Hazley Mcreynolds

UNIVERSITY HEALTH CARE

Intervention Protocol
Community Reintegration: Social,
Community and Recreational Fulfillment
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Table of Contents

Program Purpose 2
Program Description 2
Appropriate Presenting Problems Addressed 2
Referral Criteria 3
Contraindicated Criteria 3
Intervention Activities or Techniques 3
Mobility Scavenger Hunt 4
o Natural History Museum Scavenger Hunt List 9
Assertiveness Roll Playing 14
Community Weight Lifting 23
Bowling 32
Gardening Resources 40
Staff Training and Certification 48
Risk Management Considerations 48
Outcomes Expected 48
Program Evaluation 49

Intervention Protocol
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Community Reintegration: Social, Community and Recreational Fulfillment

General Program Purpose:
The purpose of this program is to help rebuild, mend or establish community roles for a patient,
whether these roles were previously held or helping discover new opportunities for involvement.
This program will assist the patient in discovering opportunities, adaptations, and methods to
have the confidence and skills to be involved in a community. After discharge patients will feel
confident in their social, problem solving and assertiveness skills for an increased quality of life.
Program Description:
This is an open group program focused on facilitating learning and developing skills necessary
for the patient to either resume appropriate social roles or assist in discovering new opportunities
for them to become engaged in their community and in their relationships for improved quality
of life post discharge. The CTRS will help the client address their assessed needs with this
program through a series of group activities with other spinal cord injuries on the unit, which
will help facilitate a peer group support. The patients family and friends will also be allowed to
participate in certain activities allowing the patient to strengthen their current relationships for a
stronger social support at home. The CTRS will get them involved in social/activity groups, and
in the community, using their professional judgment to either observe or assist the patient as
needed during activities. The ultimate goal is for the patient to be completely independent in any
of their social, community or recreational pursuits as well as knowing where to find information
or help to participate in adapted recreational activities post discharge.
Appropriate Presenting Problems Addressed:
Emotional
o Depression, loneliness and decreased sense of belonging
o Frustration/anger
o Other psychological distresses
Social
o Difficulty adjusting to their new abilities in their community
o Unawareness of the resources available to them in their community
o Problem solving and coping skills
Assertive skills
o Self-conscious about using adaptive equipment in community
Negatively affecting their ability to use adaptive equipment efficiently and
effectively
Adapting to different situations and environments

Referral Criteria:
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Doctor/Treatment team referral

Contraindicated Criteria:
Aggressive behavior
o A danger to self and to others either verbally or physically
Suicidal behaviors and/or urges
No physician/treatment team referral
Not cleared to leave facility or unit

Intervention Activities or Techniques:

Mobility Scavenger Hunt
Assertiveness Roll Playing
Community Weight Lifting
Bowling
Gardening Resources
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Mobility Scavenger Hunt

Challenge Activity

Population:
Spinal Cord Injuries
Age:
18-65 years old
Group Size:
4-8
Setting Considerations:
- Assure that the location is wheelchair accessible, and meets ADA requirements
- Proper lighting
- Group session planned during quiet business hours
- The rehabilitation vans need to have working safety straps and wheelchair lift

Group Stage Considerations:

Storming, norming and performing
Purpose:
This activity is centered on community mobility, and increased independence in the
individuals wheelchair or mobilized chair mobility. Working in a group, individuals will need to
problem solve, follow directions and communicate among themselves to achieve their personal
and group goals. Patients participating in this activity will be able to identify strategies for
cardiovascular and physical endurance, as well as the adaptations needed to participate. Patients
will need to socialize among themselves as well as with people who are in their environment and
not part of the group. Increasing patients ability to communicate with able-bodied members in
their community as well as their disabled peers.

Goals:
- Increased engagement in the community
- Increased communication skills
- Increased wheelchair mobility and use of adaptive equipment to move around in different
settings
- Increased confidence in the knowledge and skills they have acquired to interact socially,
and physically in varying environments and/or social settings.
- Increased abilities and coping skills necessary to adapt and/or problem solve in an
unfamiliar/uncomfortable situation and environment
Supplies Needed:
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- Each individuals wheelchair

- Adapted equipment per individual needs
- Different grip handles for mobilized wheelchairs
o Mobilized wheelchairs need to have full battery before outing
- Transportation
- Money for tickets (Per each individual)
- Papers and pencils (Per group)
- Manual blood pressure cuff and stethoscope (per group)
- For individuals straight catheterizing they need to have supplies with them
- Water bottles (per group)
- (2) Clean urinal (per group)
- (4) Briefs; 2 medium, 2 large (per group)
- Pack of wet wipes (per group)

