch could send her cowering away. The aquatic therapy reduced this, because, the constant sensation that water creates as it moves across the body is unlike most other tactile experiences, encompassing the whole body, as it does. The sensation was accompanied by encouragement from her clinician and family, to associate this type of whole-body tactile sensation with pleasant activity. T's family re-enforced the work at the Gudelsky center with visits to a public pool on their own, and with treats for T each Saturday after swimming. Her association of tactile sensation with pain soon diminished, and was not reported by her family as a major problem when the end of season discussion was conducted. The other main objective of the physician was to increase T's muscle tone especially on her 'floppy' left side. T was born with complications, and the umbilicus cut of oxygen supply to her brain for a brief period of time. This was cited as one of the reasons for T's slow language development, and her extreme lack of muscle tone when she was first evaluated. T had gained some muscle tone by the time that she came to the Gudelsky center, but not enough to be fully weight bearing on her left knee. The muscles in her upper left thigh, the quadriceps and the hamstrings especially were weak. The method used by the clinician was described as 'frog hands', but are commercially known as the Aquatoner for kids (c) It consists of three removable paddles, attached to a velcro strip that can be secured around an ankle or wrist. It greatly multiplies the resistance required, and the number of paddles, as well as how much surface area they cover determines how many times it multiplies the resistance. On T's right arm and leg, the Aquatoners each had only one paddle attached, for minimum extra resistance. On her left leg and arm, however, two paddles were used, to give a greater amount of resistance, even if she was not actively moving her arms and legs. The clinician used the 'frog hands' for each of the final six weeks of the therapy, and this was the period during which T manifested the most improvement. As has been stated before, the increase in muscle tone was not solely due to this, but it cannot be negated as a factor in increasing her muscle tone. The conditions that were cited as the objectives for emphasis were certainly addressed as the main priority, however, other facets of T's special needs were addressed by the aquatic therapy. The 'calming' effects of water are cited by many adults who use water not only as a medium for exercise, but also as a meditation medium. This is certainly not quantifiable, however, Paciorek's 1989 study is. When a control group of children ages six to eight with pervasive developmental delays who did not participate in twenty minutes of exercise three to five days a week⁽¹⁾ , were compared to those who swam 20 minutes three days a week, those who swam were found to have a mean attention span that was 1.6 minutes longer that their less-fit counterparts. It is difficult to evaluate what effect the aquatic therapy had on T's attention span, however, she was able to stay in the water concentrating on a single activity for a longer time as the weeks progressed, which seems to indicate an increase in this ability as well. Aquatic therapy obviously had major benefits for T, and she may clearly be counted as a child who experienced a great deal of benefit prom participating in a program of aquatic therapy.

K, the second child observed, did not have quite as beneficial an experience. His special needs were obviously quite different. K enjoyed activity in the water, and indeed, continued playing in the water with parents, after his withdrawal from the program. The water appeared not to provide the ideal environment for him to gain physical fitness, however. Some greater measure of fitness was gained, as was a greater confidence in K's own abilities, however, the massive gains that some expect to see with any new treatment did not appear. One possible error in this summation of water as not an appropriate medium for physical therapy in K's case is the time period involved. Some children may need more time than others before showing significant progress. Certain youngsters in the Gudelsky program took over 50 weeks before showing truly significant progress. In K's case however, the limited time span makes it difficult to evaluate how effective hydrotherapy was for him. However, the muscle tone recordings from his physical therapist, taken every week, and given to the program for their records show a slight but measurable decrease in muscle tone (ie. decreased spasticity) and increased control of muscle flexion and range of motion. These changes were small, but continuous. The benefits of water therapy may accrue quickly for some children, but more slowly for others. Time must be taken to determine the long term effects of any action. Due to K's shorter stay in the program, it is hard to truly evaluate the overall benefits he gained from the program, but it is certain that the small increases in ROM, control and confidence as well as the decreased spasticity are benefits, though small, which cannot be discounted. K's case is not as much of a success story as T's, but nonetheless shows that water therapy, even if it is determined not to be the best method of physical therapy for an individual, can provide some increase in the fitness level of the selfsame individual.

