Trends in therapeutic recreation

The changing face of health care is having a dramatic effect on therapeutic recreation (TR) services in physical rehabilitation settings. Nationwide, restructuring and reorganization of physical rehabilitation units is the trend as facilities struggle to increase efficiency without jeopardizing the quality of their health care services. As these changes occur approaches to therapeutic recreation service delivery for individuals with physical disabilities are being re-examined as well.

The traditional TR department, with a certified therapeutic recreation specialist (CTRS) as director, is often replaced by a "product line" or "program" model. Such models organize rehabilitative services according to the disability, diagnosis, or medical goals of the client or patient, rather than the discipline of the service provider. Thus, there is a movement away from hierarchically organized, discipline-specific services toward services that require multidisciplinary cooperation among allied health professionals.

Naturally, such change profoundly affects TR practitioners. Debbie Moore, CTRS, Sharp Rehabilitation Center in San Diego, says that cuts in middle management at her facility have been accompanied by increased productivity standards (i.e., hands-on service delivery) for allied health professionals with administrative duties. Ms. Moore was previously the supervisor of TR services, but administrative reorganization has changed her job title to lead recreation therapist, with expectations that she carry a 100% caseload as well as handling administrative activities. "If I have to be with patients every hour, I can't do the program planning and community involvement that is needed," she noted.

This kind of story is becoming increasingly common and reflects a trend away from specialization in physical rehabilitation. The result is a new challenge for TR specialists to maintain their professional identity. This is particularly difficult in light of the fact that TR specialists increasingly are being supervised by professionals from other disciplines, and these supervisors may not have a clear understanding of the purposes and scope of TR This is especially problematic for TR specialists who are new to the field and do not have past experience from which they can derive a self-image.

Managed Care

Another trend that affects both TR specialists and their clients with physical disabilities is the dramatic decrease in the length of stay for patients in rehabilitation facilities. For example, Judy Zdobysz, CTRS at the National Rehabilitation Hospital (NRH) in Washington, DC, stated, "When I came to NRH eight years ago, the average length of stay for a person with spinal cord injury was eight to nine months. Today, a person with SCI generally leaves within eight weeks." According to Ms. Zdobysz, the average length of stay at her facility for a stroke patient has declined from two to three months in 1987 to less than 25 days in 1995. Describing the situation at Craig Hospital, Sam Andrews stated." As soon the patient is mobilized, the patient is gone [dischargedl." Shortened stays mean that the TR specialist not only has less time to complete essential services (e.g., assessment, evaluation), but also less time to establish a beneficial therapeutic relationship with clients during their hospitalization. In turn, the client may leave the rehabilitation facility without mastering leisure-related skills that are essential for successful reintegration in the community.

Nonetheless, with the advent of managed care and a government focus on reducing health care expenditures, this trend is likely to stay. And there are other trends that also contribute to TR's changing nature. These include: * Client-to-staff ratios are increasing, with fewer TR specialists providing services to more clients with disabilities. The demand for increased efficiency in services and pressure for cost containment in health care will undoubtedly continue this trend. * As managed care puts pressure on specialists to prove their cost-effectiveness and contribution to positive outcomes, TR providers are devoting more of their time to promoting the profession and "selling" their services to case managers. * The use of TR in co-treatments (i.e., professionals from one or more allied health disciplines collaborating and delivering services to a single client simultaneously) is expanding rapidly. * Community re-integration, a strength of TR services in most facilities, is increasing in importance, with emphasis on functional skills that enable a client to return to his or her community as quickly as possible. Concurrently, increased collaboration is taking place between TR specialists in physical rehabilitation facilities and community recreation professionals. This helps to ensure continuity of leisure services for the person with a physical disability, thus reducing the risk of re-hospitalization. Re Americans with Disabilities Act (ADA) of 1990 will continue to help facilitate the transition of all persons with disabilities from clinical facilities to the community. * Lengthy assessments are being shortened so that essential information can be gathered at a minimum amount of time. * Cooperative ventures with governmental agencies and private businesses are being undertaken to help fund TR programs in rehabilitation facilities. * Outpatient TR services are becoming more prevalent in physical rehabilitation. Not only are outpatient services more cost-effective than in-patient care, but high-profile, community-based activities often serve as good public relations for the facility.

Programming Trends

Although trends in TR service delivery reflect rapid change, the program trends in TR for persons with physical disabilities are less dynamic. The current emphasis is on collaboration with community agencies to ensure that programs provided in clinical facilities are available to clients after discharge. Programs that once were run by TR staff members and sponsored by rehabilitation hospitals increasingly are being transferred to community control. Craig Hospital's TR program, for example, no longer sponsors a wheelchair basketball team; rather, its staff assists the community, which has assumed logistical and operational control of the team. As Sam Andrews says, "A lot of what we [TR specialists] do is to find resources in the community and sell them on the idea of training opportunities to get our patients back into the community."

TR staff at NRH also are working with community groups to expand recreational experiences for their clients. For instance, the facility has an agreement with the Wilderness Society to sponsor persons with physical disabilities on Wilderness Inquiry trips. Wilderness Inquiry, based in Minnesota, offers inclusive outdoor-related trips to participants with and without disabilities. Elsewhere, for clients interested in golf, NRH is making plans to use municipal recreation program services and facilities in Fairfax, Virginia. And, NRH and the Maryland-National Capital Park and Planning Commission are co-sponsoring a wheelchair basketball team.

As the trend toward cooperation with community-based agencies continues, a number of TR program activities for persons with physical disabilities appear to be poised for expansion. These activities, most of which encourage opportunities for transition to community living, are discussed below.

