Enhancing Quality of Life Through Aquatics Therapy

305 Pages·2011·6.79 MB·English

ANGLIA RUSKIN UNIVERSITY

Enhancing Quality of Life Through Aquatics Therapy:
EFFECTIVENESS OF ADAPTATION OF SEATING POSTURE LOADING
IN A PARTIALLY IMMERSED AQUATICS THERAPY APPROACH FOR THE IMPROVED
FUNCTIONING AND PERCEIVED COMPETENCE OF CHILDREN WITH CEREBRAL PALSY,
AS REFLECTED IN THEIR QUALITY OF LIFE:
A MULTIPLE CASE STUDY

ARIE NIV SHELEF

A thesis submitted in partial fulfilment of the requirements of Anglia Ruskin
University for the degree of Doctor of Philosophy

Submitted: 2010
This work is dedicated to my parents
SSSShhhhmmmmuuuueeeellll and NNNNuuuurrrriiiitttt
'Yivadu Lechaim Arukim', 'May you Live Long and Well'.
Your continual unconditional support,
the wonderful education and care that you granted me in all fields of my life
pointed me so successfully to the path of achieving this PhD -
TTTThhhhaaaannnnkkkk yyyyoooouuuu....

II
ACKNOWLEDGMENTS
To Wickedness the Road is quickly found.
Short is the Way, and on an easy Ground:
The Paths of Virtue must be reach'd by Toil,
Arduous, and long, and on a rugged Soil,
Thorny the Gate, but when the Top you gain,
Fair is the future, and the Prospect plain.
Works and Days
Hesiod, Book I: Line 375

This poem guided me throughout my journey to achieve this PhD. But I could not have done this alone.
My special thanks to my supervisor: To Prof. Gina Wisker ARU, UK, for your erudite new insights and
views that you provided.
To the Anglia Ruskin University 'success team' for their education, enlightenment and support
throughout my journey: Dr. Gill Robinson, Prof. Vernon Trafford, Dr. Yehodit Od-Cohen, Dr. Miri
Shacham, and Dr. Leslie Bash.
To Dr. Gill Goldzweig of the Hebrew University of Jerusalem who helped me to understand and apply
methodology during my studies for the MS.C. and PhD.
To the Israeli coordinators: Mr. Dani Shenkar and Mr. Avishai Tal
To my research team: Mrs. Ester Shmueli, thanks for your great kindness and much more, Mrs. Davida
Koseff, Mr. Yoval Tsur and Mr. Mark Visse.
To Mrs. Naomi Yalin, who enhanced the quality and comprehension of my English words and phrases.
Special thanks to the staff in 'Tamar' and 'Hadar' schools and to both the school principals for allowing
and facilitating my work, enabling me to achieve this journey.
And of course my thanks to the children and their parents who participated in this long journey home,
trusted me and were fully convinced that Partial Immersion Approach and Therapeutic Treatment Chair
did contribute to their families' quality of life.
Family support
My sincere gratitude and much more (with tears and apologies) to my beautiful girls Yam and Bar for
their specially warm emotional support and understanding of their father's 'crazy' needs.
I am also very grateful to my brother Itai for helping me design the Therapeutic Treatment Chair.

III
TABLE OF CONTENTS
Contents Page
ACKNOWLEDGMENTS III
TABLE OF CONTENTS IV
ABSTRACT XIII
Abbreviations used in the Thesis 1
Prologue 3

CHAPTER ONE: INTRODUCTION 5
1.1 The Aim and Focus of the Research 7
1.1.1 Research Objectives 8
1.1.2 The Personal and Academic Context of the Research 12
1.1.3 Main Issues Examined in the Research 13
1.1.4 The Research Process 14
1.1.5 The Research Questions Addressed by the Research Design 14
1.2 The Research Questions 15
1.3 Chapter Summary 15

