Researcher: Senior lecturer Ziauddin College

Researcher:Maharani Hina KhatriSupervisor:Abid Khan Senior lecturerZiauddin College of Rehabilitation SciencesZiauddin UniversityINTRODUCTION Cerebral palsy is the most epidemic and prevalent disease that causes severe gross motor disability due to non-progressive neurological disease.It accounts for approximately 1.5-2.5 per thousand live births.Spastic Diplegia is the most common type of CP accounting approximately 44% of total incidence and representing 80% of preterm infants.These children are symptomatic and show major symptoms of cognitive impairment, balance and coordination problem, postural instability and auditory deficits.

These impairments are due to the damage of brain areas that are responsible for postural control, cognition, speech generation and balance control through task-oriented movement training that enhances neuroplasticity in the brain.Children with Spastic Diplegia presents with the symptom of involuntary movement, balance problems.Balance disorder contribute a major challenge for cp children that causes difficulty in attaining and maintaining stability due to delayed anticipatory adjustment, limited perceptual neuromotor control and poor performance.Aquatic therapy is effective in improving the balance and gross motor function of the child.

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Because hydrostatic pressure of the water assists in muscle training and facilitates the balance and postural control.Global Burden of Disease/PrevalencePakistan-1.22 per 1000 live birthsAsia 2 to 3.6 per 1000 births.World-wide 2 per 1000 live birthsRATIONALEThe purpose of this study is to provide new beneficial treatment approach for cerebral palsy children that will serve a cost effective and time effective treatment approach based upon the compliance of children that will provide additional advantages.HYPOTHESISHA: Aquatic Therapy will improve balance and coordination in Spastic Diplegic Cerebral Palsy children.OBJECTIVES To determine the effectiveness of aquatic therapy with on ground balance exercises in diplegic cerebral palsy children.To describe the best available intervention evidence for children with cerebral palsy (CP).

Literature ReviewA study conducted by Meysam Roostaei et al, 2016 on effects of aquatic intervention on gross motor skills in children with cerebral palsy: A systemic review in which he used swimming and water walking as intervention on7-8 years old CP child for 10-12 weeks based on GMFS scale III-V and the results showed that aquatic therapy is one of the suggested intervention for children with CP.Runzen Retarekar et al in 2009 conducted a study on effects of aquatic aerobic exercise for a child with cerebral palsy: single subject design. This study was conducted on 5 years spastic diplegic cerebral palsy girl using aquatic aerobic interventions for 12 weeks. Intervention began with5 min warm up ,30-40 min aerobic excercises and ended with5 min cool down. The result of this study showed evident change after aquatic therapy. participant improved their performance, endurance and increased walking speed. It concluded that maintaining or continuing training improves level of aerobic fitness, activity and participation.

A comparison study was carried by WANEES M. BADAWY et al in 2016 on comparing the effects of aquatic and land-based exercises on balance and walking in spastic diplegic cerebral palsy children, for this study 30 children with spastic diplegia aged between 6-9 years with GMFCS II-III were included. Intervention used for it was biodex balance system for balance and biodex gait trainer II for 12 weeks. For aquatic therapy large swimming pool was used and for land-based exercises different types of mats, rolls, wedges and balance board were used. result showed significant improvement in stability, gait parameters and balance.

A single blind quasi experimental study was conducted by Chi-Jou Lai, et al 2014 on pediatric aquatic therapy on motor function and enjoyment in children diagnosed with cerebral palsy of various motor severities. 46 participants aged between 7-11 years were selected for 12 weeks aquatic therapy session. Program consist of 5-10 min warm up and stretching, 40 min pool exercises and 5-10 min cool down based on hallwick concept.

