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Aquatic physical therapy.

Brielle Hacker was only a year old when her neurologist sent her to me in October 1995 with a prescription for physical therapy which read simply, "Water Therapy." Her mother, Julie, had also been a late walker and was less-coordinated than her peers. Swimming lessons had been her family's prescription" to help her gain strength. Now, Julie felt water could also help Brielle.

My initial evaluation showed that Brielle was too weak to smile, roll over or move spontaneously because of generalized hypotonia (low muscle tone throughout the body). She required maximum assistance to hold her head up, sit, or bear weight on her hands or elbows while on her stomach. Seventy-five percent or more of these skills had to be done for her. Brielle was unable to control her own body against the force of gravity. Her lack of experience with movement also meant she had difficulty understanding the sensory messages that her muscles and joints were sending her. She had a poor understanding of her body and where it was in space. Further medical testing, including a muscle biopsy, later revealed that mitochondrial myopathy was the cause of Brielle's severe muscular weakness and developmental delay.


The physical properties of water make it a perfect medium for a child such as Brielle. Water exerts pressure in all directions providing tactile input to the skin. The child can literally feel all that surrounds her. This can help improve body image and an understanding of position in space. Buoyancy exerts a force opposite to gravity, so the body weighs less in the water than it does on land: 50-percent less in waist-deep water, 75-percent less in chest-deep water. This allows a person to move with less exertion than is required on land. Once a patient becomes stronger, on the other hand, the viscosity of water can provide resistance to movement which can be used for additional strengthening exercises.


I used several aquatic treatment techniques with Brielle to help her develop strength.

1 Lifting her in and out of the water vertically, side to side, back and forth and splashing. This stimulates the vestibular system in the ear which improves awareness of gravity, balance and coordination.

2 Hopping across the pool, maintaining good posture in selected positions and swishing her in a circular motion on her back or stomach. This stimulates the receptors in the joints and muscles to improve body image and awareness of body position in space.

3 Kicking while floating on the stomach, with the weight of the arms and legs supported by the water; moving from the back or stomach to upright to strengthen abdominal and back muscles; rolling over; supported sitting; tipping side to side in sitting to elicit balance reactions of the head and trunk; and kneeling and standing in various water depths. This strengthened the muscles in functional patterns that Brielle could use on land.

Thanks to a treatment program of aquatic and traditional physical therapy, speech therapy and medications (Carnitor[R] and CoEnzyme Q10), Brielle has made exciting progress. She is now able to smile, verbalize and laugh out loud. She sits independently and rolls over with minimal help-25 percent of the skill or less is done for her. In water, she can kneel with arm support and pull herself into kneeling and standing. Brielle still needs minimal to moderate assistance-25 percent to 50 percent of the skill must be done for her in positions where she has to hold her body against gravity, such as being in ab all-fours (hands and knees) position. She can hold her head erect in sitting and standing.

Water therapy is not a cure for the weakness caused by metabolic disease, but it allows children to develop muscle strength for movements that would be difficult "on land," while it helps normalize a child's body image.


The following terms and phrases are included in articles in this special section or will be words that parents and physicians will hear and use in working with ketogenic diets or mitochondrial/metabolic disorders.

Acidosis: an excess amount of acids in the blood.

Antiketogenic effect: anything that causes the body to start burning sugars -- rather than fats for energy again.

Carnitine: a chemical necessary for transportation of fatty acids across the mitochondrial membrane. The body makes carnitine. it is also contained in meats and dairy products.

Electron transport/respiratory chain: a series of reactions that takes place in the mitochondria and contributes to the production of energy; also called the respiratory chain.

Fasting: going without food.

Free fatty acids: a type of lipid, or fat, that circulates in the bloodstream. Triglycerides contain one type of free fatty acid.

Hypoglycemic: having a low level of glucose (sugar) in the bloodstream.

Ketogenic diet: a diet that promotes ketosis (the body burns fat instead of sugars for energy).

Ketones: byproducts of the metabolism of fat-when ketones are found in urine, it means the process of ketosis has begun.

Ketosis: the state the body reaches when it burns fat instead of sugars for energy.

Kreb's cycle: part of the cycle in which sugar is broken down to produce energy. It takes place in the mitochondria.

Medium chain triglyceride oil (MCT oil): an oil that is sometimes used in the ketogenic diet.

Mitochondrion: the part of the cell that is responsible for converting nutrients into energy, as well as many other specialized tasks. (See June 1997 issue, Part I, special section on Mitochondrial/Metabolic Disorders, pages 40-43.)

Pyruvic acid: sugar is broken down into pyruvic acid which is then used in the formation of energy.

Seizures: usual and temporary disturbances of brain function, manifested as episodic impairment or loss of consciousness, abnormal movement, or sensory disturbances. Caused by paroxysmal disturbances in the electrical activity of the brain.

Tonic-clonic: (formerly called grand mal seizures.) Generalized seizures consist of two stages: a loss of consciousness and muscle rigidity (tonic), followed by jerking and twitching of the extremities (clonic).there is often a post-seizure period of disorientation and poor coordination.

Myoclonic: seizures characterized by jerking of a body extremity or generalized tonic-clonic seizures within an hour or two of waking from sleep.

Atonic: seizures that involve a sudden loss of muscle control. These are also called akinetic seizures.

Partial: (formerly know as focal) the seizure is limited to one area in the brain. During this type of seizure, the child may experience a range of strange or unusual sensations including sudden, jerky movements of one body part, distortions in hearing or seeing, stomach discomfort, or a sudden sense of fear.

Partial seizures are classified as either simple or complex. In simple partial seizures, there is no loss of consciousness, In partial complex seizures, consciousness is impaired.

Petit-mal: now called generalized absence seizures. These are characterized by five- to I 5-second lapses in consciousness. During an absence seizure, the child appears to be staring into space and the eyes may roll upwards. Absence seizures typically occur in childhood and resolve in adolescence. Absence seizures are rare in adults.
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Title Annotation:Mitochondrial/Metabolic Disorders: Mitochondrial Diseases, part 2; includes glossary
Author:Sullivan, Jill
Publication:The Exceptional Parent
Date:Jul 1, 1997
Previous Article:There is hope.
Next Article:Two precious gifts.

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