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RESEARCH REPORT

The Effectiveness of Hydrotherapy-Halliwick Concept in Children With Juvenile Idiopathic Arthritis: Assessment and Treatment

Karastamati, Christina MSc; Chandolias, Konstantinos PhD; Grammatikou, Georgios MSc; Hristara-Papadopoulou, Alexandra PhD

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The Journal of Aquatic Physical Therapy: May/August 2021 - Volume 29 - Issue 2 - p 35-39
doi: 10.1097/JAPT-D-19-00018
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Abstract

Juvenile idiopathic arthritis (JIA) or juvenile rheumatoid arthritis is a long-term inflammatory joint disease that is commonly seen in children younger than 16 years and is of unknown origin.1 The main symptoms of the disease include swelling of affected joints, sensitivity, painful movement restriction, and gait disturbances.2 These result in decreased activity capacity and levels of physical activity.3 An urgent need to approach the disease is the cooperation among various specialties. To foster collaboration between the various scientific communities, common definitions and criteria for classifying the disease have been established according to the International League of Associations for Rheumatology. It is a fact that children have the ability to retrain and develop adaptations and new skills. Physiotherapy plays an important role in rehabilitating children and integrating activities that require endurance and strength. A part of physiotherapy also includes the hydrotherapy, which brings to a child a sense of joy and aims to increase cardiorespiratory resistance, strength, coordination, and improvement in swimming skill.4 The purpose of this study was to record and highlight the effect of the Halliwick hydrotherapy in children with JIA in a 2-month intervention program.

PURPOSE

The purpose of this study were to examine the effects of the Halliwick intervention in children with JIA and on balance and load distribution of the feet.

CLASSICAL KINESIOTHERAPY IN JIA

Before applying the kinesiotherapy, it is important to keep in mind the functional stage of the childʼs disease, its symptoms, and limitations of the assessment, if any, of the symptoms, indications, and contraindications. Classical kinesiotherapy involves soft-tissue stretches, strengthening exercises within the physiological limits of articulation, balance exercises, and proprioceptive neuromuscular facilitations. In the early stages of the disease, kinesiotherapy achieves delayed functional limitations and asymmetries that may arise. The kinesiotherapy program should be individualized for each child and based on the child's physical fitness and endurance limits.5

PHILOSOPHY OF HALLIWICK

Halliwickʼs theory is based on the 10-point program aimed at orthostatic control, rotational control, proper respiratory function, and cognitive adaptation to water, while teaching children the ability to independently swim. It is a training program in which children learn to maintain their balance, float on their backs, and then learn how to maintain balance of turbulence in the aquatic environment. The Halliwick therapy is a fundamental philosophy. The hydrodynamic principles represented in this method are the basis for all swimming education programs. Once Halliwickʼs skills have been conquered, children begin to feel comfortable in the water and gain independence. Halliwickʼs treatment provides physical, social, and spiritual benefits. Throughout the process, all swimmers improve fitness as part of the learning process. The muscular strength, endurance, and cardiovascular function of all children are improved when children participate in the treatment program. The lack of buoyancy aids and minimal support from trainers help ensure functional fitness development. Halliwickʼs activities often involve collaborative efforts, which is why the social skills of children are often increased. After developing the breath control skills, the more controlled rhythmic breathing is used for easier flotation. Most importantly, however, is to achieve comfort and relaxation while moving in the water because this facilitates learning skills. For people with severe physical and multiple disabilities, learning proper and controlled breathing often takes a significant amount of time. But these individuals can work independently and learn to swim.6

METHODS

Participants

Two groups of children participated in the research. In the first group, 11 children had a Halliwick treatment session once a week and attended a Halliwick concept session once a week and classical kinesiοtherapy in another week. The second group (control group) was attended by 5 children who had a classical kinesiotherapy treatment session twice a week. The duration of the intervention was 2 months, and the duration of each session was 45 minutes. The condition for participation in the research study was that every treatment intervention was abstained for a month, so it was started just after the summer break. Inclusion criteria were children diagnosed with JIA and aged 2 to 14 years. Exclusion criteria were the absence from the treatment for more than 1 session, possible intra-articular infusion, as well as any recurrence of arthritis. The first group consisted of 8 girls aged 2 to 15 years and 3 boys aged 10 to 14 years. The second group (control group) included 3 girls aged 5 to 10 years and 2 boys aged 9 to 14 years.