Result showed that pediatric aquatic therapy group made greater gain in gross motor function and physical activity after 12 weeks of intervention and reduced joint loading and engaged children actively in strengthening and balance exercises and reduced overuse syndrome. These findings suggest that aquatic therapy is safe and beneficial method in treatment of severe motor skills impairment. A study was conducted by Lidija Dimitrijevic et al, 2017 to find out the effect of aquatic intervention on gross motor function and aquatic skills of cerebral palsy children. For this study they selected 29 participants and divided them into two groups, one group performed aquatic exercises and other group performed dry land exercises. Aquatic group received 55 min of exercise per week and the result showed that there was significant improvement in GMFCS level post treatment assessment.Nikolaos Chrysagis et al, 2017 conducted a research on effects of an aquatic program on gross motor function of children with spastic cerebral palsy to rule out benefits of 10-week aquatic program. For this purpose, he selected 12 CP child aged between 13-20 years from physical disability schools. They divided the participants into two groups , six in experimental group and six into control group.

Aquatic exercises were performed by experimental group twice a week and followed by warm up and cool down phase. Pre and post assessment were done of all participants and result showed aquatic therapy is beneficial in improving gross motor function and balance of the child.Mariam Getz et al, 2012 conducted a study on effect of aquatic and landbased training on the metabolic cost of walking and motor performance in children with cerebral palsy: a pilot study. The purpose of this study was to compare aquatictherapy and landbased therapy, for this they selected 11 CP child and divided into two groups, six participants completed aquatic therapy and five completed land-based exercises.

The resut showed that both groups increased their walking speed and stability. Though concluded that both aquatic therapy and land-based exercises are effective in improving the walking speed, stability and balance.A research conducted by Marlies Declerk et al, 2012on benefits of swimming for children with cerebral palsy: a pilot study. The main objective of this study was to evaluate the effects of swimming on functional status quality of life and daily living of the CP child. For this reason, they selected 7 participants aged 10.2 years with GMFCS level I-III for six weeks intervention and the result showed positive improvement in the function of the CP child their activity level and quality of life.A randomized control trial was conducted by Luanda A et al,2013 on effects of treadmill gait training on static and functional balance in children with cerebral palsy: a randomized control trial. The purpose of this study was to compare treadmill gait training and over ground gait training.

For this study they chose participant aged between 3-12 years and grouped them into two. Experimental group performed treadmill training and control group performed over ground gait training twice in a week. Their pre and post assessment was done using GMFCS and berg balance scale. This resulted that both groups exhibited better functional level after intervention but treadmill training had more berg balance score after the treatment and lessen mediolateral oscillation.A randomized control trial was conducted by Tarek M. El-Gohari et al, 2017 to determine the effects of biodex balance training and conventional balance training effects on balance and gross motor skills of spastic cerebral palsy. result shoed significant improvement in the balance and functional activity after treatment.

Maria A Fragala Pinkham et al, 2013 conducted a research study on aquatic aerobic exercises for children with cerebral palsy: a pilot intervention study to find out their impact on cerebral palsy children. The main objective of the study was to evaluate function skills, endurance and cardiopulmonary capacity of the children. for this they included eight ambulatory children aged 6-15 years with GMFCS level I-III for 14 weeks twice in a week and after intervention these children great improvement in their functional capacity and daily living. Further they concluded hat those who were ambulant enough showed the great improvement in their capacities, enjoyment skills and strength.A non-randomized control trial was conducted by Hutler et al, 2005 on aquatic exercises for cerebral palsy. The main motive for this study was to identify the physical and emotional effects of aquatic therapy on the well being of the CP child. For this purpose, they selected 46 candidates aged between 5-7 years for six months.

they distributed these candidates into two groups and assigned them two therapies, one group received aquatic therapy second group received land-based exercises twice a week and gym once in a week. After intervention assessment was done that showed evident improvement in their vital capacities, endurance, strength and functional balance and cardiopulmonary function.A single group pre and post intervention study was conducted by Hsiu-ching chiu, 2018 on balance and mobility training at home using Wii Fit in children with cerebral palsy: a feasibility study. The main objective of this study was to determine that whether balance exercise can also be done at home and they prove to be effective. For this study they selected twenty cerebral palsy children aged between 6-12 years from home and applied Wii Fit balance intervention on them at home for eight weeks. They were continuously maintained by therapist and family also accompanied them in this session.

