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Monday, September 04, 2006

Elderly Recreational Therapy Activity and Intervention Plan

Description of the Individual:
“C” is a 104 year old female who resides as a long term resident at The Ocala Geriatric Center in Ocala Florida. She is a small woman (she weighs 94 pounds... which she is very proud of...especially as it is a two pound weight gain!) who seems even smaller while sitting in the wheelchair which she uses. She wears large eyeglasses, a green cap proclaiming her love of fishing, and a dark green knitted sweater. Generally she will have a knitted blanket across her lap as well. “C” is able to maneuver her wheelchair at will without assistance and generally can be found at her favorite location...the smoking area. “C” loves to smoke. If she is not outside smoking, she will sit in a busy hallway where the staff are bustling about. As staff walk by, she greets most everyone.
“C” reports she doesn’t care for television or radio and indeed, she is rarely found in the dayroom, nor does she have a television in her room as most residents. She never learned to read or write, but does enjoy stories if they are told out loud. “C” is active in her choice of church at the center and enjoys gospel singing. Her favorite past-time is fishing and she loves fried Brim. “C” is a friendly, out-going person with a great deal of energy despite her advanced age. Mentally she is clear minded. Her long term and short term memory are both strong. She appears to be of average intelligence despite her lack of educational training. “C” does recognize numbers and enjoys Bingo...two times a week just isn’t enough for her! “C” has no visitors, she states very simply: “I outlived everyone.”
“C” is thin and wrinkled, her hair is grey under the cap, and she smiles easily once she knows you. In conversation she has little trouble holding her own although her hearing is impaired. “C” enjoys a lively pace and shows little tolerance for slow activities, rather she prefers those with a bit of action. Card games “are boring”, so is TV “C” prefers activities with a clear “pay-off” such as Bingo or fishing.
Assessment of Primary Problems:
An assessment of “C” was gained by various methods over the course of several weeks. First, through observation. “C” was in the hallway on the first day I went to the center, however, she didn’t know me and did not speak at that point. Generally, she would wave or smile as I went by, and eventually I began to notice her at several of the functions. As is typical, a notation is kept of participation by the residents while they are engaged at a function/activity therefore, it was easy to monitor her participation and socialization levels. Later, I conducted an interview with “C” which was part of her yearly file review. (As opposed to the other shorter interval reviews). During the course of the review, a recreational inventory was also updated, consisting of her background activities, preference of activities, and abilities. This was used to supplement the major assessment performed upon her arrival.
Physical Assessment:
“C” is in relatively good health given her age, however she does have several age related impairments. “C” is unable to support herself due to muscle weakness and instability therefore she uses a wheelchair. Furthermore, “C” has recently been experiencing decreased upper body strength resulting in greater fatigue. This is of concern given her independent nature. It is feared that further loss will begin to hinder her ability to ambulate in the wheelchair with repercussions on her psycho-social well-being. “C” also is hearing impaired. A hearing aid restores some measure of hearing, but she requires LOUD speech. She seems to have a preference for a more noisily environment...unless she is watching birds outside (another favorite activity).
Social Assessment:
“C” presents as an outgoing and energetic individual. She clearly enjoys interacting with others and self-reports a preference for being with persons she likes. “C” does value time alone, such as that when she watches birds or prays, but generally “C” spends her time in the company of others. “C” derives personal benefit by her companionship with others. Given the degree of warmth expressed by staff and other residents toward “C”, it would appear that it benefits those around her as well.
Cognitive Assessment;
“C” is able to clearly answer relevant questions regarding the present. She is oriented toward season, date and time. She is able to identify scheduled events, recognizes persons, and interacts with others in appropriate manner given the circumstance. “C” is able to identify her weight and interact with staff regarding her care and status of health.
“C” never learned to read or write, however, given her level of interaction and responsiveness during conversations, it becomes obvious that the lack of educational training was a reflection of the socio-polictical environment of her day rather than a reflection of her actual aptitude. “C” presents as well able to acquire new information in the present day, and furthermore, “C” enjoys a terrific sense of humor. Frankly, “C” has a contagious laugh. During an interview with her, I found myself laughing like a six year old school girl.
“C” is able to respond to questions regarding the past in an accurate and timely fashion. She sometimes has trouble remembering names or exact dates of past friends and family or events, but is still able to identify and supply information. “C” is very matter of fact in regard to her being the last of her family. She does have great grandchildren, but reports they do not come to visit. “C” appears to have a clear recollection of her late husband who died some 30 years ago, and her children who are all deceased as well. Some of her happiest memories revolve around fishing which was her favorite past-time even while raising a family.
Psychological Assessment:
“C”’s level of adjustment to the great degree of loss she has experienced is remarkable. It is not that she is unaware or even that she no longer misses her family and friends, but rather “C” maintains that her faith and religious belief are enough to sustain her. “C” has a clear concept of her wants and needs, and an understanding of the method she will employ to meet those needs. She is a delight to those around her and as unscientific as it may sound...this individual has some depth. I doubt a standardized test would measure what “C” has, but if it could be bottled...there would be many more well adjusted persons.
Leisure Assessment:
“C” needs to maintain her current state of health and level of functioning. Given her independent and active nature, the decreased upper body strength she is experiencing is of great concern. “C” adamantly refuses to cease smoking therefore negating one optimum intervention. Again, given “C”’s outgoing disposition she is naturally inclined toward recreational pursuits. Therapeutic recreation is in a unique position with this client to assist in maintaining her current level of muscle functioning. By maintenance of upper body strength, the client will be able to remain independently mobile and continue to experience her level of social and mental interaction.
