the development of motor skills and causes inappropriate compensatory .... aquatic therapy on gross motor function, energy expenditure during walking,.
Aquatic Intervention in Children with Neuro-Motor Impairments
Miriam D. Getz
ISBN: 965-555-244-6
Cover design: Medar David Photography: Dan Lev Design layout and print: Sdar Zalam Tel-Aviv Israel
© 2006 M. Getz
All rights reserved. No part of this publication may be reproduced, stored in retrieval systems, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission from the proprietor.
Aquatic Intervention in Children with Neuro-Motor Impairments Zwemtherapie bij kinderen met motorische stoornissen (met een samenvatting in het Nederlands)
Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof. dr. W.H. Gispen, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen op dinsdag 20 juni 2006 des middags te 12.45 uur door
Miriam Dalia Getz geboren op 13 april 1964, te Petah-tikva, Israel
Promotor:
Prof. dr. A. Vermeer
Co-promotor:
Dr. Y. Hutzler
Contents
Contents
Chapter 1
General Introduction
Chapter 2
The Relationship Between Aqautic Independence and Gross Motor Function in Children with Neuro-Motor Impairments
21
Chapter 3
Effects of Aquatic Interventions in Children with Neuro-motor Impairments: A Systematic Review of Literature
47
Chapter 4
The Effects of Aquatic Intervention on Energy Expenditure and Gross Motor Function in Children with Cerebral Palsy
69
Chapter 5
The Effects of Aquatic Intervention on Perceived Physical Competence and Social Acceptance in Children with Cerebral Palsy
93
Chapter 6
Conclusions and General Discussion
8
111
Summary
121
Samenvatting
125
Acknowledgements
129
Curriculum Vitae
134
Chapter 1 General Introduction
Chapter 1
General Introduction The aquatic environment is commonly used by healthy and impaired populations to increase function and improve quality of life (Cole & Becker, 2004). Medical authorities recommend using the unique characteristics of the water environment as a means of rehabilitation, and in many communities aquatic facilities are highly accessible in the community for recreational activities. This accessibility allows the transfer of effective rehabilitation techniques from the medical environment to the community, empowering individuals participate in their rehabilitation. Aquatic therapy has been reported as one of the most prevalent means of treating children with cerebral palsy (Hurvitz, Leonard, Ayyangar, & Nelson, 2003). Because of its unique characteristics, the aquatic environment provides many opportunities that are difficult to be achieved in a land setting. Specific benefits include: (1) viscosity and hydrostatic pressure help exercise even weak muscle without overstressing the soft tissue or putting extreme amounts of stress or tension on specific body parts (Cole & Becker, 2004; Broach & Datillo, 1996); (2) the impact of hydrostatic pressure on blood vessels enhances circulation and respiratory activity, which in turn produces greater efficiency in maintaining general body fitness (Gehlsen, Griby, & Winant, 1984; Cole & Becker, 2004; Haung, Viega, Sila, Reed, & Hines, 1989; Hutzler, Chacham, Bergman, & Szeinberg, 1998); (3) the warm aquatic environment of 32-33C° and turbulence enhance normal muscle tone, which in turn allows more efficient movement for children with cerebral palsy (Adams & McCubbin, 1991; Cole & Becker, 2004); (4) buoyancy enables initiation of independent movement that are difficult to achieve on land because of gravitational restraints (Harris, 1978; Hutzler, Chacham, Bergman, & Szeinberg, 1998). Despite the popularity of aquatic therapy, a base of scientific evidence for its use in pediatric rehabilitation has yet to be established. Dumas and Francesconi (2001) presented a detailed annotated literature review of aquatic intervention employed in the pediatric population. The review included current research but concentrated more on the content of the studies than on the assessment of methodological quality and the reliability of outcome measures. Geytenbeek (2002) reviewed the effectiveness of aquatic interventions in the adult population and noted that the majority of clinical trials in the adult population involved people with orthopedic conditions. To date, there is a lack 8
Aquatic Intervention in Children of evidence of the effectiveness of aquatic intervention in children with neuromotor impairments, particularly in clinical trials comparing groups of children undergoing aquatic versus non-aquatic treatment modalities.
