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Kinesiology
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Aquatics Programming for
Individuals with Special Needs >
Neuromuscular Pathologies
Neuromuscular
Pathologies
Disabilities
Cerebrovascular Accident or Stroke and Hemiplegia, Spina
Bifida, Polio and Flaccid Paralysis, Cerebral Palsy, Diplegia, and Spinal
Cord Injury.
Cerebrovascular Accident or Stroke and Hemiplegia
Cerebrovascular accident (CVA)
or stroke is the result of a nontraumatic brain injury, specifically from the
occlusion or rupture of cerebral blood vessels. Patients present with
neurological deficits, loss of motor control, altered sensation, cognitive and
language impairments, and disequilibrium.
There are approximately
500,000 new stroke patients each year; CVA is identified as the third leading
cause of death in this country. CVA afflicts more men than women and is more
prevalent in people over the age of 65 (6). It is the most common of all
neurological deficits and the leading cause of gait impairment in rehabilitation
facilities.
Observational gait assessment identifies poor
coordination and dysfunctional movement patterns. Foot drop, ankle and knee
instability, loss of forward progression, and significant asymmetry lead to
decreased walking velocities.
Spina Bifida
Spina bifida occulta results
from incomplete closure of the neural tube around the 20th day of embryonic
development and may affect up to 40 percent of Americans although the deviation
remains asymptomatic. Meningocele presents as a protruding sac containing the
meninges; however, the spinal cord remains intact and can be surgically repaired
with little or no damage. Myelomeningocele accounts for 96 percent of the spina
bifida population and is the most severe form. In this case, a portion of the
spinal cord protrudes through the back and presents as a complex multi-system
involvement with both upper and lower motor neuron syndromes. Hydrocephalus is
commonly associated with both meningocele and myelomeningocele.
Myelomeningocele is the most common birth defect
in live-born infants with an incidence of 1 in 1,000 births or approximately 12
babies born per day with this pathology. Girls have a slightly higher incidence
than boys, and limb deformities often are present at birth secondary to
intrauterine positioning and muscle imbalance. Approximately 90 percent of these
lesions occur in the mid-lumbar, lumbosacral and sacral regions, making most of
these children ambulatory candidates. It is important to note the neurologic
lesion is not stable throughout growth, and continual reevaluation of function
is necessary.
General gait features include
overall limb hypotonicity, flexed posturing of the lower limbs, and decreased
velocity in an attempt to conserve energy and significant foot deformities.
Lesions at the 12th thoracic level allow for limited ambulation abilities while
lesions at lumbar levels 1 through 4 promote limited household ambulation.
Moving distally, lesions found at lumbar level 5 and below most often obtain
community walker status.
Gait impedance factors relate
to the level of paralysis, obesity, age, motivation, energy costs, degree of
deformities and decreased sensation, which can lead to pressure sores. As the
child ages and gains weight, energy costs promote decreased velocity and
activity levels, often leading to early wheelchair use.
Polio and Flaccid Paralysis
Polio is a viral infection
that affects the motor cells of the spinal cord and produces permanent paralysis
of varying degrees. Fortunately, the polio virus is preventable with
immunization but remains a major threat in many Third-World countries. There are
approximately 1.6 million polio survivors worldwide, and more than 500,000
Americans contracted the virus during the 1940s and 1950s. More men than women
were affected, with a greater percentage of lower-limb than upper-limb
involvement. The infection attacks and destroys the anterior horn cells of the
spinal cord, causing paralysis, flaccidity and atrophy. Recovery varies
considerably among patients, from permanent disability to nearly full recovery.
In recent years, postpolio syndrome has become the
primary focus of treatment for this aging population. The most common complaint
is fatigue. Additionally, many patients report new weakness in both affected and
unaffected muscle groups, pain, decrease in function, increased atrophy and
muscle spasms. Part-time wheelchair use for community outings may help to
prolong ambulatory status.
