Evidence-Informed Guidelines for Recreation Therapy programs to Enhance the Mobility of Older Adults in Long-Term Care

This presentation will provide an overview of the BCCPA Mitacs-SFU project to develop a best practices guide for recreational therapy (RT). OLTCA and ACCA are also partners in this project. Along with reviewing the results of a survey on recreational therapy in LTC that was undertaken in BC, Alberta and Ontario it will present the final RT best practices guide.
Presented by:
- Dr. Kim van Schooten, Centre for Hip Health and Mobility, University of British Columbia
- Dr. Yijian Yang, Centre for Hip Health and Mobility, University of British Columbia
- Brenda Kinch, President, BC Therapeutic Recreation Association

1. BC Therapeutic Recreation Association
BCCPA 2017 Conference

2. Therapeutic Recreation
Is a process that utilizes functional interventions, leisure
education and recreation participation
to enable persons with physical, cognitive, emotional
and/or social limitations
to acquire and/or maintain the skills, knowledge and
behaviours
that will allow them to enjoy their leisure optimally, function
independently with the least amount of assistance and
participate as fully as possible in society.

3. Trends in Therapeutic Recreation
•Leisure Ability Model
–Is the most common TR model which provides a framework for
Leisure participation, education (skill development) and
Therapeutic Interventions
•Strength Based approach
–well-being is defined as “a state of successful, satisfying, and
productive engagement with one’s life and the realization of
one’s full physical, cognitive, and social-emotional potential”
(Carruthers & Hood, 2007)

4. Trends
•Person Centred Approach
–Based on Kitwoodswork and is a concept which is intrinsic to
recreation involvement –the person is at the centre of their
choices around leisure and requires all providers to ‘know the
person’
•Montessori approach
–a method of breaking down skills required to fully participate in
an activity of interest to an individual. This approach is used
when the individual may no longer be able to participate
independently and freely in their leisure due to cognitive changes
they have experienced.

5. Examples of Strengths-Based PlanningProcess –
“I” Plan Assessment Summary
Joe is an 88 year old man with dementia.
He has a short attention span. He is very
pleasant most of the time. Joe likes to
walk around the facility a considerable
amount of his waking hours. He is unable
to distinguish between areas he is
welcomed to enter and those where his
is not welcomed. His ambulation skills are
excellent; no assistance is required. Some
residents are disturbed by him because
he may enter their rooms against their
wishes. He prefers to be with staff at all
times as he does not tolerate being
alone. He and his wife raised 11 children.
Joe owned a hardware store and was a
respected businessman in town.
I am Joe. I owned a hardware store for
years in town, and am respected in my
community. Most of my life I have been
active and around a lot of people, which I
really enjoy. My wife, Ann and I raised 11
wonderful children. I don’t remember
things as well now, but I enjoy life and
like people. I am usually in a pretty good
mood. I do love to walk –it calms me. I
enjoy walking most with others. I often
look for others to walk with me and will
look in rooms and hallways here at the
home to find walking companions.

6. Anderson & Heyne, 2012
Flourishing through Leisure Model

7. Recreation Therapist
A professional who uses assessment and
interventions to empower the individual to find
meaning through leisure by promoting optimism,
independence, healthy lifestyles and by teaching
leisure related skills. (CTRA)

8. Recreation Therapist
•Recreation Therapists with an undergraduate degree in
TR have the training and education to identify strengths
and work with the whole person.
•More recently there is the opportunity for recreation
therapists to Certify with the National Council for
Therapeutic Recreation Certification (NCTRC). The
CTRS® credential is the only international certification
designed to protect the consumer of recreation therapy
services.

9. Recreation Therapist
•Therapeutic Interventions (as cited in the Sr. Advocate report)
‘can only be carried out by a therapeutic recreation team’
•In residential care a recreation therapist needs to be regularly
monitoring and adapting the therapeutic recreation care plan
to preserve and support individual abilities

10. Recreation Program Assistant
(aka Activity Worker; Recreation Therapy Assistant)
•The Therapeutic Recreation (TR) team includes a TR
assistant who works with the recreation therapist
•This person delivers TR interventions and programming
•Assistants have a variety of qualifications from no
qualifications, certificate, diploma or a degree

