Brain Injury Rehabilitation Center of Miami

Brain Injury Rehabilitation Center of Miami
Comprehensive Program Plan

Section II
By: Michelle Muoz, Marie Pharel, and Blanca Palomino

Conceptualization
Statement of Purpose
The statement purpose of Brain Injury Rehabilitation Center of Miami is to provide a
state of the art Rehabilitation Center of Miami for adults who have suffered traumatic brain
injuries to participate as part of our inpatient or outpatient therapeutic recreation department. We
offer a clean, fun and warm environment. This facility will ensure quality therapeutic recreation
rehabilitation in the physical, mental, as well as social aspects of life. We promise to provide
outstanding professional experience to all of our clients. Our overall purpose is the individuals
quality of life, while providing them with a sense of independence and orientation through
leisure. We adapt to every need and provide assistive technology as a gateway towards
participation and inclusion. The BIRCM is unlike any other local rehabilitation center. For our
inpatient clients, we strive to make this place your home. For our outpatient clients, we want to
not only be your therapist, we want to be your friend. We ensure our clients will receive an
experience like no other rehabilitation facility could provide.
Goals (See Appendix A)
1.0 To provide services to help the clients improve independence and functioning also to
eliminate the effects of the illness and disabilities.
2.0 To provide services to help the client develop new skills through leisure activities and
a variety of adapted activities including board games, gardening, aquatics, sports, and arts
and crafts.
3.0 To provide services that teach the clients different ways to enjoy their time through
leisure in order to improve their emotional, cognitive, physical, and socials skills.

4.0 To provide services and education that help the clients improvement in their social
interaction skills by engaging in a various of activity such as, walking to the super market
to pick up items, and go to the restaurant to eat lunch with others.
5.0 To provide services and education to help the clients develop skills and appropriate
behaviors for daily living, to promote health as well as restore the level of functioning
and independence.
Program Components
Aquatics Therapy Program (Goals 1.0, 2.0, 3.0)
Description. At Brain Injury Rehabilitation Center of Miami, we offer quality aquatics
therapy program, this not only facilitate the physical aspect but a great component of this therapy
satisfies the psychological, social and leisure abilities as well. Rehabilitation in this aquatic
environment allows the client to acquire new skills necessary to live a better quality of life. The
anti gravity effect of water makes it accessible for individuals with TBI, by improving range of
motion and even strength. (Guildcraft, 2009). The TR professionals will assure a safe and
appropriate environment for rehabilitation through the different kind of activities offered. Mental
adjustment will be incorporated. To facilitate the client to respond comfortably to the tasks
attempted to be carried out. Also, the TR specialist will be focused on giving the client the
opportunity to take part of the program plan to promote independence and self-efficacy.
Activities such as: Halliwick, Aquatic PNF, aqua stretch and Bad Ragaz. Will be implemented
and adapted according to the clients objectives and program goals. Assistive technology will be
provided as well as equipment such as life jackets, (for those who suffered from paralysis),
noodles, water weights, paddleboards, and anything necessary for a successful aquatic therapy

session. The session will also be held in groups to promote social interaction, while having fun
and working together to meet goals and objectives in regards to the program.
Explanation. Individuals with traumatic brain injury benefit from the aquatic therapy
program in multiple aspects. We have the understanding that recovery from a brain injury can be
a difficult process, but this treatment modality will assure recovery time as well as patient
outcome. At our facility we require immediate rehabilitation process right after assessment in
order to reach higher outcomes. The aquatic therapy program is appropriate for this specific
population, as it facilitates freedom of movement for the many patients that suffered Paralysis as
a result of condition. The buoyancy of the water allows for increased muscular strengths. Also
quicker movements will be developed from the water resistance., which will provide a quality
therapeutic session that will be the most successful. (Dattilo & McKenney, 2011).
Spasticity is a common cause on TBI, and applying a warm water therapy can enhance
their abilities to further muscle functioning, it also facilitates range of motion and results in client
comfort. The warmth of the water helps reduce pain by relaxing tight or spasm muscles and
increasing blood flow, and the water resistance and special jets help patients strengthen muscles
and improve cardiovascular performance (Health South, 2014). This program targets the first
goal, in that it improves independence and functioning, while eliminating the illness and
disability through the different swimming activities. For instance, as the therapist provides the
client with activities choices and even allows for client ideas to be carried out in regards to the
program, a sense of self efficacy and determination is being conquered. The client has a choice
whether or not he/she wants a buddy or not, whether they are ready to do things on their own and
make the choice to not use adaptive equipment any longer. In addition, the aquatics program
rendered in our facility for both inpatient and outpatient clients ensures that the second goal is