after 8 weeks assessment was done that showed significant improvement in postural control, endurance and strength also improved child’s participation in the therapy session. Patients compliance increased this session and they clearly understood what they have to do and it proved very effective for them.A randomized control trial was conducted by Ebrahimi Atri A, et al 2011 on comparison of two exercise methods on motor performance and balance in children with spastic cerebral palsy to evaluate the effects of exercise on balance and gross motor function of the spastic diplegic children.

For this they selected 21 participants aged 7-12 years with spastic diplegic cerebral palsy and grouped them. Control group with daily activities, home exercise group that participated into daily set up and sit-stand activities and clinical group that performed exercises in clinics. They were assessed on GMFCS, TUG test and functional reach test. After all intervention the result showed that home exercise group and clinical group increased improvement in their function and GMFCS scale and functional reaching but this was decreased in the TUG level. Control group were same level and did not showed any improvement and further concluded that for improving balance and control, sit up and step up are the good choice.

Khaled A. Olama et al, 2015 conducted a research on impact of aquatic exercises program on muscle tone in spastic hemiplegic children with cerebral palsy to rule out the effects of water on the child’s muscle and their functional status and performance. The primary purpose of this study was to examine the impacts of aquatic exercises on the muscle tone and muscle integrity of cerebral palsy patient. For this reason they selected thirty spastic hemiplegic patients and they were assigned in two different groups. Group A received regular exercise programe wearing ankle foot orthosis and Group B received same exercise protocol along with the aquatic therapy. Therapy was given for two sessions per week for twenty weeks. Their pre and post assessment was done.

After assessment the result showed that their was evident improvement in Group B functional status and muscle integrity as compared to the Group A because water increases the compliance and interest of the child and also buyoncy helps them to work beter.Yehayahu Hutzler et al, 2009 conducted a research studyon effects of a movement and swimming program on vital capacity and water orientation skills of children with cerebral palsy. The purpose of this study was to find out the effects of the water on cerebral palsy children’s movement, daily living and cardiopulmonary endurance.

For this purpose they selected fourty six kindergarten children aged 5-7 years and they were assigned into two groups. The instruments used on these children was swimming session and gym, each session accounted 30 min twice a week and gym was performed once in a week for six months. The result showed children who received water therapy have increases lung comlience , pulmonary function and respiratory capacity and over all functioinal well being.Vaneesa A Scholtes et al, 2010 conducted a d study on effectiveness of functional program resistance exercise strength training on muscle strength and mobility in children with cerebral palsy: randomized control trial to evaluate the effects of progressive resistance training on functional well-being, muscle strength and balance of the CP child. For this purpose they selected 51 participants that were unilateral or bilateral spastic cerebral palsy aged 10-15 years with GMFCS level I-III. The intervention was given three times a week for twelve weeks which included leg press, and functional exercises. After twelve weeks their assessment was done and that resulted significant increase in motor skills and functional capability and mobility.A randomized control trial was done by El.

Shamy et al, 2017 on effects of antigravity treadmill training on gait , balance and fall risk in children with diplegic cerebral palsy to assess their balance control, stability and their ability to hold the posture. For this reason, they selected thirty diplegic CP children and assigned them into two groups. Experimental group received antigravity treadmill training along with traditional physical therapy regime and control group received only traditional therapy session for 20 min twice a week for three months. After three months the post intervention assessment was done and result showed that both of groups exhibited the positive change but experimental group showed more response in the terms of balance and postural control as compared to the control group.A randomized controlled trial was performed by Ni Ni Swe et al, 2015 on over ground walking and body weight supported walking improved mobility equally in cerebral palsy : a randomized control trial to assess the better intervention for the cerebral palsy child’s mobility.