11. About BC Therapeutic Recreation
Association
•Professional membership requires academic standards
and continuing education credits to maintain
professional standing
•Newly trained professional applicants must hold a
degree in Therapeutic Recreation or be certified by
National Council for Therapeutic Recreation (NCTRC)

12. Benefits of Membership for BCTRA
professional, supporting and student
members
•Resourcesfor practitioners
•Educationfor members
•Access to current research
•Financial supports
•Networking
•Student support
•Advocacy for the profession

13. BCTRA-benefits to employers
•Informationabout the association
•CTRA Standards of practice
•Standardized Recreation Therapist Job
Description
•Employers can post jobs
•Direction, contactsfor more information about
TR opportunities to ask questions
•Therapeutic Recreation Links

14. Summary –current trending best
practices in Therapeutic Recreation
•The whole personapproach
•StrengthsBased
•Do with…….not for
•Shift in thinking ………caregivers to care partners
•Opportunities & Choice(Some people need more
support to make a choice)
•Traditional large groupsare not beneficial for many
•Small groups–provide more person centred outcomes
•One to one–may be the only way to engage some
residents
•Process not the end result

15. References
Anderson, L., & Heyne, L. (2012).Therapeutic Recreation Practice: A
Strengths Approach. State College, PA: Venture Publishing, Inc.
Hood, C. & Carruthers, C. (2007) Enhancing Leisure Experience and
Developing Resources: The Leisure and Well-Being Model, Part II.
Therapeutic Recreation Journal, vol. 41, #4, p.298 –325
Mackenzie, I. (2015).Placement, Drugs, and Therapy ... we can do
better(p. 11, Rep. No. 3). Victoria, BC: BC Office of the Seniors
Advocate.

16. Thank You
Please find more information at
www.bctra.org

17. Effects of Recreation Therapy Programs
on Mobility in Older Adults in Long-term
Care: A Systematic Review
Yijian Yang, PhD,
Postdoctoral researcher
Centre for Hip Health &
Mobility,
Department of Family
Practice,
University of British

18. Background
•Recreation therapy plays an essential role in
enhancing mobility among older people in long-
term care (LTC).
•However, there is lack of clarity about the range
of recreation programs currently offered and the
effectiveness of these programs for older adults
of different physical and cognitive status.
31-05-2017 BCCPA Annual Conference 18
(Reference: Crocker et al. Cochrane Review 2013)

19. Aim and approaches
•To survey evidence on the nature and
effectiveness of recreation therapy (RT) to
enhance mobility in LTC:
–Literature review of current evidence
–Electronic surveys with RT professionals
31-05-2017 BCCPA Annual Conference 19

20. Search strategy and inclusion criteria
31-05-2017 BCCPA Annual Conference 20
Search terms
Recreation /leisure &
long-term care/nursing home
& older adults
& mobility
Identified
studies
Database
Pubmed
CINAHL
AgeLINE
CENTRAL
PsychINFO
Inclusion Criteria
1. published in English
2. from 1990 –present
3. In residential care
4. quantitative studies
5. mobility as primary outcome

21. Flow chart of search procedure
31-05-2017 21
Potentially relevant studies (n = 963)
Medline –PubMed (n=422)
CINAHL (n = 127)
AgeLine(n=349)
CENTRAL (n=58)
PsychINFO(n=9)
Potential articles based on reading the title
(n=189)
Potential articles based on reading the
abstract (n=82)
Included in the systemic review (n=64)
Articles excluded as duplicates for irrelevant (n=774):
-Not a researchstudy (n=169)
-Not residential care setting (n=83)
-Unrelated study objectives (e.g., cardiovascular, sleep,
continence, etc.) (n=379)
-Beyond scope of review (e.g., delivery of care) (n=83)
-Duplicates (n=58)
-Other (blank results) (n=2)
Articles excluded after reading the abstract(n=107):
-Additional duplicates (n=12)
-Not a research study (n=37)
-Not residential care setting (n=6)
-Primary outcomes not mobility-related (n=41)
-Beyond scope of review (n=11)
Articles excluded after reading the full-test (n=18):
-Primary outcomes not mobility-related; Not a RT
intervention) (n=14)
-Not a research study (n=2)
-Not residential caresetting (n=1)
-Beyond scope of review (n=1)
BCCPA Annual Conference