Cerebral Palsy Cerebral palsy is defined as a non-progressive insult to a developing or immature central nervous system, particularly to areas that affect motor function (Gage, 1991). Children with cerebral palsy (CP) typically experience difficulty in developing normal movement patterns. This deficiency affects the development of motor skills and causes inappropriate compensatory movement patterns that further impede development. Children with CP exhibit a variety of primary and secondary deficiencies. Exaggerated muscle tone is present in 75% of all cases and interferes with the execution of controlled isolated movements (Katz & Rymer, 1989; Lehman, Price, J.deLateur, Hinder, & Traynor, 1989; Rose, Haskell, & Gamble, 1993). Various methods have been used to manage children with cerebral palsy. Surgery, casting, and use of orthosis are preferred to prevent or correct joint deformations. Dorsal rizhotomy and drugs (e.g., botulinum toxin injections are being used to reduce exaggerated muscle tone with the aim of enhancing the acquisition of functional motor skills. Different types of therapeutic methods are being employed by practitioners working with children, including neuro-developmental treatment (NDT), sensory integration, the Vojta method, neuro-muscular facilitation, strength training, horseback riding, and hippotherapy (Hur, 1995; Siebes, Wijnroks, & Vermeer, 2002; Valvano, 2004). The treatments are aimed at improving the functional abilities and movement skills of children with CP.
Energy Cost Past research has indicated that children with physical disabilities exert more energy during walking than able-bodied children (Duffy, Hill, Cosgrove, et al., 1996). Furthermore, studies have demonstrated decreased walking proficiency and a higher than normal oxygen uptake (VO2) during walking (Campbell & Ball, 1978; Duffy, Hill, Cosgrove, Corry, & Graham, 1996; Maltais, Bar-Or, Galea, & Pierrynowski, 2000; Unnithan, Dowling, Frost, & Bar-Or, 1996). Increased VO2 may be the main contributor to fatigue in this population. 9
Chapter 1 If the higher energy consumption is not decreased, children with physical disabilities can be expected to decrease their participation in locomotor activities, further increasing body weight and fat percentage and limiting their activity rate (Longmuir & Bar-Or, 2000; Berg-Emons & Westerterp, 1998). Previous studies found a reversed relationship between muscle weakness and motor function in children with CP (Damiano, Martellotta, Sullivan, Granata, & Abel, 2000; Damiano & Abel 1996; Whiley & Damiano, 1998). Moreover, a strong positive relationship has been demonstrated between gait parameters and performance scores on the Gross Motor Function Measure (GMFM) in children with CP (Damiano & Abel, 1996; Drouin, Malouin, Richards, & Marcoux, 1996). Based on these studies, the high energy cost in children with CP can be attributed to the combination of weak muscle strength and inefficient movement patterns due to pathological muscle tone.
Perceived Competence Perceptions of competence are a major psychological function, essential for initiating and maintaining motivation for participation in activities and goal attainment (Yun & Ulrich, 1991). The terms perceived competence, selfconcept, and self-esteem have often been used interchangeably in research (Ulrich, 1987). In contrast, Harter (1982) claims that perceived competence is not synonymous to self-concept and self-esteem. Self-concept can be regarded as the perception of one’s capacity, traits, behavior, and personality; selfesteem refers to the evaluation of self-concept; perceived competence refers to the evaluation of one’s own ability in a specific skill (Elias, 2005). Scholars and practitioners have reported on the link between perceived competence, self-esteem and self-concept (Sherrill, 2004; Sherrill, 1997), with perceived competence serving as a motivational factor that affects a person’s decision whether or not to persist in a specific task. Literature pertaining to self-esteem in children with CP is inconclusive in determining whether they are likely to have lower self-esteem than their able bodied peers (Sherrill, Hinson, Gench, Kennedy, & Low, 1990; Shields, Murdoch, Loy, Dodd, & Taylor, 2006). Nevertheless, research on perceived self-competence and self-esteem of children and youths with CP during physical activity intervention have shown improvement due to physical activity intervention (Shasby, Heuchert, & Gansneder, 1984; Sherrill, et al., 1990; Hinson, Gench, Kennedy, & Low, 1990). Research measuring 10
Aquatic Intervention in Children perceived competence in children and youths with CP prior to and post aquatic interventions is scarce. Peganoff (1984) investigated the effects of an eightweek aquatic intervention on motor performance and self-perception on a 14 year old girl with CP. She reported improvement in daily living activities and active participation in pool sessions. In addition, an improvement was noted in the participant’s self-esteem. Dorval, Tetreault and Caron (1996) reported a significant relationship between self-esteem, functional independence, and aquatics activities in 20 adolescents with CP who participated once a week for 55 minutes in a ten-week program. Hutzler, Chacham, Bergman, and Reches (1998) reported no significant effects in the self-concept of 23 children with CP who participated in a six-months swimming program compared with children who participated in a land-based movement program.
