Running Head: HOLISTIC CONSULTATIVE PROGRAM

Holistic Consultative Program for Individuals with Neurological Conditions in an Adaptive

Recreation Program

An Occupation-Based Community Program in Utah

Kayla Jensen

University of Utah
HOLISTIC CONSULTATIVE PROGRAM 2

Holistic Consultative Program for Individuals with Neurological Conditions in an Adaptive

Recreation Program

The purpose of this assignment is to create an occupation-based program, directed and

organized by an occupational therapist, for an underserved population. A needs assessment was

conducted which consisted of structured and semi-structured interviews with staff and

participants of the Technology Recreation Access Independence Lifestyle Sports (TRAILS)

program, as well as direct observation of recreational activities and a review of the logistics in

the organization. A literature review was also warranted to determine effective practices with a

specific population as well as to research and learn about related programs that offered similar

services. After completion of a thorough analysis, gaps in services and areas of most benefit

were identified to create a program that incorporated a holistic approach to participating in

occupation.

Description of Setting

The TRAILS program is an adaptive recreation program within the University of Utah

healthcare system which consists of an array of networks including therapy services,

hospital/medical care, and educational opportunities. These relationships with other departments

allows for increased support to carry out the services of the organization. This program is located

amongst the inner city of Salt Lake City, Utah which consists of diverse individuals and a variety

of landscapes. The philosophy of the TRAILS program is to help individuals who have a

neurological condition to stay active through recreational activities, receive education on barriers

and adapting, prevent sedentary diseases, and to promote wellness through providing classes on a

variety of health-related topics (TRAILS: Technology Recreation Access Independence Lifestyle

Sports, 2018).
HOLISTIC CONSULTATIVE PROGRAM 3

History

The TRAILS program initially started because the inpatient rehab center noticed that

clients they were working with were returning home and not continuing to stay active in

recreation or other activities of prior interest. When asked why these individuals were not

engaging in community activities, they stated that they feared the unknown and did not want to

be put in an uncomfortable situation. When TRAILS first started, it was only available to adults

with spinal cord injuries which they saw much success with. They first introduced sports such as

wheelchair tennis and swimming since these activities did not require as much additional

equipment. TRAILS noticed that other adaptive recreation programs in Utah did not offer certain

sports that individuals expressed interest in, such as target shooting, skiing, and kayaking. It took

about a year to start a partnership with the University of Utah engineering school to design and

implement adaptive equipment to make these sports more accessible to individuals with

disabilities.

Overtime, TRAILS has continued to add various recreational activities. They try to focus

on sports and programs that other agencies are not doing. Within the last year, TRAILS has

opened their scope of service to include individuals with neuro disabilities as they recognized a

need as these clients also showed interest in what the program had to offer.

Target Population

The population seen at TRAILS are adolescents (age 16 years), and adults with varying

levels and severity of prior or recent neurological injuries. TRAILS previously focused on only

individuals who had a spinal cord injury, which is approx. 80% of their clients, but has changed

their participant criteria in the last year to include neuro disabilities, making up about 20% of the

clients in the program. Family and friends of participants are also encouraged to participate in
HOLISTIC CONSULTATIVE PROGRAM 4

some of the recreational activities to allow for familiar support, and engagement with those who

are experiencing the injury from another view point. The most common neurological conditions

seen include, but is not limited to spinal cord injury (SCI), multiple sclerosis (MS), amyotrophic

lateral sclerosis (ALS), stroke, and traumatic brain injury (TBI). Clients have varying levels of

abilities and experience unique physical and cognitive challenges that impact their participation

in everyday tasks. This population is at risk for decreased mobility and independence, decreased

social participation, increased reliability on others and use of adaptive equipment, and difficulty

with performing occupations such as self-care tasks.

The TRAILS program focuses their work on including individuals with medically

complex cases, and those who are less motivated to participate in recreation due to the symptoms

and barriers they experience. There are sub-groups within TRAILS that focuses primarily on a

specific diagnosis and/or gender to allow for individuals to connect based on similarities and

relatability. TRAILS also focuses on developing specific programs for women who have

neurological conditions.

External Influences on TRAILS

Policy

It is important that the TRAILS program considers safety and liability concerns that an

individual may experience when participating in adaptive recreation. If the program is

considering something that is new or that will possibly impact a person’s safety, they must

address it with the Utah Legal Department to make sure that it meets the guidelines for the

agency. The question the agency keeps in mind when making decisions or changes is “Is what

you are doing for the benefit of the patient?” Emergency policies are in place to protect client’s

physical health and wellbeing during participation in recreational activities. These policies
HOLISTIC CONSULTATIVE PROGRAM 5

require things such as cycling with a helmet, no straps to secure hands in place on kayaks,

weather evaluation, waivers, medical response, and event planning/details (Event Emergency

Protocol, 2018). This helps the organization keep in mind their own mission and goals as well as

the goals and safety of the clients.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is another

policy that must be considered to protect certain health information from being shared with the

community and other members outside of the TRAILS program. This policy also strives to allow

for quality healthcare to be provided while protecting personal information (Health Information

Privacy, 2018). HIPAA ensures that client information will not be shared by the TRAILS

program unless they agree or ask for it to be.

Geographic

Utah scenery consists of mountain regions, national and local parks, rural desert

communities, and access to lakes and rivers. The vast array of environments allows for TRAILS

to offer a variety of recreational activities based on the season, such as skiing and snowboarding

in the winter and cycling in the spring, summer, and fall. Utah’s population continues to grow

each year. Utah has access to community resources in larger cities such as Salt Lake City,

Ogden, and Provo. These areas have public transportation services which allow individuals to

travel locally and to neighboring areas. There are many smaller, rural communities that focus

more on self-sufficiency and sustainability through managing personal resources to provide for

one’s living. These areas have less access to community resources such as transportation.