Intervention Description:
Pre-group Work:
- Patients are pre-approved by doctors and nursing staff to leave IMRU
- Patients have been using their wheelchair for a minimum of 2 days
- Patients will have read over a packet given to them the day before on safety concerns,
how they should be loading in/out of the van, and how the straps to anchor their
wheelchairs need to be applied (packet is on the H:drive under SCI_outingsafety).
- The patient has discussed with the CTRS what their individual goals are for the outing.
*A spouse, partner or friend can accompany the individual but will be given specific
instructions not to help or step in and do a task for their loved one unless they have tried and
failed then ask for help. They may also need to take their own vehicle and meet the group at
the natural history museum.
Opening:
- Group will meet for 30 minutes in the day room
- Patients will be split into groups predetermined by the TR depending on their wheelchair
mobility skill level
o Minimum of 2 patients per group
o Minimum of 1 staff member per group
Staff for each group will have the following:
Knowledge of each individuals goals in their group
Knowledge of each individuals modifications and special
considerations
Outing backpack: this contains any supplies that maybe needed
throughout the outing (briefs, wipes, bp cuff, stethoscope,
disposable urinals, etc.), which are located in the RT office by the
coat rack.
- Patients will be given instructions as to what is expected of each group: to complete the
scavenger hunt in the time allotted (1 hour in the museum).
- TR will then give patients tips for cardiovascular and physical endurance to practice
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during the scavenger hunt

- Discussion on the packet, safety concerns or questions
Body:
- The rehabilitation vans will be used for transportation and can fit 4 wheelchairs in each
van.
- Patients will be asked to verbally direct staff on how they should safely assist patients
in/out of the vans and anchored into the vans.
- Once inside the Natural History Museum each group will be given the scavenger hunt list
(attached) and a map of the museum.
- Patients need to finish the tasks on the list, and meet back at the entrance in 2 hours.
o The TR needs to make sure everyone hears, staff and patients, what time and
where to meet.
o The TR should have the cell phone numbers of each staff members in each group,
and vice versa.
- During the hunt each patient needs to work on their own personal mobility goals, while
also working as a group to find certain items.
- Patient teams will be asked to ask a 1 stranger about an exhibit and another for directions
- Throughout the outing staff will take notice and may need to remind patients to pressure
release every 15-20 minutes.
- The last task of the activity is for patients to find and purchase one item under 10$.
o There will be a staff member there with the unit credit card to pay for these items.
If they choose to buy more they may do so with their own money.
- The group will meet back up after the 2 hours is up at the entrance
- TR will make sure every patient and staff member is present and has completed the last
task of a gift shop purchase
- Patients need to verbally direct staff in assisting them in/out and strapping their
wheelchairs into the van.
Closing:
- Upon returning to the hospital the group will meet in the day room for processing
o See discussion questions

Special Considerations or Risks:

Staff assisting with this outing should be trained on the protocols if the following should occur:
- Autonomic Dysreflexia
- Low or High BP
- Incontinence
- Fall out of a wheelchair
- Lost patient
- Social isolation/ refusal to participate
- Misinterpreting directions
- Presentation of anxiety during the outing
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Staff need to also ensure that each patient is pressure releasing every 15-20 minutes to avoid
pressure ulcers.

Possible Discussion Questions/Processing:

Remembering
- Tell me about today
o Did the prep work help?
o What did we miss?
Understanding
- How did you direct the staff in assisting you today?
- What sort of physical challenges did you encounter today?
o How were you able to work on challenges?
Applying
- How did you apply the strategies for cardiovascular and physical endurance?
Analyzing
- What was done to help prepare you for community mobility?
Evaluating
- What sort of barriers did you run into moving around in the community?
Creating
- What can be done to reduce these barriers in the future?
Remembering
- Tell me about the scavenger hunt?
o What else did you work on besides wheelchair mobility?
Understanding
- How did you approach asking for help today in the museum?
Analyzing
- What was the reaction of the person in the museum when you asked for help?
o Was this real or perceived reaction?
Evaluating
- Why is it important that you should be comfortable communicating with people in your
environment?
- What was the hardest part about being in the community?
- Did anyone experience communication barriers when you asked for help?
Creating
- What can be done to reduce the barriers in the future?
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Possible Group or Individual Assignments:

Group Assignment:
- Complete scavenger hunt list together
- Letting each member participate
- Listening to each member of the group
- Offering help or advice to members
- Supporting and encouraging each other
Individual Assignments:
- Improved wheelchair mobility skill
o Manually push chair for specified time/distance
o Independently steer mobilized chair without need for assistance for specified
time/distance
o Independently entering and exiting elevator in a timely and safe manner
o Independently maneuvering around people and objects
- Identify strategies for physical endurance
- Independently remembering and performing pressure release
- Asking for help/directions
- Participation in the group
- Purchasing one item in the gift shop as independently as possible

Modification or Adaptations:
- CTRS and staff assisting patients will know the modifications needed and be competent
in assisting these patients in each of these areas knowing that each patient will need
different adaptations depending on LOI:
o Wheelchair mobility
o Transfers
o Pressure release
o Fine and gross motor control
o Upper body control
o Torso control
- Depending of LOI individual will either be independent with reaching, and grasping
while others may need total assistance