CHAPTER TWO: THEORETICAL PERSPECTIVES 16
Precis 16
2.1 Definition of Cerebral Palsy (CP) 16
2.2 The Main Problematic Issues Associated with CP 17
2.3 The Great Environment 20
2.3.1 Gravity: The Limitations and Beneficial Effects imposed on Earth's Environment 24
2.4 Unloading and Loading Human Weight 28
2.4.1 Adaptation 29
2.4.2 Movement and Posture 35
2.4.3. Head and Body Righting 36
2.4.4. Cephalo/Caudal- Proximal/Distal Directions 37
2.4.5 Balance 38
2.4.6. Free unsupported sitting 39
2.4.7. Rhythmical Intention 41
2.4.8 Early Intervention 43
2.4.9 Amount of Intervention 43
2.4.10 Heat Principle 46
2.4.11 Specificity of Movement 47
2.4.12 Carry Over - to Gravity 47
2.5 Enhancing the Psychosocial Domain 47
2.5.1 Perceived Competence and Overcoming Fear 49
IV
2.5.2 Models of Disability and Quality of Life 51
2.6 Summary 52
2.7 The Gap of Knowledge 52
2.8 The Conceptual Framework 57
2.9 The Research Questions addressed by the Research Design 59
2.9.1 From Factual to Conceptual: The Cause and Effect Relationship 59
2.10 Adaptation Summary 64
2.11 Chapter Summary 64

CHAPTER THREE: RESEARCH PLAN AND METHODOLOGY 65
Precis 65
3.1 Introduction 65
3.2 The Research Hypothesis 65
3.3 Challenging Methodology 66
3.4 The Research Tools and Research Methods 67
3.5 The Four Stages of the Research 67
3.6 Selection of the Research Methods 69
3.6.1 Positivistic, Naturalistic and Combined Reasoning 70
3.6.2 The Post-positivist View 71
3.6.3 The Naturalistic View 72
3.6.4 The Choice of a Suitable Method 74
3.7 The Research Framework 75
3.7.1 The selection of Case Study as opposed to Action Research 75
or a Quasi-Experimental or Ethnographic Research
3.7.2 Criticism of the Case Study Strategy 77
3.8 The Research Paradigm 78
3.8.1 The Interpretative Paradigm 78
3.9 The Investigative Process: Generating and Validating Theory, the Theory of 79
PIA
3.9.1 The Sample Research Population: The Study's Universe 80
3.9.2 Inclusion and Selection Criteria (Drummond, 1994 in Shelef, 1998). 82
3.9.3 Exclusion Criteria (Drummond, 1994, in Shelef, 1998). 82
3.9.4 Case Selection 83
3.10 The Research Method 84
3.11 Collecting the Research Evidence, Testing and Analysing It 92
3.12 Data Analysis and Interpretation 100
3.12.1 Preferred Strategy to test the ability of the PIA to develop 100
Participants' Skills
3.12.2 Developing a Multiple Case Study with MMD 100
3.12.3 Developing a Cross-Cases Protocol and Study Data Base 101
V
3.12.4 Two Strategies of Data-Analysis 101
3.13 Four Research Stages 115
3.13.1 The Pilot Study 115
3.13.2 The Research Tools 117
3.13.3 Apparatus 117
3.13.4 Procedures 118
3.13.5 Conclusions 119
3.13.6 The Theoretical Foundations of the Chair (TTC) 120
3.13.7 Units of Analysis 120
3.14 The Research Questions (RQ) 121
3.15 Definition of the Present Multiple Case Study 122
3.16 Study Procedures and Protocol 122
3.16.1 Procedures relating to the Participants 122
3.16.2 Developing the RSADLOT 123
3.16.3 Case Study Design: The Issue involved 123
3.17 Validity, Reliability and Credibility 126
3.17.1 Internal Validity 130
3.17.2 Improving Validity and in particular, Internal Validity 130
3.17.3 External Validity 131
3.17.4 Construct Validity 132
3.17.5 Reliability 132
3.17.6 Improving Reliability 133
3.18 Presentation of Findings 134
3.19 Ethical Considerations 134
3.19.1 The Researcher's Role in the Inquiry 135
3.20 Chapter Summary 135