satisfied, by the development of new skills acquired through leisure, while having fun in a safe
and friendly environment. Skills such as: listening, communicating, interacting with others,
completing tasks successfully, or even coordinating their own program. Finally, the third goal of
teaching clients different ways to enjoy their time through leisure in order to improve their
emotional, cognitive and social skills is met as well. TR specialist will provide group activities
that will allow for social interaction, which will promote emotional well being. The client will
feel accomplished and engaging in the various aquatic activities will give them a sense of
purpose and motivation towards independence and socialization.
Animal-Assisted Therapy Program (Goals 1.0, 3.0)
Description. Animal-Assisted therapy is a facilitation technique that can be used to
reduce pain, anxiety, or depression, as well as, promote wellness in a persons social, physical,
and cognitive functioning. The benefits of animal-assisted therapy are numerous in the scientific
literature. Some benefits include increases in cardiovascular health, decreases pain, encourages
communication, provides comfort, and lowers feelings of anxiety (Benefits of Pet Therapy, n.d.).
The use of animal-assisted therapy dates back to the 1940s, when animals were used to cheer
wounded soldiers who had fought in the war. Researchers believe that animals including cats,
dogs, birds, horses and even dolphin have a calming effect on people and help in reducing blood
pressure, cholesterol, stress, improve fine motor, social skills, self-control and balance. (Animal
Assisted Intervention, n.d.)
Explanation. To assist people with traumatic brain injuries, dogs are involved in most
therapy programs for our clients. Dog therapy is important, and has a positive effect on the
patients pain level. Particularly for clients who love pets, interacting with dogs can heal their
broken bodies and minds. For clients with TBI who use wheelchairs, having an assisted therapy

dog can have many positive effects to their overall well-being. Having an assisted therapy dog
visit the clients in their rooms or around the facility, provides mental stimulation and can be a
positive distraction from their pain or disability (Animal Assisted Therapy, n.d.). The assisted
therapy dogs also help the clients to feel relaxed and comfortable and allows for increased
socialization.
Clients with traumatic brain injuries often experience loss of feeling and fluidity of
movement as well as emotional symptoms such as anxiety and depression. The presence of the
animal reduces pressure in the lungs and the heart, decreases blood pressure, and also reduces
stress hormones (Beetz, A., Uvns-Moberg, K., Julius, H., & Kotrschal, K, 2012). Animalassisted therapy helps the client to feel confident, less stressed, and ultimately more comfortable
in public and in the home environment.
Horticulture Therapy Program (Goals 1.0, 2.0, 3.0)
Description. Horticulture therapy (HT) is defined as a formal practice that uses plants,
horticultural activities, and the garden landscape to promote wellness for its participants (About
Horticulture Therapy, n.d.). This type of therapy program is goal oriented with clearly defined
outcomes and assessment strategies (About Horticulture Therapy, n.d.). HT provides meaningful
and purposeful activities, offers versatility, restoration, and respite from mental stress,
encourages human growth, and addresses psychological needs and the connection with the
natural world (Questions About Horticultural Therapy, n.d.). The therapeutic benefits of garden
environments have been evident throughout history dating back to ancient times (AHTA, n.d.).
Dr. Benjamin Rush, also recognized as the Father of American Psychiatry, was the first to
record the promising effects that working in the garden had on individuals with mental illness in
the 19th century (AHTA, n.d.). Rehabilitative care of hospitalized war veterans in the 1940s and

