Watsu ® Therapy for Cerebral Palsy (CP)
A case study conducted by Aleksandra Koziorowska, PT, Watsu Practitioner, Poland; Tomasz Zagórski, MSc, Watsu Instructor, Poland; Michał Murawa, DPT, University School of Physical Education, Poland, Feb 2014
This case study was conducted to evaluate the possible effects of Watsu ® therapy on a particular person with Cerebral palsy (CP).
A preliminary analysis of movement challenges posed by CP along with initiating a discussion about the effects of Watsu® therapy on a person with CP.
A case study of a 27- year-old person with GMFSC III CP was conducted to study the potential effects of Watsu therapy on three dependent variables: pain sensitivity (using the VAS scale), the autonomic nervous system (using pulse measurement of blood pressure before and after the Watsu session), and gait pattern (using a BTS smartd system).
A series of eight, 30-minute Watsu sessions were carried out on alternate days.
After finishing the therapy, the pain experienced had not changed its intensity; however, the use of painkillers was unnecessary.
The average values of heart rate and blood pressure after the session lead to the conclusion that the body reacted to the therapy with temporary relaxation. We believed that relaxation may be used for more effective therapies on land.
Gait analysis provided the least clinical information. We propose that during subsequent studies we modify the case study so that the participant has much more opportunities to walk freely so we may appreciate possible alterations in gait.
The water environment is a valuable source of multiple sensory experiences in both the mental and physical realm of persons especially those with disabilities. Thanks to the physical characteristics of water, a person who is completely dependent on others in their daily routine may experience independence and freedom of movement while in the water. This independence may give such a person a strong motivation to participate in appropriate aquatic therapy. Not only does such motivation strengthen the effects of therapy, but it also may play an important role in allowing a person to perceive life in terms of its quality when one is set free from normal external limitations imposed by gravity.
The psychological significance of water is directly linked with its influence on the physical qualities of any person immersed in it. The effect of physical properties of water on the body of a person with increased postural tone such as with a person with CP has already been confirmed through a series of experimental studies. According to Thorpe and colleagues, the upward force of buoyancy that counteracts the downward force of gravity allows one to develop skills and initiate movements which normally are not possible on the ground (Thorpe, Reilly, & Case, 2005). It also can cause a reduced flow of nerve impulses from the periphery to the CNS and a simultaneous effect of relaxing muscles (Straburzyńska-Lupa & Straburzyński, 2004) along with the reduction of involuntary movements (Hutzler, Chacham, Bergman, & Szeinberg, 1998). This fact is closely linked to a relatively high water temperature compared to body temperature. For example, in neurological disorders with increased postural tone, a neutral water temperature of 34-36°C is recommended because it enhances the effect of relaxation and can relieve pain (Straburzyńska- Lupa & Straburzyński, 2004). Hydrostatic pressure due to the density of water affects exteroreceptors of the respiratory system, making respiratory muscles work more effectively and improving the condition of other organs.
The positive effect of water on the human body can be strengthened by an appropriate choice of aquatic therapy. One of the most common forms of working with a body in water is Watsu. Watsu stands for Water Shiatsu and is a therapy that uses movement, stretching (Dull, 2008), and mobilization (Zagórski, 2008) which are coordinated with the breathing of a person lying in warm water. Throughout the session a patient is supported by a therapist who plans the Watsu session beforehand on the basis of previously-defined medical problem.
A Watsu therapy session consists of a sequence of specific Watsu positions. Each body position is determined by a therapist’s body mechanics which involves and sets in motion the whole body of a client. All the movements are global, complex and multidimensional, which makes them similar to the activities undertaken in a daily life. The effectiveness of Watsu therapy has been confirmed in treating many orthopedic and rheumatoid disorders as well as in muscle pain syndromes (Dull, 2008). Increasingly, this therapy also is used in neurological disorders characterized by increased postural tension (e.g., spastic form of cerebral palsy, or some types of stroke). In this field Watsu serves mostly as a tool for physiotherapy to prepare a client for a functional treatment carried out on the mat. This preparation is designed to reduce muscle tension, increase the range of movements in joints, and to enhance a global tranquility of the body. Therapy sessions designed for people with a spastic form of cerebral palsy (CP) consist mainly of the sequences built up on the rotation and dissociation of lower limbs which, according to neuro-developmental theory, normalize postural tension.