CHAPTER 4: FINDINGS 136
Precis 136
4.1 Research Findings Pertaining to Improvement of Independent 136
Free Sitting on a Flat Stool on Land (RQ 1)
4.1.1 Improved Free Sitting According to the Quantitative Tools 137
4.1.2 Improved Free Sitting according to the Qualitative Tool 146
4.2 Research Findings Pertaining to the Improved HHC for ADL Functioning 154
(Research Question 2)
4.2.1 Quantitative Research Findings pertaining to Improved ADL 155
Function focused on Observation and Video Film
4.2.2 Improvement of ADL Functioning according to Qualitative 161
Tool Findings
4.3 Research Findings Pertaining to Improvement in the 171
Participants' Perceived Competence (Research Question 3)
VI
4.3.1 Quantitative Research Findings Pertaining to the 171
Improvement of PC of Children with CP
4.3.2 Improved PC of Children with CP according to the Qualitative Tool 172
4.4 Research Findings Pertaining to Improved QOL (Research 185
Question 4)
4.4.1 Assessment of Improvement in QOL according to 185
Quantitative Data tools
4.4.2 Assessment of Improvement in QOL according to Qualitative 186
Data from Interviews before and after Intervention
4.4.3 The Research Categories that emerged from the Qualitative 188
Findings were matched with QOL and HRQOL Domains
4.4.4 Qualitative Descriptions of Improved QOL of Participants 191
and Families One Year after Termination of Treatment
matched with QOL and HRQOL Domains
4.4.5 The Integration of Quantitative and Qualitative Research 195
Findings, according to the Four Research Questions (RQ)
4.5 Chapter Summary 196

CHAPTER 5: DISCUSSION OF THE FINDINGS 197
Precis 197
5.1 Introduction 197
5.2 Discussion of the Findings relating to Research Question 1 198
5.2.1 Improved Posture and Balance during Independent Sitting on a 198
Stool on Land
5.2.2 Problematic Issues relating to the Cases of Manor and Avi 204
5.3 Discussion of the Findings relating to Research Question 2 212
5.3.1 Improvement of Motor Ability in conjunction with improved 212
HHC
5.4 Discussion of the Findings relating to Research Question 3 222
5.4.1 Improved Motor Functioning led to improved Psychosocial 222
Functioning
5.5 Discussion of the Findings relating to Research Question 4 228
5.5.1 Sitting Skills and Psychosocial Improvements expressed in 228
improved QOL were maintained a Year after the
Intervention
5.6 Critique: Limitations of the Research 233
5.6.1 Researcher Related Biases 234
5.6.2 Social Desirability Bias 234
5.6.3 Possible Biases due to Characteristics of the Research 234
Population: Children with CP
5.6.4 Sitting Position Assessment Related Biases 235
5.7 Chapter Summary 235
VII
CHAPTER 6: CONCLUSIONS 236
6.1 Precis and Introduction 236
6.2 General Conclusions from the Discussion 236
6.2.1 Meeting the Research Goals 236
6.3 From Buoyancy (unloading) to Gravity (loading) Conditions: Regulation, 237
Control and Gradual Progression develop Motor Functioning and Sitting
Adaptation: Factual Conclusions
6.3.1 RQ 1 and 2: Interventions employed to facilitate motor 237
function adaption of ADL.
6.3.2 RQ 3: Motor Adaptation engenders Adaptations in other 238
Domains
6.3.3 RQ 4: PIA Improves QOL 239
6.4 Improving the QOL of Children with CP: A New View of PIA- Conceptual 240
Conclusions and Implications
6.4.1 RQ 1 and 2: Interventions employed to facilitate motor 240
adaption in ADL functioning.
6.4.2 RQ 3: Adaptation engenders Adaptations in other Domains 241
6.4.3 RQ 4: PIA Improves QOL 241
6.5 MMD with Replication logic investigated the effect of an 241
applied PIA Intervention on the Adaptation Process of
Children with CP
6.6 Chapter Summary 243
CHAPTER 7: THE CONTRIBUTION TO KNOWLEDGE 245
Precis 245
7.1 Introduction 245
7.2 Regulation and Control of Buoyancy 246
7.3 Motor Adaptation engenders Adaptations in other Domains 246
7.4 PIA enhanced QOL for Children with CP and their Families 247
7.5 Tools Development 248
7.6 Analytic Generalisation 249
7.7 Motor Control and Learning Theories 249
7.8 The Appropriate Environment for Rehabilitation 249
7.9 System Theory 249
7.10 Combination of Three Models ICF, Bangma and White 250
7.11 The Theory of the Origin of Species (Darwin 1958) 250
EPILOGUE 251
A. Post- Adaptation Appreciation 251
B. The TTC Patent 252
REFERENCES 253
APPENDICES 293
DIARY OF THE RESEARCHER 359
VIII
LIST OF APPENDICES
1 Aquatics Principles 294
2 Therapeutic Treatment Chair (TTC) 296
3 Pilot Study 303
4 Shelef (1998; 2000) 310
5 Environmental Conditions 311
6 Studies with Similar Methodology 312
7 Aquatic Therapy versus Hydrotherapy 313
8 Aquatics Studies Demonstrating Psychological Benefits for 314
CP Populations
9 Placement Committee 318
10 Research Approval 319
11 Ministry of Education Approvl addressed to School Principals 321
(Letter of Consent)
12 Qualitative Interview Questionnaire 327
13 Researcher's Training: Taking a Reading according to the 328
Goniometer
14 Data Collection 330
15 Mapping the Research Equipment in the Sports Hall at the 332
Tamar School
16 Rating Scale ADL Observation Test (RSADLOT) during Free 334
Sitting
17 Interval Recording Observation (IRO) 336
18 IRO - A Picture every 30 Seconds 345
19 Mean for Improved Perceived Competence 349
20 The Rationale for the Intervention 350
21 Stimulation to the Edge of Balance Intervention 353
22 Quality of Life (QOL) 354
23 Goniometry Results 357
24 QOL Domains in Land and AT Environments 358