Reference/Source:
Austin, D. R. (2013). Therapeutic Recreation Processes and Techniques; Evidence-Based Recreational
Therapy 7th Edition. Urbana: Sagamore Publishing LLC.
Porter, H. R. (2015). Recreational Therapy for Specific Diagnoses and Conditions. Enumclaw: Idyll
Arbor, Inc.
Stumbo, N. J., & Wardlaw, B. (2011). Facilitation of Therapeutic Recreation Services; An Evidence-
Based and Best Practice Approach to Techniques and Processes. State College: Venture
Publishing Inc.
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Natural History Museum Scavenger Hunt List

Rules:
- Each member in the group needs to participate and answer/complete at least
one task
- One sheet per group, the group must complete the list TOGETHER
- ALWAYS encourage and support each other

1. One person in the group must ask someone where the elevators are to take to the third floor

2. Once everyone is on the third floor find the large purple amethyst on display

3. How long did it take for this amethyst to grow?

4. Find the glass dinosaur graveyard

5. During what ages/periods did the Dinosaurs live?

6. Locate the earthquake and seismic activity area

7. How many earthquakes does Utah get a year?

8. Travel to the watershed area

9. What is the name of a plant that is abundant to Utahs dry Landscape?

10. Another person in the group must ask for directions to the poison exhibit

11. What butterfly is poisonous?

12. As a group find your way to the gift shop

13. One by one each member in the group must ender the gift shop, find and purchase and item under
10$.
a. There will be a staff member in the gift shop to pay for the item and for help reaching
items if asked by the patient to do so
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Assertiveness Roll-playing
Psycho-educational Activity

Population:
Spinal cord injuries

Age:
18-65 years old

Group Size:
2-8

Setting Considerations:
- Weather
o Dry
o moderate temperature
- Wheelchair accessible trail
o Area along the trail that allows for the group to gather for discussion

Group Stage Considerations:

storming, norming, performing

Purpose:
The purpose of this intervention is to allow patients to experience a wheelchair accessible
hike while addressing social and communication skills. Individuals in this group will practice
assertiveness skills, and learn how these skills benefit them while in IMRU and post discharge.
While experiencing the freedom of being in nature they will practice assertiveness in different
scenarios, develop strategies for assertiveness, and group problem-solving. This will allow
patients to experience feelings associated with community engagement and provide opportunities
to come up with strategies to overcome anxieties.

Goals:
- Knowledge of leisure/recreation resources and opportunities available to them in their
community
- Increased engagement in the community
- Increased communication skills
o Increased assertiveness skills
- Increased wheelchair mobility and use of adaptive equipment to move around in different
settings
- Increased self-efficacy in their abilities to participate and engage in/with the community.
- Increased abilities and coping skills necessary to adapt and/or problem solve in an
unfamiliar/uncomfortable situation and environment

Supplies Needed:
- Role-playing scenarios that require assertiveness appropriate for the group
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o (These assertive scenario cards are located in the RT cabinet in the red index card
holder labeled: Assertiveness)
Example (manual wheelchair): Youre on your way back out to your car
and there is a slight uphill slope, nothing you havent done before and
someone runs up to you shouting Here let me help and starts pushing
you.
Example: Upon returning to work after discharge you find that your job
tasks are very different than the ones you had before. When you talked to
your boss about you returning to work you assured him that you were
capable of accomplishing all the responsibilities you had before your
accident. You even had your OT come into your office with you to make
sure everything was accessible and set up your adaptive equipment to use
the computer so you could start working on the agreed date.
- Sunscreen
- Water bottles (per participant)
o Straws (if needed)
- Each patient should have their own wheelchair and adaptive equipment for mobility
- If a patient needs reading glasses ask them to bring them along

Intervention Description:
Pre-group Work:
- Patients are pre-approved by doctors and nursing staff to leave IMRU
- Patients are able to transfer with modified help or independently
- Patients will have read over a packet given to them the day before on safety concerns,
how they should be loading in/out of the van, and how the straps to anchor their
wheelchairs need to be applied (packet is on the H:drive under SCI_outingsafety)
*A spouse, partner or friend can accompany the individual on this outing but may need to take
their own transportation to the trail head. They will also need to be in comfortable clothing,
shoes and bring their own water.

