This course has been pre-approved by the Arizona Board of Physical Therapy
Examiners for 15.0 CCUs for PTs and PTAs.

This course is about brain fitness with a focus on executive functions (move and think). One of the ideas behind plasticity processes is enhancing cerebral blood flow by increasing blood circulation, which is based on cardiovascular training, regarding a case of life-style inflammageing.

Aquatic gamification (or serious gaming in water) is a relatively recent motor-cognitive therapy, based on the emerging notion that movement in water is neuroprotective and important for brain integrity, brain vasculature health and brain plasticity. Movement intensity, e.g., is relevant as a basis for neuroplastic changes in the brain areas related to executive and motor control functions due to neurovascular and vasculo-neuronal coupling. At comparable physiological intensities, brain blood flow is higher in water than on land. Higher flow velocities increase the immune-metabolic activity of endothelial cells, supporting plasticity processes.

Moving is combined with thinking, i.e., using executive functions. Executive functions are important in (re)learning of motor skills and the planning of tasks. These are cognitive processes, necessary for non-routine (movement) control to attain chosen goals. Various publications have shown the very positive effects of environmental enrichment and – intensive – movement in water on executive functions with clinically relevant effects of playful moving with (an)aerobic components (Sato 2014, Kang 2015).

Human beings play, independent of age. Contents, intentions, and goals change with age, but there are common features between young adults and elderly that play. These features are also important for the – neurologically – impaired person, which was nicely underlined by Krakauer (2018). Elements of playful moving are: challenging, problem-solving, attention-taking, enjoyment and fun, social interaction, experiencing success and also exertion. Playful moving coincides with environmental enrichment, known to attenuate neuroinflammation and improve executive functions (Kentner, 2019). Neuroinflammation is a chronic low-grade inflammation of the nervous system that can occur in a variety of neurodegenerative – and metabolic diseases.

Underlying mechanisms might be neurophysiological, circulatory, and immunological changes in the brain. These have been well documented, showing (temperature dependent) changes in cerebral blood flow during immersion (Parfitt 2017, Carter 2023), changes in corticospinal excitability (Sato 2020, Le Cong 2022), increases in growth factors like the Brain Derived Neurotrophic Factor (Bansi 2013), or modification of the expression of pro- and anti-inflammatory cytokines (Pochmann 2018): all aspects of neuroprotective mechanisms.

Water is a great environment to combine all elements, especially when possibilities to move on land are limited because, e.g., of fall risk: playful movement and focusing on postural control (during e.g. agility) in water is THE alternative (Shariat 2023). Executive functions are used in relation to, e.g., obstacle negotiation, reaching to the limits of stability, reacting to unexpected perturbations, using double-tasks, etc.

Summarizing in one sentence: the added immuno-metabolic effects of (intensive) exercise in water opens a door to include cognitive elements – especially executive functions – during motor control in complex situations. These situations often have an equilibrium component and might be difficult to achieve on land when working with patients with increased fall risk.

REFERENCES:

Bansi J, Bloch W, Gamper U, Riedel S, Kesselring J. Endurance training in MS: short-term immune responses and their relation to cardiorespiratory fitness, health-related quality of llife, and fatigue. J Neurol, 2013;260:2993-3001.

Carter HH, Pienaar O, Coleman A, Cheng JL, MacDonald MJ, Naylor LH, Green DJ. The effects of water temperature on cerebral blood flow during aquatic exercise. European Journal of Applied Physiology, 2023, https://doi.org/10.1007/s00421-023-05264-7

Kang D-K, Park J-Y, Jung J-H, Park J-J. Development of Combined Aquatic Exercise Program to Improve Functional Fitness and Cognitive Function for Elderly with Mild Dementia. Exercise. Science,2015; 24: 415-423.

Kentner, A. C., Hannan, A. J., Donaldson, S. T., eds. (2019). Environmental Enrichment: Enhancing Neural Plasticity, Resilience, and Repair. Lausanne: Frontiers Media. doi: 10.3389/978-2-88945-969-8

Krakauer JW, Cortés JC. Non-task oriented approach based on high-dose playful movement exploration for the upper limb in stroke: a proposal. NeuroRehabilitation 43 (2018) 31–40. DOI:10.3233/NRE-172411

Le Cong D, Sato D, Ikarashi K, Fujimoto T, Ochi G and Yamashiro E. Effect of whole-hand water flow stimulation on the neural balance between excitation and inhibition in the primary somatosensory cortex. Front. Hum. Neurosci. 16:962936. doi: 10.3389/fnhum.2022.962936

Parfitt R, Hensman MY, Lucas SJE. Cerebral Blood Flow Responses to Aquatic Treadmill Exercise. Medicine & Science inSsports & Exercise, 2017. DOI: 10.1249/MSS.0000000000001230

Pochmann D, Krause Peccin P, Reichert I, da Silva V, Pires Dorneles G, Peres A, Nique S, Striebel V, Rostirola Elsner V. Cytokine modulation in response to acute and chronic aquatic therapy intervention in Parkinson disease individuals: A pilot study, Neuroscience Letters. https://doi.org/10.1016/j.neulet.2018.03.021

Sato D, Seko C, Hashimoto T, Sengoku Y, Nomura T. Differential effects of water-based exercise on the cognitive function in independent elderly adults. Aging Clinical and Experimental Research,2014, DOI 10.1007/s40520-014-0252-9

Sato D, Yamashiro K,Yamazaki Y, karashi K, Onishi H, Baba Y, Maruyama A. Priming Effects of Water Immersion on Paired Associative Stimulation-Induced Neural Plasticity in the Primary Motor Cortex. International Journal of Environmental Research and Public Health, 2020. DOI 10.1007/s40520-014-0252-9.

Shariat A, Najafabadi MG, Dos Santos IK, Anastasio AT, Milajerdi HR, Hassanzadeh G, Nouri E. The effectiveness of aquatic therapy on motor and social skill as well as executive function in children with neurodevelopmental disorder: A systematic review and meta-analysis. Arch Phys Med Rehabil. 2023 Sep 8:S0003-9993(23)00518-X. doi: 10.1016/j. apmr.2023.08.025.

*All other references will be discussed during the course 

Johan Lambeck, PT, owns an Aquatic Therapy Consultancy in the Netherlands, being a knowledge broker trying to implement the existing evidence in the daily practice of aquatic therapy.In 2020 he received the Award “Excellence in Aquatic Physical Therapy”, issued by the Academy of Aquatic Physical Therapy-APTA. He is a long time editorial board member of the Journal of Aquatic Physical Therapy. He was named the Aquatic Therapy Professional of the year in the United States by ATRI in 1998

From 1979 – 1998 he was in charge of the Department of Aquatic Therapy in the Rehabilitation Centre Sint Maartenskliniek (Nijmegen, NL) and was affiliated as Free Research Associate to the Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Belgium, co-responsible the EU Erasmus Aquaevidence/Aquaoutcome project till 2017. Since 2017 he is Honorary Professor at the Zhongshan Vocational College, Nanjing, China.

He is co-founder of the International Halliwick Association (IHA) and the Association International Aquatic Therapy Faculty (IATF) in which he is Senior Lecturerand vice-chair.

Johan has taught over 1000 seminars in 53 countries on almost all topics in aquatic therapy. He is the author or co-author of 4 books / CDRom’s/websites, over 45 published articles and chapters in (peer reviewed) journals and books on aquatics and aquatic therapy.

In 2005, he joined the Cochrane Collaboration balneotherapy review group. Johan was co-founder of the aquatic network of the WCPT/World Physiotherapy and performed aquatic projects for WHO.

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