Disabilities | Free Full-Text | Wheelchair Dance: Exploring a Novel Approach to Enhance Wheelchair Skills, Belongingness and Inclusion among Children with Mobility Limitations
1. Introduction
Considering that playful approaches and activity-based interventions are recommended for the pediatric population and given limited evidence on innovative approaches for manual wheelchair skills training in pediatrics, an inclusive dance camp for youth integrating the WSTP was developed. The objectives of this study were to: (1) explore participation experiences of young people with disabilities and professional adult dancers without disabilities in an inclusive dance camp; (2) explore the influence of the inclusive dance camp on wheelchair skills and wheelchair use confidence in young people.
2. Materials and Methods
2.1. Design
2.2. Conceptual Framework
2.3. Participants
The dance group included three young dancers (YD) who used manual wheelchairs and three professional adult dancers (PAD) without mobility limitations. The YD who used manual wheelchairs were recruited from the Marie Enfant Rehabilitation Center in Montreal (Canada) using a convenience sampling strategy. Occupational therapists shared invitation forms with young people who: were between 10 and 18 years old, used a manual wheelchair for more than 4 h a day, were able to propel their manual wheelchair independently for a distance of at least 10 m, and understood simple instructions with a two-step sequence (determined by the referring clinician). Young people with medical contraindications to physical activity practice, who received surgery within the past 6 months, or had a moderate to severe intellectual disability were excluded. PADs without mobility limitations were recruited using a purposive sampling strategy. The dance teachers of the camp invited PADs from their network who were at least 18 years of age and presented good interpersonal relationship skills (e.g., attentive, caring, funny, reliable).
2.4. Dance Camp
Daily post-camp meetings. Meetings were held every evening post-camp to adjust the program and activities according to participants’ energy levels, needs, preferences and responses to the activities that were carried out during the day. As the dance camp progressed through the week, meetings were helpful to determine ways to better incorporate wheelchair skills training in the dance activities.
Integration of the wheelchair skills training. During the first two days of the camp, wheelchair skills training consisted of group practice of skills based on motor learning principles with only YDs. Starting on day three until the end of the camp, skills training was integrated throughout dance or musical games involving all dancers to facilitate group cohesion, engagement, and motivation. During the dance and musical games, the adult dancers were invited to experience using a wheelchair and the YDs who used manual wheelchairs gave them wheelchair skills training tips. An example of one game was the musical train, in which everyone followed the first person who set the rhythm (i.e., the conductor), and when the music stopped, the conductor had to perform a challenging manual wheelchair skill and everyone else had to perform the same skill after. The bachelor student and the two occupational therapists helped the morning and afternoon dance sessions when required by teaching the techniques to perform wheelchair skills using motor learning principles. The principles employed included demonstrations in combination with verbal instructions, provision of extrinsic (e.g., verbal knowledge of performance) and intrinsic (e.g., using bubble wrap [auditory feedback], a mirror [visual feedback]) feedback, segmentation, simplification, and progression. Wheelchair skills training activities were integrated in the morning or afternoon dance sessions depending on the energy level of the dancers.
2.5. Data Collection
Observations. Participant observations were conducted throughout the camp by the occupational therapy student (JB). Documentation of individual factors, interactions with other participants and camp facilitators were collected in a reflexive journal. Some sessions were filmed, and photos were taken to be analyzed and included in the observations. A daily logbook completed by the two dance teachers prior to and at the end of each camp day also supported the documentation of the contents, the process, and the adaptation of the activities of the dance camp.
Procedure. For the YDs, the WheelCon-M-F-P, the selection of two skills from the WST as individual goals and the WST were (in order) administered pre- and post-camp. The PACES, FSS and focus group were conducted three days after the end of the dance camp. For the three PADs, PACES and FSS were completed right after the end of the camp whereas the focus group was completed the next day.
2.6. Data Analysis
3. Results
3.1. Participants
3.2. Experience of Participation in the Dance Camp and Influence on Wheelchair Mobility
3.3. Mastery
YDs expressed enjoyment learning new techniques to perform manual wheelchair skills, such as placing casters in a trailing forward position before leaning to reach an object on the floor: “the little wheels, that’s something new I’d never heard before. […] And that allowed me to learn it […] I found it interesting. [YD 3]”. The three YDs reported improvements in their manual wheelchair mobility during the camp, for example in doing transient tips with their wheelchairs (i.e., lifting the front casters slightly off the ground). Furthermore, mastering different techniques allowed them to not only use wheelchair skills in dance settings, but also to integrate them into their daily lives. YD 3 explained, “the lateral movement, I didn’t really use it before. Now, I learned how to do the movement […] When I move, I tell myself I can do a lateral movement to achieve such thing”. The improvements were also apparent in the WST results with individual scores increasing by 16.7% (YD1), 19.4% (YD2), 16.7% (YD3) from pre- to post-camp.
