Evaluation

Early evaluation of the patient is essential to obtain important information about the patient’s leisure background and lifestyle. During the early evaluation, the therapeutic recreation specialist becomes acquainted with the patient and family, states the purpose of the intervention, and, when the time is appropriate, discusses what therapeutic recreation entails. In general, the patient with a relatively new injury and the patient’s family are understandably preoccupied with the severity of the medical situation and are not receptive to much more than words of optimism and encouragement. This applies regardless of the severity.

Additional information can be obtained from the family at appropriate times. Often family members are willing to discuss which recreation, leisure, and sports activities the patient enjoyed prior to the injury.

Functional information should be gathered through Functional Independence Measure protocols (developed at State University of New York at Buffalo) in a coordinated effort with other treating disciplines.⁸ The Leisure Competence Measure (developed at Parkwood Hospital and Oklahoma State University) also should be used to focus on leisure concerns.³ The Leisure Competence Measure assesses leisure skills, attitudes, and preferences. These items in conjunction with the Functional Independence Measure can provide clear information on patient status and, more importantly, an indication of what should be addressed in a collaborative and cooperative interdisciplinary approach to developing an effective, efficient treatment program. It is important to understand that any measurement should be used as just that, and that the ultimate focus must be on an effective outcome well beyond discharge. Assessment modalities have been compiled in the three-volume series Assessment Tools for Recreational Therapy.¹ The authors present a vast array of assessment processes that can be of value in therapeutic recreation intervention.

Active intervention

As soon as the patient is medically stable and settled into the routine of daily therapies is typically the appropriate time for the therapeutic recreation specialist to begin working in earnest to implement leisure assessment modalities. Long-term (discharge and postdischarge) and short-term (main amount of time of patient’s initial stay) goals can be established. Again, collaboration with other disciplines is imperative to implement fast and efficient use of staff. Physicians, nurses, other therapists, and counselors can provide information that will assist the therapeutic recreation specialist in determining the proper timing and intensity of therapeutic recreation intervention.

During the assessment, the exact role of therapeutic recreation should be reviewed with the patient and family so that they formulate realistic expectations of the recreation staff. Recreation has such broad and general meaning to people of varied backgrounds that it cannot be assumed that the patient and family will automatically understand the role of therapeutic recreation staff.

Early intervention with the patient is frequently and effectively enhanced by strong, active physician support. Initiating activity in conjunction with other therapy activities and/or appropriate nursing functions greatly enhances the relationship between the therapeutic recreation specialist and the patient and family. Examples include (1) coordinating with the physical therapists using a basketball to work on strength and endurance, along with eye–hand coordination, while exploring basketball and its required adaptations as a viable sports and recreational pursuit; and (2) nursing staff and therapeutic recreation specialists coordinating sitting tolerance, self-medication protocol, or implementation of meaningful activity designed to reduce unnecessary dependency on nurses.

Therapeutic recreation specialists should be adequately and properly trained, and any process essential to the general safety and comfort of the client should be implemented. Although other staff generally works with the patient when all the specialty support disciplines are more readily available, the therapeutic recreation specialist often works with the patient during times or in locations when or where those services are reduced or unavailable. This is not to say that the therapeutic recreation specialist should go beyond what is deemed reasonable by the attending physician, but that the therapeutic recreation specialist should perform in competent fashion those functions that family members are ordinarily expected to perform. This clearly enhances patient availability for therapeutic recreational activities and sessions. It also serves as a positive example, often encouraging family members to become proficient in those functions sooner.

The skill training phase of therapeutic recreation intervention includes four general components: values clarification, communication, use of adaptive techniques, and use of adaptive equipment. Values clarification is an important component because it provides the high quadriplegic with enhanced insight into the types of events and activities most important to him or her. He or she often can learn not only what aspects of his or her life are important but, more importantly, why. A clearer understanding of why certain events, thoughts, and activities are important greatly enhances the perception of needs. When needs are more clearly understood, then identifying and meeting those needs become easier. The therapist and the patient can set out to meet those needs rather than expend unwarranted time and energy trying to duplicate activities in which the patient was engaged before injury. The amount of time that the patient and the therapeutic recreation specialist spend together is limited, so it is essential to make most efficient use of that time. This becomes increasingly essential as the average time the patient spends in the health care facility steadily decreases.

It is important to review the communication and decision-making skills of the patient and family. This is not the time to make major changes in the patient’s communication techniques with family and friends, and attempting to make major changes in the family’s communication style with the patient is not practical. However, it is important to review with each the value of communicating needs beyond basic survival needs such that positive outcomes are enhanced.

All rehabilitation disciplines should strive to encourage all parties to clearly communicate their values and needs while maintaining the same parties open to hearing and understanding the values and needs of others. The recreational setting is an excellent medium in which to review and possibly refine such skills. It is a more realistic and practical setting with real issues in value judgment, community interaction, and interpersonal communication that constantly but naturally occur among family members and friends. For example, having an older child assist his or her hemiplegic parent into and out of the car gives both child and parent a “hands on” experience of the effort involved (which sometimes is less involved than feared).

Clearly sharing the patient’s needs and desires with others through assertive behaviors and having realistic expectations of others (i.e., family and friends accompanying the patient) are extremely important tools for successful social and leisure encounters that will help the individual and family become less dependent on the health care system in the long run. Therapeutic recreation specialists should dedicate substantial time and effort in communication skill enhancement as well as decision-making training with the patient and, if possible, the family. A shopping trip is an excellent medium to practice effective options for requesting assistance while providing the patient with the opportunity to exercise self-directed decisions. Dealing with a store clerk, cashier, waiter, and family in a public forum provides the essential components to practice vital interactions.

Adaptive techniques must be learned in place of typical methods of function. For example, the individual may need to learn to throw a ball or to draw with the hand and arm opposite the one used before the disability. The ability to use one hand instead of two to perform a motor task takes effort and innovation. Use of adaptive equipment also may be necessary. Adaptive swim strokes to compensate for imposed limitations can be appropriately implemented.

Skills in the use of adaptive equipment, whether durable medical equipment or less medically essential equipment, must be learned. A broad spectrum of equipment is available, such as a mouth-operated long bow trigger, a bowling adaptation that attaches directly to the patient’s chair (Fig. 47-1), a fishing device that casts and reels without requiring the use of hands (Fig. 47-2), and a pool cue modified for disabled use (Fig 47-3). The social/recreational experience is greatly enhanced as the individual learns and practices appropriate and effective use.

Fig. 47-1 Bowling from a power wheelchair using the IKAN bowler.