Cerebral Palsy and Diplegia
Cerebral palsy is a
non-progressive insult to the brain occurring prenatally, perinatally or
postnatally. Approximately 750,000 people are diagnosed with cerebral palsy, and
86 percent of these cases are congenital in nature. The most common causes
associated with cerebral palsy remain low birth weight and prematurity (birth at
less than 32 weeks).
While the neurological damage is non-progressive,
the orthopedic problems resulting from the insult are very progressive.
Ninety-one percent of children who have cerebral palsy present with spasticity,
predisposing these children to an ongoing battle with contracture formation.
Asymmetric muscle involvement compounds movement patterns although ambulation is
achieved by 70 percent of the entire cerebral palsy population.
Spastic diplegia accounts for
approximately 40 percent to 50 percent of children affected by this disorder. Of
this group, it is estimated almost 90 percent achieve ambulatory status. The
gait pattern often is precarious and may be observed as a "controlled fall" from
one limb to the next. These children often are unable to stand and balance well
statically, using momentum and velocity to maintain their upright posture and
forward advancement. Hip adduction, internal rotation and flexion contractures
further deviate the hip joint alignment and often result in dislocation.
Pharmacological intervention
may help to address the hypertonicity but also may produce undesirable side
effects. Early intervention with physical therapy and orthotic treatment
programs has produced positive long-term effects for patients with cerebral
palsy.
Spinal Cord Injury
Injury to the spinal cord may
be the result of trauma, vascular disorders, tumors, infectious conditions and
developmental disorders. The neurologic level of injury identified refers to the
most caudal segment of the spinal cord with intact motor and sensory function.
There are approximately 30 to 50 spinal cord injury cases per million
(approximately 200,000 individuals in the United States each year) with mild to
severe injuries. The average age of injury is 26 years, with men more often
injured than women. Eighty percent of the spinal cord injured population is
under the age of 45, and approximately 25 percent of all spinal cord injuries
result from violence.
Sixty percent of these individuals retain a strong
desire to walk after their initial injury. With combined upper and lower motor
neuron deficits, patients with incomplete lesions are more likely to ambulate
than those with complete lesions. Children tend to be more adaptable and often
surpass adults with similar lesion levels in terms of function and ambulatory
abilities. Key lower-limb muscles and muscle grade strengths required for a
reciprocal gait pattern are fair hip flexors bilaterally and fair knee extensor
strength unilaterally. Generally, the ambulatory potential after injury relates
to the level and completeness of the lesion as well as residual strength and
function of lower-limb muscles.
Teaching Suggestions
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Modify strokes, entries, and water safety
skills on an individual basis after determining extent of involvement.
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Lower the intensity of swimming by
proposing an underwater recovery of the arms during swim strokes.
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Individuals need to continue to practice
water walking, sidestepping, jogging, sliding, lunging and grapevine to
maintain and/or improve fitness.
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Incorporate frequent rest periods during
aquatic sessions.
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Toning and flexibility movements of
low-aerobic intensity can be rotated with high-aerobic intensity
activities to give participants recovery periods during workout
sessions.
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Lower intensity of exercise by not raising
arms out of water above head during vertical exercises.
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Communicate frequently about exertion
level. Use the perceived exertion scale to monitor participants fatigue
level (Borg 1982). ie, Ask on a scale of 1-10 how they are
feeling, to get an idea.
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Swimming and Aqua-Exercise is a
recreational activity that individuals with various Neuromuscular
Pathologies can benefit from and enjoy throughout their lifespan.
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Floatation devices such as noodles, rescue
tubes, and other swim tubes can be used for additional support.
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Water temperature should be between 85
degrees and 90 degrees F.
Sample Activities
Stretching
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Wall Walking (30 Seconds with heels flat /
30 seconds on toes)
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Advanced movements. Go right / left/ cross
hands over and under. Stabilize body with feet on the bottom of
the pool or in a prone position.
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Toe Raises
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Heel Raises
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Shoulder Circles
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Shoulder Lifts
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Shoulders Forward then Back
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Arm Circles under the Water,
Forward/Backward, Big/Small
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Trunk Rotations R/L
Noodle or Barbell Activities (Arms)
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Push down into water (10)
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