Children with profound intellectual and multiple disabilities are children with profound intellectual disabilities (IQ < 20), profound neuromotor dysfunctions and sometimes with sensory impairments. These children might have neither an apparent understanding of verbal language nor a symbolic interaction with objects (Nakken & Vlaskamp, 2007). These children are dependent on support from others in most aspects of their daily needs such as communication (Maes et al., 2007).
Due to their motor disabilities and general health complications, these children are at risk of pain-related medical conditions (Breau et al., 2002, 2003; Cascella et al., 2019). Severe spasticity may lead to contractures and joint dislocations, both of which are risk factors for secondary health complications such as pain (Hill & Goldsmith, 2009). Children with profound intellectual and multiple disabilities frequently have general health conditions associated with pain, such as seizure disorders, tube feeding and gastroesophageal reflux disease (Hogg, 1992; Böhmer et al., 1999; Zijlstra & Vlaskamp, 2005). As a result, daily care activities such as dressing or diaper changing might be painful because of the movement and exertion involved (Bodfish et al., 2006; Zernikow et al., 2012).
Aquatic therapy is a common pain relief treatment for some painful clinical conditions (Kamioka et al., 2010; Mooventhan & Nivethitha, 2014; Macías-Hernández et al., 2015). The therapeutic effects of aquatic therapy rely on the hydrodynamic properties of water (such as buoyancy, relative density, resistance, viscosity, turbulence, and hydrostatic pressure) (Nissim et al., 2019).
Aquatic therapy was found to be a pain relief treatment among people with fibromyalgia (Assis et al., 2006), multiple sclerosis (Castro-Sanchez et al., 2012) and neurologic or musculoskeletal disease (Hall et al., 2008). However, so far, there is no data from clinical trials or real life concerning the effect of aquatic therapy on pain among children with profound intellectual and multiple disabilities. In the current study we report on the effect of aquatic therapy on pain-related behaviours during daily care activities among children with profound intellectual and multiple disabilities.
Fifteen caregivers provided informed written consent to participate in the study. Forty-one children with a profound intellectual disability (IQ below 25 or a developmental level up to 24 months) in combination with motor and/or sensory disabilities were selected. Two children dropped out since they could not participate in the aquatic therapy during the experiment time. This left a total of 39 children with profound intellectual and multiple disabilities (19 male and 20 female) aged between 4 and 18 years (with a mean age of 8.82 years). The children’s characteristics can be seen in Table 1.
This prospective observational monocentric study was approved by the Chief Scientist of the Israeli Ministry of Education and by the Ethics Committee of David Yellin Academic College of Education. All the children in this study
Table 1. Characteristics of the participants.
participated in a weekly 30-minute aquatic therapy session between January and March 2020. During the aquatic therapy sessions, the Halliwick method was used. The Halliwick approach is a popular aquatic therapy technique used mainly with the paediatric population and with persons with neurological problems (Barker et al., 2014; Hou, Wan, & Li, 2010). The Halliwick method treatment uses fluid and mechanical properties of water and is based on postural control by mobilizing and controlling body parts through the “Ten Point Program” (for more information about the Hallwick method please see Gurpinar et al., 2020). Data were collected at school during routine daily care activities (dressing or diaper changing) by the caregivers. Data were collected four times during the study period: twice up to two hours after an aquatic therapy session, conducted by qualified hydrotherapists and twice at corresponding times not following an aquatic therapy session. That is, data for times not following aquatic therapy session was collected at the same time of day the data after the aquatic therapy session was collected (aquatic therapy sessions take place on Wednesdays during school between 8:00 am to 12:00 pm, and thus the data was collected twice on Wednesdays between 10:00 am to 14:00 pm. Data for times not following aquatic therapy sessions was collected at the same time of day not on Wednesdays).
The Non-Communicating Children’s Pain Checklist–Postoperative Version (NCCPC-PV) was selected for this study. The NCCPC-PV was designed to be used for children who are unable to speak because of cognitive (mental/ intellectual/developmental) impairments or disabilities. The NCCPC-PV was designed to be used without training by parents, caregivers, or by other adults who are not familiar with a specific child. It contains six of the seven subscales of the original version (vocal, social, facial, activity, body and limbs, physiological) (Breau et al., 2002). The Eating–Sleeping subscale of the original version was not included in the current study. Caregivers indicated how often each item was observed during dressing or diaper changing (not at all: 0, just a little: 1, fairly often: 2, very often: 3). Scores for all items were summed to create total scores.
2.4. Data Analysis
We calculated NCCPC-PV mean scores for two conditions: the NCCPC-PV mean score for the two times up to two hours after an aquatic therapy session and the NCCPC-PV mean score for the two times following an aquatic therapy session. For comparing the NCCPC-PV mean scores, we used a paired sample t-test. Since there was a significant difference, we added Cohen’s d for evaluation of meaningfulness. Significance was set at a level of <0.05. For statistical analysis, we used SPSS Statistics 25.
We included 39 children with profound intellectual and multiple disabilities into this prospective observational study.
In Figure 1 we can observe the statistically significant difference between NCCPC-PV mean score for up to two hours after aquatic therapy and NCCPC-PV mean score for times not following aquatic therapy (t = 3.784, p < 0.01) with large effect sizes (d = 0.8773).
To our knowledge, this is thus far the first report on the effect of aquatic therapy on pain among children with profound intellectual and multiple disabilities. In our study, there were significant differences between the NCCPC-PV mean score for up to two hours after aquatic therapy and the NCCPC-PV mean score not following aquatic therapy. These findings are in line with previous studies that found a positive effect of aquatic therapy on pain relief in people with musculoskeletal
Figure 1. Difference between NCCPC-PV mean score up to two hours after aquatic therapy and NCCPC-PV mean score not after aquatic therapy (t = 3.784, p < 0.01).
conditions (Baena-Beato et al., 2014; Castro-Sanchez et al., 2012; Mannerkorpi et al., 2009); our study expands the scope to children with profound intellectual and multiple disabilities. Children with profound intellectual and multiple disabilities are at risk of pain (Breau et al., 2002, 2003; Cascella et al., 2019), especially during daily care activities such as dressing or diaper changing (Bodfish et al., 2006; Zernikow et al., 2012). Finding an intervention program that might decrease pain levels during everyday activities is crucial. Controlling pain via an intervention programme, such as aquatic therapy, might be beneficial for a large range of conditions, among them an increase in the children’s availability for learning and a better ability to withstand dental care treatments. We believe, therefore, that educators, medical and para-medical experts could find our results interesting for helping in reducing pain for children with profound intellectual and multiple disabilities.
There are several limitations to this observational study that should be acknowledged. First, intervention duration effect on pain is still unknown. Second, the small sample size of the study prevents further sub-analyses, such as examination of the effect of participants’ characteristics (for example: upper/lower limb physical impairment, deformation, gastroesophageal reflux) on the results. Finally, assessing pain of children with profound intellectual and multiple disabilities who are unable to self-report their pain, since they lack the capacity to verbally communicate is very complex and challenging (Carter, et al., 2017; Carter et al., 2016). Aquatic therapy’s effect on pain should not be based on the caregiver’s assessment alone, but also on objective measurements of pain. Future studies are needed to investigate these factors.
In conclusion, the current study provides first evidence that aquatic therapy may help reduce the pain for children with profound intellectual and multiple disabilities during everyday activities.
The authors would like to thank AL-BAKRIEH SCHOOL for its cooperation.
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