Cerebral palsy (CP) is a lifelong disorder that produces a variety of sensory-motor, cognitive, communication, and behavioral disorders that influence children’s activities and participation [1
]. Rehabilitation is a complex process that seeks to promote the highest possible levels of participation and quality of life, for both the child and the family. Often, these children cannot attend regular schools and therefore require special education. Students with CP have major needs at school, and health professionals have a role to play in advocating, educating, and supporting students at school [2
]. Joint educational and rehabilitative programs should be person-centered, considering all dimensions, while involving the child, the family, life events, and the environment, in order to address the numerous problems in a holistic manner [2
There are significant differences between the level of participation and performance of activities at school among typical students and students with CP [3
]. Mei et al. found that the activities and participation of children with CP are mainly related to early learning tasks, communication, mobility, and interactions, based on the experiences of parents. According to the previously mentioned authors, therapists must seek to overcome the potential negative impact of the illness on participation levels, by addressing physical difficulties, as well as numerous social and environmental factors, such as communication, support, or environmental attitudes [4
]. These findings emphasize the continuing need to provide rehabilitation interventions aimed at overcoming learning and environmental barriers to support inclusive education [3
]. An inclusive school culture is crucial for students with CP. Their rehabilitation and education environments must prioritize the promotion of an open and positive school culture built around inclusive problem-solving practices. Thus, school staff, health professionals, families, and students can work together to improve the student experience [2
Children and youth with CP who undergo rehabilitation in specialized schools may respond differently to structured exercise programs, particularly with regard psychosocial outcomes such as mental health, and academic and social development [5
]. The inclusion of aquatic therapy (AT) programs in schools may be beneficial as aquatic exercise can provide a fun and motivating form of physical activity, supporting the physical, social, and emotional well-being of children and youth with CP [6
]. In addition, water exercise is among the most common physical activity modality chosen by children with CP and their parents [9
], often representing the first choice in addition to regular therapy [10
]. Often, AT is more conducive to independent activities and participation compared to many conventional land-based therapies. A number of therapeutic effects have been demonstrated for AT, along with relevant clinical effects. This is reflected in the results of systematic reviews on children with CP, with improvements of gross motor skills, walking endurance and gait efficiency related to systemic cardiorespiratory adaptations in adolescents with CP [6
]. Furthermore, aquatic exercise has shown to be feasible with minimal adverse effects [8
The Aquatic Therapy Core Sets (CSs) describe the aquatic therapy profile of children and youth with neurological disorders [11
]. The development of CSs for the specific health care context of AT assists clinicians in identifying relevant categories to describe function and appropriate measurement tools to use in practice and research related to AT [12
]. However, these CSs did not include the educational environment in the context where these activities take place. This study is an attempt to research how to operationalize the included AT CSs categories in school settings. The aim of this study was to describe the experience of children with cerebral palsy participating in a therapeutic aquatic program within a special education school, as well as that of their parents and the education and therapy professionals.
2. Materials and Methods
Qualitative studies are useful for understanding the beliefs, values, and motivations that underlie individual health behaviors [13
]. Furthermore, qualitative studies have been used to research the experience of parents of children and youth with CP to identify a list of relevant intervention categories for AT [14
], as well as issues regarding their experiences of evidence-based assessment practices [15
] and the participation in community-based physical activity [16
] or the barriers and facilitators for physical activity in special education [5
A qualitative case study with embedded units was developed [13
]. These units comprise different participants, contexts, places, and moments, connected by the phenomenon under study [17
]. In this study, the phenomenon under study was the influence of the application of AT in children and youth with CP in specialist schools, as experienced by different participants, (including students, parents, and other participants in their therapeutic and educational context, such as health care professionals and special education teachers). This study encompasses the family and the health context, and it appears in different places such as school rooms, homes, and swimming pool. For this reason, a qualitative descriptive case study with embedded units was conducted [17
]. A case study may be formed of different units, all of which help to describe a complex phenomenon. These units may be different participants, from different contexts and places who are only connected by the phenomenon under study [17
]. A case study design should be considered when: (a) the focus of the study is to answer ‘how’ and ‘why’ questions; (b) you cannot manipulate the behavior of those involved in the study; and (c) one wants to cover contextual conditions because he or she believes they are relevant to the phenomenon under study [18
The AT intervention took place at a pool located in the APACE special education school (Toledo, Spain, https://www.apacetalavera.es/centro-educacion-especial/
). This AT treatment was part of the special education programs of the APACE-Talavera Association, which also includes an early intervention center, an occupational center, and a day center. The main goal of this AT program was to enhance the potential cognitive, sensorimotor, and social improvements among children and youth with CP, as a feasible alternative to conventional physical therapy. The interventions performed by aquatic therapists included Watsu, Craniosacral Therapy in Water and Water Specific Therapy-Halliwick. Individual AT sessions were performed by the same physical therapist, twice a week, with an average duration of 45 min, depending on age.