Opening:
- Group will meet for 30 minutes in the day room before leaving
- Patients will be told where the group will be going:
o Silver Lake Boardwalk Trail
A beautiful loop trail up Big Cottonwood Canyon which circles a
picturesque lake that is surrounded by mountain views. It is a popular
short trail that is easy for those in a wheelchair to enjoy. The parking is
also right next to the boardwalk, and there are some viewpoint areas that
can be used to gather as a group
- The TR will then discuss assertiveness
o Today we will learn to recognize habits or behaviors that will empower you to
stand up for your rights and the rights of those around you, Assertive behavior is
neither aggressive or passive, but it is concerned with clear, honest, direct
communication (Austin, 2013). Its an important skill to have to become more
assertive in social relationships and in community settings especially when you
may rely on others to do tasks for you
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o On our drive over to the trail, and on our stroll around the lake I want you all to be
thinking about what you think being assertive is, and how you could be more
assertive in different scenarios. Along the trail we will be role playing scenario
cards I have using I messages, which encourages everyone to practice taking
responsibility for their own feelings and actions rather than passing on the blame
to others.
Body:
- The rehabilitation vans will be used for transportation and can fit 4 wheelchairs in each
van
- Patients will be asked to verbally direct staff on how the staff should safely assist them
in/out of the vans and anchored into the vans
- Arriving to the board walk the TR will remind the group to focus on assertiveness
- At a viewpoint about halfway around the lake the therapist and staff will gather the group
for discussion
o Im going to give each of you a scenario card that you will read to the group. You
will then be asked how you would react to this situation, and why its important
that you be assertive in this scenario
For individuals with poor fine motor the card may need to be held by staff
for them to read
For individuals who have poor eye sight the card may be read allowed for
them.
o TR should open scenarios up to the group for different ideas and allow for the
group to work toward a solution or alternative solutions
o After everyone in the group has had a turn to contribute the TR will talk about
how practicing these skills will reduce their anxiety of asserting themselves in
varying social and community settings.
o TR should let everyone enjoy the view point in silence a minute longer before
directing them back to the van. TR will present the group with the following
thought to ponder individually on the way back to the van:
On the path back to the van take a moment to look around, and think about
how open and non-restrictive this outdoor environment is. How does this
relate to having the ability to express yourself and be assertive in the
different situations youll encounter in the future?
Closing:
- Returning to the hospital patients will meet in the day room to discuss the outing, and
processing
o See discussion questions

Special Considerations or Risks:

Staff assisting with this outing should be trained on the protocols if the following should occur:
- Autonomic Dysreflexia
- Low or High BP
- Incontinence
- Fall out of a wheelchair
- Lost patient
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- Social isolation/ refusal to participate

- Misinterpreting directions
- Presentation of anxiety during the outing

Staff need to also ensure that each patient is pressure releasing every 15-20 minutes to avoid
pressure ulcers.

Possible Discussion Questions:

Remembering
- Where did we go today?
Understanding
- What was most memorable about the trail?
Applying
- Why are trails like this important to have?
Analyzing
- Why is it important to you that there are multiple wheelchair accessible trails?
Evaluating
- How did todays trail relate to having the ability to express yourself and be assertive in the
different situations youll encounter in the future?
Creating
- How can you take advantage of resources like this after discharge?
o Discuss other outdoor recreation resources that are wheelchair accessible
Remembering
- What is assertiveness?
Understanding
- What does it mean to be assertive in a situation that can impact your rights?
Applying
- What are the different strategies we identified today to improve our assertiveness?
Analyzing
- What types of scenarios where the hardest for us to be assertive in?
Evaluating
- What are the advantages of being assertive in the future?
Creating
- How will you be able to apply the strategies today?
o What is the best way to feel confident in your abilities to be assertive

Possible Group or Individual Assignments:

Group:
- Support and encourage each other
- Group problem solving
o Finding alternative solutions
Individual:
- Practice positive self-talk
- Practice I messages
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- Increase wheelchair mobility

- Asking for help or assistance with needed
- Increased self-expression
- Increase social involvement/group involvement

Modification or Adaptations:
- CTRS and staff assisting patients will know the modifications needed and be competent
in assisting these patients in each of these areas knowing that each patient will need
different adaptations depending on LOI:
o Wheelchair mobility
o Transfers
o Pressure release
o Fine and gross motor control
o Upper body control
o Torso control
o Bowel and Bladder Control

Reference/Source:
Austin, D. R. (2013). Therapeutic Recreation Processes and Techniques; Evidence-Based
Recreational Therapy 7th Edition. Urbana: Sagamore Publishing LLC.
Christensen, K. M., Holt, J. M., & Wilson, J. F. (2013). The Relationship Between Outdoor
Recreatino and Depression Among Older Adults. World Leisure Journal, 72-82.
Porter, H. R. (2015). Recreational Therapy for Specific Diagnoses and Conditions. Enumclaw:
Idyll Arbor, Inc.
Stumbo, N. J., & Wardlaw, B. (2011). Facilitation of Therapeutic Recreation Services; An
Evidence-Based and Best Practice Approach to Techniques and Processes. State College:
Venture Publishing Inc.
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Community Weight Training

Physical Activity

Population:
Spinal cord injuries with a LOI C6 and below

Age:
18-65 years old

Group Size:
2-8

Setting Considerations:
- Meets ADA requirements
- Proper lighting
- Access to bathroom
- Proper adaptive equipment for weight training
- Established a day and time appropriate for the group to come

Group Stage Considerations:

norming and performing

Purpose:
The purpose of this activity is to teach patients about proper weight training techniques and
adaptations with a SCI while in a community setting. Increased strength and knowledge of
weight training will assist patients in managing their bodies and help develop the skills to
participate in varying recreational activities. They will be introduced to the Copperview
Recreation Center; its different adaptive sports program, and be comfortable utilizing this
resource post discharge. With the skills and knowledge learned from this activity they will be
comfortable initiating a weight training program after discharge, as well as being comfortable
utilizing this community resource for other recreational pursuits.