Intervention

Supervision was provided by a professor in the MSc program in Pediatric Physiotherapy, and activities were conducted by a licensed pediatric physical therapist in the Halliwick therapy. The treatment was done individually, with the physiotherapist and the child in the pool and parents behold from outside of the pool. The pool was 5 × 5 m size, and the water temperature varied between 30°C and 32°C. The treatment sessions included activities that can be grouped into the following 8 categories: in-out of water, breath control, in-water orientation, anteroposterior rotation, lateral rotation, combined rotation, vibration, and sinking. These activities are designed to strengthen muscles, increase range of motion, facilitate posture and balance reactions, reduce pain, increase adaptability in the water, promote fitness, and improve respiratory support. Classical kinesiotherapy took place in a physiotherapy laboratory room individually. The equipment used was rubber for muscle strengthening, balance trays, and inclined escalator.

Assessment Tools

The Berg balance scale was used to measure static and dynamic balance. The measurements were made before and after the end of the interventions. Each measurement lasted 15 to 20 minutes. The Berg balance scale comprises a total of 14 simple balance activities, standing, sitting, reaching, and transfers. The success rate of each activity is scored from 0 (incapable) to 4 (independent), and the final measure is the sum of all scores.

A modular platform system was used to measure plantar pressure in the static phase. This platform supplies quantitative information on plantar pressure through the calculation of parameters such as foot contact area, maximum pressure, average pressure, and center of pressure. The tests were done before and after the end of the interventions. Both the experimental and control group were assessed utilizing the Letense Biomech software (Loran Engineering, Bologna, Italy) mat system for acquisition of plantar pressure mapping data. The plate (50 mm × 70 mm × 4 mm) has an active sensor area of 9 mm × 9 mm, 2304 sensors, each with a dimension of 9 mm × 9 mm. Plantar pressure and other kinetic data were sampled at 100Hz, utilizing the two-step protocol. Both assessment tools were used by the pediatric physiotherapists.

RESULTS

Berg Balance Scale

For a simpler and more comprehensible description of the results of this research, we categorized the measurements according to the literature into 3 groups:

  • Wheelchair occupancy: rating 0 to 20 on the Berg balance scale.
  • Walk with support: 21 to 40 on the Berg balance scale.
  • Independent: rating 41 to 56 on the Berg balance scale.

First Group (Hydrotherapy Intervention).Table 1 includes the minimum and maximum values, mean, and standard deviation in Berg balance scale measurements before and after the hydrotherapy intervention.

TABLE 1 - Measurement With the Berg Balance Scale in the First Group
N Minimum Maximum Mean SD
Berg balance scale before the intervention 11 24.00 55.00 40.7273 10.26734
Berg balance scale after the intervention 11 24.00 55.00 42.5455 9.98362
Valid N (listwise) 11

Control Group (Classical Kinesiotherapy).Table 2 includes the minimum and maximum values, mean, and standard deviation in Berg balance scale measurements before and after the classical kinesiotherapy intervention.

TABLE 2 - Measurement With the Berg Balance Scale in the Control Group
N Minimum Maximum Mean SD
Berg balance scale before the intervention 5 32.00 46.00 40.0000 5.52268
Berg balance scale after the intervention 5 33.00 46.00 39.6000 4.61519
Valid N (listwise) 5

Observing the mean values in Tables 1 and 2, it appears that in the first group, the variation between the mean values is slightly larger than the variation between the mean values of the control group. This means that the improvement in balance was slightly greater in the first group.

Modular Platform System

First Group (Hydrotherapy Intervention).Table 3 provides the minimum and maximum values, mean, and standard deviation of the platform indication of both feet before and after the hydrotherapy intervention.

