Functional Outcomes and Therapeutic Benefits of Recreation Therapy

1. Presented by: Dr. Gene Hayes, PhD, CTRS Jac Conley, GRA Therapeutic Recreation The University of Tennessee SRTS, May 15-17, 2013 Functional Outcomes and Therapeutic Benefits of Recreation Therapy

2. Learning Outcomes • 1. Each participant will demonstrate the ability to develop appropriate goals to enhance functional outcomes, • 2. Each participant will identify behaviors that address abilities or tasks demonstrated by the client that can be observed and measured, • 3. Each participant will list two purposes of functional assessments.

3. What Is Functional Outcomes • Functional outcomes is a method of working with a client that the insurance companies are requiring to prove medical necessity and allow therapists to get paid. They are more interested in what is going on in the clients functional life, rather that what is going on in a therapy session. It is the only thing they can measure.

4. Functional Outcomes • They only want to know if the client can resume normal activity, not if the client is completely recovered from his/her injury….

5. Functional Outcomes • Functional outcomes involves setting goals with the client to get the client back to normal functioning assuming that he/she has limited function. A functional goal starts with a long term goal such as ‘resume walking 100 feet within 6 weeks. It is further broken down to a short term goal such as ‘walking 30 feet within 2 weeks.’

6. Introduction To Functional Domains Functional skills - abilities or tasks demonstrated by the client that can be observed and measured Purpose of functional assessments: • Measure the level of skill • Identify underlying causes • Identify possible actions to address a need The professional should draw from multiple measurements of the ability or task

7. Standard Domains • 4 primary domains of functional skills: • Physical/Psychomotor • Cognitive • Social • Emotional/Psychological/Affective • Sometimes talk about a 5th –Spiritual- • The use of these 4 domains in health care dates back to before the 1920’s

8. R T Interventions To Enhance Functional Skills Within The Domains • What interventions can the CTRS provide to address the appropriate functional outcomes in the 4 domains? • Let’s look at each domain separately

9. I. Physical/Psychomotor Domain • Grasps and Grips • Coordination • Gait • Endurance/Activity Intolerance The CTRS must be able to provide a gross identification of function and whether it is within normal range or not

10. Grasps and Grips • Grasp • Describes the position of the client’s thumb and fingers when holding something • Each is associated with specific developmental levels • Grip • The measurement of the amount of pressure exerted by the hand and fingers • Act of holding something

11. Coordination • Refers to the client’s ability to move through space and manipulate his/her environment in a synchronized manner • Body mechanics - the muscle’s ability to maintain balance and muscle effectiveness against the pull of gravity to carry out the desired task

12. Key Elements of Body Mechanics • Alignment - ability to purposefully place the various parts of the body in the proper relationship to each other • Balance - ability to hold one’s position steadily with one’s weight distributed equally on the base of support

13. Key Elements of Body Mechanics • Base of Support - ability to maintain a solid base of support even when one is moving; fluid base of support • Gravity - ability to hold one’s body in place against gravity; ensuring that the line of gravity is within one’s base of support

14. Gait • Refers to the client’s style of walking • Assessed based on motor patterns, rhythm, cadence, and speed • 14 common gaits are discussed on page 313-314 in ‘Big Red Book’ • Ex. Antalgic Gait, Ataxic Gait, Four Point Gait

15. Endurance/Activity Intolerance • Relate to client’s ability to attend to a task, maintain energy level, and produce an adequate output • Fatigue - a lack of energy that can apply to a variety of the body’s systems and affects performance • Activity Intolerance includes endurance and also looks at pain/discomfort, irritability/distractibility, and the side effects of medications • Deconditioning - the body’s response to inactivity in which cardio-vascular endurance and muscle strength decrease and cognitive status dulls

16. II. Cognitive Domain • Attention/Concentration • Awareness • Generalization and Transfer • Initiation • Memory • Mental Flexibility • Orientation • Planning and Organization • Problem Solving Vision, Perception, and Cognition: A Manual for the Evaluation and Treatment of the Neurologically Impaired Adult by Zoltan (1996)‏

17. Attention/Concentration • CTRS must determine whether a loss of attention is due to ‘detection’ or ‘decision/response’ • The ability to detect a new stimulus is very likely a different neurological system than the ability to attend to a task.

18. Mindy Brown - Concentration

19. Attention/Concentration

20. Awareness • Implies that client is cognizant of stimuli in surrounding environment or stimuli that are internally produced • Client demonstrates this awareness through some kind of response

21. An Awareness Test for Drivers

22. Generalization and Transfer • Refer to the client’s cognitive ability to modify a previously learned skill to attempt a similar but different task • Often tested by modifying the presentation of a task

23. Generalization

24. Initiation • The inability to initiate purposeful, appropriate activity is one of the most common impairments addressed by TR services • Using perceived positive consequences is the best way to promote long-term independence in initiation

25. Awareness

26. Memory • A complex, multi-sensory function • Impacted by mood, attention span, level of stress, and ability to filter information • Can be measured using a number of standardized testing tools, such as the Mini-Mental State Examination, or through the use of everyday activities

27. Mental Flexibility • Ability to switch activities • Ability to modify a learned skill in order to better meet the demands of the environment http://www.tysknews.com/LiteStuff/mental_flexibility_test.htm How Mentally Flexible Are You? 27 D in a W 24 H in a D 99 B of B on the W 11P on a FBT

28. Orientation • Should be described using adjectives • 9 Characteristics of Orientation by Deitz et al (p. 317): • May be reflected verbally or behaviorally • Disorientation may be temporary or long-lasting • Often viewed as being all or none • Some domains are more resistant to breakdown than others • Person, place, time sequence of recovery • Temporal orientation is multi-dimensional • Disorientation is often associated with memory impairment • Vulnerable to the effects of brain injury • When long-lasting, disorientation requires attention