Goals:
- Learn and understand proper forms and techniques lifting weights with their LOI
- Understand the types of adaptations needed to participate in weight training
- Knowledge of leisure/recreation resources and opportunities available to them in their
community
- Increased engagement in the community
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- Increased self-efficacy in their abilities to participate and engage in/with the community.
- Ability to appropriately manage self
o Ability to cope with their bodies, and care for self in different settings and time
constraints
o Increased strength to manage their bodies and the demands of ADLs and/or
recreational pursuits

Supplies Needed:
- Adaptive straps and handles for pulleys/cables
- Transfer boards (if applicable)
- Anchor straps for wheelchairs
- Seatbelts for individuals (if applicable)
- Water bottles

Intervention Description:
Pre-group Work:
- Patients are pre-approved by doctors and nursing staff to leave IMRU
- Patients have been cleared to lift more than 10 pounds
- Patients are able to transfer with modified help or independently
- Patients will have read over a packet given to them the day before on safety concerns,
how they should be loading in/out of the van, and how the straps to anchor their
wheelchairs need to be applied (packet is on the H:drive under SCI_outingsafety)
- Copperview Recreation Center knows the day, time and how many group members will
be coming
*A spouse, partner or friend can accompany the individual to learn about the resources and
programs available at the Copperview Rec Center, but may not participate in the weight training.

Opening:
- Group will meet for 30 minutes in the day room before leaving
- They will be partnered up with another member of their group predetermined by the TR
depending on their LOI and strength
o Minimum of 1 staff member per group
Staff for each group will have the following:
Knowledge of each individuals modifications, strength and special
considerations
Outing backpack: this contains any supplies that maybe needed
throughout the outing (briefs, wipes, bp cuff, stethoscope,
disposable urinals, etc.), which are located in the RT office by the
coat rack.
- Patients will be given instructions on the days itinerary, and give them the handout of the
Salt Lake Countys adaptive recreation program
o (Handout is in the H:drive under SLcounty_adaptiverec)
- Patients will be able to ask questions about the rec center, weight training with a SCI, and
any other concerns or questions
Body:
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- The rehabilitation vans will be used for transportation and can fit 4 wheelchairs in each
van.
- Patients will be asked to verbally direct staff on how they should safely assist them in/out
of the vans and anchored into the vans.
- The group will check in with the front desk and be given a brief tour of the facility while
asking questions about their adaptive rec programs by one of the TR staff at the rec center
o Pre-arranged by the TR on IMRU
- In the weight training gym, the TR will demonstrate the movements and the different
adaptations that can be done for each movement to the patients
o Depending on the types of adaptations needed per group
- The staff will then guide and assist patients to which weight station, pulleys/cable
weights throughout the workout
- Before the patients do a movement the therapy staff will again demonstrate the movement
they will be working on and show the specific adaptations that they will need
- Patient will be taught by the staff so they may learn to direct assistance in the future on
the following;
o Setting up their chair
o Anchoring their chair
o Transfer assistance
o Setting up weights
o Asking for specific adaptive handles or straps
- Patients will be encouraged to ask for help from the staff
- Partners will be able to ask each other for advice and give each other encouragement and
support
- Patients will be required to pressure release every 15-20 minutes throughout the activity
- After the workout session is complete the patients will again need to verbally direct staff
on how they should safely assist them in/out of the vans and anchored into the vans.
Closing
- Returning to the hospital patients will meet in the day room to discuss the outing, and
processing
o See discussion questions

Special Considerations or Risks:

Staff assisting with this outing should be trained on the protocols if the following should occur:
- Autonomic Dysreflexia
- Low or High BP
- Incontinence
- Fall out of a wheelchair
- Lost patient
- Social isolation/ refusal to participate
- Misinterpreting directions
- Presentation of anxiety during the outing

Staff need to also ensure that each patient is pressure releasing every 15-20 minutes to avoid
pressure ulcers.
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Possible Discussion Questions:

Remembering
- What did we learn today about the Copperview Recreation Center?
o What were some of the adaptive programs that stood out to you?
Understanding
- Why is it important to know that these types of resources are out there?
- What did you enjoy the most about the weight training?
Applying
- How can you apply what youve learned today about weight training and the adaptive
programs into your life after discharge?
Analyzing
- How will participating in an adaptive recreation program like weight training affect your
life?
Evaluating
- How do you think weight training will affect your ability to participate in different areas
of your life?
o ADLs?
o Recreation and Leisure pursuit?
o Body management during activities in general?
- How do you think learning about and participating in different adaptive recreation
programs will affect your ability to participate in different areas of your life?
o ADLs?
o Recreation and Leisure pursuit?
o Body management during activities in general?
Creating
- What sort of barriers do you see trying to participate in recreation in the future?
o What are ways to overcome these barriers?
- How can we discover different types of adaptive programs available to you?
- What adaptive recreation program/sport/activity was interesting to you the most?

