The effect of performance-focused swimming training on clinical outcomes in young people with cerebral palsy who have high support needs

Abstract

People with Cerebral Palsy (CP) are typically less physically active than the general population and, consequently, are at increased risk of a range of preventable diseases. Evidence indicates that low-moderate doses of physical activity can reduce disease risk, and improve clinically important outcomes including fitness and function. The effect of high doses of physical activity have not been thoroughly evaluated in people with CP, however in the general population it is known that doses of physical activity much higher than those recommended as guidelines elicit the greatest health gains.Para athletes with CP who compete in Para Sport typically engage in lperformance-focusedr sports training - a form of physical activity which is primarily undertaken for the purpose of enhancing performance in a chosen sport and which is, typically, relatively high-dose. Anecdotally, many Para athletes report that participation in performance-focused sports training confers meaningful clinical benefits which exceed those reported in the literature, however supporting scientific evidence is lacking. The aim of this thesis is to investigate the effect of performance-focused swimming training on clinical outcomes in young people with cerebral palsy who have high support needs.Chapter 1 briefly orientates the reader to the research area, presents the aims of the thesis and outlines the structure of the document. Chapter 2 is a review which comprises two Sections, A and B. Section A reviews the scientific literature relevant to physical activity and cerebral palsy. Findings confirm that people with CP, and particularly those with high support needs, are less physically active than the general population. The review also presents indirect evidence supporting the notion that the relatively large doses of physical activity undertaken by Para athletes with CP may elicit correspondingly large clinical improvements, but notes the absence of direct, high-quality scientific evidence.Section B of Chapter 2 reviews the literature relevant to the methodological challenges faced by researchers who aim to inform practice in neurorehabilitation. The literature indicates that researchers investigating novel interventions should employ a phased approach to knowledge building, with the first phase comprising rigorous proof-of-concept work and evaluation of feasibility, acceptability, safety and efficacy of the intervention. The review also found evidence in support of using Single-Case Experimental Designs (SCEDs) as a rigorous research method which yields high level evidence from a small sample of a given population, and is particularly suited to addressing the research questions within this program of research.Chapter 3 presents the first study, a proof-of-concept intervention in which a single person with moderate CP (GMFCS II) who had not previously under-taken any competitive swimming training completed a 16-month performance-focussed swimming training program. The proof-of-concept design permitted development and refinement of testing and training procedures and no substantial adverse events were recorded. The participant was highly engaged throughout the 16 months (high enjoyment, high training compliance) and over the course of the intervention, marked improvements in swimming performance were accompanied by improvements in gross motor functioning, fatigue and mental health. Outcomes from the study indicate that the model of intervention n a 16-month swimming training intervention for a novice swimmer with moderate CP n is feasible, safe and effective and, additionally, provided low-level evidence that improved swimming performance achieved through performance-focused swimming training is accompanied by improved clinical outcomes in both physical and psychosocial domains.Following the proof-of-concept study, methods for evaluating the effect of performance-focused swimming training on clinical outcomes in people with cerebral palsy who have high support needs were developed. These methods are described in Chapter 4 and were utilised in Chapter 5, which is the main study within the thesis. Three participants with CP (GMFCS IV) who had high support needs were recruited and demonstrated high levels of engagement with the intervention. Swimming performance and gross motor functioning showed statistically significant improvements in response to two 16-week exposures to performance-focused training, and declined in response to two 5-week withdrawals of training. Findings suggest that performance-focused swimming training elicits meaningful therapeutic benefit for this population, and participation in para sport may have the capacity to prevent gross motor declines which occur during adolescence.Chapter 6 describes the overall findings of the thesis, and provides a summary of the contributions that this thesis has made to the literature. The program of research described in this thesis has developed new knowledge in the field of para swimming for people with CP, including novel training load and swimming performance data, and process learnings for overcoming barriers to participation. Chapter 6 also describes implications for clinical rehabilitation, and considers the clinical utility of performance-focused sport for young people with CP who have high support needs. Further, this chapter provides direction for future research which is required in this field.n