Adventure/Risk and Outdoor Activities. Although they long have been popular among persons with physical disabilities, activities that include adventure and risk are receiving increasing emphasis in physical rehabilitation. Craig Hospital, for example, works with the Colorado Ballooning Club to provide its clients with opportunities for hot air ballooning. Other adventure/ risk activities popular in physical rehabilitation include caving, whitewater rafting, parasailing, kayaking, jet-skiing, rappelling/rock climbing, and SCUBA diving. Skydiving by persons with high spinal cord injuries is another popular activity as was highlighted in the May/ June 1994 issue of New Mobility magazine. In this article, Randy Haims, a person with C2 quadriplegia who uses a "vent" for respiration, described his skydiving experiences: A message to quads and quads on vents: Don't let society, family, doctors, or anybody set limits on your life. Life is short enough; be adventurous, yet careful, and above all, be limitless" (p. 22). Other outdoor activities - such as backpacking, camping, hunting, and fishing - also continue to be popular among TR specialists as a means of developing functional skills, providing challenges, and facilitating community transition.

Active and Competitive Sports. Sport activities offering vigorous physical exertion often are employed in physical rehabilitation. Traditionally, skills in wheelchair basketball, track and field, and tennis have been taught by TR specialists, but the list of active sports that involve people with physical disabilities is growing constantly. Water and snow skiing, for example, provide physical challenges and are ideal for facilitating community reintegration. Sandy Trombetta, director of the Eighth National Disabled Veterans Winter Sports Clinic, commented, What we've learned through the years is that skiing is not only a recreational activity. We've seen it improve the overall rehabilitation potential of our patients, as well as their general health and fitness" (Disabled Vets, 1994). Quad rugby is also popular in physical rehabilitation because it offers a vigorous team sport for persons with high-level spinal cord injuries.

Handcycling. Although it could be classified as an active sport, handcycling deserves separate recognition because it is a new and unique addition to TR programs in physical rehabilitation. As noted by DeLil (1993), "For those not into athletic competition, the new handcycles raise the level of `tricycle' performance to the equal of bicycles, allowing easy participation in recreational bicycle outings with family and friends as well as engaging in plain old-fashioned exercise" (p. 16). Because it enables "equal" participation with family and friends who bicycle, handcycling is an ideal activity to enhance community reintegration. While handcycles are not yet widely used in physical rehabilitation facilities, they are definitely a part of the future of TR for persons with physical disabilities.

Health Enhancement Activities. Aerobics, dance, adapted aquatics, weight training, and other fitness-related activities are growing in popularity in physical rehabilitation. These activities not only aid clients in successfully making the transition to community programs but many of them also can be linked directly to improved functioning (i.e., reimbursable service). The Sharp Rehabilitation Center offers a multifaceted TR program that emphasizes wellness and health enhancement.

Computer-related Activities. Computers rapidly are becoming a necessity in contemporary society, and their use in TR programs for persons with physical disabilities is expanding. Citing the potential of computer usage in TR, Buckley (1993) highlighted 18 functional skills that can be improved by using a variety of software programs. As computers become more affordable to people with disabilities for use at home, they also will become a more important part of TR services in physical rehabilitation facilities.

Technology and Other Tools

Underlying all of the program trends in TR and physical rehabilitation are technological advancements and innovations. Lightweight wheelchairs, for example, enable persons with physical disabilities to participate in sport activities that were impossible a few years ago. Additional technological advances important to TR in physical rehabilitation include all-terrain wheelchairs, switch technology (see Crouse & Deavours, 1993), monoskis, and handcycles. Additional information on specific assistive technology is available from Abledata (see next section).

Co-treatment and other forms of collaboration with a variety of allied health fields also are becoming essential for TR specialists. Although transdisciplinary efforts may blur professional roles somewhat, the end result should be enhanced cooperation among allied health disciplines and, more important, better services for clients.

Of course, the fundamental goal of TR services in physical rehabilitation is to enable clients to return successfully to their communities. This not only requires improvement of functional skills, but it also means that physical and social environments in the community must be receptive to the individual. TR specialists need to ensure that their clients with physical disabilities are able to participate in all aspects of community life.

Resources are Numerous

The most valuable resources available to TR specialists in physical rehabilitation are other TR specialists working with persons with physical disabilities. Debbie Moore emphasizes this point: "Networking is the key to keeping up-to-date in TR." In addition to TR-related professional networks, a few valuable resources are: * Abledata. This is a computerized database that includes over 15,000 commercially available products that are useful to persons with disabilities. For more information, contact the National Rehabilitation Information Center, 8455 Colesville Road, Silver Spring, MD 20910. * Sports `n Spokes. This is a bimonthly magazine that focuses on sports and recreation for persons with physical disabilities. Contact PVA Publications, 2111 East Highland Avenue, Suite 180, Phoenix, AZ 85016-4702. * New Mobility. This bimonthly publication includes information on a variety of topics related to physical disability. Contact Miramar Publishing Company, 6133 Bristol Parkway, P.O. Box 3640, Culver City, CA 90231-3640. * Integrated Outdoor Education and Adventure Programs. This textbook, written by Schleien, McAvoi, Lais, and Rynders, provides hands-on information for developing an adventure-based program that focuses upon inclusion. Contact Sagamore Publishing, P 0. Box C)47, Champaign, IL 61824-0647.

References

Buckley, I J. (1993). Computer-assisted treatment in therapeutic recreation. Palaestra, 9(4), 31-39.

Crouse, J., & Deavours, M.N. (1993). Switch technology in therapeutic recreation programming. Palaestra, 9(4), 31-39.

DeLil, H. (August, 1993). Hands-on mobility. Mainstream.

Disabled vets to experience freedom in Colorado Rockies. (1994). Palaestra, 10(2),58.

Haims, R. (May-June, 1994). High quad bails out. New Mobility,

COPYRIGHT 1995 National Recreation and Park Association
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