Possible Group or Individual Assignments:

Group:
- Support and encourage each other
- Increase knowledge of community resources
Individual:
- Practice positive self-talk
- Increase wheelchair mobility
- Increase knowledge of weight training with a SCI
- Directing staff in assisting them
- Asking for help or assistance with needed
- Problem solving and adapting their surroundings

Modification or Adaptations:
- CTRS and staff assisting patients will know the modifications needed and be competent
in assisting these patients in each of these areas knowing that each patient will need
different adaptations depending on LOI:
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o Wheelchair mobility
o Transfers
o Pressure release
o Fine and gross motor control
o Upper body control
o Torso control
- Depending of LOI individual will either be independent with reaching, and grasping
while others may need total assistance
o Adaptations can be made for different weight lifting movements depending on the
individuals abilities

Reference/Source:
Porter, H. R. (2015). Recreational Therapy for Specific Diagnoses and Conditions. Enumclaw:
Idyll Arbor, Inc.
Wise, J. B., & Hale, S. B. (1999). Strenghtening and Generalizing Self-Efficacy in a Male With
A Spinal Cord Injury. Therapeutic Recreation Journal, 333-340.
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Bowling
Game-Like Activity

Population:
Spinal cord injuries

Age:
18-65 years old

Group Size:
2-8

Setting Considerations:
- Meets ADA requirements
- Proper lighting
- Access to bathroom
- Ramps and bumpers available
- Reserving lanes during quiet business hours

Group Stage Considerations:

Storming, norming and performing

Purpose:
The purpose is to introduce patients to adaptive bowling techniques, and equipment while
providing and opportunity to enjoy time outside of the hospital with their peers and family.
Family members are encouraged to participate in the activity encouraging social and physical
participation from the patient. Patients will be able to connect the skills and techniques learned
from adaptive bowling to tasks performed in their everyday lives.

Goals:
- Increased knowledge of adaptive bowling
- Knowledge of leisure/recreation resources and opportunities available to them in their
community
- Increased engagement in the community
- Increased social support network
- Increased self-efficacy in their abilities to participate and engage in/with the community
- Increased confidence in the knowledge and skills they have acquired to interact socially,
and physically in varying environments and/or social settings
- Increased problem solving skills

Supplies Needed:
**TR should have knowledge of bowling and the varying types of adaptations and techniques
that can be implemented for individuals with a SCI at varying LOIs
- Each patient should have their own wheelchair
- Wrist support or straps
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- Adaptive bowling equipment

- IKAN bowler

Intervention Description:
Pre-group Work:
- Individuals are pre-approved by doctors and nursing staff to leave IMRU
- Patients will have read over a packet given to them the day before on safety concerns,
how they should be loading in/out of the van, and how the straps to anchor their
wheelchairs need to be applied (packet is on the H:drive under SCI_outingsafety)
*Family, friends, loved ones are encouraged to come and given a week notice of the day and
time. They will need to take their own transportation, and pay for their own bowling shoes, food
and drinks etc.

Opening:
- Group will meet in the day room before leaving
- Patients will be shown a PowerPoint on wheelchair bowling (H:drive under
SCI_bowling.ppt)
o The power point contains videos on manual and mobilized wheelchair bowling
adaptations, along with pictures and descriptions of different adaptive technology
and techniques
- Patients will then be allowed to ask questions, voice concerns before leaving.
Body:
- The rehabilitation vans will be used for transportation and can fit 4 wheelchairs in each
van.
- Patients will be asked to verbally direct staff on how they should safely assist them in/out
of the vans and anchored into the vans.
- The group will be separated into lanes by the amount of assistance needed/types of
adaptations needed
o manual wheelchairs
o mobilized wheelchairs
- Patients will each have time with the staff learning bowling techniques and adaptations
unique to the patient
o Before they bowl TR will again describe the wheelchair bowling technique the
patient will implement
o TR will demonstrate it (as accurate as possible)
o TR will then guide the participant through the motions
Having the patient try several times without a ball to get the technique
down
o Patient will then be given the opportunity to implement their techniques and
adaptations
Patients in the group will be encouraged to:
Verbally and physically support each other
Offer tips or advice/ mentor each other
o Families/friends will be allowed to bowl alongside their loved ones
o After an hour of bowling the patients will again need to direct staff in assisting
 33

them in/out of the vans

Closing:
- Returning to the hospital the group will return to the day room for processing
o See discussion questions

Special Considerations or Risks:

Staff assisting with this outing should be trained on the protocols if the following should occur:
- Autonomic Dysreflexia
- Low or High BP
- Incontinence
- Fall out of a wheelchair
- Lost patient
- Social isolation/ refusal to participate
- Misinterpreting directions
- Presentation of anxiety during the outing

Staff need to also ensure that each patient is pressure releasing every 15-20 minutes to avoid
pressure ulcers.

Possible Discussion Questions:

Remembering
- What did we learn about today?
Understanding
- Why is bowling an easily adaptive sport?
- What types of techniques/adaptive equipment worked for you?
Applying
- How can participation in adaptive sports impact your life?
o Physically
o Socially
o Mentally/Emotionally
Analyzing
- Why can adaptive sports have this type of impact on you as an individual?
o On your family/friends?
Evaluating
- What kind of positive impact can these newly learned skills have on your life?
o Can they translate into any other areas in your life that can be advantageous?
- What were some of the difficulties in learning these new skills and adaptations?
o Why were these difficult?
o How did you overcome them?
Creating
- How can we apply what weve learned today into our lives going forward?
- In what ways can we take the time to practice these new skills?