TRAILS seeks to collaborate with rural organizations that offer recreation, such as the St.

George marathon, to elicit participation from individuals with disabilities who live in these

geographic locations. There are barriers to providing services statewide including limited
HOLISTIC CONSULTATIVE PROGRAM 6

transportation, lower volunteer involvement, and decreased funding. TRAILS is responsible for

all logistics and organization of the event if they register clients to participate in these rural

activities.

Sociocultural

Social and cultural factors impact the lives of individuals with neuro disabilities and their

participation in recreation. Social roles consist of the behaviors that one demonstrates during a

social situation. These roles allow individuals to participate in many occupations of their

choosing and have an interactive lifestyle. However, many individuals with neuro disabilities are

stigmatized due to the symptoms they present with and the behaviors that are associated with the

condition. Often, individuals with these conditions have lower levels of social participation and

are less motivated to engage in occupations. Warner, Desrosiers, Packer, & Stadnyk, 2018

discusses the relationship between one’s social roles, stigma, and quality of life, as he explains,

“stigma is a significant factor in the accomplishment of two social roles: interpersonal

relationship and recreation” (p. 214).

Another social factor that influences one’s participation in adaptive recreation is family

and social support. Many of the participants of TRAILS are encouraged by their loved ones to

engage in recreational activities. When a participant has a support system that is willing to assist

when needed, such as providing transportation to events and participating in activities with the

client, the individual often feels more motivated to try something new and challenging. Social

support is also helpful when it comes from another client who has similar experiences and

difficulty with life skills. Having the opportunity to relate to another person while endeavoring

on something unfamiliar, influences whether a person wants to get involved in a program like

TRAILS.
HOLISTIC CONSULTATIVE PROGRAM 7

A cultural factor that influences engagement in adaptive recreation are the beliefs that

others have regarding a person’s ability and function post injury. Society often assumes that

individuals with disabilities are less capable of doing things since they have lost function,

whether physical or cognitive. This view can result in these individuals developing “learned

helplessness,” leading to a decrease in trying unfamiliar and challenging activities.

Economic

Salt Lake County is a community that has access to many services including

transportation, tourism attractions, and employment opportunities. However, individuals with

disabilities are often limited in their ability to access these resources due to their deficits and

their financial support. Individuals who have a severe disability that prevents them from working

a full-time job can qualify for Medicare disability pay. This consists of a fixed amount

designated by the government that individuals are provided once a month. Applying for financial

assistance is time consuming and often not enough to support all the needs that these individuals

have. Once a person receives this type of financial support, he or she is unable to work over a

certain number of hours due to the possibility of losing their funds. This also limits individuals

participation in TRAILS as many participants do not have the means to pay for transportation to

travel to the recreational activities offered.

Political

The political standing in Salt Lake County is more diverse than in other parts of the state.

Based on registered voters, 37% of individuals classify themselves as Republican, while 16% of

individuals are classified as Democratic. Many individuals, 45%, are unaffiliated with either

political party (Voters by Party and Status, 2018). This unique divide in opinions can impact

access to healthcare services, regulation of state and government funding, and the organization of
HOLISTIC CONSULTATIVE PROGRAM 8

business and non-profit programs. TRAILS gets involved with politics when it is seeking for

financial support, as well as to understand the laws and politics regarding the logistics and

regulations they must meet and follow.

Demographic

Salt Lake County consists of 71% Caucasian individuals, while the other 29% is made up

of many ethnic backgrounds (Quickfacts Salt Lake County, UT, 2017). However, due to efforts

in creating programs for refugee resettlement, there has become an increase in diversity.

TRAILS supports all backgrounds and ethnicities in participating in adaptive recreation. This

program only limits individuals by diagnosis to target specific outcomes. TRAILS provides

services primarily to individuals who have a spinal cord injury, accounting for 80% of the

participants, and also individuals with other neurological conditions, which makes up

approximately 20% of participants. Ages of these participants range from 16 – 70 years old,

however the average age of members is between 30 – 40 years old. Many clients are unique by

race, age, income, and living situation. This allows for a more collaborative approach in working

cross-culturally to achieve overall participation and independence through occupation.

Services Provided for TRAILS

Staff

There are 3 employed staff members, including the program director, adaptive sports

coordinator, and office manager, who are responsible for taking care of the logistics to operate

the TRAILS program. They are responsible for duties including scheduling monthly events,

organizing recreational activities, contacting clients, and collaborating with related organizations.

Other responsibilities are assigned to individuals who work in the therapy and education

departments at the University of Utah. These individuals are not employed by TRAILS,
HOLISTIC CONSULTATIVE PROGRAM 9

however, they are willing to dedicate their time to assisting participants with their physical and

cognitive needs to participate in TRAILS activities. This program relies heavily on participation

from volunteers to carry out recreation and wellness services.

Related Services

Individuals are notified by therapy services, inpatient and/or outpatient, of the services

provided by the TRAILS program. It is the responsibility of occupational and physical therapists

to educate clients on the services provided, as well as offer appropriate resources and support to

help clients get involved in adaptive recreation. Once notified, clients fill out an application to

give details regarding their interests and their medical condition. TRAILS provides adaptive

sports including indoor spinning, hand cycling, kayaking, sailing, target shooting, skiing,

swimming, and wheelchair tennis. There is much focus on participation in sports, however, there

are additional programs available to support other client needs (TRAILS: Technology Recreation

Access Independence Lifestyle Sports, 2018).

