Abstract
Sailing might produce a positive effect on a patient’s general health and become an integrated part of rehabilitation. Our hypothesis was that a specific technological rehabilitation program might be used to prepare a group of disabled subjects for sailing. Seventeen patients (age range: 9-20) with impairments in motor coordination and balance and 15 healthy subjects participated in the study. The study was divided into the virtual-technological sailing phase, theory-practice phase, and sports phase. Proprioceptive platforms were used to evaluate balance, and the Child Health Questionnaire–PF50 was used to evaluate quality of life. Trunk displacement and the center of pressure velocity improved significantly after the virtual-technological sailing program. As regards quality of life, the physical and psychosocial score significantly improved at the end of the program. A technological rehabilitation training improved balance in disabled subjects and may be used to prepare them for a real sailing course. Sailing improves the quality of life of disabled subjects and could be used in the rehabilitation.
Sailing is a very complex activity that involves the perception and integration of both exteroceptive and proprioceptive stimuli owing to the fact that it is practised in a stimulating environment, such as the sea or a lake. Sailing is considered to be a realistic and practical sport for people with disability that may exert positive effects on self-esteem and general health.
As sailing is usually considered a dangerous, elitist, and expensive sport, people with no previous experience may be discouraged from attempting to go sailing, not to mention those who have any form of disability. New technologies, a growing awareness of the need, and a rising demand by and on behalf of persons with a disability have led to a marked increase in the spectrum of sports available to such people, including sailing. Indeed, sailing simulators provide a safe and easy means of learning the skills required to navigate as well as of bridging the gap between dry-land and on-the-water sailing.
Quality of life is a very important goal in the rehabilitation process. 1,2 Scientific research designed to improve quality of life using sports activities in disabled patients is of great importance and interest. 3 -6 Although a number of studies have shown a positive effect of sport on quality of life in healthy subjects, 7 -11 few data are available on the effect of sport on the quality of life of disabled subjects. 3 -6
No previous studies have investigated the opportunities provided by sailing for rehabilitation and recreation purposes for disabled children. One pilot study based on a sailing simulator used for the rehabilitation of 3 patients with spinal cord injury yielded positive results on self-esteem and the general health of the participants. 12
Our hypothesis is that specific technological balance rehabilitation (using virtual reality and proprioceptive platforms) may effectively prepare children and adolescents for the sport of sailing. 13,14
The aim of this study was to evaluate the effects of a virtual-technological sailing program, followed by a sailing course, on the balance and quality of life of subjects with a motor and balance disability.
Materials and Methods
Population
Seventeen patients (age range: 9-20, 9 male and 8 female) with a neurologic disability, consisting mainly in a coordination and balance deficit (6 cases were also mentally retarded), and a group of 15 (age range: 9-26, 4 male and 11 female) age-matched healthy subjects were enrolled in the study.
The group of patients suffered from the following diseases: 7 patients were affected by dyspraxia, 4 by cerebral palsy, 3 by myelomeningocele, 2 by spastic paraplegia, and 1 by arthrogryposis (Table 1). The inclusion criteria were IQ ≥70 and age between 9 and 25 years. The study protocol was approved by the local ethics review board, and written informed consent was obtained from each subject.
Sample Diagnosis.
Abbreviations: ARTG, arthrogryposis; DP, dyspraxia; MMC, myelomeningocele; PCI, cerebral palsy; PPSE, hereditary spastic paraplegia.
Study Design
This study was divided into 3 phases. The virtual-technological sailing phase (Phase 1), which focused on technological balance rehabilitation, including training based on virtual reality (Nirvana, BTS, Italy) and proprioceptive platforms (Prokin, Tecnobody, Italy), and lasted 3 months (2 sessions a week); the theory-practice phase (Phase 2), including theoretical lessons (essential right-of-way sailing rules, position of crew and skipper, points of sail, sailing maneuvering techniques, and boating and sailing knots) and practical exercises on the sailing simulator (2 sessions a week for 1 month, with specialized instructors); the sporting phase (Phase 3), consisting of a sailing course at the Anzio Navy Sailing Club that lasted 2 months (1 session a week) (Figure 1).