TABLE 3 - Measurement With the Platform in the First Group
Descriptive Statistics
N Minimum Maximum Mean SD
Indication of the left foot before the intervention 11 29.70 91.10 57.4818 18.41786
Indication of the right foot before the intervention 11 8.90 70.30 42.5182 18.41786
Indication of the left foot after the intervention 11 40.30 66.00 53.4909 7.53252
Indication of the right foot after the intervention 11 34.00 59.70 46.5273 7.53274
Valid N (listwise) 11

Observing the mean values between the right and left feet before and after the intervention, it appears that the variation in preintervention indications is greater than the variation after the intervention. This means that after the intervention, the distribution of plantar pressure is more uniform than before the intervention.

Control Group (Classical Kinesiotherapy). Observing the mean values between the right and left feet before and after the intervention, it appears that the variation in preintervention indications is greater than the variation after the intervention. This means that after the intervention, the distribution of plantar pressure is more uniform than before the intervention (Table 4).

TABLE 4 - Measurement With the Platform in the Control Group
Descriptive Statistics
N Minimum Maximum Mean SD
Indication of the left foot before the intervention 5 59.50 78.30 65.6000 7.32871
Indication of the right foot before the intervention 5 21.70 40.50 34.7800 7.82764
Indication of the left foot after the intervention 5 56.40 69.50 60.8800 5.19971
Indication of the right foot after the intervention 5 30.50 43.60 39.1200 5.19971
Valid N (listwise) 5

Indications per Foot

Table 5 presents the frequency and relative frequencies for the variable of indications of the platform for the left foot before the intervention (first group). The valid column shows the percentage distribution of pressure as it appears on the platform. Table 6 presents indications about the left foot after the intervention (first group). Table 7 presents indications about the right foot before the intervention (first group). Table 8 presents indications about the right foot after the intervention (first group). Table 9 presents indications about the left foot before the intervention (control group). Table 10 presents indications about the left foot after the intervention (control group). Table 11 presents indications about the right foot before the intervention (control group). Table 12 presents indications about the right foot after the intervention (control group).

TABLE 5 - First Group
Valid Left Foot Before the Intervention
Frequency Percent Valid Percent Cumulative Percent
25-50 3 27.3 27.3 27.3
50-75 7 63.6 63.6 90.9
75-100 1 9.1 9.1 100.0
Total 11 100.0 100.0

TABLE 6 - First Group
Valid Left Foot After the Intervention
Frequency Percent Valid Percent Cumulative Percent
25-50 3 27.3 27.3 27.3
50-75 8 72.7 72.7 100.0
Total 11 100.0 100.0

TABLE 7 - First Group
Valid Right Foot Before the Intervention
Frequency Percent Valid Percent Cumulative Percent
0-25 1 9.1 9.1 9.1
25-50 7 63.6 63.6 72.7
50-75 3 27.3 27.3 100.0
Total 11 100.0 100.0

TABLE 8 - First Group
Valid Right Foot After the Intervention
Frequency Percent Valid Percent Cumulative Percent
25-50 8 72.7 72.7 72.7
50-75 3 27.3 27.3 100.0
Total 11 100.0 100.0

TABLE 9 - Control Group
Valid Left Foot Before the Intervention
Frequency Percent Valid Percent Cumulative Percent
50-75 4 80.0 80.0 80.0
75-100 1 20.0 20.0 100.0
Total 5 100.0 100.0

TABLE 10 - Control Group
Valid Left Foot After the Intervention
Frequency Percent Valid Percent Cumulative Percent
50-75 5 100.0 100.0 100.0

TABLE 11 - Control Group
Valid Right Foot Before the Intervention
Frequency Percent Valid Percent Cumulative Percent
0-25 1 20.0 20.0 20.0
25-50 4 80.0 80.0 100.0
Total 5 100.0 100.0

TABLE 12 - Control Group
Valid Right Foot After the Intervention
Frequency Percent Valid Percent Cumulative Percent
25-50 5 100.0 100.0 100.0

Observing these tables, it appears that in the first group, there is a significant improvement in the distribution of plantar pressure, whereas in the control group there is no significant improvement.