This program currently provides a spinal cord injury forum which is a six-week program

that offers education on the physical, spiritual, emotional, and social barriers that individuals

with this condition face. Classes specifically address advocacy, health promotion, psychosocial

factors, sexuality, assistive technology use, transportation, women’s wellness, aging, and

disability. The forum is available for clients, care givers, family members, and health care

providers to discuss a collaborative approach to create change and eliminate barriers.

A wellness program has been designed to meet other lifestyle needs outside of

recreational participation. Wellness services include education on exercise, weight management,

nutritional consultation, massage, health risk management, yoga, driving stimulation, and

cognitive exercises. The most recent program that TRAILS implemented is “Ladies in Motion,”
HOLISTIC CONSULTATIVE PROGRAM 10

which offers opportunities for women with neurological injury to meet once a month and

participate in activities that focus on social interaction, adaptive recreation, and creating unity

among members with similar stories.

Many of the services mentioned are offered year-round and individuals are free to

participate in as much or as little as they want to. Those who participate in TRAILS are

considered “lifelong participants” and can participate in the services long-term if desired.

Funding Sources

The TRAILS program is funded primarily through grants which are applied for every

quarter for various programs. Additional funding is distributed for services provided by inpatient

rehab services at the University of Utah hospital to support the needs of adaptive equipment,

salaries, and wellness programs. Funding is limited for programs that target specific genders

and/or diagnoses, creating a barrier for TRAILS in developing new services. TRAILS is not a

paid service, and therefore does not require members to pay to participate in the program.

Future Plans

There are many goals that TRAILS has to improve the delivery of their services and to

expand the scope of the program. The first goal is to receive more funding to support the needs

of specific groups within their program, such as “Ladies in Motion.” More funding will allow for

consistency of program activities to continue a regular schedule. Another goal that this program

wants to achieve is implementing more focus on wellness from a holistic approach. This will

involve adding more programs that address different client factors including physical, cognition,

spiritual, etc. The last goal that TRAILS wants to focus on is offering more opportunities to

individuals with lower level injuries as these individuals are often less interested in participating
HOLISTIC CONSULTATIVE PROGRAM 11

in recreational activities. Making sure there is available adaptive equipment as well as help from

staff and volunteers is a vital piece in assisting clients who experience more complex injuries.

Programming Strengths and Areas for Growth

Administrative Staff Perspective

Program Director

A structured interview was conducted with the TRAILS program director. The program

director is responsible for scheduling of events, organizing volunteer involvement, and

participating in grant writing. The program director discussed that the current strengths of

TRAILS includes the support that this program has from an academic institution, and having all

healthcare professions involved in decision making. TRAILS utilizes local resources and

connections with others to maintain all that is required for the services they offer. A

collaboration effort is in place with the engineering college at the University of Utah to improve

adaptive equipment designs and to build needed equipment for individuals to participate in the

sports and activities provided. University students are also involved in TRAILS through

volunteering which is an asset in making sure the programs run efficiently and give the physical

assistance required.

An interdisciplinary team consists of recreational/occupational/physical therapists,

nursing, and doctors to make decisions about best practices for an individual to participate fully

in the TRAILS program. The collaboration among healthcare practitioners allows for a more

well-rounded approach in setting up the services so that clients succeed.

The program director stated that one of the biggest gaps in services is not looking at

individualized goals and outcomes. A client’s goals are identified when the person is receiving

inpatient and outpatient therapy services. TRAILS often recruits individuals who are currently
HOLISTIC CONSULTATIVE PROGRAM 12

receiving therapy services or those who had previously received therapy. These participants then

fill out an application stating what they want to accomplish by participating in TRAILS.

However, there is a disconnect between what the client wants to be able to do and what the

program offers. The activity is often organized and set up one way, and it can be challenging to

adapt parts of it for the clients who have different needs or goals.

Adaptive Sports Coordinator

A semi-structured interview was conducted with the adaptive sports coordinator, who is

responsible for attending adaptive recreation events, organizing and setting up necessary

equipment, and collaborating with the engineer college to request and design special equipment.

He considers strengths in services as providing physical activities year-round so that individuals

always have something they can get involved in. He also appreciates the collaboration and access

to adaptive equipment provided by the engineering department. He mentioned that one of the

biggest barriers and/or weaknesses is not being able to offer transportation to individuals who

want to participate in the sports.

Client Perspective

Direct observation, as well as four semi-structured interviews was conducted with

participants of the TRAILS program; questions for these interviews are given in appendix A.

There are many different types of clients who participate in the TRAILS program. There are

individuals who like to do every activity and sport offered, those who only focus on one sport

and stick to it, those who like to go to the specific groups (e.g. wellness, SCI forum, Ladies in

Motion, etc.), those with significant impairment, those who have more physical function, and

individuals who require more effort to encourage them to participate. Gathering different

perspectives highlighted strengths and weaknesses according to the user of the services.
HOLISTIC CONSULTATIVE PROGRAM 13

Overall, clients appreciate having the opportunity to participate in adaptive recreation

with other individuals with similar abilities. Most clients feel that TRAILS offers a good variety

of recreation activities. A strength that the clients mentioned is that the staff and volunteers are

non-judgmental and willing to help with adjusting the equipment and changing the sports to meet

their individual needs. They mentioned feeling safe and accepted, making it comfortable to show

up and try new things even when unfamiliar with it.

A barrier that was consistently mentioned involved the logistics of travelling to places

and getting to the events provided. Many individuals have complex disabilities impacting their

ability to drive a vehicle. It is challenging for individuals to use paratransit services as it must be

scheduled for a specific time and requires payment to use. This prevents many people from

getting to the activities, ultimately resulting in decreased participation and motivation. Another

area for growth that was mentioned is not having enough activities that focused on other

recreation in relation to lifestyle, as stated in the title of TRAILS. There was increased desire to

incorporate programs that involved a social component and programs that had less emphasis on

sports only.