Possible Group or Individual Assignments:

Group:
 34

- Support and encourage each other

- Increase knowledge of community resources
Individual:
- Practice positive self-talk
- Increase adaptive equipment knowledge
- Increase adaptive sports knowledge
- Increase social participation
- Strengthen social support
- Asking for help or assistance with needed
- Increased problem solving skills

Modification or Adaptations:
- CTRS and staff assisting patients will know the modifications needed and be competent
in assisting these patients in each of these areas knowing that each patient will need
different adaptations depending on LOI:
o Wheelchair mobility
o Transfers
o Pressure release
o Fine and gross motor control
o Upper body control
o Torso control
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 39

Gardening Resources
Creative Activity

Population:
Spinal cord injuries

Age:
18-65 years old

Group Size:
2-4

Setting Considerations:
- Wheelchair accessible garden boxes
o Two planter boxes
Access easier for manual wheelchairs
Access easier for mobilized wheelchairs
- Adaptable gardening tools
- Dry weather
- Moderate temperature

Group Stage Considerations:

storming, norming and performing

Purpose:
The purpose of this intervention is to introduce patients to gardening, adaptive equipment for
gardening, and to give them the opportunity to connect with their families and peers. This
activity allows individuals with a SCI make connections with past patients with a SCI, see how
they have grown and expand their social support network. Seeing the progress others have made,
and the impact on their community will encourage and motivate patients to succeed in their
endeavors after discharge.

Goals:
- Knowledge of gardening and adaptive tools for gardening
- Knowledge of leisure/recreation resources and opportunities available to them in their
community
- Engagement in the community
- Strengthened support network
- Increased self-efficacy in their abilities to participate and engage in/with the community
 40

- Increased self-esteem

Supplies Needed:
- Pansies (per participant)
o If possible TR will ask participants before purchasing pansies what color they
would like their flower to be
- Adaptive spray bottle
- Adaptive gardening equipment
o Wider grips and straps for shovels

Intervention Description:
Pre-group Work:
- TR will contact and invite past patients with a SCI to take part in this activity (1-3 past
patients)
o Some patients have agreed/inquired about being a mentor post discharge while on
IMRU, others have called in after discharge offering to be a mentor
o These patients have been a part of this program while on IMRU and also planted a
flower in the planter box
- The TR can plan on a facetime call if an in person visit is too hard to schedule
*A spouse, partner or friend can take part in this activity. They will be encouraged to ask
questions during the group along with their loved ones.

Opening:
- Patients will meet outside on the rehabilitation patio where the wheelchair accessible
garden planters are located
- They are instructed on the basics of gardening:
o How often they should be watered
o Weeding/removal of dead plants
- TR will then ask the patients to think about the symbolism this flower has to their own
lives and frontload the session with the following statements/questions:
o Were taking it from one setting to another, and allowing it to flourish in this new
garden. How can this relate to your experience?
Your own lives have been uprooted from where they were and now they
will need to find resources and skills to grow in their new environment
and setting
What are the resources you need in your life that you feel you cant
grow without post discharge?
o These will be discussed during processing
Body:
- Patients will pick their plants and an area in the raised garden theyd like to place it
o For those patients with little to no upper body they will be encouraged to verbally
instruct staff throughout this process, but should still do as much of the task as
possible
- Patients will be encouraged to do as much of the work as independently as possible
- TR will point out that there are flowers and plants in that garden from patients who have
been through and felt exactly how they have
 41

- Patients will then be introduced to the guests that have joined them for this session
o Name, age, LOI and how long ago they were on IMRU
- Patients will be invited to then introduce themselves:
o Name, age, LOI and how long they have been on IMRU
- Guests will then take a turn pointing out their flower in the garden (if possible)
o If not they can talk about the experience they had while doing this and what they
thought of while planting it:
Their fears/anxieties post discharge
What resources they thought they would need or wouldnt need
o Guests may then share how their lives and experiences have been after discharge:
The resources theyve used in the community
What their favorite recreational activity is
The most difficult adaptation
- Patients and their families will then be encouraged to ask questions and discuss concerns
they may have with past patients
Closing
- After guests leave the group will gather inside the day room for processing
o See discussion questions

Special Considerations or Risks:

Staff assisting with this outing should be trained on the protocols if the following should occur:
- Autonomic Dysreflexia
- Low or High BP
- Incontinence
- Fall out of a wheelchair
- Lost patient
- Social isolation/ refusal to participate
- Misinterpreting directions
- Presentation of anxiety during the outing

Staff need to also ensure that each patient is pressure releasing every 15-20 minutes to avoid
pressure ulcers.