Functional Approach Traditional interventions for enhancing motor performance in children with CP are based on the neuro-motor developmental approach (Bobath & Bobath, 1984). In contrast, recent literature recommends increasing interventions emphasizing learning and relearning practical tasks based on the functional approach (Ketelaar et al., 2001; Siebes, Wijnroks, & Vermeer, 2002). The functional approach regards a person as part of a system including environmental and task contexts, and requires the interaction of several subsystems in reference to a specific skill within the context of the environment in which it is performed (Gibson, 1979; Newell, 1991; Newell & Valvano, 1998; Shumway-Cook & Woolacott, 2001). The therapist is described as an agent of change, facilitating the child’s search for an action solution that will enable a task to be performed or redefined (Valvano, 2004). From this perspective, the practitioner is expected to use varied environmental stimuli and practice enabling the child to select an effective movement pattern. The unique qualities of the aquatic environment are used to facilitate a pattern shift (Scholz, 1990; Thelen & Smith, 1994).
11
Chapter 1
International Classification of Functioning, Disability and Health (ICF) Introduction of a new model for specifying function and disability by the World Health Organization (WHO), known as the International Classification of Functioning, Disability and Health (ICF, 2001), has affected the conceptualization of outcome interventions for people with special needs. Specifically, the definition of health status has shifted from a medical to a psycho-social perspective, focusing on the disease consequences for quality of life in an ecological context (Battaglia et al., 2004). Practitioners are increasingly interested in functional intervention outcomes rather than merely affecting or improving impairment outcomes such as range of motion (ROM), muscle tone, and other physiological measures (Valvano, 2004). According to the ICF, a person’s functioning is a result of dynamic interactions of three dimensions with the environment. The three dimensions are (1) impairments of body structures or body functions; (2) activity limitations such as difficulties in performing a specific task or lacking the skills required for everyday living; and (3) participation restrictions with respect to social roles. Furthermore, the ICF addresses the effect of personal and environmental contextual factors on the three dimensions. Current literature on disability research (Dodd, Taylor, & Damiano, 2002) highlights the importance of addressing performance enhancement in all three dimensions of the ICF (i.e., function, activity, and participation). Several studies have examined whether performance in a specific motor task (Damiano & Abel, 1996; Drouin, Malouin, Richards, & Marcoux, 1996) or improvement of physiological components (Parker, Carriere, Salsberg, & Bar-Or, 1993) affect overall motor function. In terms of the ICF, the question is whether improvement of a certain body function or of a specific activity affect overall motor performance. The focus of this thesis is to investigate the effect of aquatic-based activities on motor function in children with cerebral palsy and associated neuro-motor impairments. According to the ICF framework, the aquatic environment can be regarded as a change in contextual factor. From this perspective, the objective of the present thesis is to study the effect of changing the contextual factor from a land-based to an aquatic intervention, based on the level of performance demonstrated on land.