Specific parts of the Canadian Occupational Performance Measure (COPM) were

administered to clients at TRAILS to understand, in greater detail, the day to day challenges that

individuals face due to their medical conditions. The COPM gathers information to highlight

what a person’s typical day consists of. This assessment then highlights task that are difficult in

various aspects of life such as, self-care, functional mobility, work, volunteer, household

management, socialization, and leisure. The top 5 barriers become the focus and the person is

asked to put a numeric value, 1-10 (1 – not satisfied at all, 10 – very satisfied) to the performance

and their satisfaction with how they are doing with the task (Carswell, McColl, Law, Polatajko,
HOLISTIC CONSULTATIVE PROGRAM 14

& Pollock, 2004). This assessment identified a few common barriers that four individuals with

neurological conditions faced and that they felt were most important to address including:

1. Difficulty with self-care tasks (brushing teeth, getting dressed)

2. More time spent at home (less socializing)

3. Difficulty finding rides/getting around in the community (community mobility)

4. More reliance on others (household management)

5. Not sure how to do things differently; not sure if capable (active recreation)

The clients I spoke with demonstrated positivity, although many experienced traumatic

events leading to a different life than expected. These individuals are motivated to make the best

of the situation, to adapt their environment, and change their perspective on how things “should

be done.”

Graduate Student Perspective

A mixture of structured and semi-structured interviews, direct observation, hands on

experience, and completion of the COPM were completed to gather information on the supports

and barriers to providing services through the TRAILS program. An analysis and review related

to gaps in services was administered to determine the use and effectiveness of an occupation-

based program to be implemented as a part of TRAILS.

Strengths

TRAILS is an established program with many strengths in providing opportunities to

address the needs of individuals with unique challenges and abilities. This program has access to

many resources and help from the university as well as support within the agency to carry out the

services and programs they are interested in doing. TRAILS makes changes based on input and

suggestions provided by health care staff who view the client from a unique perspective. Many
HOLISTIC CONSULTATIVE PROGRAM 15

of the recreational activities are offered year-round, providing lots of opportunities for

individuals with disabilities to be engaged in something meaningful.

Areas for Growth

The TRAILS program strives to make the adaptations that a person needs to help them

fully participate in the services offered. However, each person has different goals that they want

to achieve and reasons they are participating in the program. Especially for persons with

disabilities, working toward and achieving a goal creates value and meaning in one’s life. It is

important that this program makes the changes necessary within their services so that individuals

can reach the goals they set.

A barrier in this organization that prevents the continuation of some services includes

limited funding. Programs within TRAILS are inconsistent due to not being able to financially

support specific groups such as for women only or spinal cord injury clients. Equipment is

sometimes repaired or invented by staff in the office because there are not enough funds to

purchase new adaptive equipment. Limited funding also prevents the program from offering

other beneficial services such as transportation to access the recreational activities. Although

TRAILS has the opportunity to apply for many grants and receives funding from inpatient rehab

services, it is still limited in supporting all of the needs and plans that this program has.

A unique trait about this program is their attention to individuals with complex

disabilities and higher level injuries. These individuals require more physical assistance, support

for safety, and adaptive techniques and equipment to participate in day to day activities. The

recreational activities currently provided often require much more physical ability then

participants have. Staff and volunteers will provide the help that is required for the individual to

participate in the activity. For example, one client told of his experience kayaking. He said that
HOLISTIC CONSULTATIVE PROGRAM 16

his hands were placed on the oars but because he had no control of upper extremity movement,

he knew he was not the one moving the kayak, but rather the volunteer was doing all the work

behind him. This is an example of the need to find the right challenge for these individuals to be

as independent as possible through recreation. There may be other programs more engaging for

individuals with complex conditions and/or another way that these individuals can participate in

the already established activities.

Individuals with disabilities often demonstrate decreased social participation and less

motivation to engage in community activities. TRAILS offers an environment for participants to

connect with others who have similar challenges, goals, and interests. Most of the services

provided do not directly focus on a social component, but rather more emphasis is on individual

participation. As demonstrated by the Ladies in Motion group, it is apparent the impact that a

social component can have on one’s decision to get involved. Providing an opportunity for

individuals relate to others and create bonds among members may increase the number of

participants and lead to a more effective program. It is vital that a person is viewed from a

holistic approach and that their occupational needs are met to help him or her live a meaningful

life.

Evidence-Based Practice

A literature review was conducted to highlight the most common occupation-related

needs that individuals with neurological impairment have, and to learn about the evidence

associated with occupational therapy involvement in adaptive recreation programs. The most

accessed databases include Google Scholar, PubMed, SAGE Premier Journals (GWLA), and

PsychInfo. These databases were discovered through the University of Utah Health Sciences

Library. Search terms included the following: adaptive recreation, neurodisability, physical
HOLISTIC CONSULTATIVE PROGRAM 17

function, community partnerships, spinal cord injury deficits, TBI, community re-integration,

peer-mediated intervention, occupational therapy, and social participation. The British Journal

of Occupational Therapy, OTJR: Occupation, Participation, and Health, and other health related

journals were searched for significant articles. Whether an article was kept or not depended on

the relatability of the subject and/or the outcome of the research. Twelve articles were used to

construct the literature review and their findings are discussed below.