Goals and Objectives:
The agency at which the client resides is dedicated to
· “Preserving Dignity” and “Respecting Individual Rights”.
· “Maximizing Functional Abilities”.
· “Assuring a nurturing environment”.
In keeping with the agenda of the agency, the Therapeutic Recreation department recognizes the need for dignity and respect in the pursuit of maximum functioning. As opposed to other modes of service delivery, recreation does NOT concentrate upon the disabling factors experienced by the residents, but rather fully enables the clients to make use of those abilities which remain in-tact.
· In “C”’s case, the primary goal would be To maintain level of upper body strength.
· Short term goal would be for “C” to learn to bowl by throwing a ball and knocking down pins.
· The behavioral objective will be for “C” to engage in bowling two times per week for one half hour in order to maintain current level of upper body functioning as determined by objective measures/test administered by physician and physical therapist.
· Process: “C” will engage in bowling two times per week for one half hour.
· Product: maintenance of current level of upper body functioning.
Due to “C”’s current loss of upper body strength, there is the risk of reduced independence, decreased overall health and psychological well-being, and declining energy level. By concentrating on “C”’s current ability to engage in more active pursuits, a greater degree of muscle strengthening is achievable. Bowling provides a psychological outlet for her high degree of interaction and preference for activities with a “pay-off”. Furthermore, bowling uses range of motion exercises and upper body strength to address her specific concern in a “fun” manner.
Activity Analysis: Bowling:
Using the Avedon Activity Analysis, the various elements of bowling have been categorized in order to analyze the components of the game. This allows a greater degree of comparison and contrast between the clients skill, interest, and ability, and the given requirements of the game. Additionally, modifications are more easily identified by scrutiny of the essential characteristics of the activity.
Purpose of the Game:
The main objective in bowling is to obtain a strike. A strike is when all 10 pins are knocked down by one throw of the ball. Otherwise, the aim is to knock down as many pins as possible out of 300.
Procedure for action:
To begin, an appropriately weighted ball designed specifically for bowling is chosen. The ball should fit comfortably upon the first three fingers of the predominate hand of the player. The weight should be born easily. Once a proper fit is established, there is typically a special shoe to be worn. Scoring is automated and consists of one point for each pin knocked down. A perfect score is 300 points. A strike is when all ten pins are knocked down with one throw of the ball. A spare is when all ten pins are knocked down in two attempts. There is an alley with ten pins at the end. The player approaches a line and throws the ball, underhandedly, towards the ten pins. Generally, the player leans into the throw and attempts to set the ball steadily down while aiming at the center pin in order to maximize the number of pins hit by the ball. The ball is returned and the player has a second attempt if a strike did not result from the first attempt. After two attempts, the pins are reset. If the individual is alone, the next set is now attempted. If the player is playing with or against others, the other player approaches the line and attempts to knock down pins.
Rules governing action:
Each player may attempt to knock down a set of ten pins only two times per frame. If a strike results, then it is the next persons turn unless it is the final frame. You cannot cross the line while throwing the ball at the pins.
Number of required participants:
Only one person is required to play. A person may compete against their own best score, or play with others. There is virtually no limit to the number of players.
Results or pay off:
There is the immediate thrill of watching the pins go down...especially if a strike is the result. A person can compete against their own best score or compete with other persons. The ultimate game consist of 300 points.
Abilities and Skills Required for Action:
· Physical Domain
· Standing, bending, and throwing are primary body positions required.
· The arms, hands, legs, feet, neck, head, upper, and lower torso are used.
· The activity requires bending, stretching,standing, walking, reaching, grasping, and throwing.
· Coordination between parts and movement is high.
· Touch and sight are the primary senses required for the activity.
· Eye-hand coordination and strength are required.
· Endurance, energy, and flexibility are helpful but can be compensated for
·
· .
· Social Aspects
· Given the nature of the game, bowling can be played as either an extra individual pursuit or an aggregate pursuit. As an extra-individual pursuit, the action is directed by a person toward the object and requires no contact with anyone else. This would be the social degree experienced by a player while playing alone. Generally however, this is not considered as fun. Bowling is a competition sport at its best, so for the remainder of this paper, it will be analyzed as such. Therefore it would fall under that of an aggregate pursuit where the action is directed by a person toward an object while in the company of other persons.
· The game requires only one person.
· The participants may be spaced closely or distantly. During competition, there is one player per lane...with buffer lanes surrounding.
· Communication is possible through the activity itself.
· The activity is competitive by nature.
· Little physical contact is demanded and the activity is gender neutral.
· The activity is fairly highly structured with high levels of noise.
· Cognitive aspects:
· There are a moderate number of rules, which are easily understood.
· Little long term memory is needed, and only an average degree of immediate recall is necessary.
· The game requires little strategy and very little verbalization of thought process.
· Concentration is moderate; reading, writing, and spelling are rarely used.
· Mathematical ability is rarely used due to computerized scoring, but otherwise, a low level of math is necessary. The overall intellectual level needed is not high.
· The ability to identify form, shape, size, etc. Is not high.
· The ability to identify numbers and colors is needed but on a low end.
· The ability to use body parts is high; left/right, up/down, around, over/under, person/object, etc. Is all used.
· Affective aspects
· Joy and/or frustration probably rate the highest in opportunities for emotional response to the game. Guilt, fear, and pain are relatively rare. Anger may be triggered at times.
Interaction patterns:
As previously mentioned, aggregate interaction pattern would apply.
Physical setting & environmental requirements:
In a bowling alley. A specially equipped lane, structure, and building designed specifically for bowling.
Required equipment:
Man-made articles consisting of a specially designed ball, shoes, and facility.


