Effect of Aquatic Therapy Program on Balance in Children With Spastic Diplegic Cerebral Palsy

Cerebral palsy (CP) is the most common cause of permanent motor disability in childhood, with spastic diplegia being the most prevalent subtype, characterized by bilateral lower limb spasticity, impaired postural control, and significantly compromised balance - deficits that restrict functional mobility and participation in daily activities. These balance impairments arise from disrupted selective motor control, abnormal muscle tone, reduced proprioceptive integration, and impaired neuromuscular coordination, and represent a central therapeutic target in paediatric rehabilitation. Aquatic therapy exploits the physical properties of water - buoyancy, hydrostatic pressure, warmth, and viscosity - to reduce spasticity, facilitate movement, and promote motor learning in a safe environment, with meta-analytic evidence confirming significant improvements in gross motor function compared to land-based approaches. However, studies specifically targeting balance as a primary outcome in children with spastic diplegic CP remain limited, representing a clinically important gap that this study seeks to address.

• aquatic therapy (Other): Aquatic therapy is a specialized rehabilitation approach that utilizes the physical properties of water, including buoyancy, hydrostatic pressure, and resistance, to facilitate movement and improve functional performance in children with diplegic cerebral palsy. The aquatic environment reduces weight-bearing demands, allowing safer practice of balance, gait, strength, and motor control activities while minimizing joint stress. Regular aquatic therapy may enhance muscle strength, postural stability, mobility, and overall participation in daily activities.
• land exercise program (Other): The control group participated in a conventional land-based exercise program consisting of stretching, strengthening, balance, and functional mobility exercises. The program focused on improving lower-extremity muscle strength, postural control, gait performance, and overall functional abilities through activities performed on a stable surface. Exercises were progressed according to each participant's abilities while maintaining consistency in treatment duration and frequency across the study groups.

Primary outcomes

• static balance [baseline]: Static and dynamic balance will be assessed using the Biodex Balance System. Stability indices will be recorded to evaluate postural control and balance performance

Sex: All, ages: 5 Years to 12 Years

Inclusion Criteria:

1. Confirmed diagnosis of spastic diplegic cerebral palsy by a paediatric neurologist or developmental paediatrician
2. Age between 5 and 12 years
3. Classified at GMFCS levels I-III
4. Bilateral lower limb spasticity with a Modified Ashworth Scale (MAS) score of ≥ 1

Exclusion Criteria:

1. Athetoid, ataxic, or mixed-type cerebral palsy
2. GMFCS levels IV or V (non-ambulatory children)
3. Uncontrolled seizure disorder or epilepsy not managed by medication
4. Open wounds, skin infections, or active dermatological conditions contraindicating water immersion
5. Fear of water (aquaphobia) or inability to tolerate the aquatic environment