The target population for this study was aged years with GMFCS level I-III that were selected from the special needs schools. Thirty participants were distributed into two groups, experimental group received bod weight supported walking and control group received over ground walking 30 min a week for 8 weeks and there was significant improvement in experimental group after 4 week and result after 8 week showed that both groups showed almost same changes but body supported walking was proved to be more effective in balance than over ground walking.A randomized control trial was conducted by Hatem Mohsen et al, 2014on effects of a new physical therapy concept on dynamic balance in children with spastic cerebral palsy to investigate the effects of a gait training and mobilization on the functional and dynamic balance of spastic diplegic cerebral palsy patient. For this purpose thy selected thirty spastic diplegic cerebral palsy children aged 6-8 years both male and female, they were assigned into two groups randomly. Experimental group received antigravity treadmill training 20 min twice in a week for 3 months and their balance was assessed on biodex balance scale. Result showed that there was significant improvement in the balance of children after their pre and post assessment value and though it concluded that treadmill training os proven effective in maintaining the balance of the children with cerebral palsy.A.H Rasooli et al, 2017 conducted a hypothetical study on therapeutic effects of antigravity locomotor training (ALterG) on postural balance and cerebellum structure in children with cerebral palsy to determine the effectiveness of treadmill training on the cerebral palsy and for this they randomly slected the participants and assigned them intervention with 45 min of treadmill training three times a week for two months and they were assessed on posturography and functional anisotrophy.

Their pre and post treatment assessment was done and the end of two months result showed that antigravity locomotor training was effective in improving functional isotrophy and balance control in the cerebral palsy children.Akmer Mutlu et al , 2009 done a systemic review on treadmill training with partial body weight support in children with cerebral palsy: a systemic review to determine the effects of the treadmill training on functional balance of cerebral palsy children and for this they collected eight research articles with supporting literature. These articles contained 41 participants and the interpretation of these articles suggested that treadmill training effects the balance of cerebral palsy child hence to be proven more. A randomized control trial was performed by the Katel L.Willoughby et al , 2009 on efficacy of partial body weight supported treadmill training compared with over ground walking practice for children with cerebral palsy: a randomized control trial to assess the efeectiveness of treadmill training on walking and balance of the cerebral palsy patient.

For this purpose they selected thirty four participats aged 5-18 years with GMFCS III or IV for nine weeks and they were assigned into two groups. Experimental group performed treadmill training and control group performed over ground walking twice a week for nine weeks. Result showed that over ground candidate showed improvement in walking distance but they did not improved walking speed, strength and functional balance and for these outcomes partial weight support treadmill training was very effective.A pilot study was done by Devrim Tarakei et al, 2013 on Wii based balance therapy to improve balance function of children with cerebral palsy : a pilot study.

The main purpose of this study was to determine the effects of Wii based balance therapy on balance of cerebral palsy children. For this reason they selected 14 ambulatory children who was assessed on the basis of the functional reach test , TUG and 6 min walk test. The participants were provided Wii balance board therapy in the supervision of the therapist two times a week for twelve weeks and the result showed that Wii balance board is a convenient method, easy to use and safe and can be added in the conventional therapy regime to add benefits to the static balance of CP child.Ramstrand et al, 2012 conducted a study on can balance in children with cerebral palsy improve through use of an activity promoting computer game? To investigate that Wii balance board are effective in improving postural control and balance of cerebral palsy child. For this reason, they selected eighteen hemiplegic and diplegic cerebral palsy children and assigned them two groups, one group received video game and balance board and other group did not received any therapy. Interventions was performed for 30 min a day for 5 weeks and after 5 weeks assessment was done of both groups and there was no significant effect on balance and hence it concluded that only 30 min video game cannot improve the balance only and should be accompanied with other balance exercises.-STUDY POPULATION AND SAMPLINGandINCLUTION CRITERIAChildren diagnosed with cerebral palsyChildren with level I or II on GMFCS,(Goss motor functional classification system)Age 7-11 years Mild or no cognitive impairment EXCLUSION CRITERIA Children with open wounds and infective skin diseases.

