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Enhancing Quality of Life Through Aquatics Therapy

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Enhancing Quality of Life Through Aquatics Therapy 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 Shmuel and Nurit '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 - Thank you. 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.
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