Flowchart of the study. Phase 1: virtual-technological sailing phase; phase 2: theory-practice phase; phase 3: sports phase.
Balance Evaluation
The balance evaluation was performed by means of proprioceptive platforms, in the static standing and sitting positions. A stabilometric assessment was performed and the following parameters were considered: area and perimeter of the center of pressure, anteroposterior and mediolateral center of pressure velocity with the eyes open and closed. The anteroposterior, mediolateral, and total root mean square of the trunk movements (with the open eyes and closed eyes) were also calculated to measure the stability of the trunk.
Quality of Life Evaluation
The quality of life was assessed by means of the Child Health Questionnaire–PF50 for children-adolescents. This questionnaire is a generic health-related quality of life tool that measures the physical and psychosocial well-being of children with or without disability above the age of 5 years and consists of domains representing the most essential components of a child’s health-related quality of life. The Official Child Health Questionnaire–PF50, which is a cross-culturally adapted and validated Italian version, was administered to the patients’ parents according to standardized methodologies. 15 The Child Health Questionnaire–PF50 is a disease-specific measure that consists of 50 items covering the general health status of patients. This questionnaire has the advantage of being a quick and easy health-related quality of life measure that can be used in conjunction with other more functionally based outcome measures to assess the effects of an intervention. This questionnaire provides 15 specific categories of physical and emotional scores (4 specific categories regarding the patients’ parents: parental time, parental emotional, family activity, family cohesion, and others regarding the children: physical functioning, role physical, bodily pain, global general health, general health, change health, role emotional behavior, behavior emotional, mental health, global behavior emotional, self emotional) summarized into 2 main scores: physical score (PhS) and psychosocial score (PsS). Very low physical scores indicate severe physical dysfunction, distressful bodily pain, frequent tiredness, and unfavorable evaluation of the health status. Very low psychological scores indicate frequent psychological distress, and severe social and role disability due to emotional problems. 16 Higher Child Health Questionnaire–PF50 scores indicate better health.
Technological Instruments
Virtual reality system Nirvana
It allows the subject to move freely in the virtual environment without the need for any devices (a semi-immersive reality). This system is connected to a projector or a large screen as it reproduces an interactive series of exercises and, thanks to an infrared video camera that analyzes the patient’s movements, it creates interactivity. It supplies virtual reality scenarios and the subject interacts with these scenarios by moving; any change in movement modifies the virtual scenario.
Proprioceptive platforms
We used 2 platforms, one for the evaluation/training in the standing position and another in the sitting position. These systems are used to work on postural control by means of proprioceptive and visual stimuli. Both systems are composed of a network of sensors that can detect the minimum angular displacements and loads applied by the patient to the platform. When the patient interacts with the platform, the movements, which are converted into electrical impulses before being processed by a dedicated software, are displayed directly on the monitor in the form of a track that closely follows the angular movement of the platform or the loads applied to it. 17
Technological Rehabilitation Treatment
A virtual reality system and proprioceptive platforms were used for the technological balance training.
The virtual reality training consists of exercises in which the subject has to reach and touch elements randomly projected onto the wall (animals, flowers, etc). If the subject hits the target element within a set period of time, a visual transformation combined with an acoustic feedback is triggered; otherwise, the figure disappears. This training includes several exercises designed to improve:
motor control and mobility (abduction and reaching) of the upper limb and motor control and mobility of the trunk.
The technological balance training using these proprioceptive platforms (in the standing and in sitting positions) is designed to improve the load symmetry, to expand the trunk excursion in relation to the support base conditions, and to improve the safety, accuracy, and motor coordination of the body in unstable conditions. Virtual programs also were used to achieve these rehabilitation aims.