We included participants who could provide information regarding the phenomenon under study. As the AT intervention was framed within the rehabilitation program of a special education school, we included all those who participated in the program and who fulfilled the inclusion criteria.
Thus, the inclusion criteria for the participants in this case study were as follows:
Family context: children and youth with a diagnosis of CP, between the ages of 3 and 21 (the age range for the school), who at the time of the study had been receiving aquatic therapy for at least one year and who signed the informed consent; their parents, who signed the informed consent.
Educational and therapy contexts: health care and education professionals taking care of the children involved in AT at the time of the study, members of the teaching or rehabilitation staff, and who signed the informed consent.
The student exclusion criteria were: having an absenteeism rate of over two weeks for health reasons in the previous school year, not being able to verbally express themselves fluently, requiring communication aids, and refusing to participate in the study.
2.4. Sampling Strategies
A purposeful sampling strategy was employed [19
] to deliberately select children and youth who participated in the AT program, together with their parents, teachers and therapists. Thus, 28 families who were participating in the AT program of the APACE school at the time of the study were contacted by sending them a letter and form. Ultimately, 14 families accepted to participate in the study, who fulfilled the inclusion criteria and whose parents granted consent for their participation. In addition, four teachers and four therapists who had worked with the children included in the study were invited to participate in this study. Finally, two teachers and three therapists agreed to participate. Thus, 27 participants were included in the final sample and there were no dropouts (Table 1
2.5. Recruitment Procedure
The data collection consisted of two phases. In the first phase, non-participant observations and informal interviews were conducted. In the second phase, in-depth interviews and focus groups were conducted. The researchers explained the purpose and design of the study to the school principal and students during an initial face-to-face contact session. Separate information sessions were held for students, their legal guardians, and the health and education professionals. During these meetings, the study was described and questions were answered. Finally, participants were invited to participate in the study. All the informative sessions were held at the APACE school.
2.6. Research Team and Reflexivity
The research team was comprised of seven individuals (four women and three men). Three members were physical therapists, in addition there was a speech therapist, an occupational therapist, a social worker and a teacher. Four members of the team had clinical experience in pediatrics. Three researchers had prior experience in qualitative design studies. Prior to the study, the researchers’ positioning was established according to their previous experience and their motivations [19
2.7. Data Collection
The aim of this case study was to obtain an in-depth and multi-perspective, holistic understanding on the phenomenon of interest, which implied the need for multiple data sources and multiple data collection instruments (Table 2
]. The data were collected through non-participant observation, informal interviews, semi-structured interviews, focus group and researcher field notes. This data gathered information on: (a) the meaning of AT and prior experiences, (b) the influence of AT within the school, (c) CP factors for which AT is most useful, and (d) difficulties implementing AT. A series of questions was established for each unit of analysis. (Supplemental Materials Tables S1–S3
2.7.1. Non-Participant Observation and Informal Interviews
Bearing in mind that most children and youth were cognitively impaired, together with the difficulty of maintaining a fluid communication process, data collection began with non-participant observation. According to this method, the researcher approaches the participants in their own environment, instead of vice versa. The observation was aimed at analyzing the impact of the AT intervention on the performance of the children’s functions and their participation in their educational environment. The researcher had no relationship with the observed group, attempting to collect observational field notes in a systematic and discrete manner. The settings for the observations were: (a) the designated therapy areas (swimming pool, speech therapy and occupational therapy work rooms); (b) the communal areas (bathrooms, dining room and recreation). Observations were made before and after the intervention. Documentation of non-participant observation data consisted of field notes recorded in field notebooks. These data are records of what the researcher experiences, what he or she learns through interaction with other people, and what the person observes [23
During the observations, the researchers engaged in informal conversations and/or interviews with the participants. These were informal, unplanned, and unprepared conversations that arose during the work and interaction in the field and study environment that allowed them to discuss and deepen their knowledge of relevant issues, or ask questions about events [23
]. The interviewer approached the participants and asked them about the possibility of inquiring about their perspectives on aquatic therapy by conducting an informal interview with those who agreed to participate (Table 2