Among the wheelchair skills selected by each YD as individual goals, the skill “Turns in place” improved by 66.7% (YD2), the skill “Maneuvers sideways” improved by 33.3% (YD3) and there were no changes in the four other skills.
Both YDs and PADs reported that YDs had a higher confidence level in using their wheelchairs: “I have improved my confidence with my wheelchair [YD1]” and “you could see the girls gaining confidence in their artistic expression, depending on their ability [PAD 2]”. YD 1 also mentioned that the wheelchair skills training activities were her favorite and that all the activities at the camp helped her to improve her confidence in using her wheelchair. The level of confidence remained almost the same for YD1 (0.8%) and improved for YD2 (11.4%) and YD3 (4.5%) from pre-to post-camp.
PADs also noticed improvements among YDs. Observations made by PAD3 on YDs’ capacity to perform the transient tip illustrate this evolution: “just like doing little pops […] they had us do the exercise with the bubble wrap on the floor and everything; she got it, like, on the first try, whereas at the very beginning, it was more challenging”. That the PADs tried the different wheelchair skills themselves helped them to notice improvement and mastery among YDs. It was observed that the YDs were encouraging PADs to try the skills and were proud to teach them the techniques. In fact, PAD1 noticed: “They were the ones who showed us, who taught us a little bit about how things were done, […] it motivated them. So, the roles would change during the week”.
Additionally, peer exchanges and peer learning were observed throughout the camp. For example, YD1 and YD2, who were less experienced, were watching YD3′s movements and trying to imitate her in the stationary wheelie practice.
3.4. Belongingness and Meaning
YDs stated that it was rare for them to be around other adolescents in wheelchairs and reported this as a benefit of the camp. However, YD3 mentioned: “The atmosphere was good, but I think the age difference [between young people and adults] made a bit of a clash”. Indeed, the three YDs would have liked to have had moments of exchange independent of the rest of the group: “I think we all have things in common. We can share everything. It’s like not every day that you’re going to be like this with people […] who are in wheelchairs too. Yeah, well for once we could have talked about it” [YD1]. It was also observed that the YDs did not interact frequently with each other by themselves until the last day of the camp. PAD3 specified that the camp is a rich opportunity for teen dancers to meet: “These are young people who are quite isolated regarding their mobility. Then, it recreates a social circle. […] Even at the end, I saw YD3, she was like, ‘Come on, YD1, let’s go practice the wheelie’ […] a new friendship was created just like that” as she noticed interactions on the last day. Participants also stated that being around other wheelchair dancers (teachers and YDs) enhanced their belief in their possibilities: “It also inspires me to see everything that’s possible because it seems to me … that there’s not much that’s so possible for me, when on the contrary, sometimes, it can even be an advantage [YD3]”. The possibility that the PADs could move on the YDs’ wheelchair to perform acrobatics while dancing together was perceived as an advantage by YD2, and YD1 specified: “This was beautiful”.
Regarding interactions with the PADs, YD3 explained: “There was a great atmosphere. But yeah, maybe, two weeks, we might have had time to dance more with others, develop more bonds”. However, YD1 reported changes regarding her level of comfort with people entering her own bubble. Indeed, she discovered she was less comfortable than what she thought with having unknown people close to her in the beginning of the camp: “Sometimes I wasn’t too comfortable when people touched me. I wasn’t always comfortable touching other people”. Additionally, YD1 identified that she was shy because she was unfamiliar with dance partners, “I found over time, I started […] to be less uncomfortable when people touched me […] They are new people, so we needed to get to know each other”. In this regard, the three YDs appreciated that PADs asked for their consent before interacting and dancing with them or touching their wheelchairs.
3.5. Challenge
Participants considered the level of challenge to be medium, which they appreciated as YD1 stated, “I wanted it to be challenging, but […] I wanted something that was relaxed, that was fun, and then you were learning things. And still with some effort”.
For the adult dancers, some mentioned that they could have had a higher level of difficulty, especially in the movements where they were not interacting with the YDs. However, PAD2 specified that the context was not oriented on performance according to her: “I don’t think I pushed myself technically, but I don’t know if I would want to push myself technically, in a context like that. I find that the objective is more in the meeting with the other” [PAD2].
3.6. Engagement
Different strategies were used to stimulate engagement in the program. For example, using a playful approach integrating dancing to the practice of wheelchair skills was particularly appreciated by all dancers, as explained by YD1: “That’s what I preferred. […] When we put on music […] that said, like: «Jump» Well, you had to lift up your casters”. In fact, the game to practice the transient tip using bubble wrap and music (i.e., propelling the wheelchair at a speed following the rhythm of the music and, in front of each strip of bubble wrap placed on the floor, lifting casters) was one of the YDs’ favorite activities.