12
Aquatic Intervention in Children
Outline of the Thesis The specific objective of the present thesis is to investigate the effect of aquatic therapy on gross motor function, energy expenditure during walking, and perceived competence in children with cerebral palsy and related motor impairments. The theoretical framework of the thesis is based on a functional approach that complies with the ICF. The thesis includes four data-based chapters, each of them with a specific rationale. The thesis incorporates the effect of the aquatic environment on children with neuro-motor impairments in a functional context. The outcome measures of each chapter address specific dimensions of the ICF, as shown in Figure 1 and detailed below. International Classification of Function ICF Function
Activity
Participation
Outcome Measures GMFCS (Chapter 2)
AIM (Chapters 2, 4, 5)
Energy expenditure (Chapter 4)
PEDI (mobility & self-care domain) (Chapters 2, 4)
Perceived competence Social and motor sections(Chapter 5)
GMFM (Chapters 2, 4)
PEDI social domains (Chapter 5)
Contextual Factors The implementation of the aquatic environment as a means to improve performance Figure 1. Outline of the ICF framework and the outcome measures used in the thesis Chapter 2 addresses the relationship between activity measures on land and in the aquatic environment as indications of the external validity of the aquatic contextual factor for treatment of motor function. Specifically, the main 13
Chapter 1 question addressed is whether motor performance in the aquatic environment as measured by the Aquatic Independent Measure (AIM) is related to motor performance on land as measured by the Gross Motor Function Measure (GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI). GMFM and PEDI were used to measure the level of functional motor abilities because they are considered to be the most reliable and valid instruments in detecting functional change over time (Ketelaar, Vermeer, & Helders, 1998). Chapter 3 addresses current research documenting the effectiveness of aquatic therapy in children with neuro-motor impairments. Three literature reviews have been published to date about the effectiveness of aquatic therapy (Broach & Dattilo, 1996; Dumas & Francesco, 2001; Geytenbook, 2002). Dumas & Francesco (2001) presented an annotated bibliography of aquatic therapy in pediatrics of 16 articles. Although not all articles reviewed were clinical trials, the authors stated the need for more evidence-based designs with functional outcome measures. However, no review was performed to date on published clinical trials addressing the assessment of methodological quality and reliability of outcome measures. The purpose of the review in Chapter 3 is to determine the effectiveness of aquatic therapy in children with neuromotor impairments as documented in clinical trials. A systematic analysis of the literature was performed to address the need for more evidence-based research documenting the functional outcomes of aquatic interventions. Chapters 4 and 5 report on clinical trials examining specific outcomes of the participation of children with cerebral palsy in an aquatic therapy program. The research design incorporates control groups that received landbased therapeutic exercise interventions. Chapter 4 reports on motor and physiological changes that may be achieved in the aquatic environment. In terms of the ICF, the focus of this chapter is on the function of the cardiovascular system and on activity and participation dimensions (GMFM & PEDI). Specifically, three questions are asked: Does participation in an aquatic therapy program improve walking economy in children with cerebral palsy as measured by the Energy Expenditure Index? Does participation in an aquatic therapy program improve metabolic values in children with cerebral palsy as measured by Cosmed? Does participation in an aquatic therapy program improve overall motor 14
Aquatic Intervention in Children function in children with cerebral palsy as measured by PEDI (motor and selfcare domain) and GMFM? Chapter 5 reports on the social changes that may be triggered by the aquatic environment. The focus of the chapter is on measures of the motivation and participation dimension (PEDI, social function domain) of the ICF. Specifically two questions are asked: Does participation in an aquatic therapy program improve perceived competence in children with cerebral palsy as measured by the Pictorial Scale of Perceived Competence and Social Acceptance (motor and social domains)? Does participation in an aquatic therapy program improve social function in children with cerebral palsy as measured by PEDI (social function domains)? Chapter 6 describes the main findings and limitations of the thesis. It presents recommendations for further research and effective outcome measures for implementing aquatic interventions in children with neuromotor impairments.