Timing
The timing of the evaluations was divided as follows: T0 (Pre–virtual-technological sailing phase), T1 (Post–virtual-technological sailing phase), and T2 (Post–sports phase) (Figure 1).
Statistical Analysis
The statistical analysis was performed using the Statsoft (Tulsa, OK) package. All the data were tested for normality by means of the Shapiro-Wilk test. Because the variables were not normally distributed, the Mann-Whitney test was used for all the investigated variables to determine differences between the following 2 groups: patients versus the healthy control group. The Wilcoxon test was used to compare the stabilometric assessment at T0 with that at T1 (T0 vs T1), and the assessment at T1 with that at T2 (T1 vs T2). Moreover, Spearman rank correlation coefficient test was used to investigate any correlations between the stabilometric variables. The significance level for all parameters was set at P <.05. These comparisons were made in both the sitting and standing conditions.
Results
Balance
Comparison between patients and healthy group
Stabilometric data of our patients at T0 were compared with those of an age-matched healthy control group in both the standing and sitting positions.
Table 2 shows that all the balance parameters were statistically different between patients and healthy subjects.
Stabilometric Evaluations in Standing and in Sitting Position: Mean, SD, and P Level of the Stabilometric Parameters in Healthy Subjects and in Patients.
Abbreviations: CE, eyes closed; CoP, center of pressure; HS, healthy subjects; OE, eyes open; Pts, patients; RMS, root mean square; T0, Pre–virtual-technological sailing phase.
The most significant differences were observed for the following data: the total root mean square of the trunk during the evaluation with the eyes open in both the standing (P < .002) and sitting (P < .0001) positions, the area of the center of pressure during the evaluation with the eyes open in both the standing (P < .002) and sitting (P < .0001) positions. Moreover, our sample of patients displayed abnormal balance control at the beginning of the study in both the standing and sitting positions (Table 2).
Balance Assessment in Pathological Group
Stabilometric evaluation in the standing condition
The total root mean square of the trunk movements improved significantly between T0 and T1 as well as between T1 and T2 (P < .002 and P < .001, respectively) when evaluated with the eyes open (Figure 2A). There was thus an improvement in trunk displacement in the anteroposterior and mediolateral directions in the standing condition at the end of the technological balance rehabilitation and a further improvement after the sailing course.
Balance evaluation in the standing condition: (A) total root mean square of the trunk movements at T0, T1, and T2 measured with the eyes open. (B) Balance evaluation in the sitting condition: anteroposterior and mediolateral and velocity of the centre of pressure (CoP) and (C) total root mean square of the trunk movements at T0, T1, and T2 measured with the eyes open.
Stabilometric evaluation in the sitting condition
At the end of the technological balance rehabilitation (T0-T1) and at the end of sailing course (T1-T2), we observed a significant improvement in the anteroposterior and mediolateral velocity of the center of pressure, as measured with the eyes open (P < .001) (Figure 2B). A significant improvement in this condition was also observed in the total root mean square of the trunk movements (T0-T1 P < .0001 and T1-T2 P < .0001, respectively) (Figure 2C).
An improvement in trunk stability (displacement and velocity) was observed both after the technological balance rehabilitation and after the sailing course in the sitting position.
Quality of Life
The second objective of the study was to assess any effects exerted by the program on the quality of life of the subjects by means of the Child Health Questionnaire–PF50, a validated questionnaire for children-adolescents. Figure 3 shows the quality of life data and statistical results after the sailing course (T2) compared with the baseline evaluation (T0). A significant improvement was observed at the end of the course, if compared with the baseline, in global general health and bodily pain (P < .05), behavior emotional (P < .02), and role emotional behavior, role physical, mental health, physical score, and psychosocial score (P < .01) (Figure 3).