PAD1 also observed an increased engagement among all participants when the structure of wheelchair training activities was modified around the middle of the camp to use a more playful approach and include everyone: “I found it very well structured: the classes, the workshop times, and even more since it was worked on in game mode, that we got so involved, all week long of course, but I found that when there was music as from the middle of the week (i.e., when music was added in the specific wheelchair training times during the dance sessions) […] it motivated them even more”. As such, dancers noticed the adjustments to programs and activities that were made along the camp.
Participants strongly agreed with experiencing flow during (median FSS score of 76.9%) and with enjoying (median PACES score of 91.4%) the inclusive dance camp, which may facilitate feelings of engagement. Moreover, YDs experienced a good balance between soft and calm music and more energetic rhythms used in the choreography which they all enjoyed. PAD3 expressed how inspiring and motivating the meeting with a professional wheelchair dancer and artist was: “[…] it was a major highlight of the week’s program, I think, because having feedback like this from an adult in the same situation, who is just as able as anyone else of wanting to dance, and of making a living out of something that motivates her, I find it very inspiring. And I hope that it can motivate them, [YDs] and give them the desire to continue”.
3.7. Autonomy
Even though the studio was an environment really appreciated by dancers, independent access to the building was limited. Wheelchair users needed help to enter the building and to open the doors of the elevator to access the studio. YD1 mentioned: “It was just annoying that, like, you were by yourself, and then you couldn’t really take it (the elevator)”.
Generally, in the dance camp, participants felt they were free to choose to participate in an activity or not: “there are always activities proposed, but there was never an obligation to do them. It’s a proposal, it’s an invitation, you give what you can give [PAD2]”.
Finally, involvement in the creative process, namely in the choice of music and creation of the choreography, was perceived as engaging and brought pride to dancers, as PAD1 and YD3 said: “In the creation, they [the teenagers] have been active in everything they have done regarding the music (…)” [PAD 1]. “I preferred the creation […] I am used to do choreographies that are already planned. I find that it adds like a, a little bit of pride when we are the ones creating it” [YD3]. Musical propositions were showed at the beginning of the camp by the musician according to YDs’ musical preferences. After the first presentation of the music, it was observed that YD3 specified what kind of music she would want for her number, and the musical arrangement was then modified by the musician to better fit her preferences. YD2 also mentioned she appreciated integrating her favorite movement in her creation.
3.8. Safe, Welcoming and Inclusive Environment
Dance camp structure. The structure was appreciated and was adjusted over the five days to the needs and energy of the dancers: “I thought the structure was really, really good; to start in the morning, afterwards, to see according to the girls’ energy for the week. […] Let’s say, it’s like, one morning, we started early with the creation. So, that was good, because that way, the energy was concentrated in the morning”. [PAD 1]. However, integration of wheelchair skills training into dance in a welcoming, fun and inclusive way was a difficult task and was modified throughout the camp after daily debriefing. There was kind of a ‘clash’ between the dance activities and the wheelchair skills training. Therapists felt they were disturbing the activities when teaching a skill or giving tips while the YDs were dancing, and they did not want to separate participants with disabilities from the group to practice skills individually. These findings prompted the team to reflect during the daily post-camp meetings and propose a new approach from day 3, where the training was brought into playful training activities integrating dance movement, music, collaboration with PADs and everyone’s creativity. Along with training activities the skills were integrated in dance choreography. For example, the skill ‘reaches objects’ was practiced with fluid movement of the hands going to the floor and back. All participants mentioned that they enjoyed this new format and that it better met their needs.
Number of participants. The number of participants was found to be appropriate according to the PADs: “For me, […] I found that we really were the right number [three teenagers and three adults]. More, in the space we had, with everyone’s bodies, with the wheelchairs and all that, it would have been really complex. Then, even to make connections, really, all together, not to lose the concentration, then the energy of everyone, I find that it is good”. [PAD 1].
Inclusive environment. YD3 explained she was often infantilized in her daily life because of the height difference between an adult standing and a youth sitting in a wheelchair, and she often felt the need to prove herself. However, the inclusive environment helped her: “Eventually, I realized that I didn’t have a point to prove here. But it’s like a reflex that I end up taking, when I meet new people”. Adult dancers explained how dance, to its very essence, promotes inclusion in their relationship and interaction with others: PAD 1: “when you dance or when you work with any person, it’s a different reality. […] There’s a communication done through the body, which is even more present, but all that, it’s something I could really relate just through our practice and not just through disability”.
Dance camp location. The transition from the rehabilitation center to the dance studio had several benefits according to the participants. First, YD3 mentioned that she preferred the space that a studio offered: “For sure, whenever I’m in a studio, I really like it because I really have like a lot of space to do a lot of stuff”. In addition, all participants mentioned preferring the studio for the brightness. Also, YD1 and YD3 agreed on the preference for a place outside of hospital settings: “Even if you say like, you know, for once I come here [to the rehabilitation center] like to have fun, me what I was thinking is like I’m coming back to the same place for like the fourth time this week [YD3]”.