Task Analysis for bowling:
After having defined the main characteristics of bowling in general, it is now important to analyze the associated task as related to individual participation.
The individual must be able to pick up a bowling ball, swing the ball, aim the ball, and release the ball. The individual should be able to walk, bend, and stretch in order to propel the ball toward the pins. The individual needs to align the ball during release in the direction of the pins; this requires eye-hand co-ordination. The individual needs to add the number of pins knocked over to the previous number of pins knocked over.
Modifications to Activity:
By now it is apparent that “C” is not able to do several of the primary actions normally associated with bowling, however, that does not mean she would not enjoy or benefit from the game once modifications are implemented. Using the “Activity Modification Chart” provided in the hand-out for this course, an analysis of needed physical and functional modification would be as follows:

Game:
Bowling

Procedure:
Approach
Bend
Stretch
Throw

Rules:
Take turns
Mobility:
Wheel-
chair

Use of
guided
lane or toss
from
wheelchair

Same
Upper
limb dys.
Yes

Begin slow
and light.
Shorten
length.
Use of guide.
Same
Breathing:
Moderate
due to age.

Modify
pace.




Same
Commun-
cation:
Hearing
Impaired.
Doesn’t
read or write.

Speak
loud and
clearly.
Result:
Hit pins.
Try to get best of 300.
Try to beat
opponents
score.

Skills:
Eye-hand
coord.
Speed.

Equipment
Ball
Shoes
Bowling
alley.



























Same








Speed replaced by accuracy.

Light ball.
No shoes necessary.
Shorten lane.
Make ball and pins very visible.
Use a lane then graduate to self propelled, then use of light equip.














Same








Speed replaced by accuracy.

As listed.






























Same








Use of wheelchair
Slow pace
Rest in between turns.
Monitor energy level after each turn.


























Same

Prizes for
Winner.





Have score-keeper.
Loud communication.
Body language.



