DISCUSSION

Sixteen children with JIA, 11 children who followed a hydrotherapy and kinesiotherapy program and 5 children who followed a kinesiotherapy program, participated in this study. The results showed that children in the first group who followed a hydrotherapy program showed improvement in the distribution of plantar pressure and the shift of center of gravity to the midline. The research result seems to agree with other researchers as a reference to the effect of hydrotherapy on children with JIA. In 2005, Epps and colleagues7 compared a group of children with JIA who followed classic physiotherapy with a team that followed classical physiotherapy and hydrotherapy in terms of cost and effectiveness. The results showed that the group that followed hydrotherapy had better therapeutic effects than the other group, but the cost difference was minimal.7 Fragala-Pinkham and colleagues8 investigated clinically significant improvements in functional mobility, gait resistance, movement range, muscle strength, and reduction in pain in a pediatric hospital JIA trial applying hydrotherapy in addition to classical physiotherapy. In a recent review of 2017, Fellas et al9 presented a series of conservative treatments for the improvement in lower-limb symptoms of JIA. Common leg pathologies include edema, sensitivity, pain, and muscle atrophy due to inflammatory reactions. The review concludes that physiotherapists can use a range of therapies beyond classical therapy, including taping, orthotics, and hydrotherapy.9

CONCLUSIONS

Several remarkable results have been obtained from this study. In the second group attended by children following a classical kinesiotherapy program, there was no significant change in the distribution of plantar pressure, while the first group following a hydrotherapy program experienced a significant change in the symmetrical distribution, transferring weight to the end of child suffering from JIA. The Berg balance scale evaluation showed no change in the control group, whereas the first group experienced a small improvement in the balance. The absence of a change in the second group (control group) is likely to occur because the intervention time was 2 months; on the contrary in the first group, water as a therapeutic agent offers advantages such as reduction in gravitational forces, buoyancy, hydrostatic pressure, and the appropriate temperature, which may help speed up the results of the intervention.

FUTURE PROPOSALS

On the basis of the aforementioned results, the following can be proposed:

  • Integration of children with JIA alongside a hydrotherapy program.
  • Establishing the monitoring of (1) balance and (2) distribution of plantar pressure in children at regular intervals.
  • To inform the scientific therapeutic community about the usefulness of hydrotherapy with the Halliwick concept on balance but mainly on the lower-limb symptoms caused by the disease.

Future studies may need to focus researchersʼ interest in the complex assessment of the parameters of the individual factors of distribution of plantar pressure by investigating their variation by gender, age, in short and long terms, and a larger sample of population.

REFERENCES

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2. Fairburn PS, Panagamuwa B, Falkonakis A, et al. The use of multidisciplinary assessment and scientific measurement advanced juvenile idiopathic arthritis can categorise gait deviations to guide treatment. Arch Dis Child. 2002;87(2):160–165. doi:10.1136/adc.87.2.160
3. Armbrust W, Siers NE, Lelieveld OT, Mouton LJ, Tuinstra J, Sauer P. Fatigue in patients with juvenile idiopathic arthritis: a systematic review of the literature. Semin Arthritis Rheum. 2016;45(5):587–595. doi:10.1016/j.semarthrit.2015.10.008
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5. Chandolias K. The effectiveness of the Bobath neurodevelopmental treatment and Halliwick hydrotherapy in the treatment of children with cerebral palsy (published doctoral dissertation), 2019, University of Thessaly. doi:10.26253/heal.uth.8228
6. Grosse SJ. Water freedom for all: the Halliwick method. Int J Aquatic Res Educ. 2010. doi:10.25035/IJARE.04.02.10
7. Epps H, Ginnelly L, Utley M, et al. Is hydrotherapy cost-effective? A randomised controlled trial of combined hydrotherapy programmes compared with physiotherapy land techniques in children with juvenile idiopathic arthritis. Health Technol Assess. 2005;9(39):iii–iv, ix-x, 1-59. doi:10.3310/hta9390
8. Fragala-Pinkham MA, Smith HJ, Lombard KA, Barlow C, OʼNeil ME. Aquatic aerobic exercise for children with cerebral palsy: a pilot intervention study. Physiother Theory Pract. 2014;30(2):69–78. doi:10.3109/09593985.2013.825825
9. Fellas A, Coda A, Hawke F. Physical and mechanical therapies for lower-limb problems in juvenile idiopathic arthritis a systematic review with meta-analysis. J Am Podiatr Med Assoc. 2017;107(5):399–412. doi:10.7547/15-213
Keywords:

hydrotherapy; juvenile idiopathic arthritis (JIA); philosophy of Halliwick

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