Grace Lebrecht

RECTH 4320
Recreational Therapy Assessment of an Individual with a Physical Disability

Identifying Data
Name (use alias for confidentiality) Rod Shirley
Age 55
Gender male
Date of Admission to Facility/Program 3 years ago
Primary Diagnosis MS
(The dx/s that caused the admission or referral of the client)
Secondary Diagnoses none
(Other dx/s that are still active – the person is still experiencing – that are
not the primary reason for admission/referral of the client)
Past medical history none
(Other dx/s that the client had in the past that are no longer active)
Precautions Fall risk
Diet Doesn’t eat cumquats, allergic to orange juice
Medications Ocravis (MS), DMT (disease modifying therapy)
Education (highest level achieved) Bachelor of science
City & state of residence; characteristics of home & living situation Holladay, UT, with spouse
Employment status & occupation Retired on disability
Social roles/social support Husband, friend, church, neighbor mows lawn,
Religious and cultural values Church--LDS
Life habits Don’t drink, don’t smoke, don’t chew, watch Netflix,
Client goals (What does he/she hope to accomplish?) Stand and shave—that’s why he comes. He’s a homebody
Reasons for admission To be stronger before MS takes it all away
(What is the main reason the person is at your particular facility or
participating in this program; e.g., respite, decreased independence in
functioning, rehabilitation)
Reason for referral to RT Recreational therapy services aren’t offered at this facility.
(Reason for referral will vary by setting/program, please be sure to talk with
your supervisor to find out the specific reason for RT treatment/services;
what is hoped to be accomplished through Rec Therapy services at this
facility/program?)

Using the facility RT assessment tool, secondary sources (e.g. chart, family, staff, etc.), and/or a standardized RT assessment tool, conduct a functional skills
assessment of your client and list your assessment findings in the chart below. This section should be reflective of skills of a 2 nd year RT Student.
Assessment Methods
Instructions: What assessment
tool/source/method did you utilize
(e.g., medical chart review,
observation within activity,
discussion with a specific team
member/team/physician, client or
family interview, standardized
assessment tool, etc)? What
specifically did you look for/do?
Why did you do this (how does it
relate to the client’s diagnoses)?
 Observation, medical chart
review, client interview.
 Looked for physical
functioning because of
diagnosis
 Looked at quality of life as
physical capabilities decline
Functional Skills Assessment
Assessment Domains
Do not write anything in this
column.
Note: While all domains are
important, since this course
focuses on clients with physical
disabilities, be certain you have
comprehensively assessed physical
functioning.
Physical functioning
Cognitive functioning
Speech/language/communication
functioning
Psychological/emotional
functioning
Sensory functioning
Assessment Findings
Instructions: Report measureable
assessment findings. After each
finding, indicate the source where
you obtained the information using
the below codes: (e.g. Hard of
Hearing –O,MC; Loneliness – SR; R
Hemiparesis – O, MC, P)
O Observation
MC Medical Chart
T Standardized Assessment Tool
(administered by you)
P Pt hx (anything told you to by
the family, other team
members, etc.)
SR Self Report (items told you to
you by the client)
Utilizes walker-O
High-O,SR
Easily communicates without
impairment-O
Emotionally stable-O,SR
No hearing/vision loss-O,MC
Interpretation of Findings
Instructions: After reviewing your
assessment findings, what
preliminary conclusions can you
draw from the assessment data?
How do you foresee the client’s
strengths/weaknesses impacting
his/her recreation/leisure
engagement, health, and quality of
life (RT scope of practice)?
*Pay careful attention to when it is
appropriate to use absolute (e.g.,
will) verses flexible (e.g., could,
might, may) terms.
Fall risk—may limit independence in
activities
Activities should involve higher
cognitive skills to reflect his abilities
Communication won’t be an issue—
utilize activities which involve
communication
Client understands his diagnosis and
has accepted it in a healthy way—
this will make interventions easier
High sensory functioning will make
communication/intervention
 implementation easier
Social functioning Has solid support system-SR Integrate support system into
intervention—let them help
Self-care functioning Needs assistance with household Wants to be able to stand and shave
chores, but is able to care for himself- —work on standing for longer
SR periods of time without using arms
for balance
Play/leisure/recreation/community Declining as his physical capabilities Client feels as his physical
functioning decline-SR capabilities decline, so do his leisure
activities. This may make
interventions more meaningful for
him as he realizes that he is able to
still participate.
Leisure Lifestyle Review
Identify leisure interests and activity patterns for your client. Each activity should be coded as a current, past and/or future interest.
Add additional rows if needed.
Current (C), Activity How often With who Where Other Notations (possible information to include):
Past (P), & 1) Provide other specific notations about the activity that does
Future (F) not fit in the previous columns.
interests 2) Explain the barriers (or foreseeable barriers/challenges) to
performing the activity.
*List in this 3) Explain the facilitators that could enhance the client’s ability
order to participate in the activity.
4) Explain any reasons to be concerned about the activity (e.g.,
unhealthy, could cause harm to self or others).
5) Explain reasons (if known) about why past activities are not
being done any more.
6) Explain motivation for participating in this activity.
P, C Travelling Once a year wife San Francisco,
Portland,
Canada,
Arizona,
Hawaii
P Walking/jogging 3x a week By himself, Around
with dad neighborhood
P Biking Daily By himself To work