Common Deficits and Characteristics of Individuals with Neurodisabilities

It is vital to understand the needs, deficits, and characteristics of the relevant population

to better address their occupational goals. To do this, literature was reviewed and gathered to

develop an overview of the common barriers that hinder one’s participation in meaningful

occupations. Individuals with neurodisabilities have varying characteristics based on the

diagnosis they have. However, there are some similarities in the way that these conditions

present and how it impacts a person’s ability to adapt. Some common characteristics include co-

morbid conditions, loss of physical function and mobility (physical inactivity), depression, social

regression, decline in quality of life, anxiety, decrease of life satisfaction, loss of roles, and less

community participation. These factors often lead to an inability to positively adapt to the

biopsychosocial deficits of the condition, changing environments, and increased reliance on

others for assistance (Barone & Waters, 2012). Occupational therapists, who commonly work

with this population to improve one’s ability to engage in life activities also stress that this

population often experience cognitive deficits, behavioral changes, and communication needs

(Turner-Stokes, Disler, & Williams, 2007).

This population has experienced a life-changing event that requires the ability to adapt

and re-evaluate how a person completes basic everyday tasks such as moving from one surface
HOLISTIC CONSULTATIVE PROGRAM 18

to another, getting dressed, and eating their favorite meal. Due to deficits in physical function, it

is common that this group uses and relies on adaptive equipment such as a mobility device

(wheelchair, walker, or cane), augmentative communication device, or other tools to assist with

these common activities. The ability to participate fully in meaningful occupations is often

limited, and in return may result in declining health due to a feeling of loss of purpose and/or a

decrease in functional abilities (Cunningham, Wensley, Blacker, Bache, & Stonier, 2012).

For those who have had a neurological condition for much of their life, compared to those

who have experienced an unexplained onset due to a health related or traumatic event, the

experience is quite different. These individuals have learned to adapt, as it has been a lifetime

journey of adjusting to the barriers, coming to an understanding of the condition, and coping

with the deficits involved. Although this group still experiences some of the common deficits

and display similar characteristics listed above, it is the stigmas and perceived abilities

designated by society that presents the biggest challenge to overcome. Individuals with

disabilities are often viewed by others as incapable, invaluable, helpless, and continuously

dependent on others. These assumptions decrease a person’s desire to be involved in community

activities with individuals who are unwilling to understand their abilities and function

(Lundberg, Taniguchi, McCormick, & Tibbs, 2011).

Adaptive Recreation Participation Post Injury

Research supports that physical activity, especially for individuals with disabilities, can

prevent chronic medical conditions from developing, increase muscle function, and improve

cognitive skills. However, according to Lape et al. (2018), of the “53 million adults in the United

States who have a disability [who] are at high risk for physical inactivity, only 53% report

engaging in at least one 10-minute bout of aerobic physical activity in a week” (p. 507).
HOLISTIC CONSULTATIVE PROGRAM 19

Individuals with disabilities may require a different approach to address the physical,

psychological, and social factors to receive the same benefits associated with physical activity

for the typical population (Lape et al., 2018).

Adaptive recreation consists of activities, the majority with emphasis on sports, that have

been customized and changed to meet the needs of individuals with varying abilities. Benefits

associated with these programs include an increase in self-efficacy, social support network, and

life satisfaction. Additional themes, including improvements in both physical and psychological

health, have been noted as to what motivates a person to participate in adaptive recreation

programs.

Benefits of Getting Involved

The physical and health benefits is an important aspect of participating in recreation as

individuals can improve their function in daily living. Social connections among peers with

similar disabilities or relatable experiences allow individuals to have a role model and support

network to encourage them to participate in activities that are challenging. The social component

is also valuable in adaptive recreation as it provides an opportunity for individuals to learn from

others who can relate about strategies to adapt during a specific task. Self-efficacy, or the belief

that “one can,” often takes place of the “disability identity” that individuals place on themselves.

Adaptive recreation provides an environment where individuals are encouraged to take on new

identities through participation in an activity of choice that may be unfamiliar. By doing so,

individuals can eliminate their doubts and can instead take control of what is important to them.

The physical environment should be considered when offering adaptive recreation resources. It is

best when the service provided is easily accessible, meaning appropriate equipment is available
HOLISTIC CONSULTATIVE PROGRAM 20

based on the needs of the participant, the area is open and easy to maneuver in, and

transportation needs are met (Lape et al., 2018).

Obstacles That Limit Participation

Individuals with neurological conditions may experience complex symptoms impacting

their physical and cognitive function and that pose as a barrier to community mobility and

participation in occupations. There are obstacles that often inhibit a person’s involvement in

adaptive recreation as many individuals have limitations in what they can physically do.

Transportation is one of the primary concerns and barriers for individuals who are interested in

participating in adaptive recreation programs. Many factors are associated with transportation

that could be a possible influence on whether a person chooses to participate in adaptive

recreation programs and if their participation is sustained throughout. These factors may include

travel distance to program location, cost of travel, and reliance on friends and families for

transportation. To address this, research suggests that having a primary location and offering

multiple sites for recreational activity may allow for increased and sustained participation

(Blauwet et al., 2017).

Meeting the Needs of All Individuals with Complex Neurdisabilities

Another barrier often associated with participation in adaptive recreation programs relates

to the severity of the disability and the level of dependency on others for assistance. Sports may

be motivating to some individuals who have mild impairment, while non-sport activities may

provide a more familiar environment and social support to individuals with severe impairment

(Truelle, Fayol, Montreuil, & Chevignard, 2010). It is more common for those who have low

functional impairment to participate sport-related services as they do not require much

assistance. However, individuals with moderate to high functional impairment are less inclined
HOLISTIC CONSULTATIVE PROGRAM 21

to get involved as they need more attention and support to participate successfully. This

“specialized treatment” may deter these individuals from joining in adaptive recreation if it is

focused on sports as this group wants to be treated as typical participants.

