Inclusive and Supportive Education Congress International Special Education Conference Inclusion: Celebrating Diversity? 1st - 4th August 2005. Glasgow, Scotland

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DESCRIPTION AND EVALUATION OF A TEACHING PROGRAM
TO DEVELOP AQUATIC MOTOR SKILLS IN PATIENTS
SUFFERING FROM MEDULLAR LESIONS

Vera Lúcia Israel- Pontifical Catholic University of Paraná, Brasil
email: israel.v@pucpr.br

Maria Benedita Lima Pardo- Departament of   Psychology, Federal University of Sergipe, Brasil
email: pardomb@infonet.com.br

INTRODUCTION

Water has been used for therapeutic purposes for a long time, but at different times aquatic rehabilitation has been redefined (Becker & Cole, 1997). Hydrotherapy has received a great impulse in the last decades, since it has been considered a viable treatment with good results, when used both isolated or in conjunction with other treatments.

For all persons Hydrotherapy brings important advantages related to the recovery of movements and other positive effects. For the persons suffering from medullar lesions Hydrotherapy seems to have fundamental importance when planned with specific exercises appropriate to the characteristics of each case and associated with functional activities. Inside a heated swimming-pool, the water provides a support that facilitates the movements of the person with medullar lesion (paraplegic or tetraplegic). This support produces an integral physical stimulation and benefits not only the physical health but also the social integration of the person, by the development of motor skills and by the contact with new persons in and out the rehabilitation environment.

The analysis of a great number of patients with medullar lesions (Israel, 1995) showed the need of an adequate planning for Hydrotherapy, based on the definition of specific objectives, elaboration of series of exercises and evaluation of acquisitions of the patients. The search for the literature revealed that the use of teaching programs is unusual in Physiotherapy and there were few scientific works about Hydrotherapy that described the sequence of worked behaviors, as well as the procedures that were applied. Trying to contribute to develop systematic knowledge about how to work with Hydrotherapy this research has the objective to evaluate a teaching program planned to develop aquatic motor skills, inside heated swimming-pool, for persons with medullar lesion, seeking for their independence and adaptation in the liquid environment. Another preoccupation was to gather data about the influences that this kind of work could have on the daily life of those persons.

THE TEACHING PROGRAM

The teaching program (Israel, 2000) was elaborated in accordance with Skinner’s (1967) learning principles, which were extended to the individualized approach of the student by Keller (1972). So the major learning principles applied on that planning were: a progressive work with the different target behaviors (successive approximation); immediate feed-back to the well sucessful behaviors (differential reinforcement); the establishment of conditions that benefited the appearance of those behaviors by the introduction of supportive procedures (discriminative stimuli) with the aim to help the patients to surpass their difficulties. In accordance to Keller (1972) all that work should respect the  rhythm of learning of each patient.

The teaching program was planned in accordance with the following steps (Pardo, 1997):
1- definition of behavioral objectives: intermediate and final objectives. The final objective was defined in terms of the acquisition of the behaviors that allowed the patient to be “adapted and independent in his movements in the water”. The intermediate objectives were defined in terms of 26 behaviors to be progressively acquired (Israel & Pardo, 1998). To facilitate the acquisition those behaviors were organized in groups in accordance with their functional similarity. These groups were named as phases of treatment (Israel, 2000).   The phases of treatment and the behaviors they comprised were: adaptation ( 8 behaviors); mastering of the liquid medium ( 8 behaviors); specialized therapeutic exercises (4 behaviors); global organic fitness ( 6 behaviors).
2- choice of procedures to be used in intervention. Each intervention session lasted 30 minutes. At the beginning of the session the physiotherapist observed the physical condition of the patient and verified the necessity of using relaxation techniques to reduce a muscular spasticity. She was also available to discuss the doubts of the patient about his state and the treatment. The session was divided into three sections. The first ten minutes were used to the heating or relaxation of the muscles; the second ten minutes were used to the learning of the target behaviors, which were introduced progressively as the patient mastered each one; the third ten minutes were used to train behaviors learned in that session or to review behaviors learned in past sessions. During that work the physiotherapist used supportive resources (physical and verbal) to facilitate the training and the mastery of the behaviors.

3- Definition of the evaluation criteria . Those criteria were defined in terms of five levels of performance that were graduated from no execution of the movement, to execution of the movement with independence and mastery.   Level 1 was the non execution of the behavior by the patient; level 2 was the execution of the behavior with the support of the physiotherapist in more than two parts of the body (total support); level 3 was the execution of the behavior with the support of the physiotherapist in one or two parts of the body (partial support);   level 4 was the execution of the behavior without support but with partial control and coordination of the movement;  level 5 was the execution of the movement with independence and a good control and coordination.