22. Locations of the studies
31-05-2017 BCCPA Annual Conference 22
20
5
4
3
3
3
2
2
2
2
2
2
3
2
2
1
1
1
1
1
1
1

23. Recreation therapy (RT) programs
•Common RT programs:
–Walking (n = 19),
–Strength/resistance training (n = 18), 10 with walking, dancing or active games
–Tai Chi (n = 8)
–Dancing (n = 7)
–Active ball games (n = 6)
–Exergaming(n = 4)
–Yoga (n = 2)
•Delivered by:
–Physiotherapist or occupational therapists (n = 18)
–Trained exercise instructors (n = 13)
–Recreation therapists (n = 4)
–Care staff or research assistants
31-05-2017 BCCPA Annual Conference 23

24. Primary outcome measures
•Outcomes related to mobility:
–Functional mobility
•(e.g. Timed Up & Go (TUG), gait speed and the 6-minute walk)
–Balance
•(e.g. One-leg stand, Berg balance scale, tandem and semi-tandem stand)
–Muscle strength
•(e.g. Quadriceps strength, hand grip strength)
–Flexibility
•(e.g. Sit and Reach, shoulder range of motion)
–Performance of activities of daily living (ADL)
•(e.g. Functional Independence Measure, BarthelIndex)
–Falls
31-05-2017 BCCPA Annual Conference 24

25. Effects of RT programs on primary outcomes
31-05-2017 BCCPA Annual Conference 25
0
5
10
15
20
25
30
Functional
Mobility
Balance Muscle Strength FelixibilityPerformance of
ADL
Reduced falls
Number of studies
Walking Tai ChiActive ball gameStrength trainingExergaming Dancing Yoga

26. Secondary outcomes
•Fear of falling
–Improved in 7 studies
•Quality of life
–Improved in 3 studies
•Depression
–Improved in 2 studies
•Self-esteem
–Improved in 2 studies
31-05-2017 BCCPA Annual Conference 26

27. Summary
•Effective RT programs that improved functional
mobility for older adults in LTC were walking
program, Tai-Chi, and active ball games.
•Tai Chi, dancing, and exergaming also improved
strength and flexibility. Resistance training was
commonly incorporated into other programs.
•Walking program is generally feasible for older
adults with a broad range of cognitive function.
•Most participants in the studies are women, and
cognitively less impaired.
31-05-2017 BCCPA Annual Conference 27

28. Facilitators and barriers
•Facilitators:
–Clear instruction and demonstration
–Peer and facility staff reinforcement on the participation
–Using an attendance record to monitor adherence
–Personalized interventions
–Low cost and easy to implement
•Barriers:
–Difficulty in following instructions for individuals with dementia
–Distraction when interventions taking place in public areas
–Low staff / resident ratio
31-05-2017 BCCPA Annual Conference 28

29. Limitations
•None of the 64 studies provided a clear definition of
recreation therapy.
•Many studies were not sufficiently blinded.
•Study sample size was generally small
•Loss to follow-up was remarkably high.
•Lack of male participants in the studies.
•Did not involve participants with moderate to severe
dementia.
31-05-2017 BCCPA Annual Conference 29

30. Acknowledgement
•Injury Prevention and Mobility
Laboratory
Stephen Robinovitch, Professor
All lab members
•Centre for Hip Health and
Mobility
Heather McKay, Professor
Joanie Sims-Gould, Assistant
Professor
31-05-2017 BCCPA Annual Conference 30

31. Effects of Recreation Therapy Programs
on Mobility in Older Adults in Long-term
Care: Survey of Recreation Therapists
Kim van Schooten, PhD
Postdoctoral researcher
Dept. Biomedical Physiology and Kinesiology, Simon Fraser University
Centre for Hip Health and Mobility, University of British Columbia

32. Which programs are most effective
and suited for specific phenotypes?
17-05-01 32BCCPA Conference, van Schooten

33. Electronic survey of RT experts
Aim:
•to gain insight into recreation therapist’s current
practice of mobility enhancement among long-
term care residents
Specifically:
1.to identify the highest regarded programs;
2.to identify beneficial programs for specific outcomes in
the domain of mobility (falls, physical activity and
physical capacity) and well-being;
3.to identify suited programs for phenotypes based on
gender, independence and cognition
17-05-01 BCCPA Conference, van Schooten 33