In this case, the activity requires a substantial degree of modification. Due to “C”’s limited degree of mobility, her hearing impairment, and the inability to read or write, several of the fundamental activities normally associated with bowling require modification in order to meet her needs of the activity. Rather than concentrate efforts on areas such as her ability to keep score, it would be preferable to have a score-keeper available so that the primary purpose for the activity would not be interfered with due to the communication process. Also, if communication with others was a problem the intermediary would serve as the referee so to speak.
The program would be responsible for teaching the basic rules and requirements to “C”. This would require loud speech and teaching by example. Keeping the rules to the most elementary format would reduce the time needed for skill acquisition. This is important given that the learning of the skill is secondary to the implementation phase of the activity. Also, due to “C”’s low tolerance for boredom, it is important to not make the activity a frustrating experience.
To begin with, the activity would be performed in a sitting position with the use of a bowling guide which directs the ball down the alley. The ball and pins could be brightly colored plastic games such as those used with children. This would allow her to practice while not being physically exerted. The alley could be shortened to approximately 15 feet in order to build a measure of success while she is learning. There is a very nice hallway in the facility which would be perfect for a bowling lane as it is able to be blocked off without endangering the ability to maintain access to all residents. Otherwise, there is a nice area outside or in the activity room which could be used while at the facility. Due to the weather, it would be preferable that an indoor site be used in order to maintain the ability to play in any weather condition.
After “C” successfully learned the basic rules of the game, the next level of participation would include the removal of the bowling guide for the ball. The plastic ball would be light weight and able to be tossed from a sitting position. Once again, after this transition, the next step would be to switch to a cork ball such as those used by children. As the physical condition permits, the weight of the ball could be increased in small increments. Meanwhile, the mobility and use of her arms would assist in maintenance of upper body stamina, increased circulation, and the important aspect of independent mobility she currently enjoys.
In regard to the pins, brightly colored plastic pins would be the first used while she was learning the game. This would assist in her recognition of pins as those which lead to a better score versus those which do not. Also, since the pins are plastic, they require less strength in order to knock them over. As her strength increases, the pins can be weighted in order to make them more difficult to knock down. In this manner, by manipulating the weight of the ball, and the weight of the pins, it will be one more method to employ in analyzing her increased level of strength. Furthermore, a chart listing all weight increases and scores of bowling can supplement the physical test as administered by the physician and the physical therapist.
Facilitation/Leadership concerns:
Issues for me as a leader/teacher:
One thing which became apparent almost immediately was the degree to which I verbalize instructions and tend to speak quietly. Having worked as a substance abuse counselor often required me to speak in a “calming” manner, therefore I find that I often speak softly and slowly. This is probably more pronounced by my having been around blind persons for so long. Taken as a whole, my interaction skills with a hearing impaired person are not what they could be. Generally I tend to use a lot of motion or movement when I speak which compensates to a small degree, but I would definitely have to adjust my communication technique to “C”’s needs in order to effectively interact and teach her to bowl.
After taking the above into account, I would proceed to teach “C” the activity by undergoing the following steps.
First, I would assess “C”’s aptitude for bowling by introducing “C” to bowling by taking her by to see others bowling and making sure she found it interesting. One thing about “C”, she knows what she likes or dislikes and at 104 years old...she isn’t about to do anything she doesn’t like! Assuming that “C” is interested, I would then begin to plan the actual components of bowling. To begin with I would schedule a time and date to begin her “bowling lessons”. As stated in the modification component above, I would implement the process by teaching her to bowl through the use of a ball guide and a lightweight plastic bowling set. Gradually the weight and length would be adjusted to her level of ability. The guide would be removed and again a transitionary period would ensue. Finally, I would evaluate the process by comparing her physical ability, her self reports and level of participation and interaction, and the objective criteria such as weight gain of the ball, increased mobility of “C” herself, better performance while bowling, etc..