Sport-Focused Recreation

Adaptive recreation programs focus primarily on offering sport related activities with an

emphasis on physical participation. There is little to no incorporation of recreation programs that

stress the importance of spiritual, mental, and/or emotional health, lacking the holistic

perspective of individuals with disabilities. Complex neurological conditions result in symptoms,

such as increased fatigue and limited mobility that prevent or discourage individuals from

participating in activities that elicit much physical exertion (Jaarsma, Dijkstra, Geertzen, &

Dekker, 2014). Individuals with these conditions also express that there is a lack of recreation or

activity possibilities that meet their needs and allow them to fully participate without much

assistance from others (Tasiemski & Brewer, 2011). Engaging in activities of interest that are

meaningful is an important factor which can enhance one’s functional abilities and long-term

engagement in adaptive recreation. By offering a multi-approach to wellness through a well-

rounded recreational task, individuals have an opportunity to improve their physical, social,

emotional, and mental health (Cunningham, Wensley, Blacker, Bache, & Stonier, 2012).

Occupational Therapy Role in Community Participation and Re-Integration

Occupational therapy (OT) has many functions in assisting an individual to participate in

meaningful occupations or activities by overcoming barriers because of an injury, diagnosis, or

other challenging condition or experience. Occupational therapists seek to identify deficits to

assist in the development of the skills necessary to participate in self-care tasks, work/community

responsibilities, and activities of leisure. Occupational therapists attend to all client factors
HOLISTIC CONSULTATIVE PROGRAM 22

including personal, environment, and the occupations a person engages in or desires to get

involved in. This multi-dimensional approach has a greater impact than only physically-focused

activities (Cunningham, Wensley, Blacker, Bache, & Stonier, 2012). When adaptive recreation

programs are supported by healthcare professionals, such as physical, occupational, and

recreational therapists, individuals tend to feel more comfortable and hopeful that their needs

will be met (Blauwet et al., 2017).

Social Participation

A component of community re-integration is the need to get involved in activities

associated with a specific group of people. This may include completing household

responsibilities such as grocery shopping and paying bills, using public transportation, going to

work, and/or participating in leisure activities. These types of public activities require individuals

to interact socially to some extent with another person as well as to interact with the

environment. Individuals with disabilities may find themselves disconnected from their social

outlets due to stigmas associated with their diagnosis or because of a lack of connection or

relatability to societal peers (Warner, Desrosiers, Packer, & Stadnyk, 2018).

Adapting to a life with a neurological condition is challenging as a person is required to

change the way he or she interacts socially. Cheung et al. (2013) found that individuals with

neurological injury demonstrate increased motivation to participate in physical activity when the

program is delivered by a peer. This research also highlighted that peer mentorship improved

patient’s self-efficacy, action planning, and increased their desire to participate in physical

activity long-term.

Adaptive recreation offers an opportunity for individuals with similar experiences to

relate and connect over a shared interest or new skill development. This environment can support
HOLISTIC CONSULTATIVE PROGRAM 23

the social needs that this group may require reintegrating into society and partaking in the vast

array of occupational opportunities.

Adaptive Equipment Design and Implementation

Occupational therapists have an important role in supporting the needs of individuals

with complex disabilities in providing the appropriate adaptive equipment and environmental

modifications necessary to help a person succeed in participating in occupations. Occupational

therapists recommend specific adaptive equipment or devices to support individuals in

completing activities of daily living (ADLs) such as bathing, dressing, and toileting, to assist

with at home occupations such as cleaning, and to support community mobility and integration.

Therapists select equipment based on evidence and an in depth understanding of client deficits

and strengths to improve overall occupational performance. At times, occupational therapists

must use creativity to develop an adaptive device personal to the user as there is nothing for

purchase available (Friederich, Bernd, & Witte, 2010). The ability to be resourceful is necessary

when adaptations are required, but not easily obtainable or accessible. Adaptive recreation

requires the use of equipment to be designed in such a way that tailors to the physical and

cognitive needs, as well as allows individuals with complex neurological conditions to contribute

and participate fully in the activity.

Adaptive recreation uses equipment to allow individuals of all abilities to participate in

the services provided. However, these devices have limitations in adaptability and may be

difficult to adjust for each person interested in participating in adaptive recreation. Individuals

require varying assistance with physical impairment and/or cognitive function. It is vital that the

design is malleable to be able to change to meet the needs of all individuals with

neurodisabilities.
HOLISTIC CONSULTATIVE PROGRAM 24

A Holistic Approach to Improve Participation

Participating in an adaptive recreation program is one approach for individuals with

disabilities to re-integrate into the community by doing something that helps a person feel

accepted, challenged, and successful. Occupational therapists seek to help individuals adapt

within their environment to access the resources available and navigate the community to

participate in desired occupations. Occupational therapists are experts at task analysis, making

environmental adaptations, functional activities, compensatory strategies, and life skill

development. Offering a holistic and interdisciplinary aspect to adaptive recreation programs

may encourage a participant to get involved in community-based recreation as it will allow for

the needs of the client to be met so he or she can become self-reliant and confident in his or her

abilities (Truelle, Fayol, Montreuil, & Chevignard, 2010).

Summary of Evidence

As stated previously in the philosophy statement, the TRAILS program strives to support

individuals with neurological disabilities to participate in adaptive recreation to prevent the

development sedentary conditions and to promote well-rounded wellness services. To achieve

this purpose, TRAILS offers a variety of recreational sports, educational forums, and

interdisciplinary connections to encourage and support individuals to be proactive in improving

their health post injury. While these services primarily address physical health, there is less focus

on psychosocial factors, environmental barriers, and non-sport recreational activities. The

literature review emphasized the need to provide a holistic program to address the physical,

emotional, social, and mental deficits and challenges that individuals with neurological

conditions experience. These challenges include decreased social participation, depression, loss

of physical function, loss of role and purpose, less community integration, and decline in quality
HOLISTIC CONSULTATIVE PROGRAM 25

of life (Barone & Waters, 2012). It is important to consider what motivates individuals to get

involved in adaptive recreation programs, what constitutes sustained engagement, what the

barriers are that limit participation, and areas for change to improve the delivery of services.