Urinary and bowel incontinence. Visual or auditory impairments. Seizures. SAMPLING Envelop method of SamplingDATA COLLECTION METHODS AND INSTRUMENTSMETHOD Individual subjects will be equally divided into two groups, group A and group B.

Group A will receive aquatic therapy and group B will receive over ground balance training. Each group comprises of 39 subjects.Group A Frequency = 3-5 days a week Intensity = 2-3 sets,1set=10 repetitionsTime = 30 minutes, exclusive of 5 minutes warm-up and 5 minutes cool down Type = balance exercises Group B Frequency = 3-5 days a week Intensity = 2-3 sets,1set=10 repetitionsTime = 30 minutes, exclusive of 5 minutes warm-up and 5 minutes cool down Type = balance exercisesBoth groups will receive intervention for 12 weeks. Exercise Termination Criteria Sudden Onset of dyspneaDrop in saturation. Participant requests to stopPhysical manifestations of severe fatigue Joint or muscle pain that becomes aggravated with exerciseMATERIALS An aquatic therapy pool and over ground balance exercises will be used in this study as the intervention to improve the balance of cerebral palsy children A pulse oximeter for measuring heart rate.SAMPLE SIZEThe sample size is calculated by using WHO software for sample size calculation. The refrence study for saple size calculation was ”pediatric aquatic therapy on motor function and enjoyment in children diagnosed with cerebral palsy of various motor severities” by keeping 95% of confidence level 80 % power of a test A sample Size of 78 is calculated DATA ANALYSIS METHODSData will be analyzed on SPSS 22.0.

For the demographic data descriptive statistical tool i.e. mean, median, frequency, range S.D will be used.Paired t test will be used to see the pre and post mean difference on balance within the group.

Independent t test will be used to compare the mean difference on balance scale between the groups i.e. aquatic therapy and over ground exercise.STUDY PERIOD8 months after approval of synopsisSTUDY TYPE Randomized Control trail. PARTICIPANTS IN THE STUDYAll participants in the study will be recruited on the basis of weight, age and disabilitis.

Participants will be recruited from rehabilitation Centre (AURA) regardless of their gender, socioeconomic status. Screening of subjects will be done on the basis of GMFS scale and pediatric balance scale. Study will be conducted at AURA.ETHICAL CONSIDERATIONS Confidentiality: information and findings of every subject will be remain confidential Autonomy: every subject has a right to left study at any time Justice: equal benefits will be given to the every subject Nor maleficence: this study will not do any harm to the subject in any way.Consent form will be taken from every individual. Consent form”Comparison of aquatic therapy and on ground balance exercises on balance in diplegic cerebral palsy children” I Mr /Miss /Mrs _____________________parent/guardian of ______________ give consent that the data obtained during this treatment session may be used for research. I have been informed that,The result of this study may be potentially beneficial to patient in the future.

I have been informed that these therapy regimes pose no potential health risk to my child.I have been informed that I will not receive any monetary or other benefits for any participation.The data of my son/daughter, hospital records will be kept confidential.Subject parent/guardian’s Signature ________________ Subject’s Name: ___________________Researcher’s Name ________________ Researcher’s Signature_____________REFERENCESLai, C.J., Liu, W.Y.

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A., 2017. Effects of aquatic intervention on gross motor skills in children with cerebral palsy: a systematic review. Physical & occupational therapy in pediatrics, 37(5), pp.496-515.Shamekh Mohamad El Shamy, 2017. Effect of antigravity treadmill training on Gait, balance and fall risk in children with diplegic cerebral palsy, Am J Phys Med Rehabil,96:809-815BADAWY, W.

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