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The Effects of Watsu Therapy on Autonomic Cardiovascular Modulation and Flexibility of Children with Cerebral Palsy

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The Effects of Watsu Therapy on Autonomic Cardiovascular Modulation and Flexibility of Children with Cerebral Palsy Baltic Journal of Health and Physical Activity 2020; 12 (4): 21-32 Journal of Gdansk University of Physical Education and Sport e-ISSN 2080-9999 ORIGINAL doi: 10.29359/BJHPA.12.4.03 The effects of Watsu therapy on autonomic cardiovascular modulation and flexibility of children with cerebral palsy Ertan Tufekcioglu Physical Education Department, King Fahd University of Petroleum and Minerals College of Sciences, Dhahran, Saudi Arabia abstract Background: ‪We aimed to compare and examine the effect of aquatic interventions, Watsu® vs Immersion, on the autonomic nervous system and the range of motion in children with cerebral palsy, due to common belief that use of Watsu is beneficial for the special needs. Material and methods: ‪Twenty-three children (age 7.5±2.8) were randomized to receive Watsu® therapy and Immersion interventions in the cross-over, age-stratified study. Each therapy session lasted 30 minutes twice a week for a total of 10 weeks in two non-consecutive periods. Short-term heart rate variability parameters by using a Polar H7 heart rate sensor with a signal processing software and the passive range of motion by using a universal goniometer was measured at baseline and post-treatment. Results: ‪Watsu® therapy significantly improved the heart rate variability parameter (pNN50, t = 2.312, p = 0.031) and lower flexibility (t = 6.012, p = 0.000) in comparison to immersion. Conclusions: ‪In comparison to immersion, Watsu® therapy was shown to be safe and effective for the autonomic modulation and flexibility of children with cerebral palsy. Therefore, it is recommended as a complementary tool for physical therapy on land. Key words: cerebral palsy, heart rate variability, flexibility, Watsu. article details Article statistics: Word count: 3,660; Tables: 7; Figures: 4; References: 55 Received: May 2020; Accepted: September 2020; Published: December 2020 Full-text PDF: http://www.balticsportscience.com Copyright © Gdansk University of Physical Education and Sport, Poland Indexation: Celdes, Clarivate Analytics Emerging Sources Citation Index (ESCI), CNKI Scholar (China National Knowledge Infrastructure), CNPIEC, De Gruyter - IBR (International Bibliography of Reviews of Scholarly Literature in the Humanities and Social Sciences), De Gruyter - IBZ (International Bibliography of Periodical Literature in the Humanities and Social Sciences), DOAJ, EBSCO - Central & Eastern European Academic Source, EBSCO - SPORTDiscus, EBSCO Discovery Service, Google Scholar, Index Copernicus, J-Gate, Naviga (Softweco, Primo Central (ExLibris), ProQuest - Family Health, ProQuest - Health & Medical Complete, ProQuest - Illustrata: Health Sciences, ProQuest - Nursing & Allied Health Source, Summon (Serials Solutions/ProQuest, TDOne (TDNet), Ulrich’s Periodicals Directory/ulrichsweb, WorldCat (OCLC) Funding: Author gratefully acknowledges the support provided by Deanship of Scientific Research at King Fahd University of Petroleum & Minerals through Project IN 151004 for this research. Conflict of interests: Author has declared that no competing interest exists. Corresponding author: Dr. Ertan Tufekcioglu, King Fahd University of Petroleum and Minerals, College of General Studies - Physical Education; KFUPM, Dhahran, 31261; Saudi Arabia, e-mail: [email protected], [email protected] Open Access License: This is an open access article distributed under the terms of the Creative Commons Attribution-Non-Commercial-No- Derivatives 4.0 International (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits use, distribution and reproduction in any medium, provided the original work is properly cited, the use is non-commercial and is otherwise in compliance with the license. www.balticsportscience.com 21 Tufekcioglu E. Watsu therapy and cerebral palsy Balt J Health Phys Act. 2020;12(4):21-32 INTRODUCTION Cerebral palsy (CP) is considered a static encephalopathy in which the primary lesion is non-progressive. CP is the most common physical disability, as 1 in 323 children has been identified with CP [1]. The growth, plasticity, development, and maturation of the central nervous system can change the clinical presentation, such as movement limitation and impairment of postural control resulting from damage to the immature brain over time [2]. Motor dysfunction and neuromuscular disorders following the neurological deficit and the autonomic nervous system (ANS) imbalance in CP cause disturbance in a homeostatic state, a decrease in the adaptive capacity of the cardiac regulation, and other concomitant chronic disorders [2]. Motor incapacity in CP is a progressive disorder. However, early