THE METHOD

Participants

The subjects were 6 white men with medullar lesions. Three of them were paraplegic and three were tetraplegic. Their age  varied from 29 to 49 of age and five of them had learned to swim before their participation in the research. Before initiating their participation in the research all of them were physically evaluated, by a physician, so they were released to participate in the teaching program to develop motor skills. During the data collection none of them were participating in another kind of training.

Research Design

The design of the research adopted the methodology of the subject as his own control and data was collected before (pre-test), during and after (post-test) the intervention
sessions as shown in Diagram 1.

Local

For the solo evaluations, before and after the intervention sessions it was used a room of nearly 24 square meters. For the aquatic evaluation and intervention sessions it was used an adapted swimming –pool  4x6   wide  and 1,20m deep, equipped with ramp, steps, plateau and bars, heated to 33/34ºC.

Diagram 1- Research Design

Data collection

During the solo evaluation,  the participants were interviewed about their personal data, history of the lesion, present problems, practice of sportive activities. It was also observed with the support of a guide certain movements and their functionality, for example, types of functional locomotion (independent, with wheel chair, with crutch), the motor skills they could perform, transfer from wheel chair to the “tatame” and the contrary, the motor skills performed on the “tatame” (to sit independently, to change position, to roll, to keep the cat position, to keep on feet, to keep on the knees).

During the aquatic evaluation and intervention sessions data were collected with the support of a guide containing the 26 behaviors previewed to be acquired by the participants. In the aquatic evaluation session the participants were asked to perform the 26 behaviors and no support was given to them. All the sessions were filmed and the behaviors observed were classified by two independent observers according to the level of performance defined in the evaluation criteria. The concordance index between the two observers varied from 92% to 100%.

Data Analysis

The data obtained during the interviews were submitted to a content analysis and the results of the initial interview were compared with the final interview. The data collected during the solo evaluation were classified and compared with the data collected in the initial evaluation and the final evaluation.

The data collected in the aquatic evaluation before and after intervention sessions, as well as those collected during the 15 intervention sessions were classified according to the criteria of evaluation and put in figures to show the evolution of the performance of each participant.

To demonstrate the evolution of the  initial and final level of learning for the group of paraplegic, for the group of tetraplegic and for the whole sample it was applied the non-parametric test of Wilcoxon.

RESULTS AND DISCUSSION

Figure 1 shows the results obtained by P1 ( paraplegic) in the initial and final evaluations in the water and during the intervention sessions. The data are showed in terms of average calculation. We can observe that in spite of the variability of the performance during sessions this subject presented a clear tendency to improve his performance in all the behaviors expected in the different phases of treatment. The average of the evaluation of the behaviors as a whole changed from 2,45 in the initial evaluation to 4 in the final evaluation, which represented 75% of acquisition of the target behaviors, that is to say,   at the end of the teaching program this subject was capable to perform most of the behaviors with independence.

Figure 1. Evolution of behaviors of patient   P1 during treatment   phases: (A) Adaptation, (D) Mastering of liquid medium, (E) Specialized therapeutical exercises, (Cd) Global organic fitness.

Figure 2 shows the results obtained by T1 (tetraplegic) in the initial and final evaluations in the water and during the intervention sessions. We can see that this subject showed a good acquisition of the behaviors except those of the specialized therapeutic exercises.   The good   results and stability of the behaviors obtained in the phases of mastering of the liquid environment and global conditioning could   be explained partially   by his previous experience with swimming. The behaviors expected by the specialized therapeutic exercises where he obtained his worst performance involved behaviors related to walking in the water, which were specially difficult for his type of lesion. The average of the evaluation of the behaviors as a whole changed from 3,05 in the initial evaluation to 4,12 in the final evaluation, which represented 75% of acquisition of the target behaviors, that is to say, at the end of the teaching program this   subject was capable to perform most of the behaviors with independence.

Figure 2. Evolution of behaviors of patient   T1 during treatment   phases: (A) Adaptation, (D) Mastering of liquid medium, (E) Specialized therapeutical exercises, (Cd) Global organic fitness.

To answer the question about the effectiveness of the teaching program to establish the target behaviors it was applied the Wilcoxon non-parametric test .This test showed that for the paraplegic group all the behaviors presented significative     difference between the initial and the final evaluations, except one of them. For the tetraplegic group only 3 from 26 behaviors didn’t present significative difference. And for the whole sample the difference between the initial and the final evaluation were significative for all the 26 worked behaviors.