There are a few components which I did not mention in the activity modification area above which I feel to be integral components of the success of the activity given “C”s disposition. First of all, the activity should include the opportunity for interaction with others. Secondly, the activity should be noisy, upbeat, and full of fun. Due to this, I would use bright colors, give out prizes for all types of things such as the next person to hit a strike, or booby prizes for the next gutter ball (a sucker maybe?) and the like. This leads into the next topic...my choice of this activity.
Frankly, every time I ran this idea past anyone their first response was that 104 year old women don’t bowl. However, I decided to pursue the idea of bowling for two reasons. First of all, during the course of working on this project, “C”’s condition has not improved. In fact, her record was flagged last week for a team review in order to determine means of increasing her upper body strength. (At least I know I was on target for something!). It was determined that her main problem is indeed lack of use. “C” is active in numerous activities, but things such as Bingo don’t address her particular problem. There doesn’t seem to be any underlying disease process, just a lack of use. Bowling would address this issue.
The second reason is that the concept of 104 year old women bowling is a bias which is not substantiated by reason. Given a little creativity, a few modifications, and an open mind, it would appear that bowling may very well suite “C”. She likes a little action, enjoys a pay-off, has little use for activities with abstract outcomes such as aerobics, and most of all...she likes to have fun. “C” also enjoys “new” things. Bowling may not be new to many persons, but “C” was not exposed to a great number of things during her younger years. “C” was born long before the civil rights movement took hold in this country and so very many of the experiences taken for granted by the average citizen of today were never even a consideration for “C”. She enjoys new experiences and activities of a more upbeat nature, the motion and area of the body to be used are in keeping with her needs, and the overall activity is capable of being modified...so I went with bowling.
My role in working with “C” would be to teach her the game; monitor her progress. Determine her baseline level of functional ability. Modify the game in order to meet her needs. Increase or decrease the weight and length of equipment and space in order to address her ability on a daily basis. Provide incentives and pay-off’s in the form of small prizes. Provide assistance as needed. Provide opportunity for interaction with other residents. Update her chart in order to determine her rate of response to the activity and make needed adjustments as called for. Evaluate and amend the activity as needed. Although I would be teaching the activity in order to pursue a team approach to service provision directed at the identified problem (upper body maintenance), I would include a small degree of reinforcement in the form of small prizes, and emphasize the potential for fun. Again, recreational therapy is in a unique position with this client mainly due to her disposition.
The type of facility would be the center itself unless provisions for transportation could be arranged. If possible, I would take her to a real bowling alley simply because she would get a kick out of it. Otherwise, I would make the hallway or the activity room a bowling alley two afternoons a week. In order to do so I would need a child’s play bowling set and inflatable bumpers. These are inexpensive but the two or more ramps used to guide the ball may cost more unless I could find them used. Still, it is a one time expense which can be used repeatedly. The last cost would be that of small prizes. Basically, the equipment needed would be limited.
Implementation/Instructional Plan;
The step by step process of teaching the activity with two one hour sessions over a six week period would be as follows:
Week One:
Day one: Introduce to activity. Watch another bowler. Discuss basic rules.
Day two: Bring her own equipment. Use a ball guide. Have her aim the ball and release the ball from her wheelchair. No weight in the ball. Not weight in the pins. Shorten the lane to approximately 15 feet. Have her take a turn and rest. Monitor.

Week Two:
Day one: Repeat day two from last week but add attention to rules. Have her pick up her own ball and place in the ball guide before aiming and releasing. Monitor.
Day two: Repeat previous day. Attempt a half pound increase in weight of ball. Have her pick up her own ball with a half pound of weight and place into ball guide before aiming and releasing.