Aquatic therapy is not a cure-all, and should not be touted as one. It can have good effects in the treatment of pediatric disabilities, and although all children will not have results as spectacular as T's the current information seems to indicate that most children can gain at least some benefit from regular aquatic exercise. Whether their gain is simply an enjoyment of the 'relaxing qualities' of the water, or intensive gain of muscle tone, or aerobic capacity, it is beneficial, and reason enough for aquatic therapy to be considered as a viable and very current option in treatment, or therapy of children with special needs. A larger investigation, involving much more than two children, would obviously allow for grater depth of understanding regarding the extent to which hydrotherapy can be relied on as a treatment method. Lacking the resources for such an investigation, it is acceptable, with the proof demonstrated, to conclude that since aquatic therapy has a number of very good qualities, and can have a highly beneficial effect for some children must be relied upon, that it is a good treatment tool for pediatric disabilities.

Appendix A

T. is a 6-year-old petite girl. She is of slim build. She has unusually short hair. Her mother keeps her hair short to facilitate T's personal grooming. She has a very low hairline, that touches her eyebrows, and an unusually large amount of body hair, which has been targeted as possibly a side effect of her disability. She is an only child, but in her house live many cousins and her maternal grandparents. She is of Vietnamese ancestry. Her parents are in their late forties, and are first generation immigrants. T. has not been formally diagnosed, as her behavioral problems display characteristics of pervasive developmental delays, arthritis in her hands and left-side spasticity. T. does not use vocal language. Communication is rare. She uses techniques of hand signals, both ASL and self-generated. She only interacts with people who are known to her. Her doctor recommended her for the program in an attempt increase muscle tone on her left side and to desensitize her to touch stimuli.

Week 1

The first day that T. came to the center she was holding her mother's hand tightly. When the head clinician took T's hands to assist her to the pool for therapy, T. pulled her body away from the clinicians and transferred her hold to her mother's legs. Then T. began to yell with out using any language and began to bite herself on her arms. Her mother stated: "It's ok, she is just a little bit nervous." Her mother picked up T. and placed her in the personal clinician's (the clinician who was assigned to her case) arms, while the clinician was already standing in the pool. When T. was placed in the clinician's arms, she increased the volume of the vocalizations she was making and she began to flap her arms. When the clinician brought T. close to her body, T. grabbed the clinician's neck, and continued vocalizing, although the repetitive movement of her arms stopped. The clinician allowed T. to maintain her hold on the clinician's neck, and began to walk around the pool talking quietly to her, emphasizing that "The pool is fun." and "You will like swimming" Towards the end of the session, T. relaxed her hold on the clinicians neck enough that she could be placed on her back in the water for brief periods before she resumed loud vocalization. When the session was over, the clinician reenforced that T. "Did a good job." and was a "great swimmer."

Week 2-9

The same procedure for getting into the water was repeated each week. Deviations from routine were accompanied by tears and loud vocalization. However, the time that T. spent vocalizing loudly at the beginning of the session was shorter. By the middle of the session, she was usually quiet. At this point, the clinician stopped simply walking around the pool and began the initial modeling. She placed T. on her lap in the 2 foot deep section of the pool and began to model the use of hands to 'dog-paddle' with T's hands on top of her own. The modeling was repetitive, and was taken up by T. within a few weeks in contrast to her usual arm flapping movement. The rest of the weeks were spent using that arm movement while held securely by the clinician.

Week 10

The next week, T. got in the water by holding onto the clinician's neck as she walked down the stairs into the water. The water itself was 70 degrees, about 20 degrees below the recommended temperature, and T.'s oversensitive touch reflex was aggravated, as was the arthritis in her hands. She spent the session vocalizing at a high volume and was crying within ten minutes of getting into the water. The clinician exited the water and wrapped a towel around T., and said that she felt "today just isn't a day to force it for her."

Week 11-12

Same basic procedure as Week 9, but more emphasis on using arms to 'catch things', especially the 'floppy' left arm. Her vocalizations are shorter each week, and are decreased in volume .

Week 13-15

The next three weeks, T's family was visiting relatives and did not attend clinic.