But what can we say about the influences that this teaching program could have on the daily life of those persons? Let’s summarize the responses of the subjects about that issue into their principal categories of content.

What have improved: the subjects pointed various kinds of improvement, for example, pain diminution in some parts of the body, increasing of the sensibility to the movements inside the water, increasing of the muscular force of superior and inferior members, increasing of muscular resistance, improvement of the control of urinary bladder and of intestine, better control of muscular spasticity, improvement of the transfers from the wheel chair to another chair or to bed, a better control of torso.

Some of them also indicated improvement in psychological aspects as they said “I felt more motivated” or “I like to be in the water, so my head felt better”.   

General improvements were also mentioned, for example, “I was without motivation and I passed from zero to ten”, “I guess that it was very good”, “I feel better in my body”.

Aptitudes and other changes: the subjects related other kinds of changes like “I have changed my way of eating”, “I felt worried with my femur’s osteoporoses and now I’m walking carefully”, “I’ve learned many wrong things and now I’m trying to change”.    

The future : some of the subjects talked about their future saying “I’ll continue the hydrotherapy”, “I intend to lose weight”, “I want to take care of my femur’s problem”.

Other significant changes were observed by the physiotherapist during the final solo evaluation that we describe as follows:

For the paraplegic : better movements (more confidence) in the transfer from wheel chair to tatame, to pass from sitting in the wheel chair to be on foot and back to sitting with less support, to walk with support.

For the tetraplegic: improvement in the transfers from the wheel chair with less support, independence in the movements of rolling on the tatame, more velocity in the movements, improvement in the handling of the wheel chair.

It is important to stress that the physiotherapist gave frequent support to the behaviors and questions of the subjects and also feed-back related to their performances. This kind of action made it possible the adaptation of the teaching program to the needs of each subject during the development of the work. All the participants pointed out the relevance of doing something more in spite of their limited physical conditions. For some of them the teaching program was the first experience with which they were improving even though they had experienced another type of rehabilitation.

Cohen (1999) pointed out that programmed exercises could stimulate process at neurological level. The person has different kinds of learning until to take control of the movements through conditioning. This author considers that those processes explain the individual differences related with the velocity of learning.   This could happen with the six participants of that research which had different grades of learning of the 26 behaviors trained.

According to Levitt (1997) daily activities need some abilities that must be developed, just as, to control the posture or to maintain the equilibrium, to set in motion, to use the hands, to watch, to hear, to perceive using the tact, the pressure, the temperature, the olfaction, the sense of equilibrium, to understand what one’s says, to communicate with or without speech. The teaching program succeeded in stimulating some of   those abilities.

In the water the activities must progress smoothly from simple to more complex forms so that the person with medullar lesion could master new motor movements that seldom could be performed outside the water. It is possible to the person with medullar lesion surpass the physical limitations imposed by the lesion developing his motor skills in accordance with the aspects related to his neurological recovery and time of lesion. The Hydrotherapy organized as a teaching program benefited the motor rehabilitation of the participants and also contributed with the personal valorization of each of them.

REFERENCES

BECKER, B.E., COLE, A.J. (1997) Comprehensive aquatic therapy. Boston/U.S.A.: Butterworth- Heinemann.

COHEN,H. (1999) Neuroscience for rehabilitation. 2ºed. Philadelphia/U.S.A.: Lippincott, Williams & Wilkins.

ISRAEL, V.L. (1995) Description of a hydrotherapy procedure for patients with medullar lesions: stage I. Proceedings of the 12 th International congress of the World Confederation for Physical Therapy. Washington, D.C./U.S.A., Jun. 25-30, p.19.

ISRAEL, V.L. (2000) Hidroterapia: um programa de ensino para desenvolver habilidades motoras aquáticas do lesado medular em piscina térmica. Tese de Doutoramento. Programa de pós-graduação em Educação Especial. Universidade Federal de São Carlos. São Carlos, SP.

ISRAEL, V.L., PARDO, M.B.L.(1998) Identificação de comportamentos motores aquáticos primordiais para adaptação do lesado medular na água. Revista Brasileira de Fisioterapia. V.3, Suplemento, p.47.

KELLER,F.S. (1972)   Adeus Mestre! Ciência e Cultura.24(3), 207-217.

LEVITT, S. (1997) Habilidades básicas: uma abordagem global. Um guia para o desenvolvimento de crianças com deficiência. Campinas: Papirus.

PARDO, M.B.L. (1997) Princípios da Educação.Planejamento de ensino. Ribeirão Preto: Culto à Ciência.

SKINNER, B.F. (1967) Ciência e comportamento humano. Brasília: Ed. Universidade de Brasília.

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