Adaptive recreation offers many benefits to those who partake in the services offered.

Physical activity is recommended for individuals post neurological injury as it can improve their

function with daily activities. There are increased social factors that are met through recreational

involvement such as connecting with others who have similar experiences and learning how to

adapt to new and unfamiliar situations from a peer. Adaptive recreation offers an opportunity

designated for individuals with disabilities, to participate in a variety of activities that a person

may be interested in while receiving increased health benefits.

There are many obstacles that should be considered which may affect a person’s ability to

participate in adaptive recreation. Transportation is a concern for individuals who do not have

the ability to drive a vehicle and are unable to rely on paratransit services or family and friends

(Blauwet et al., 2017). Another challenge is meeting the needs of all individuals based on the

disability that a person has. Some individuals may enjoy and benefit highly from sport-focused

recreation while others may prefer non-sport activities that focus on a social, cognitive, or

emotional skill (Truelle, Fayol, Montreuil, & Chevignard, 2010). The last area for improvement

to be explored is the social relationships among participants. Research supports that individuals

with neurodisabilities often experience a regression of social interaction, despite their desire to

engage with others (Warner, Desrosiers, Packer, & Stadnyk, 2018). By offering a social network,

with participation in a related interest, individuals will have another peer that can provide

support, education, and friendship to cope with their life-changing experiences.

HOLISTIC CONSULTATIVE PROGRAM 26

TRAILS has a desire to focus their efforts to provide for the needs of individuals with

severe or complex neurodisabilities. However, there are components of the program that require

change to support the needs of their participants. A comprehensive needs analysis and literature

review has established the need of a holistic consultative program. The first area to be improved

is including additional services that support the needs of those who are less interested or unable

to participate in sport or primarily physical activities. The next area that should be addressed is

equipment design and implementation to better support the functional abilities of participants

with both low impairment and severe injuries. Another adjustment to be added is including a

social, peer-mentorship service within the recreational activities that are already established.

Additionally, transportation should be considered in relation to the peer-mentorship intervention.

This program would improve individuals with neurological disabilities social relationships,

physical function, adaptability, community reintegration, and confidence.

An occupational therapist would be best suited in implementing a consultative approach,

using a holistic perspective, to further develop this program to meet all the client factors

impacting a person’s participation in TRAILS (Cunningham, Wensley, Blacker, Bache, &

Stonier, 2012). This program will fulfill a need identified by administrative and staff personnel,

participants who have neurodisabilties, and observation of services and logistics of the

organization, and supports the philosophy of the Technology Recreation Independence Lifestyle

Sports (TRAILS) program and goals of its participants.

Program Proposal: Holistic Community Program for Individuals with Neurological

Conditions in an Adaptive Recreation Program

Program Overview
HOLISTIC CONSULTATIVE PROGRAM 27

The prospective program will be provided through consultative services aimed at

addressing the biopsychosocial factors including peer mentorship, as well as focus on changing

and/or adding volunteer education and equipment design to meet the needs of participants of the

TRAILS program. Additionally, this program will develop new recreational activities that

increase opportunity for individuals with complex disabilities to get more involved. This

program will strive to alleviate the gaps in services discovered through the needs analysis and

will also implement strategies highlighted in relative literature for individuals with neurological

conditions in adaptive recreation programs. The program will continue to support TRAILS’

philosophy in providing recreational opportunities to improve physical function and will

additionally offer a holistic approach to address other client factors.

There will be three focus areas that will be adapted to meet the needs of staff, volunteers,

and participants of TRAILS. The parts of the program that will receive intervention will include

volunteer education including equipment design, diversity of program activities, and peer

mentorship opportunities. Through volunteer education, there will be more emphasis on tailoring

to individual needs and established goals set by the client. A community document will be

created which will inform volunteers of participant’s abilities, goals, and level of function. To

ensure that volunteers are prepared to meet the physical, cognitive, and social barriers these

individuals face, education forums will be held on a variety of topics. Diversity of programs will

consist of an introduction to two new activities, gardening and cooking, which will be adapted to

meet the needs of all participants. The addition of these activities will help clients learn to adapt

with their new conditions as they are representative of everyday functional tasks that participants

are involved in. Peer mentorship is an area that is necessary to improve overall participation in

recreational activities, and to minimize low levels of motivation and/or high levels of anxiety
HOLISTIC CONSULTATIVE PROGRAM 28

about learning new skills through recreation. Peer mentorship will involve individuals who have

both severe or complex injuries and those who have minimal physical or cognitive impairment.

As noted in the needs analysis, transportation is a large barrier to attending the recreational

activities, therefore, peer mentorship will also include the development of a ride share program

by those who have access to and are able to drive a vehicle.

As described in the needs analysis, it is important to address the social, economic,

political, geographic, and demographic factors of the participants of TRAILS. The purpose of the

proposed program is to target client factors such as physical mobility and social engagement, as

well as organize or create recreational activities which allows these individuals to use their

current skills and function to participate with as little involvement or assistance from others. This

program will also include volunteer education and training to assist those who help support the

recreational events to be informed on the various neurological conditions and current functional

abilities of the participants. Currently, most activities provided by TRAILS emphasizes a

physical component, requiring increased physical movement and/or strength to participate fully.