The aim of this case study was to evaluate the impact of a series of Watsu therapy sessions on an individual with spastic cerebral palsy, and to make an attempt of a preliminary study of the problem as well as initiate a scientific discussion on the effectiveness of Watsu therapy on the body with the symptoms of spastic cerebral palsy.
Case Study Participant
This case study of a 27-year-old woman with a spastic form of cerebral palsy syndrome was carried out at the swimming pool in Koziegłowy, near Poznań in Poland. Gross motor skills of the person involved in the study were classified at GMFCS level III.
Every day in order to leave her house she had to use a wheelchair so she would be classified as primarily non-ambulatory. At home she also used a walker to move around her house. Throughout an extended period of time before and during the research she did not participate in any other therapy in order to avoid confounding any other positive or negative effects from other therapies. She also provided written consent to the research and publication of the results.
This case study intended to identify effects of the Watsu therapy on her condition which was based on an analysis of three variables: the sensation of pain experienced by the client, the functioning of the autonomic nervous system, and her locomotor gait patterns.
During the case study a visual – analog scale was used (VAS) to assess the pain sensitivity. A patient was also asked to locate the source of pain and tell about the ways of dealing with it. The evaluation was made twice, before and after Watsu session.
Autonomic Nervous System Functioning
The effect of Watsu therapy on the autonomic nervous system was determined by the examination of blood pressure and pulse (heart) rate gauge (Tensoval Comfort Company, Paul Hartmann, Germany). The measurement was taken each time before entering and after leaving the changing room at the swimming pool.
Gait was assessed using an objective test, called smartd BTS System (BTS SpA, Italy). The study was carried out at the Department of Biomechanics at the University of Physical Education in Poznań. In this case the task of walking with a walker was analyzed. Because of the walking frame structure, markers were placed only on the body of the examined person. Measurements were made both before and after a series of Watsu sessions. We analyzed time parameters as well as distance parameters and kinematic gait.
During the study, the participant was involved in eight, 30-minute Watsu sessions, held every second day. Each Watsu session consisted of the same sequence that was set at the beginning of the series. Each session occurred in water that remained at the same temperature each day and was carried out with the same therapist. The selection of the sequence was made on the basis of the knowledge of the concept of neuro-developmental therapy (NDT) which includes Bobath techniques in reducing postural tone. Therefore, during each session, we used mainly Watsu positions built up on the rotation of the lower limbs relative to a trunk, trunk rotation relative to the pelvis and lower limbs, and the dissociated movement of one leg contrasted with the other.
Before the first session of Watsu, pain was assessed on the visual – analog scale (VAS) as level 2 out of how many levels?. It was located mainly in the lumbar spine and remained regardless of the change of position. Before the therapy started every second day the participant regularly had taken pain killers which were available from a pharmacy. The first pain evaluation was made on a day when the client took pain pills. After finishing a series of Watsu sessions, the pain still was assessed at level 2, but taking painkillers was not necessary. Throughout the study period the participant did not take a single tablet. The pain, however, did not change its location.
Impact on Autonomic Nervous System
The impact of Watsu therapy on the autonomic nervous system was assessed by measuring heart rate and blood pressure before and after each session (i.e., before entering and again after leaving the changing room at the swimming pool).
The average value of heart rate measured before each session of Watsu was 93 beats / min. and after the session 87 beats / min.
The difference between the highest and the lowest heart rate measured before the sessions was 18.
The decrease from the maximum heart rate to a minimum level immediately after the Watsu sessions was larger and equaled 23.
After seven out of the eight sessions, the final heart rate was lower than the initial one. The biggest difference between the initial and the final heart rate was evident on the third day, when it equaled 14.
Figure 1 illustrates how the pulse was shaped each day after therapy. For both measurements before and after the sessions, heart rate did not decrease linearly. During 8 sessions only once was the final heart rate higher than at the beginning. It can be influenced by the weather which improved during the study period and the conditions at the pool during the session which included noise from other people in the water.
Figure 2 shows the systolic blood pressure measured before and after each session of Watsu. As it indicates, during the first six days the final pressure is lower than the initial one, and the last two rates are as high as the blood pressure measured before the session. The average systolic blood pressure measured before the session was close to 114.5 mmHg, and the final 107 mmHg. The difference between the maximum and the minimum initial pressure in the series was 27, while the maximum difference in final systolic pressure was equal to 13.