Week Three:
Day one: If client was able to bowl comfortably with one half pound of weight than increase weight of ball. If not, maintain current weight. Emphasize accuracy.
Day two: Again, check weight of ball for comfort. Continue to emphasize accuracy. Encourage client to Push the ball while releasing the ball into the ball guide.

Week Four:
Day one: Consistently check weight and comfort of ball. By now client is familiar with aiming and pushing the ball during release. Point out strategic pins by placing brightly colored pins to aim at. For example, a red pin in front for a strike. Client is now lifting a ball, placing it into a guide, aiming, and pushing for a release.
Day two: Client can now compete as she has full range of knowledge and skills. Encourage with small prizes. Have fun.

Week Five:
Day one: Discontinue all weight in ball. Have client attempt to bowl one half game without ball guide. Emphasize range of motion activity used to propel ball down alley. Monitor closely for fatigue.
Day two: Again use the empty ball. Client is to pick up own ball and propel down alley. This time attempt an entire game.

Week Six:
Day one: Client is to continue to pick up own ball and propel down alley towards pins. Add one quarter to one half pound of weight to the ball for the first half of the game.
Day two: Same as above for the entire game.

By the end of week one the client should be able to aim the ball at the pins and release.

By the end of week two, the client should be able to pick up her own ball, place it into the ball guide, aim and release.

By the end of week three, the client should be able to pick up her own half pound ball, place it into the ball guide, aim, and Push upon release.

By the end of week four, the client should be able to pick up her own ball, place it into the ball guide, aim at strategic pins and push upon release. Also, client can compete at this stage.

By the end of week five, the client should be able to pick up her own ball...without weight...aim, and propel toward the pins.

By the end of week six, the client should be able to pick up her own ball with weight, aim, and propel toward the pins.

Evaluation Plan:
In order to determine the effectiveness of the program I would use several methods. First of all, a baseline of “C”’s current level of functioning would be determined through the physical therapy department. This would serve as an objective measurement to determine real versus perceived gains in actual physical functioning.
Next, a baseline of “C”’s recreational ability on her bowling would be taken. By measuring her ability to comfortably pick up, aim, and release a ball, a measurement of her growth can be determined. One aspect of the bowling which is particularly beneficial, is that it can be modified to a substantial level given the ability to dictate weight and length of the alley. Given “C”’s advanced age, the basic mobility of her upper body and a limited degree of weight would prove to be beneficial. If she were able to increase the original weight by two-fold, a corresponding degree of upper body strength would be measurable. Additionally, range of motion can easily be measured as another objective criteria to the level of physical functioning.
In Conclusion:
Given the goals of the TR Service Model it would appear that all fundamental components are included. First of all, the individual aptitude, attitude, and level of functioning has been accounted for. Modifications and expectations are appropriately oriented. Members of the treatment team are included as valuable resources for evaluation while maintaining the unique providence of recreation by enhancing an existing ability. Education has occurred in the teaching of a new skill and participation by the client is encouraged to challenge the targeted physical level of functioning. Ultimately the psycho-social benefits may well remain the most important area of independent functioning obtained as a secondary effect of the activity. Meanwhile, the physical functioning can be easily monitored and chartered. Given the clients ability to self-report her satisfaction or dissatisfaction, appropriate responsiveness can be forthcoming in the event of fatigue or other concerns. However, it should be mentioned that the client should NOT be primarily responsible for communicating these potential problems. A careful and ongoing monitoring of her level of fatigue should be conducted due to the potential of the client to become to enthusiastic and thereby neglect to report, or fail to notice, her own level of fatigue. At this point the activity could become counterindicative to therapeutic outcomes.
The client would derive a clear therapeutic outcome by the activity. An established base of functioning and measurable gain could be documented. The client would acquire a new skill through the education of a new game. The increased opportunity for interaction and socialization would further benefit her outgoing disposition. Additionally, her participation in a recreational means of therapy provide a positivist approach to meeting her physical and social needs without unduly emphasizing the negative aspects of physical functioning. The whole person is taken into consideration and by providing for her current physical concerns, ultimately her social and emotional concerns can be anticipated and maintained to their fullest extent.

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