Possible Discussion Questions:

Opening questions:
- What did we learn about gardening today?
- What types of tools will you need to garden at home?
- How can gardening impact you as an individual?
o On the community?
Remembering
- What did I ask you to think about while gardening?
- What did you think about our guests?
o Was their information/stories helpful?
Understanding
- What types of resources do you need to grow at home as an individual?
Applying
 42

- How are those resources going to impact your growth?

Analyzing
- Does anyone want to share what resources and skills they feel they will need to grow
after discharge?
- Did anything the guests say surprise you?
o Did they address any areas that have been concerning you?
Why was that an area of concern?
Did they help ease or increase that concern?
Evaluating
- What are the types of resources that they mentioned they took advantage of after
discharge?
Creating
- How can you take advantage of the same/similar resources?
- What other types of resources are available to you for support and growth?
- What strategies have we learned that we can use to cultivate and strengthen our support
systems at home?

Possible Group or Individual Assignments:

Group:
- Support and encourage each other
- Increase knowledge of community resources
- Peer mentorship
Individual:
- Practice positive self-talk
- Increase knowledge of gardening
- Directing staff in assisting them
- Asking for help or assistance with needed
- Problem solving and adapting their surroundings
- Strengthen social support network

Modification or Adaptations:
- CTRS and staff assisting patients will know the modifications needed and be competent
in assisting these patients in each of these areas knowing that each patient will need
different adaptations depending on LOI:
o Wheelchair mobility
o Transfers
o Pressure release
o Fine and gross motor control
o Upper body control
o Torso control

Reference/Source:
Austin, D. R. (2013). Therapeutic Recreation Processes and Techniques; Evidence-Based
Recreational Therapy 7th Edition. Urbana: Sagamore Publishing LLC.
 43

Porter, H. R. (2015). Recreational Therapy for Specific Diagnoses and Conditions. Enumclaw:
Idyll Arbor, Inc.
Stumbo, N. J., & Wardlaw, B. (2011). Facilitation of Therapeutic Recreation Services; An
Evidence-Based and Best Practice Approach to Techniques and Processes. State College:
Venture Publishing Inc.
Stumbo, N. J., Wilder, A., Zahl, M., DeVries, D., Pegg, S., Greenwood, J., & Ross, J.-E. (2015).
Community Integration: Showcasing the Evidence for Therapeutic Recreation Services.
Therapeutic Recreation Journal, 35-60.
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Staff Training and Certification:

Utah state License as a; TRS and/or MTRS
National Certification; CTRS
Transfer Training
CPR
Behavior Management
Manual BP

Risk Management Considerations:

Autonomic Dysreflexia
Temperature Regulation
Transportation risks:
o Seat Belt
o Wheelchair properly anchored
Emergency Contacts
o Facility; doctors, or other treatment team staff
o Patient; family members and or family

Outcomes Expected:
Knowledge of leisure/recreation resources and opportunities available to them in their
community
Increased engagement in the community
Increased communication skills
o Increased assertiveness skills
Increased social support network
Increased wheelchair mobility and use of adaptive equipment to move around in different
settings
Increased self-efficacy in their abilities to participate and engage in/with the community.
Increased confidence in the knowledge and skills they have acquired to interact socially,
and physically in varying environments and/or social settings.
Ability to appropriately manage self
o Ability to cope with their bodies, and care for self in different settings and time
constraints
o Increased strength to manage their bodies and the demands of ADLs and/or
recreational pursuits
Increased abilities and coping skills necessary to adapt and/or problem solve in an
unfamiliar/uncomfortable situation and environment
 49

Program Evaluation:
Standardize testing
o Right after admission and just before discharge to compare results and outcomes
Administer Post-Session Report Form and compare results over the course of their stay
o Use each report to adapt sessions to better meet client goals and outcomes
Gathering formative information throughout the patients stay on IMRU
o Observation of patients behavior on outings
o Observation of patients attitude toward community, recreation and social roles
o Observation of patients ability to adapt to new abilities and new environments
Gathering summative information at discharge
o Review documentation throughout patient stay
o Determine if client goals and outcomes were met
o Interview client to determine their evaluation of their participation and the
programs effectiveness
o Formulate a plan that will encourage patients continued participation in their
community, and recreational activities
H. McReynolds TRS, CTRS 2/22/17
 50

Professional References
Austin, D. R. (2013). Therapeutic Recreation Processes and Techniques; Evidence-
Based Recreational Therapy 7th Edition. Urbana: Sagamore Publishing LLC.
Porter, H. R. (2015). Recreational Therapy for Specific Diagnoses and Conditions.
Enumclaw: Idyll Arbor, Inc.
Stumbo, N. J., & Wardlaw, B. (2011). Facilitation of Therapeutic Recreation Services;
An Evidence-Based and Best Practice Approach to Techniques and Processes.
State College: Venture Publishing Inc.
Stumbo, N. J., Wilder, A., Zahl, M., DeVries, D., Pegg, S., Greenwood, J., & Ross, J.-E.
(2015). Community Integration: Showcasing the Evidence for Therapeutic
Recreation Services. Therapeutic Recreation Journal, 35-60.