15
Chapter 1
References Battaglia, M., Russo, E., Bolla, A., Chiusso, A., Bertelli, S., Pellegri, A., et al. (2004). International Classification of Functioning, Disability and Health in a cohort of children with cognitive, motor and complex disabilities. Developmental Medicine and Child Neurology, 46, 98-106. Berg-Emons van den, R.J., Baak van, M.A., & Westerterp, K.R. (1998). Are skinfold measurements suitable to compare body fat between children with spastic cerebral palsy and healthy controls? Developmental Medicine and Child Neurology, 40, 335-339. Bobath, K., & Bobath, B. (1984). The neurodevelopmental treatment. In Scrutton, D. (Ed.), Management of motor disorders of cerebral palsy. Clinics in Developmental Medicine, 90. London: Heineman Medical Broach, E., & Dattilo, J. (1996). Aquatic therapy: A viable therapeutic Recreation intervention. Therapeutic Recreation Journal, 3, 213-229. Campbell, J., & Ball, J. (1978). Energetics of walking in cerebral palsy. The Orthopedic Clinics of North America, 9, 374-377. Cole, A.J., & Becker, B.E. (2004). Comprehensive Aquatic Therapy (2nd ed.). Philedelphia: Butterworth Heinenman. Damiano, L.D., & Abel, M.F. (1996). Relation of gait analysis to gross motor function in cerebral palsy. Developmental Medicine and Child Neurology, 38, 389-396. Damiano, D.L., Martellotta, T.L., Sullivan, D.J., Granata, K.P., & Abel, M.F.(2000). Muscle force production and functional performance in spastic cerebral palsy: Relation on co-contraction. Archives of Physical Medicine and Rehabilitation, 81, 895-900. Dodd, K. J, Taylor, N.F., & Damiano, D.L. (2002). A systematic review of the effectiveness of strength-training programs for people with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 83, 1157-1164. Dorval, G., Tetreault, S., & Caron, C. (1996). Impact of aquatic programmes on adolescents with cerebral palsy. Occupational Therapy International, 3, 241-261. 16
Aquatic Intervention in Children Drouin, M., Malouin, F., Richards, C.L., & Marcoux, S. (1996). Correlation between the gross motor function measure scores and gait spatiotemporal measures in children with neurological impairments. Developmental Medicine and Child Neurology, 38, 1007-1019. Duffy, C. M., Hill, A. E., Cosgrove, A. P., Corry, I. S., & Graham, H. K. (1996). Energy consumption in children with spina bifida and cerebral palsy: A comparative study. Developmental Medicine and Child Neurology, 38, 238-243. Dumas, H., & Francesco, S. (2001). Aquatic therapy in pediatrics: Annotated bibliography. Physical and Occupational Therapy in Pediatrics, 20, 63-79. Elias, C. (2005). The development of perceived competence in children with mild intellectual disabilities. Doctoral dissertation, Utrecht University, The Netherlands. Gage, J. R. (1991). Cerebral palsied gait. In Gage JR. Gait analysis in Cerebral Palsy. Clinics in Developmental Medicine, 121, (pp. 101-172). London: MacKieth Press. Gehlsen, G. M., Grigby, S.A., & Winant, D.M. (1984). Effects of an aquatic fitness program on the muscular strength and endurance of patients with multiple sclerosis. Physiotherapy, 64, 653-657. Geytenbook, J. (2002). Evidence for effective hydrotherapy. Physiotherapy, 88, 514-529. Gibson, J.J. (1979). The ecological approach to visual perception. Boston: Houghton-Mifflin. Harris, S.R. (1978). Neurodevelopment treatment approach for teaching swimming to cerebral palsied children. Physical Therapy, 58, 979-983. Harter, S. (1982). The perceived competence scale for children. Child Development, 53, 87-97. Haung S., Viega R., Sila U., Reed E., & Hines S. (1989). The effect of swimming in asthmatic children: Participants in a swimming program in Baltimore. Journal of Asthma, 26, 117-121.
17
Chapter 1 Hur, J.J.(1995). Review of research on therapeutic interventions for children with cerebral palsy. Acta of Neurology Scandinavia, 9, 423-432. Hurvitz, E.A., Leonard, C., Ayyanger, R., & Nelson, V.S. (2003). Complementary and alternative medicine use in families of children with cerebral palsy. Developmental Medicine and Child Neurology, 45, 364-370. 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, 176-181. Hutzler, Y., Chacham, A., Bergman, U., & Reches, I. (1998). Effects of a movement and swimming program on water orientation skills and self concept of kindergarten children with cerebral palsy. Perceptual Motor Skills, 86, 111-118. Katz, R.T., & Rymer, W.Z. (1989). Spastic Hypertonia: Mechanisms and measurement. Archives of Physical Medicine and Rehabilitation, 70, 144-155. Ketelaar, M., & Vermeer A. (1998). Functional motor abilities of children with cerebral palsy: A systematic literature review of assessment measures. Clinical Rehabilitation, 12, 369-380. Ketelaar, M., Vermeer, A., Hart, H., Petegem-van Beek, E., & Helders, P. (2001). Effects of a functional therapy program on motor abilities of children with cerebral palsy. Physical Therapy, 9, 1534-1545. Lehman, J.F., Price, R., J. de Lateur, B., Hinderer, S., & Traynor C. (1989). Spasticity: Qualitative measurements as a basis for assessing effectiveness of therapeutic intervention. Archives of Physical Medicine and Rehabilitation, 70, 6-14. Maltais, D B., Pierrynowski, M R., Galea, V A., & Bar-Or, O. (2005). Physical activity level is associated with the O2 cost of walking in cerebral palsy. Medicine and Science in Sports and Exercise, 37, 347-353. Newell, K. M., & Valvano, J.