29. Planning and Organization • Requires ability to visualize future goals • Requires ability to identify actions that need to be taken, resources that need to be secured, and methods of realizing the vision

30. Problem Solving • Ben-Yishay and Diller’s 8 stages of problem solving (p. 318): • Formulate the problem • Analyze conditions of the problem • Formulate a strategy and plan of action • Choose the relevant tactics • Execute plan • Compare solution against problem • Determine satisfaction with solution and closure • Integrate into attitudes and skills and personalize

32. III. Social Domain • Social Roles • Social Patterns • Social Skills • Social Support Psychometrically, the ability to measure functional skills in this domain is the least developed area of measurement.

33. Social Roles • Role - to act in a manner that represents what would be expected • People generally assume multiple roles • Internal and external conflict arises when one does not fulfill his/her perceived role or when one’s different roles conflict • Social Role Strain - stress experienced when there is conflict or problems with the roles assumed by an individual

34. Have you ever been in this situation?

35. Social Patterns • Refer to the patterns of interaction between people • Avedon (1974) developed one of the better constructs related to social patterns. It is the primary description of interactions patterns used in TR today. • Intraindividual (self) Unilateral (Affects only one entity) • Extraindividual (Group to Self) Multilateral (Affects multiple entities) • Aggregate(Support Group) Intragroup (Occur within one group) • InterindividualI (Specific persons)Intergroup (2 or more social groups)

36. Common Areas of Suboptimal Functional Social Skills Boundaries • Ability to maintain a healthy physical and psychological delineation between oneself and others or the environment • Violations may be due to lack of impulse control, lack of appropriate ego boundaries, or poor physical space boundaries Coping • Knowledge and related skills associated with surviving stress • Defense Mechanisms- psychological processes that protect an individual from anxiety and from awareness of internal or external dangers or stressors Conflict • the disagreement between 2 people or expectations

37. Social Support • Refers to the family, friends, and community support that one has available • Can refer to one’s perception of his/her available support

38. IV. Emotional/Psychological/ Affective Domain • 2 part assessment: • Client description of his/her emotions, feelings, or mood • Therapists observations of client behavior and body movements Cultural constraints, cognitive impairments, discomfort with staff, and purposeful deceit contribute to clients inability to be fully reliable in reporting their feelings

40. Categories of Observed Affect • Appropriate - condition in which the emotional tone is in harmony with idea, thought, or speech • Inappropriate - disharmony between the emotional feeling tone and idea, thought, or speech • Restricted/Constricted - reduction in intensity of feeling tone • Blunted -disturbance in affect; severe reduction in the intensity of externalized feeling tone • Flat - absence or near absence of any signs of affective expression • Labile - rapid and abrupt changes in emotional feeling tone; unrelated to external stimuli

41. R T Interventions To Enhance Functional Skills Within The Domains • What interventions can the CTRS provide to address the appropriate functional outcomes in the 4 domains? • Let’s do an activity!!!!!

42. Therapeutic Benefits • Primary Benefits • Physical (functional outcomes)‏ • Activities of daily living • Increased opportunity for participation • Improved coordination and physical fitness • Endurance • Balance

43. Therapeutic Benefits • Primary Benefits • - Cognitive/Educational (functional outcomes)‏ • Learning opportunities • Learning new skills and activities • Opportunity for success • Creativity • Problem solving • Generalization and transfer

44. Therapeutic Benefits • Primary Benefits: • Social (functional outcomes)‏ • Socialization/informal group participation • Group identity • Relationship with adults of a nonprofessional nature • Opportunity for sharing • Appropriate social behavior • Appropriate dressing, grooming, friendships

45. Therapeutic Benefits • Primary Benefits: • Attitudes/emotional/affective (functionaloutcomes)‏ • Independence/self-confidence • Improved behavior • Improved cooperation • Heightened morale • Appropriate expression of feelings

46. Appropriate Goals and Objectives • States an outcome that is observable • Does not rely on “pop-culture” language • States why the outcome is important to the client • States amount of assistance that will be used • Specifies how the outcome will be measured • (“Guidelines for Therapists:”)

47. Specific Functional Outcome behaviors • Improving head control • “Susan will use controlled head movements to activate a head switch that manipulates her power chair, so that she can independently maneuver her power chair in a public setting” • Improving balance • “Paul will use balance to walk from his table to the sink independently, so that he can wash his hands before eating dinner with minimal assistance.” (“Guidelines for Therapists:”)

48. Purpose of Functional Assessments • Prevent advancement of a disability through earlier identification of functional loss • Show’s therapist specific limitations as well as progressions • Ensures that the program is appropriate according to the client’s needs • Establishes a bottom line of evaluation when working with other health care workers (Granger, Hamilton, Robert, Zielezny & Frances, 1986)

49. References • Ministry of Children and Family Development, (n.d.). Guidlines for therapists: Writing funcitonal outcomes. Retrieved from website: www.mcf.gov.bc.ca/at_home/pdf/guidelines_functional_outcomes.pdf • Granger, C. V., Hamilton, B. B., Robert, K. A., Zielezny, M., & Frances, S. S. (1986). Advances in functional assessment for medical rehabilitation. TGR, 1(3), 59-74. (Granger, Hamilton, Robert, Zielezny & Frances, 1986)

50. If you would like an electronic copy of the presentation please e-mail: • Dr. Gene Hayes at Ghayes1@utk.edu or thecampkoinonia@gmail.com