Major Concerns

Given your assessment findings, what are three priorities for
treatment/service? List one overarching area in each box.
Make sure at least one of these relates to physical functioning.
Improve balance
Increase leisure participation
Increase leisure awareness
Why is this a priority? Explain how it relates to participation in healthy
leisure activities (especially those that are meaningful to the client), as
well as how it relates to health promotion, rehabilitation, and/or quality
of life.
This will allow the client more independence. It will potentially enable
the client to achieve the goal of standing and shaving.
The client has few leisure activities he currently participates in.
Increasing his leisure will increase his quality of life.
Client may not realize how many leisure activities he can potentially
participate in with his diagnosis. A leisure education course on this topic
may be beneficial in increasing leisure participation and quality of life.
 RT Treatment Plan

GOAL #1 (broad):

Improve Balance

Objective for Goal #1
List an intervention/activity that you
could use to address the objective.
Explain your clinical reasoning for
choosing each (provide a STRONG
justification, possibly reference your EBP
article).
List the treatment structure that would be How will you
best to address the objective and explain your evaluate/measure the
clinical reasoning for choosing the specific client’s progress toward the
treatment structure (1:1, 2:1, small group, objective?
large group). Remember, variation is good.
Ideally not all interventions will be
implemented in the same structure. Are there any other
outcomes that could be
addressed and measured
Describe the technique/s you will use in your within the proposed
treatment sessions to address the objective interventions? If yes,
and explain HOW you are going to apply the explain. For example, does
technique/s to address the objective. What are the client have needs or
YOU going to do (specifically) within the deficits in other areas that
treatment sessions to help the client progress could also be addressed and
in meeting the objective (educate, prompt, measured within the
cue, encourage, reinforce, etc.)? proposed interventions?
How? Explain.

Condition: in the MDRT Intervention/Activity: Tx structure: Explain Evaluation/Measurement:

Behavior: demonstrate
improvement
Criteria: compared to their
initial results.
Full objective:
The intervention used is Tai-chi. The
“push-pull” and “circle the globe”
exercises are taught to participants.
Clinical Reasoning:
This intervention should be implemented on a
2:1 ratio. One instructor will give verbal cues
and demonstrate each Tai-chi exercise.
Another instructor will monitor the participant
using a gait belt. This will ensure the safety of
the client as well as allow the closer instructor
to correct the client’s posture in the moment.
Explain
Progress will be measured
using the Multi-Directional
Reach Test (MDRT). This test
will be administered before,
during, and after
Client will demonstrate
improvement in all areas of
the Multi-Directional Reach
Test, compared to their initial
results.
List article in APA format
(http://apastyle.org/)
*Remember to attach a copy of your full article.
What is the connection between the article and your client’s goal
and/or objective?
These exercises encourage correct intervention.
posture and address balance.
Technique/s: Explain
First, the client will be educated on the Other Outcomes
benefits of Tai-chi on balance. This will allow Addressed/Measured:
the client to understand why this specific Explain
intervention is being implemented. Following
While the main focus of the
the education, the client will begin learning the
intervention is to improve
exercises. It is the job of the recreational
balance, leisure awareness
therapist to provide not only physical support
could also be addressed at
for safety, but also emotional encouragement.
this time. The client should
Prompting will be the responsibility of the first
be made aware that the
therapist. Correction will fall on the therapist
intervention is going to be a
working the gait belt. This will also allow this
leisure activity. This
therapist to encourage and reinforce correct
particular client is having a
posture and execution.
hard time recognizing new
leisure activities, so the
therapist should use this
intervention to explain that
Tai-chi and similar activities
can improve his leisure
living.
Evidence Based Practice Related to RT Treatment Plan
Schilling, M. L., Beattie, L., Bell, K., Jacques, O., & Lyon, C. (2018). Effects of tai chi,
fitness boxing, and video activities on the balance and endurance of a participant with
multiple sclerosis: A case study. Activities, Adaptation & Aging.
https://doi.org/10.1080/01924788.2018.1500054
This article provided the intervention which will be implemented with the client. In this
article, it is shown that Tai-chi improved the balance of participants of the study. This
evidence is the basis for the current client’s intervention; the same intervention will be

Describe how you would implement the intervention/activity in
relation to how it is described in the article. If you are making
changes, explain.
Describe the population referenced in the article (e.g.,
community-based adults with spinal cord injury, children with
cerebral palsy, veterans with amputations). If it is not the same as
your client’s, explain your reasoning for thinking it is still
appropriate.
Describe the service environment referenced in the article (e.g.,
adapted sports camp, inpatient physical rehab hospital, skilled
nursing facility, community wellness center). If it is not the same
as your client’s, explain your reasoning for thinking it is still
appropriate.
Describe the effectiveness (outcomes) the article reports related
to the identified intervention/activity/technique specifically with
the target population.
How is the effectiveness that is reported in the article useful or
relevant to your situation (your treatment of this specific client)?
In your own words, how would you answer if another
professional, an insurance company, a client and/or a family
member asked you to explain (justify) why you chose to address
the needs of your client with this specific
intervention/activity/technique? Be sure to reference the
research article in your response, citing how the research article
implemented with the current client.
One change being made is that the other activities will not be included. In the article,
fitness boxing and video activities were also used in addition to the Tai-chi. In the case
of the current client, only Tai-chi will be implemented as an intervention.
The participant in the article is a sixty-year-old male diagnosed with MS who has
experienced declining symptoms in the past two years. This is appropriate as the
current client is a fifty-five-year-old male diagnosed with MS who is also experiencing
declining symptoms and a decline in leisure activity.
The service environment is not specified in the article. This intervention is still
appropriate for the current client because it can be implemented in any environment,
as very little equipment is needed. The intervention itself requires no equipment
besides a gait belt, but that is mobile. The MDRT requires no equipment to perform.
The article reports that the client demonstrated improvement in all areas of the MDRT
except lateral movement left, which was variable throughout the intervention. Upon
conclusion of the intervention, the client’s scores were close to normal for a sixty-year-
old male in three of four categories.
This is relevant especially to the current client because of his similarities to the client in
the article. The two are close in age, and have the same diagnosis. Success for the client
in the article indicates success for the current client.
The current client has expressed interest in being able to stand and shave. In addition,
his overall balance could be improved, evidenced by the use of a walker to get around.
This intervention has been proven to be effective with a client very similar to the
current client. Both are similar in age, diagnosis, and symptom level. This evidence
indicates that the intervention could have the same success with the current client. The
article states that “Upon conclusion of the intervention, the participant’s score was
directs or supports your point of view. close to expected norms for individuals 60 years and older in three of the four
categories of this test.”