). This information was different from information collected using other data collection tools (observation, interviews, and focus groups) [19
2.7.2. In-Depth Interviews and Focus Groups
The interviews and focus groups were conducted by a researcher who had not been involved in any medical treatment related to the participants. A question guide was used to explore relevant areas of study to address the proposed research objectives. The construction of the question guide was based on previous studies and a literature review [19
]. These questions were written with a sufficiently open statement so as not to direct the participants’ answers. The semi-structured interviews and the focus groups were conducted in Spanish, and subsequently audio-recorded and transcribed verbatim after obtaining permission from participants. During the interviews, the researcher took notes on contextual descriptions, participants’ non-verbal responses, the use of metaphors within narratives, and other relevant points raised by the interview participants [19
2.8. Data Analysis
A thematic and inductive analysis was conducted [19
] by three researchers (EMB, JGR, and JPC). This type of analysis is consistent with the design in covering the multiple perspectives of the case study participants [20
]. Full verbatim transcripts were created for each of the semi-structured interviews, focus groups, informal interviews, and researchers’ field notes [19
]. Thematic analysis [25
] consisted of identifying the most descriptive content to obtain codes and then reduce and identify the most common categories. In this manner, clusters of codes (categories) were formed, i.e., similar points or content that allowed the emergence of themes describing the experience of the study participants [19
]. To identify the relevant content, researchers read and reread the text, adding marginal notes and forming initial codes [22
]. This method generates an increasing level of abstraction and complexity for the analysis from codes to categories and, finally, themes [19
]. This process of coding was performed separately for the interviews and researcher field notes, as well as for the parent and health care professional groups. A coding grid or matrix was created with the codes and categories [27
]. A matrix or coding grid is a format used to display qualitative data that systematically presents information so the user can draw conclusions and take needed action(s) [27
]. Within this grid, we identified the narratives that justified the obtained results [27
]. This process of thematic analysis was carried out separately on non-participant observations, informal interviews, focus groups, and semi-structured interviews. Subsequently, joint meetings were held to pool the results of the analysis. In addition, data collection and analysis procedures were discussed at these meetings. In the event of differences of opinion, the identification of the topic was made via consensus among the members of the research team. Finally, the research team held joint meetings to present, combine, integrate, and identify the final themes [20
] (Figure 1
). Notably, the final themes were decided by researcher consensus [17
]. No data analysis software was used.
2.9. Quality Criteria
The guidelines for conducting qualitative studies established by the consolidated criteria for reporting qualitative research [28
) and the recommendations for the design of Case Study Research in health care using the DESCARTE model [20
] were followed. Also, the criteria for guaranteeing trustworthiness by Guba & Lincoln were applied [29
]. The techniques performed and the application procedures used to control trustworthiness are described in Table 3
. The use of these methods to increase rigor are compatible with case-study designs [18
This study was approved by the Clinical Research Ethics Committee of the San Pablo-CEU University (133/17/TFM) and permission was also obtained from APACE-Talavera. Furthermore, this study adhered to the principles articulated in the WMA Declaration of Helsinki [31
]. Written consent and permission to record the interviews were obtained from all of participants and their legal guardians in the case of underage participants.
The findings of this study reveal the perspectives and opinions of children and youth, parents, educators, and therapists regarding the application of AT in the context of special education schools among severely impaired students according to the GMFCS. Our findings provide insight on the relevant practical and meaningful areas of influence that AT targets for the improvement of cognitive and sensorimotor function. The participants in this study also stressed that water is a facilitating environment that promotes participation and transfer of learning.
Our findings cover the main relevant areas of functioning described by the agreed AT CSs for children with neurological disorders [11
], with CP being the most prevalent pediatric neurological disorder. The AT CSs project and our school intervention project in CP with severely disabled students agreed on themes related to mental functions, muscle functions, mobility, learning, and transfer. Our results support the idea that the ability to move in the water is an instrumental aspect of AT treatments [11
]. Also, the ability for these sessions to enhance subsequent learning and the capacity to task-solve and meet various demands are key features of aquatic interventions, which have a major impact on the school and family environment.