As far as diastolic blood pressure measured both before and after the session is concerned, it does not change so much as a systolic blood pressure. After the session it is lower than before the session, but it occurs (the first and fourth day) that it is higher than the initial value. From the fifth session a regular decrease in both diastolic pressures is noticeable. The minimum diastolic blood pressure was recorded after the last, eighth session, and was 60 mmHg, while the maximum, on the fifth day during the first measurement and was equal to 84 mmHg. The average diastolic blood pressure, before the session was 76 mmHg, and after 73.5 mmHg.
Impact on Gait
The third parameter showing the effect of Watsu therapy on a high postural tone was gait, which was tested thanks to the analysis of temporal, kinematic and length variables. This type of movement was characteristic only for the participant. It was possible to distinguish one full cycle of gait and compare it before and after Watsu therapy. The analysis of temporal measures of gait revealed that the most noticeable changes were those which referred to the proportions between the various stages of walking tested before the first Watsu session and after the therapy sessions. In the final session the stance phase in both limbs was shortened, while the response phase lasted longer than in the first session. In addition, %-cycle dual- stance phase of a left lower limb was reduced from 87 to 72.3, which may confirm a subjective visual impression of greater smoothness in gait during the final session. A smoother motion may be a result of the changes in the measures of length.
It is worthwhile to stress that the length of the step increased from 0.09m to 0.13m. This change indicated an increase in the base of support on the surface and may have influenced the stability of gait. Average walking speed in the first session was 0.18 m / s, while in the final session it was about 0.3 m / s greater. Gait was also analyzed in terms of kinematics which registered increased ranges of motion of the pelvis and hip joints in the sagittal, coronal and transverse planes of movement. After comparing the results of the study before and after Watsu sessions, the changes are visible mainly in the rotational movements of the pelvis. A gradual reduction of 4 internal
rotation of the pelvis on the left side of the lower limb in the early stance phase is noticeable. The results of other ranges of motion (the pelvis in the sagittal plane, frontal and hip in the frontal, sagittal and transverse) did not differ between the first and second examination.
The results presented may illustrate the effects of the Watsu therapy on the case study participant who had a high postural tone as a result of spastic cerebral palsy. Obviously, it is impossible to extrapolate conclusions for the whole population of people with cerebral palsy syndrome. This issue requires much further analysis and studies employing a sample of multiple individuals using more advanced methodology.
Judging by the positive reaction of the body in the current case participant, continuation of a regular Watsu therapy possibly could have a long-term effect. Taking into account the extremely short period of the therapy (a total of four hours over a 15 day period and a previous history of rehabilitation of the person tested, the fact that she no longer had need for taking painkillers seemed a remarkable change. Median values of heart rate and blood pressure after the session allowed us to conclude that the body reacted by temporarily relaxing and lowering these physiological variable values, which can be used for more effective therapies on the ground as well.
The gait analysis leaves greater uncertainty. When comparing temporal and length parameters of gait between the first and the second test sessions, we noticed a change, but the differences were small and the results certainly require further studies. Kinematic gait analysis provided the least information. It seems that for further studies this research tool should be modified so that a subject has much more opportunity to walk freely.
We hope that our case study research may trigger more discussions and encourage others to pursue further studies on the effect of Watsu therapy on persons with abnormally high postural tone. It may also contribute to the development of a new, more efficient methodology which in the future can result in solving the problem of people with spastic cerebral palsy syndrome.
- Dull, H. (2008). Watsu freeing the body in water. Middletown CA: Watsu Publishing.
- Hutzler, Y., Chacham, A., Bergman U., & Szeinberg A. (1998). Effects of a movement and swimming program on vital capacity and water orientation skills of children with cerebral palsy Developmental Medicine and Child Neurology, 40(3), 176-181.
- Straburzyńska-Lupa, A., & Straburzyński, G. (2004). Fizjoterapia. Warszawa, PZWL.
- Thorpe DE., Reilly M., & Case L. (2005). The effects of an aquatic resistive exercise program on ambulatory children with cerebral palsy. Journal of Aquatic Physical Therapy, 13, 21–35.
- Zagórski, T. (2008). Watsu – nowy wymiar rehabilitacji w wodzie. Rehabilitacja w praktyce, 3, 44-45.
LIST OF ABBREVIATIONS
- CP – cerebral palsy
- VAS – visual – analog scale
- CNS – central nervous system