Week 16-19

T's vocalization was louder initially, but subsided as quickly as before her vacation. She was still being handed into the pool, but sometimes would sit on the side, and push herself in. Week 16, a volunteer entered the water to assist the clinician, and moved T's legs in a kicking motion while the clinician modeled correct hand posture, and then let T try it on her own. By week 17 and 18 where this was repeated, T had a sense of the movements required in kicking and could kick when the clinician said "Kick!" but only for short periods. By week 19 she was able to kick strongly enough to make a splash, which made her smile, but her kicking was not continuous, as she would only kick when told to by the clinician. At the end of the session, frog hands were introduced, and played with, but not formally used for training.

Week 20

T. came back she repeated vocalizing loudly and had to be handed into the pool by her mother, while vocalizing loudly and flapping her arms. As soon as she was in the water she stopped this, and smiled. The clinician took T. and got 'frog hands' (large pads which increase resistance on the limb as it is moved through the water) and showed them to T and explained what they did. The clinician placed one on each of T's hands and feet and commenced to propel her around the pool, while saying: "paddle with your arms." and "kick, kick, kick!" T laughed and used her legs and arms in motions approaching dog-paddle approximately fifty-five percent of the time. The other part of the time she let her arms and legs be pulled back by the resistence of the water as it flowed past her body. She got out of the pool at the end of the session and was wrapped in a towel in a chair while her mother conferred on T's progress with the clinician. The clinician said that she felt that T's touch reflex was "slowing getting less sensitive" and her parents concurred. They then discussed the path that they wanted her therapy to take in the next few weeks. T fell asleep during this five minute conference.

Week 21

The next week, T got in the water by coming down the ramp in the clinicians arms, but once in the water pointed up the ramp. The clinician went to pick T up, but T pushed on the clinician's arms and began to toddle there herself. Much of the rest of the session was spent exploring the walking ability that T had just manifested in the water. T was non-weight bearing on land, except with a great deal of assistance from a person standing behind her. In the water, the clinician held T's hand and T held the wall and walked back and forth in the shallow water for the duration of the session. This was a great breakthrough for T and her parents were crying what they said were "tears of happiness." The head clinician said "T--- you are such a super girl!!!" T had been using more and more attempts to pull herself into ambulatory positions, but the lack of muscle tone in her left leg made it hard for her. The space of time in the pool was, her mother said "The very first time she actually went somewhere walking." T smiled throughout the session.

Week 22-25

Walking back and forth in the shallow end was repeated for about half the session. After the first half, the clinician made the ASL sign for frog, which was the sign that she had made each time that they had looked at or used the 'frog hands'. T smiled and they proceeded to use the 'frog hands in a modified, supported dog-paddle for the rest of the session. This routine was repeated each week.

Week 26

The final week, T got in, walking down the 'wet ramp' (a ramp that is covered with water) holding the railings and the clinicians hands. Once in the water she began to try to paddle, causing the clinician to grab for her to keep her from hitting her head on the side of the pool. As it was the last day, the clinician put arm floaties (air sacs that are placed around a child's arms to hold them up in the water) on T's arms as well as the 'frog hands.' This allowed T to move around the pool independently and she smiled and laughed, and began to kick vigorously. She maintained her level of energy throughout the session and at the end of the session walked onto actual dry land for two steps at the bottom of the ramp, before her left knee stopped weight bearing. Her family and physical therapist, all of whom had come to observe the last week applauded for her and she smiled and laughed. As T got dressed with her cousin, her parents the clinician and the physical therapist conferred. T had been tested the day before the final session by the physical therapist, in terms of her muscle tone, her overall health and her sensitivity to touch reflex. The physical therapist found that her muscle tone had increased to the point where it was a viable option to consider KAFOs (Knee-Ankle-Foot Orthoses) to control the alignment of her foot and knee for proper weight bearing. Her coordination had also improved, in the testing situation and at home. Also at home, her independence had grown from being unwilling even to brush her hair, to a desire to get dressed in the morning. The decision was made that at least some of her progress was due to the work that she did in the Gudelsky program and her parents decided to continue to bring her for the winter session.