34. Demographicsof respondents
•437 respondents
•92% female
•65% full time
•25% had 10 to20 yrs
of experience
•51% RT and40% RT
manager
•Allinvolvedin
planning, leadingand
assistingof RT
17-05-01 BCCPA Conference, van Schooten 34
86
18
96
60
35
17
2

35. Questions-Highestregarded
programs
Please rank the following programs based on your belief in
their effectiveness to restore and maintain mobility among
long-term care residents:
•Exergaming
•Cooperative ball games
•Dancing
•Competitive ball games
•Group exercise/structured group programming
•Yoga
•Tai Chi
17-05-01 BCCPA Conference, van Schooten 35

36. Response -Highestregarded
programs
1.Group exercise (36%; e.g. Sit and Be fit, Osteofit,
Carefit, Fun and Fitness)
2.Cooperative ball games (17%)
3.Dance (12%)
4.Tai Chi (11%)
5.Yoga (11%)
6.Competitive ball games (10%)
7.Exergaming(3%)
17-05-01 BCCPA Conference, van Schooten 36

37. Questions-Beneficialon specific
outcomes
In your opinion, is this program beneficial for the majority of
residents to promote:
•Physical
–Independence in ADL
–Safe mobility
•Balance
•Strength
•Endurance
•Flexibility
–Fall reduction
•Social interactions
•Psychological well-being
•Cognitive function
17-05-01 BCCPA Conference, van Schooten 37
Anderson & Heyne, 2012

38. Response -Beneficialon specific
outcomes
•Physical
–Independence in ADL: Yoga andGroup exercise
–Safe mobility: Yoga
•Balance: Tai Chi andYoga
•Strength: Allhigh
•Endurance: Allhigh
•Flexibility: Yoga
–Fallreduction: Yoga andGroup exercise
•Socialinteractions: Ballgames
•Physchologicalwellbeing: Allhigh
•Cognitivefunction: Allmoderate
Overall qualityof life
17-05-01 BCCPA Conference, van Schooten 38

39. Questions-Suitabilityfor
phenotypes
In your opinion, is this program in the current
format beneficial for people with a specific:
•Gender(Men/women)
•Cognitive performance (CPS 0-2, 3-4, 5-6)
•Activity of daily living performance (ADL self
0-2, 3-4, 5-6)
17-05-01 39BCCPA Conference, van Schooten

40. Response -Suitabilityfor
phenotypes
•Gender
–Men: Allhigh
–Women: Allhigh
•Cognitiveperformance
–CPS 0-2: Allhigh
–CPS 3-4: Ballgames high, Tai Chi moderate
–CPS 5-6: Coopballgames & Dancing moderate, Tai
Chi low
•ADL performance
–ADL 0-2: All high
–ADL 3-4: All high
–ADL 5-6: Ballgames moderate, Tai Chi low
17-05-01 BCCPA Conference, van Schooten 40
1
2
3
4
5
6
7
Tai Chi Yoga Coop. Ball
games
DancingExergamingComp. Ball
games
Group
programs
Men
Women
1
2
3
4
5
6
7
Tai Chi Yoga Coop. Ball
games
DancingExergamingComp. Ball
games
Group
programs
Intact
Mild
Severe
1
2
3
4
5
6
7
Tai Chi Yoga Coop. Ball
games
DancingExergamingComp. Ball
games
Group
programs
Intact
Mild
Severe

41. Conclusion
1.Structured group programs are rated most effective to
improve mobility in older adults in LTC, followed by ball
games and dancing
2.Yoga was favoured for most mobility outcomes –
scientific evidence is still lacking
3.Suitability is ranked similar among phenotypes, except
for people with severe ADL/cognitive impairments, who
may currently be underserved
17-05-01 BCCPA Conference, van Schooten 41

42. Acknowledgement
Injury Prevention and Mobility
Laboratory
Prof. Stephen Robinovitch, PhD
All lab members
Centre for Hip Health and
Mobility
Prof. Heather McKay, PhD
Assis. Prof. Joanie Sims-Gould, PhD
31-05-2017 BCCPA Annual Conference 42

43. Could we use the Inter-RAI MDS,
specifically ADL and CPS, scores
as screening for allocating
residents to interventions?

44. Would differentiation of specific
groups of residents (phenotypes)
be more feasible than
individualized programs and
more effective than a “one-size-
fits-all” approach?

45. Should we aim for a core set of
outcomes for all (recreation)
therapy programs in residential
care?