The participants in our study showed that the heightened sensory perception associated with water immersion enables children to experience and awaken functions also on a cognitive level, enabling them to actively connect with their surroundings. In a previous study examining mental functions [14
], parents highlighted improvements in concentration, orientation, attention, and emotional processes after beginning AT. The parents justified this because they considered that the children worked in a highly motivating environment, making them feel more awake and alert, as previously outlined by Lai et al. [32
]. However, other authors have shown that being in the water changes the cortical activation of the sensory and motor areas, via the hydrostatic pressure offered by the aquatic environment [33
]. In addition, the site specificity of in-water induced cortical activities has been investigated to assess the activation of sensory, motor, and higher order areas related to motility during water immersion using functional near infrared spectroscopy (fNIRS). Sato et al. demonstrated that water immersion induces cortical activity, and that this activity is specific to specific areas of the brain due to the distribution of neurons activated by specific somatosensory stimulation of the environment [33
In this study, the participants reported changes in the muscles, affecting positioning and mobility, in different situations after coming out of the water. This is consistent with the findings by Chrysagis et al. [35
], who described changes in spasticity and active/passive range of motion among children with CP treated with AT. Previous studies have shown that these postural improvements lead to modifications in the motor skills of children with CP receiving AT, with a significant effect on the gross motor function outcomes using the Gross Motor Function Measure (GMFM) [32
]. Lai et al. described such improvements even for children with GMFCS level IV [32
]. Similarly, Getz et al. [38
] showed that children with more severe motor dysfunction, as classified by the GMFCS, may display superior performance in aquatic environments compared to their performance on land, which is consistent with our findings on the severity of children in special education settings in schools, who are restricted in their ability to perform many activities on land. One possible reason for this may be the thermal and mechanical effects of aquatic exercise [32
]. The mechanical properties of the aquatic environment offer benefits by decreasing the effect of gravity and joint loading, optimizing postural control, and muscle strength. The viscosity of the water allows for fluid movement patterns to be experienced. Fragala-Pinkham et al. have argued that these factors improve neuromuscular coordination, muscle endurance and aerobic capacity [39
]. In addition, the increased unloading of body weight may facilitate an increase in muscle strength, thus allowing children to initiate movements that are more restricted on land [7
]. However, in this study, fatigue was mentioned as a potential negative effect on later activities in the classroom or in therapy, suggesting that an appropriate exercise prescription should be made by health professionals, as also noted by Cleary et al. [5
Our findings reveal that learning and the subsequent transfer of knowledge may be facilitated after working in the water. Thus, Sato et al. [41
] argue that in the field of neurological pathology, not all subjects achieve the expected results based on various proposals for rehabilitation at the level of learning and plasticity, due to the variety of pathologies and working environments. However, it should be noted that Sato et al. suggest that while working in water, the effects of neuroplasticity in motor areas of the cortex enhances the performance of essential functions related to motor learning and memory, which are a fundamental part of neurological rehabilitation [41
Parents of children with CP give importance to communication and its influence on children’s independence, behavior, and relationships [4
], in line with our findings regarding communication activities and social participation in schools that promote AT sessions. In the opinion of other authors, however, it is the enjoyment of water activity through play that justifies the higher performance of the children afterwards. Lai et al. [32
], showed that aquatic exercises promote pleasure, providing an opportunity to increase children’s enthusiasm and enhancing motor development. Other authors also point to the fact that it is essential for the individual concerned to be cooperative and to participate in the session, to enable appropriate treatment planning and progress [7
]. Direct involvement of staff or family members in activities can help encourage children to meet their developmental needs. In particular, during aquatic sessions, the support of parents, teachers, and other health professionals is considered essential. In our study, the main difference with other more clinical settings outlined in AT CSs [11
], was the absence of parents during the sessions at school. Although, in this case, family members were not allowed to participate directly during the intervention sessions, throughout the focus group, parents acknowledged that the children demonstrated a positive attitude when going to other pools after receiving AT at the special education school.
This study presents interesting findings in terms of how children perform their tasks or participate in the classroom during their learning processes. Furthermore, the findings regarding the transfer of their basic needs to their daily lives is particularly noteworthy. Thus, the more dependent children enjoyed the moment of grooming, dressing and undressing, and those who were less dependent began to cope more easily with the small challenges of these activities of daily living. The interviews with the professionals revealed that the acquisition of responsibilities through routines, the greater skill in grooming activities, self-respect and self-knowledge, and the dressing and undressing that are developed in relation to the aquatic activity generated further learning and a subsequent transfer of skills. Overall, after the sessions in the pool, they described interesting dynamics in the classroom, intervention rooms at school or at the home, where they pointed out that learning was transferred from the educational/therapeutic environment to the family.
It is important to note that case studies include different units of analysis that allow a more in-depth understanding of the phenomenon, as well as serving as a triangulation technique to enhance the quality of the study and to provide information from other perspectives, besides the student’s own perspective [20
]. Nonetheless, this study has certain limitations. First, the study included a small number of participants. Second, the qualitative nature of this study means that the purpose of this study was to describe the experiences of the participants and therefore these findings cannot be generalized. Finally, the number of female and male participants was different in each group. This may affect findings, as the perspectives may be different based on the participants’ gender.