1950s, notably expanded acceptance of the therapeutic benefits of the practice (AHTA, n.d.).
Since then, horticulture therapy has attained much credibility and has been accepted as an
effective therapeutic modality.
Horticulture therapy is used in a wide variety of settings from rehabilitative, community,
vocational, or residential. There are also various types of programs and structured activities
within HT that may be facilitated by the therapist according to the needs of the client. Some
examples may include planting vegetable seeds, transplanting flowers, and even more creative
activities like making an indoor terrarium or creating pressed flower cards. Different types of
gardens are also used within HT to accommodate client treatment goals. Some examples include,
healing gardens, which are plant dominated environments and are generally associated with
hospitals and other healthcare settings (AHTA, 2007). Healing gardens are designed as a place
for clients, visitors, and staff to retreat and relax in a calming and peaceful atmosphere. A
therapeutic garden is considered a subcategory of a healing garden. In a therapeutic garden,
clients can meet treatment goals and perform horticultural and non-horticultural activities
(AHTA, 2007).
Explanation. The Horticulture therapy program provides our clients with traumatic brain
injury exposure to nature and activities that promote healthy cognitive, psychological, social, and
physical functioning. The focus of this program will depend on how the therapist and other staff
members feel it can best address the clients needs (Simson, S., & Straus, M. C, 1998). Our
therapy sessions are provided individually or in groups and offers unique opportunities for
relaxation, enjoyment, and creative expression. Social skills are a focus of horticulture therapy
and can include benefits in social interaction, group cohesiveness, and provide healthier patterns
of social functioning (AHTA, 2007).

Since many of our clients have impairments in cognitive functioning due to TBI,
horticulture therapy can provide an opportunity for early successes since the activities are
relatively simple and can be highly structured (Simson, S., & Straus, M. C, 1998). Our recreation
therapists are prepared with verbal cues, checklists, and pictures to help the client understand and
grasp the concepts of the activities. Horticulture therapy can enhance cognitive functioning,
improve concentration, stimulate memory, improve goal achievement and attentional capacity
(AHTA, 2007). Psychological benefits also result from HT and may include an increase in
quality of life, mood, and self-esteem, decreased anxiety and depression, an improved sense of
control and personal satisfaction (AHTA, 2007).
Horticultural activities can be modified in complexity and structure. The recreation
therapist can also alter the amount and type of assistance that is given to the client. Physical
impairments are also common for individuals with TBI. Many have issues with nerve damage,
loss of gross and fine motor control, and visual or perceptual impairments (Simson, S., & Straus,
M. C, 1998). For these physical difficulties, our program provides a number of adaptive
technology to assist clients with completing the tasks effectively. Some special tools and
equipment include, lightweight tools, weighted forearm cuffs, attachable handles for longhandled garden tools, gloves for individuals who are tactile defensive, and flags to use as
memory markers. Horticulture activities like cutting and placing plants, can help improve clients
mobility, memory, and endurance. Other benefits include decrease stress and heart rate, promotes
physical health, and improves fine and gross motor skills (AHTA, 2007).
Community Reintegration Program (Goals 1.0, 4.0, 5.0)
Description. According to Salzer (2006), community integration is the opportunity to
live in the community and be valued for ones uniqueness and abilities, like everyone else.