diagnosis and treatment can improve its condition [3, 4]. ANS activity is amenable to interventions in CP, and the ANS modulation can be observed using non-invasive heart rate variability (HRV) analysis [5,6]. HRV, neural regulation of the heart is the variation of beat-to-beat R-R intervals and the quantitative markers of ANS modulation in milliseconds recorded by an electrocardiogram [5]. HRV is considered for clinical evaluation and to assess the effect of non-pharmacological therapeutic interventions [7], in detecting and following disease processes [8] and as an index activity of the neurophysiological pathway [9]. Assessing HRV that indexes neuro-cardiac functioning can improve our understanding of ANS to interventions in CP [10]. Additionally, it was shown that HRV is linked to autonomic maturation and neurodevelopment [4]. Reliable HRV recording necessitates finical consideration of methodological factors including the study protocol (recording time of day; waking status, sample characteristics (explicit exclusion criteria; the proportion of male participants), ECG signal acquisition and pre-processing settings (i.e., prerecording acclimatization period, recording posture, sampling rate, filtering algorithm) and HRV rational decisions (analyzed recording duration, epoch lengths). The holistic and somatic therapies can stimulate the vagal nerve and reduce stress hormones alleviating several pediatric conditions, including cerebral palsy [11]. The body has the potential to influence the mind via the bidirectional pathway between the brain and body for psycho-somatic and emotional healing [12]. There is empirical evidence in favor of water (aquatic) therapies for a variety of physical and psychological disorders [13]. In rehabilitation, reduced gravitational forces create a very therapeutic condition for increased mobility. On land, the range of motion (ROM) is targeted using passive stretches provided by a therapist (manual) and sustained stretches in which the patient is placed in a position (positional) for extended periods [14, 15]. Active aerobic aquatic exercise intervention studies dominate the literature [3, 20]. Passive Watsu is the only method combining a series of flowing movements, stretches, and manipulations and the least investigated complementary tool in multimodal aquatic treatment settings [16]. The combination of specific techniques and the feeling of trust in warm water can influence emotional state [17], relaxation and autonomic cardiac regulation [18]. Moderate pressure touch and therapeutic properties of warm water might double the expected effects due to potential emotional contagion [19]. For high-quality design studies, standardized protocols with adequate sample sizes, scope, and good reports about the testing procedure are needed [16, 20, 21]. On this subject, our general aim is to contribute to evidence-based rehabilitation in CP. Mainly, the aim is www.balticsportscience.com 22 Baltic Journal of Health and Physical Activity 2020; 12 (4): 21-32 Journal of Gdansk University of Physical Education and Sport e-ISSN 2080-9999 to examine and compare the effect of passive Watsu therapy and immersion protocols on HRV and ROM parameters in children with CP. MATERIAL AND METHODS The single-blinded randomized and age-stratified crossover study took place in two non- governmental rehabilitation complexes providing treatment and therapeutic work on land and in water to the patient with a variety of physical disorders. SUBJECTS Twenty-three children (n = 23, age 7.52 ±2.78, BMI 19.04 ±1.62), more than power analysis of G*Power recommendation (#15), participated in the study. They were diagnosed with clinical mild/moderate spastic CP (International Classification of Diseases and Related Health Problems 10th, ICD-10), of either gender, showing the absence of seizures for the past 30 days with no medical history of ANS effecting diseases participated in this study. They were able to understand basic verbal commands and report sensitivity to pain. All test procedures and arrangements were explained to the parents or caretakers, who then signed the informed consent document approved by the Deanship of Scientific Research. Significance (p > 0.05) were not seen in the physical characteristic of the groups (Table 1). Table 1. Physical characteristics of the groups. Mean (SD) Group Age (years) Weight (kg) Height (m) BMI (kg/m2) Mean 7.92 17.92 0.97 18.99 WI (n = 12) Std. 3.12 4.56 0.13 1.77 Mean 7.09 16.61 0.93 19.09 IW (n = 11) Std. 2.43 3.44 0.10 1.53 Mean 7.52 17.29 94.83 19.04 Total (N = 23) Std. 2.78 4.03 11.26 1.62 The portion of the participants in level II was 52.2%, whereas of the participants in level I – 48.8%, based on the gross motor function classification system (GMFCS). Regarding topographic distribution, 7.7% had diplegia, and 92.3% had hemiplegia (Table 2). Table 2. The participants’ GMFCS levels and topographic
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