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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

  • Modify strokes, entries, and water safety skills on an individual basis after determining extent of involvement.
  • Lower the intensity of swimming by proposing an underwater recovery of the arms during swim strokes.
  • Individuals need to continue to practice water walking, sidestepping, jogging, sliding, lunging and grapevine to maintain and/or improve fitness.
  • Incorporate frequent rest periods during aquatic sessions.
  • Toning and flexibility movements of low-aerobic intensity can be rotated with high-aerobic intensity activities to give participants recovery periods during workout sessions.
  • Lower intensity of exercise by not raising arms out of water above head during vertical exercises.
  • 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.
  • Swimming and Aqua-Exercise is a recreational activity that individuals with various Neuromuscular Pathologies can benefit from and enjoy throughout their lifespan.
  • Floatation devices such as noodles, rescue tubes, and other swim tubes can be used for additional support.
  • Water temperature should be between 85 degrees and 90 degrees F.

Sample Activities

  • Wall Walking (30 Seconds with heels flat / 30 seconds on toes)
  • 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.
  • Toe Raises
  • Heel Raises
  • Shoulder Circles
  • Shoulder Lifts
  • Shoulders Forward then Back
  • Arm Circles under the Water, Forward/Backward, Big/Small
  • Trunk Rotations R/L

Noodle or Barbell Activities (Arms)Push down into water (10)

  • Bend Noodle In and Out / Together and Apart (10)
  • Above the Head (10)

Noodle or Barbell Activities (Legs)
  • Knee lifts / Right and Left (10) Alternate lift (R/L)
  • Individual may Lift Legs with hands if necessary.
  • Side Leg Lifts with Legs Straight (10) Alternate Lift (R/L)
  • Pinwheel Left and Right (10)

Cardio / Strength and Endurance

Lower Body

  • Water Walking
  • Marching, Lunging, Side-Steps, Grapevine, Backward, etc.
  • Kick Backs
  • Kicks with each Leg (Low-30 degrees, Medium-45 degrees, High-90 degrees)
  • Flutter Kicking (On Side or with a Kickboard)
  • Hopping (Alternating R / L)
  • Spot Jump (Forward, Backward, Side-to-Side)
  • Slow Jogging
  • Twisting
  • Jumping Jacks

Upper Body

  • Punching Arm Motion
  • Circular Arm Motion - Wax On / Wax Off
  • Front Arm Raises (With or Without Dumbells)
  • Biceps Curls Palms Up (With or Without Dumbells)
  • Tricep Curls Palms Down (With or Without Dumbells)
  • Jumping Jacks
  • Elbow to Knee
  • Volley and Toss Balls
  • Rotator Cuff (Like a Duck)
  • Arm Strokes Forward (While Kicking or Walking)
  • Arm Strokes Backward (While Kicking or Walking)

Cool Down

  • Slow Walking
  • Easy Kicking on Wall/ Bicycle on Wall.
  • Toe Raises
  • Heel Raises
  • Shoulder Raises / Deep Breathing
  • Knee Extensions (R/L)
  • Arm Extensions

* Depending on the severity of their disability, some participants may not be able to perform all of the activities. These are only suggestions and need to be modified to meet individual needs.


Lepore, M., Gayle, W.G., & Stevens, S. (1998). Adapted aquatics programming: A professional guide. Champaign IL: Human Kinetics.

Norvell, N.L.(2000). Aqua activities for high school physical education classes. JOPERD, 71 (9), 45-49.

Pathology forum: Characteristic gait patterns in neuromuscular pathologies. (1997). Journal of Prosthetics and Orthotics, 9, (4), 163-169. Retrieved on June 14, 2004 from

This content was created by
Vicki Foederer, a Master’s student in Adapted Physical Education and
Robin Stephens, a Doctoral Student in Adapted Physical Education
at Texas Woman’s University, as part of the requirements for
“Aquatics for Special Populations”, Huettig, Summer. 2004

page last updated 1/3/2017 1:00 PM