Community re/integration outcomes often include goal attainment, functional abilities,
vocational status, psychological status, cognitive functioning, and overall feelings of well-being
and independence (Community Integration, 2007). The history of community reintegration dates
back to when Congress passed the Rehabilitation Act of 1973, that prohibits discrimination
against people with disabilities. This was done as a part of a larger movement to achieve
community integration and inclusion for those with disabilities in society (Rosenthal, E., &
Kanter, A., 2012). The most recent statute that recognizes the disability population is the
Americans with Disabilities Act of 1990. The ADA prohibits discrimination towards individuals
with disabilities in the areas of employment, public life, transportation, telecommunications, and
public accommodations (Rosenthal, E., & Kanter, A., 2012).
Community reintegration as a treatment modality that aims to help clients get back to
living their lives independently. This involves performing activities of self-care, instrumental
activities of daily living like home management, rest and sleep habits, work demands, play,
leisure, and social participation. Therapists often provide community reintegration training in day
programs, home health agencies, Medicaid waiver programs or private practices. Types of
structured activities that could be incorporated into a community re/integration program are relearning social skills, using daily planners to practice memory compensation techniques, re-learn
activities of daily living such as bathing, toileting, dressing and grooming, as well as, preparing
meals, shopping, and managing financials (Community Reintegration, 2016).
Explanation. People who suffer a traumatic brain injury often experience impairments in
motor, sensory, cognitive, and behavioral functioning. After injury, many find it difficult to return
to regular life activities like going to work or school, or engaging in activities that he/she once
enjoyed. These clients may also experience decreased balance and coordination, memory

impairments, difficulty organizing and sequencing activities, and making decisions (Community
Reintegration, 2016). Impulsive behaviors may also result from a traumatic brain injury and
visual or auditory functions can also be affected (Community Reintegration, 2016).
A recent study by Truelle, Fayol, Montreuil, and Chevignard (2010) suggests For
persons with severe TBI trying to achieve the best possible community integration a new
semiology is required, not just limited to medical care, but also involving social and
psychological care that is tailored to the needs of each individual and family, living
within his/her environment. Currently, only a minority benefit from well validated
programs.
A community re/integration program can provide our clients with TBI, the tools they
need to effectively return home and live independently in society. Our program focuses on regaining physical, self-care, and general cognitive skills, as well as, provides information and
resources for leisure in the community. The skills learned in the rehabilitation program can be
transferred into real life settings such as the home or workplace when taken into the community.
The clients individual abilities are taken into account when creating an appropriate community
re/integration program. The therapist looks at all aspects of the persons life including activities
of daily living, instrumental activities of daily living, like rest and sleep habits, work demands, as
well as play, leisure and social participation (Community Reintegration, 2016).
Clients with TBI begin regaining the skills in the rehabilitation setting to ultimately be
able to practice them in the community. Our program takes clients to real life settings such as the
grocery store, bank, mall, bus/train, workplace, home, or any other environment where skills can
be performed. Skills like using daily planners or checklists, helps the client with TBI to
compensate for memory loss. Social skills training is also provided to help the individual regain
10

techniques in communication. Identification and development of new interests and leisure
hobbies is also a vital part of our community reintegration program that helps the individual
experience satisfaction and confidence while regaining their maximal level of independence.
Expressive Arts Program (Goals 1.0, 2.0, 3.0)
Description. Expressive arts Therapy was legitimately founded as a professional
organization in 1994 (IEATA) The Purpose of Expressive Arts program conducted in our facility
is to ensure the client with independence and a level of functioning in regards to diagnosed
condition. Also, it targets the engagement in a leisure activity that will improve the client on
emotional aspects as well. Soon after TBI clients often experience emotional trauma as well.
Depression and anxiety may develop and severe their overall wellbeing.
At Brain Injury Rehabilitation Center of Miami, we will host a variety of expressive arts
activities. Such as, Music therapy, Arts and crafts, and even Writing therapy. All these types of
expressive arts therapy will provide opportunity for choice, while healing through the use of
imagination and the various forms of creative expression. Music Therapy is the clinical and
evidence-based use of music interventions to accomplish individualized goals within a
therapeutic relationship by a credentialed professional who has completed an approved music
therapy program. (Music, 1998-2014) All the other various form of expressive art will serve as
an essential technique to allow the individuals to express themselves, while gaining artistic skills
that will provide them with a deeper purpose in life and self-fulfillment.
Explanation. Therapeutic use of Arts will allow patients to feel a sense of
accomplishment and to develop skills such as fine motor coordination, problem solving and
following direction. Most importantly our crafts give patients an opportunity to relax and have a
good time (Guildcraft, 2009). Very often soon after TBI individuals will have difficulty
11