(1998). Therapeutic intervention as a constraint in the learning and relearning of movement skills. Scandinavian Journal of Occupational Therapy, 5, 51-57. 18
Aquatic Intervention in Children Newell, K. M. (1991). Motor skill acquisition. Annual Review of Psychology, 42, 213-237. Parker, D. F., Carriere, L., Hebestreit, H., Salsburg, A., & Bar-Or, O. (1993). Muscle performance and gross motor function of children with spastic cerebral palsy. Developmental Medicine and Child Neurology,35, 17-23. Peganoff, S. A. (1984). The use of aquatics with cerebral palsied adolescents. American Occupational Therapy, 38, 469-473. Rose J., Haskell, W. L., & Gamble, J.G. (1993). A comparison of oxygen pulse and respiratory exchange in cerebral palsied and non-disabled children. Archives of Physical Medicine and Rehabilitation, 74, 702-705. Shasby, G., Heuchert, C., & Gansneder, B. (1984). The effect of a structured camp experience on locus of control and self-concept of special populations. Therapeutic Recreation Journal, 18, 32-40. Sherrill, C. (1997). Disability identity and involvement in sport and exercise. In K. Fox (Ed.). The physical self (pp. 257-286). Champaign, IL: Human Kinetics. Sherrill, C., Hinson, M., Gench, B., Kennedy, S.O., & Low, L. (1990). Selfconcepts of disabled youth athletes. Perceptual and Motor Skills, 70, 1093-1098. Sherrill, C. (2004). Adapted physical activity, recreation and sport: Crossdisciplinary and life-span. (6th ed .). New York, NY: McGraw Hill. Scholz, J. P. (1990). Dynamic pattern theory - Some implications for therapeutics. Physical Therapy, 70, 827-843. Shields, N., Murdoch, N., Loy, Y., Dodd, K. J., & Taylor, N. F. (2006). A systematic review of the self-concept of children with cerebral palsy compared with children without disability. Developmental Medicine and Child Neurology, 48, 151-157. Shumway, A., & Woollacot, M.H. (2001). Motor control theory and practical applications (2nd ed.). New York: Lippincot Williams & Wilkins. Siebes, R.C., Wijnroks L., & Vermeer A. (2002). Qualitative analysis of therapeutic motor intervention programmes for children with cerebral palsy: an update. Developmental Medicine and Child Neurology, 44, 593-603. 19
Chapter 1 Thelen, E., & Smith, L. B. (1994). A Dynamic Systems Approach to the Development of Cognition and Action. England: MIT Press. Valvano, V. (2004). Activity focused motor interventions for children with neurological conditions. Physical and Occupational Therapy in Pediatrics, 24, 79- 107. Ulrich, B. (1987). Perceptions of physical competence, motor competence, and participation in organized sport: Their interrelationships in young children. Research Quarterly for Exercise and Sport, 58, 57-67. Unnithan, V.B., Dowling, J.J., Frost, G., & Bar-Or, O. (1996). Role of cocontraction in the O2 cost of walking in children with cerebral palsy. Medicine and Sciences in Sports and Exercises, 28, 1498-1504. Whiley, M.E., & Damiano, D.L. (1998). Lower extremity strength profiles in spastic cerebral palsy. Developmental Medicine and Child Neurology, 40, 100-107. World Health Organization, ICF: international classification of functioning, disability and health. Geneva: WHO. Retrieved May 2001 from http://www3.who.int/icf/icftemplate. Yun, J. & Ulrich, D. A. (1997). Perceived and actual physical competence in children with mental retardation. Adapted Physical Activity Quarterly, 14, 285-297.
20
Chapter 2 The Relationship Between Aquatic Independence and Gross Motor Function in Children with Neuro-Motor Impairments
Getz, M., Hutzler, Y., & Vermeer, A. (2006, in press). Adapted Physical Activity Quarterly.
Chapter 2
Abstract Purpose: The purpose of this study was to investigate the relationship between motor performance in the aquatic setting as measured by the Aquatic Independence Measure (AIM) to motor performance on land as measured by the Gross Motor Function Measure (GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI). Fourty-nine children with neuro-motor impairments ages 3 to 7 participated in the study. Pearson correlations were applied to determine the relationships between the AIM and the GMFM, PEDI and the Gross Motor Function Classification System (GMFCS). Results: Significant correlations were found between the total AIM and GMFM scores (r=69, p