Appendix B

The other child is K, a boy of about 9 years old. He has short black hair, brown eyes, and smiles frequently. While pregnant with K, his mother had eaten improperly cooked pork on a cruise ship, and an unknown teratogen caused lesions to develop on his brain and left him with abnormally high muscle tone (spasticity), and what was diagnosed as mixed-type Cerebral Palsy. K is a quadriplegic, and uses a wheelchair for all of his mobility. He is prone to clonis (an involuntary shaking of a muscle) and needs constant care. He is unable to perform any personal functions. He has had 4 surgeries on his legs to lengthen the tendons in them, in hopes to continue to enable him to attempt to use them, and another is scheduled for the coming winter. He was recommended to the program by a friend of the family, and having consulted their physician, decided to give the program a try.

Week 1

K arrived 5 minutes early, and was eager to get in the water. He displayed no reticence about the water as he was handed to the volunteer by his father. His father and mother sat by the side of the pool and watched K for the entire session. K was unable to support himself in any way and was unable to hold himself up, so activity in the pool was done in a supported back float position. Major work for this session was done in acclimatizing K to the supported back float position and talking about swimming while floating around the pool. He was encouraged to try and kick, but despite obvious effort, the only movement that was self generated was spastic twitches. Another volunteer aided by moving K's legs, to simulate muscle action, and stretch the muscles. K talked to the volunteers about several different topics, and had to be reminded to concentrate on kicking, but he continued to converse.

Weeks 2-9

The procedure that was established the first day was continued. The only change was in an slightly increased motion of the legs, and bending of the knees. As the weeks progressed, imitative behavior seemed to become the method best for allowing K to increase his movement, as he was more able to kick after his legs had been moved in a vigorous kicking motion by a volunteer. Resistance was encountered when suggestions of floating on one's stomach were proposed, so the decision was made to continue working in this manner, and increasing muscle tone in K's legs.

Weeks 10-12

These weeks were used for K's "tummy" work as it was called. The same procedure of exhortations to kick and periods of modeling was maintained, except instead of floating on his back, K was now held on his stomach to kick. K had some resistance to this, and would ask whether he could swim on his back instead, but stomach posture was maintained to work more muscles in K's legs, which his physical therapist had said seemed to be growing more spastic, and tighter, thus restricting mobility. A kick-board was used as an additional support.

Week 13

K was away with his family on a holiday vacation.

Week 14

K was allowed to alternate between front and back postures, but still cannot move his arms while in the water. His kicking proficiency has stabilized, at about the same level it was at at his 9^th week in the program. He can auto-initiate kicks, but does so rarely, and this activity requires a great deal of physical strain on his part. Mostly his kicks are false "clonis-kicks" when his clonis masquerades as kicking behavior, or heterodynes with actual effort to produce small kicks. As he seems to be better able to produce true kicks after his legs have been kicked for him, K had kicking modeled followed by a brief session on independent kicking. Imaginative play such as "I'm a motor boat! Let's make my motor go by kicking" was introduced in an effort to increase K's interest level.

Weeks 15-18

K's procedure was stabilized as described in week 14. No major regressions or progressions in his ability were observed, however his parents commented that his confidence in his ability to move his legs in physical therapy sessions had increased, even if the actual muscle tone was not as responsive. His interest level remained high, although K resisted intoduction of arm moving behavior.

Week 19

The parents of K arrived and said that he was being withdrawn from the program to join a parental-assisted special needs softball team. The thanked the volunteers and allowed K to enter the water to play with the volunteers, where he laughed and engaged in limited kicking behavior to splash other volunteers. In the conference between the parents and the leaders of the program, the parents said that they wished to take some of the pressure off of K to increase his physical fitness level, while still maintaining the fun. They said that they felt that the work in the water was overly strenuous, and that since K had a permanent condition, it was better not to make him feel conscious of his weakness. They said that they appreciated all the work, but felt that, due to the particular quality of K's special needs, standard physical therapy would be the best for him.

Weeks 20-26 K's parents had withdrawn him from the program, as noted in Week 19, and so observations for weeks 20-26 are therefore necessarily incomplete.

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