expressing themselves. As a result, become frustrated anxious, depressed, and even angry. Not
functioning the same way and not having the same abilities may hinder them from selffulfillment, as they have no form of expression. This specific treatment modality of expressive
arts provides a variety of ways to express those feeling, thoughts and emotions that this specific
population may have gone through after injury.
As for arts and crafts the client may choose activities like ceramics, painting, sculpting,
making fantasy jewelry, and other activities that require creativity. This will require patience
from both the therapist and the client to come up with a final artistic product that will satisfy the
client. It is important for the therapist to create a social environment, in order to have a bridge of
ideas that will satisfy the clients and the program plan. This program will require many supplies.
For example, paint brushes, paint, all the material needed to build a sculpture, beads for our
bracelet/ necklaces making, and more.
Another form of expressive arts can be music therapy. This was introduced to our facility
as a form of lessening depression, and anxiety. This kind of art is one of the most expressive of
them all. It is language to the soul and its a form of communication, this expressive art provides
with the ability to feel, and let go off past feelings and negative thoughts. This program would be
assigned to our patients who suffer from cognitive and an emotional disorder first as this
programs goal is meant to provide comfort by creating less anxiety and stress. The music
expressive therapy could take place in a form of song writing in a poetic theme. or using
instruments to create sounds, such as Recorders. The therapist will teach the clients the basic
musical notes and provide the client with musical paper lines in order to have them compose
their own music, and come together at the end to present their final product. With the assistance
12

of the TR professional, tuning and theme songs will be facilitated to create harmonic and
pleasant sounds for all. This allows the patient to be creative and communicative as well.
Appendix A
Program Component Chart
THERAPEUTIC RECREATION COMPREHENSIVE PROGRAM GOALS
Functional Intervention
1.0
Leisure Activity Skills
Community Reintegration Training2.0
4.0
Leisure
Leisure
Awareness
Education
3.0
5.0
13
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About
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American Horticultural Therapy Association (AHTA). (2007). Retrieved October 13, 2016, from
http://ahta.org/sites/default/files/Final_HT_Position_Paper_updated_409.pdf
Animal Assisted Intervention. (n.d.). Retrieved October 14, 2016, from http://www.aaiint.org/aai/animal-assisted-intervention/
Animal Assisted Therapy. (n.d.). Retrieved October 14, 2016, from http://www.bcftbi.org/tbiresources/animal-assisted-therapy.asp
Beetz, A., Uvns-Moberg, K., Julius, H., & Kotrschal, K. (2012). Psychosocial and
Psychophysiological Effects of Human-Animal Interactions: The Possible Role of Oxytocin.
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Community Integrated Brain Injury Rehabilitation: Treatment Models and Challenges for
Civilian, Military, and Veteran Populations. (2007). Retrieved October 13, 2016, from
http://www.brainline.org/content/2009/06/community-integrated-brain-injury-rehabilitationtreatment-models-and-challenges-for-civilian-military-and-veter_pageall.html
14

Community Reintegration of Persons With Brain Injury. (2016). Retrieved October 13, 2016,
from
https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/RDP/Facts/Co
mmunity Reintegration fact sheet.ashx
Dattilo, J., & McKenney, A. (2011). Facilitation Techniques in Therapeutic Recreation. State
College: aquatic therapy, Inc.
Guildcraft. (2009). Guildcraft Arts and Crafts. Retrieved from Guildcraft Arts and Crafts:
http://www.guildcraftinc.com/category.aspx?zcid=189
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Rosenthal, E., & Kanter, A. (2012). The Right to Community Integration for People with
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Salzer, M. S. (2006). Psychiatric rehabilitation skills in practice: A CPRP preparation and skills
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15
Simson, S., & Straus, M. C. (1998). Horticulture as therapy: Principles and practice. New York:
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Truelle, J., Fayol, P., Montreuil, M., & Chevignard, M. (2010). Community integration after
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Comprehensive Program Plan