LIST OF TABLES
1 Differing Treatment Loads in CP Aquatics Studies 44
2 The Research Questions that led the research from the 55
Factual to the Conceptual Level in relation to Different
Disability and Rehabilitation Models
3 Aims and Objectives of the different Research Stages 69
4 Body Measurements and Characteristics, including 81
Participants' Abilities
5 The Research Tools - Method 85
6 Details of all Treatment Interventions by Participant 98
7 MMD showing Details of Interventions according to 99
Participants and Base Lines, using Quantiative Core and
Supplementary Qualitative Methods
8 MMD showing Details of Data Collection and Analysis 103
according to Base Lines, Quantitative Core and
Supplementary Qualitative Tools
IX
9 Total summary and calculation score of participant with 109
tools: RSADLOT and GMFM
10 Triangulation Strategies employed in response to Research 112
Questions
11 Summary of Quantitative and Qualitative Research Findings 113
collected in response to the Four Research Questions
12 The Inquiry Validation Process 128

13 Type of Tool and Data collected to answer Research 136
Question 1
14 Effectiveness of Intervention in different Environments: Input 139
- Participants' Treatment Time (in minutes) Output -
Amount of Improvement (in degrees)
15 Effectiveness of Intervention in different Environments 142
measured by SACND Rest Module:
Input - Participants' Treatment Time (in minutes)
Output - Amount of Improvement (in points)
16 Data Collection for Research Question 2 155
17 Effectiveness of Intervention in different Environments 157
measured by SACND Reaching Module:
Input - Participants' Treatment Time (in minutes)
Output - Amount of Improvement (in points)
18 Differences in acheivements of different participants between 160
Pre-and Post-intervention tests for each Dimension (in %) as
a result of the different Treatment Environments, according
to Rating Scales Questionnaire-GMFM
19 Type of Tool and Data Collected to answer Research 171
Question 3
20 Type of Tool and Data Collected to answer Research 185
Question 4
21 Quantitative Findings: Total mean differences for all 186
participants by measuring tool between pre-post evaluation of
motor improvement that formed the basis for the evaluation
of improvement in physical functioning and perceived
competence domains of QOL
22 Categories emerging from the Qualitative Findings matched 190
with QOL Domains
23 Research Questions: Integration Between Theories, Concepts 228
and Models, from Factual to Conceptual Levels of Research

LIST OF TABLES IN APPENDICES
Appendix 3 1 Passive and Active ROM Evaluations 304
Appendix 5 1 Average Environmental Conditions during 311
Treatment, by Participant
Appendix 5 2 Land Environment Conditions during 311
Assessments, by Participant

Appendix 6 1 Other Studies that have used Sampling, Design 312
and Methodology similar to those used by the
Present Study
Appendix 8 1 Aquatics Studies Demonstrating Psychological 315
Benefits for CP Populations
X