Mean and statistical results of the Child Health Questionnaire (CHQ-PF50) recorded at T0 and T2. GGH, global general health; PF, physical functioning; REB, role emotional behavior; RP, role physical; BP, bodily pain; BE, behavior emotional; GBE, global behavior emotional; MH, mental health; SE, self emotional; GH, general health; CH, change health; PE, parental emotional; PT, parental time; FA, family activity; TOT-PhS, physical score; TOT-PsS, psychosocial score; FC, family cohesion.
Discussion
This is the first time an experimental study based on a specific virtual-technological rehabilitation program, with virtual reality and proprioceptive platforms, has been used to prepare a group of disabled children and adolescents for sports sailing.
After a virtual-technological rehabilitation program, in which sailing was simulated by means of virtual reality and proprioceptive platforms, our patients displayed a significant improvement in balance, which was maintained at the end of the program (after the real sailing course). We wish to stress that our sample included disabled children and adolescents with abnormal balance, as observed at the baseline evaluation, and that our virtual-technological rehabilitation program was focused on the treatment of balance.
These data suggest that technological rehabilitation, using virtual reality and proprioceptive platforms, provides an effective means of treating adolescents and children with abnormal balance, and it could be used to prepare disabled subjects for sailing. These technologies offer patients continuous visual feedback of their postural control and enhance the strategies they adopt to achieve balance. In this way, patients can compare what they feel at the proprioceptive and kinesthetic levels with what they carry out at the motor level.
The whole project, including the virtual/technological program and sailing course, also improved physical aspects (including pain) and mental/emotional/psychological aspects of the quality of life of our patients. Indeed, it is noteworthy that the 2 main scores, that is, Physical score and Psychosocial score, improved significantly after treatment, thereby pointing to an overall beneficial effect on the quality of life in our patients.
We hypothesize that sailing, thanks to the perception and integration of both exteroceptive and proprioceptive stimuli (offered by the environment in which sailing is performed, ie, the sea or lake), improves quality of life by incrementing self-esteem and general health.
The positive effect of sport, in general, on quality of life has previously been reported in healthy subjects, 7 -11 whereas few data are available on the effect of sport on the quality of life of disabled subjects, and none on sailing. 3 -6 These studies suggest that sport should be adopted as an integrated part of rehabilitation in subjects with disabilities, a concept that was first proposed by Sir Ludwig Guttmann in Great Britain in the mid-20th century 18 and supported at the same by the founder of our institution. Our study further supports this concept and highlights the potential use of technological instruments to prepare subjects with disabilities to start a sport, such as sailing.
This project allowed us to verify that sailing, using specialized instructors, is a safe sport even for children and adolescents with mental retardation, as demonstrated by the fact that a lot of our patients were affected by coordination disorders (dyspraxia) and mental retardation.
This is the first time sailing has been shown to improve the quality of life of disabled children and adolescents.
The limitations of our study are the small sample size and the heterogeneity of the diseases affecting our patients.
Nevertheless, our data suggest that a rehabilitation training, using a virtual-technological sailing program, improves balance in children and adolescents with disabilities and helps to prepare these subjects for a real sailing course. Sailing, comprising both a virtual and real phase, improves the quality of life of disabled children and adolescents and might be used as an integrated part of their rehabilitation program.
Footnotes
Acknowledgments
We thank Giuliana Rinaldi, Laura Cortellini, Laura Fedeli, Laura Masetti, Federica Marchetti, Marta Mannina, Anna Pecora, Fabio Barbieri, and Rodolfo Bergamaschi for their help.
Author Contributions
IA, LI, FMM, and LP designed the study. LI enrolled and screened the patients. II, AC, and CP collected the data. CI and IA analyzed the data and did statistical analysis of the data. IA, CI, and II wrote the manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was financed by the Don Carlo Gnocchi Foundation of Rome (in partnership with the Italian Sailing Federation) and by the Equal Opportunities Department to support interventions aimed at the affirmation of equal opportunities for persons with disabilities in sport.
Ethical Approval
The study protocol was approved by the local ethics review board and was carried out with signed parental consent and/or patients’ consent.