However, the new program services will offer adaptive recreation that will be accessible to

individuals with varying levels of injury severity and focus on activities of daily living that

participants must attend to on a regular basis. Currently, there is minimal education for

volunteers on participant medical conditions, current function, and/or areas that these individuals

need assistance with. Education primarily focuses on the mission of TRAILS, available

equipment, and schedule of events. While these are important to the organization of activities, it

is also vital to address the direct physical, cognitive, and social needs of the participants and how

volunteers can be supportive of these identified essentials.

Program Value
HOLISTIC CONSULTATIVE PROGRAM 29

Individuals with neurological conditions often have trouble re-integrating into the

community following the onset of injury as it impacts one’s physical, social, or cognitive

function. These changes in a person’s role or how one participates in an occupation may create

barriers to enduring the challenges of learning a new set of skills to complete everyday and

recreational tasks. By enhancing and adding to the services provided by TRAILS, this program

will address many of these barriers such as reduced social connections, low adaptability,

decreased desire, lack of transportation, and limited knowledge about the health condition and

related outcomes. As stated within TRAILS philosophy, this program will promote wellness

through education on resources and by implementing appropriate tools for each client based on

their individual plans for a healthy lifestyle. Attending to the individual needs of the clients and

developing solutions to overcome these challenges will increase participation in adaptive

recreation and provide opportunities for these individuals to learn what he or she is capable of.

Occupational Justice

The holistic community program will reduce the impact that occupational deprivation and

occupational imbalance has in a person’s life when the environment and/or tasks are not set up to

meet their needs. When individuals experience a loss of physical and/or cognitive function, they

often are deprived of occupational opportunities. This is often referred to as occupational

deprivation. This may be due to environmental barriers and/or a decrease in options that meet

individual needs. This program will attempt to reduce or eliminate some of the barriers

impacting occupational performance and engagement while implementing new resources that

support participation.

Those who have neurological impairment often experience an imbalance in physical,

psychological, and social participation; this is also known as occupational imbalance. These
HOLISTIC CONSULTATIVE PROGRAM 30

imbalances may result in one of these areas being significantly less than another. For example, a

person may be very physically active and involved, however, may continue to experience

depression due to an absence of social relationships or because of a lack in confidence. This may

be related to changes in physical function and/or the inability to adapt to environmental and

personal changes. By offering a program that addresses social connections, inclusion of common

activities, and innovative equipment design to meet individual abilities, these individuals will be

able to find more balance and improve overall quality of life.

Prevention

This program will be implemented with individuals who have already experienced an

injury and therefore does not meet the qualifications for primary prevention. However, this

program will strive to prevent further decline from occurring as a result of decreased community

mobility, misinformation about a diagnosis, and/or limited social participation with others.

Additionally, this program will seek to provide resources, knowledge, and support to improve

overall occupational performance. This population is considered an at-risk group as they have

many physical and cognitive traits that could lead to additional consequences if not given

adequate care and attention.

To support clients through secondary preventative methods, details regarding client’s

medical conditions and possible symptoms will be collected to determine what each participant

is at risk for. By learning about this, participants will be able to engage in recreational activities

that are suitable and appropriate based on their health status and current condition.

TRAILS offers many opportunities to reduce risks for further injury and/or complication

due to a sedentary lifestyle. Tertiary prevention focuses on improving performance, reducing

risks, and increasing opportunities for those who have an existing condition. By offering a
HOLISTIC CONSULTATIVE PROGRAM 31

program that introduces a focus on peer-mentorship, socializing, and equipment design to

include individuals of all abilities, those with neurological conditions will be able to maximize

function to participate in the things they are interested in.

Rationale for Occupational Therapy’s Role

To effectively implement this program which addresses the multi levels of a person’s

health, it is vital to consider all the personal and environmental contexts, influences, and barriers

to participation in the available adaptive recreation services. It is also important to understand

what is required to engage in the activities provided. Furthermore, understanding the individual’s

condition and how it impacts function is relative to considering how that task needs to be adapted

to meet the client’s current function. Occupational therapists have the knowledge base to perform

an in-depth activity analysis to determine the physical, cognitive, and social factors required to

complete a given task. Once this is determined, occupational therapists are trained to adapt the

environment and/or task to help the client be successful in completing the occupation with the

physical mobility and mental function that he or she demonstrates. Another skill that

occupational therapists are proficient at is adapting needed equipment to be used for both

recreational, personal care, and completion of home responsibilities. Equipment can be modified,

designed, and created to meet the specific physical structure and/or mobility that a person has to

participate in meaningful occupations and increase their independence.

Occupational therapists evaluate the holistic view as they address the person,

environment, and occupation. Within this program, the occupational therapist will provide

consultant services to address a variety of areas that will support the participants in all areas that

impact their participation. Having an occupational therapist implement this program rather than

another professional would be most appropriate as occupational therapists have a broad scope of
HOLISTIC CONSULTATIVE PROGRAM 32

practice and focus on client factors beyond the condition, and will assess the environment to

make it accessible to the client. Occupational therapists assist clients in navigating barriers and

creating opportunities to participate independently in occupations that are meaningful. These

occupations may include but are not limited to leisure activities, social participation, tasks at

home, managing one’s health, and/or community mobility. The program is focused on the

development of occupation-based services which correlate with many of these same areas. These

include volunteer education and equipment design to allow for community and recreational

participation, development of new activities to correlate with common tasks at home, and a peer

mentorship service to increase participation and improve relationships with others who have a

similar experience.

The University of Utah Health system is well connected and involves individuals from

various disciplines with efficient teams that work to provide for the necessary health services of

clients. TRAILS is a part of the network and therefore they receive some input from others,

including occupational therapists. Although this is available and a valuable resource, these

therapists are also involved in direct patient care through inpatient and outpatient services.

Having a consultant occupational therapist whose only focus is improving and creating services

offered by the TRAILS program would allow for a more direct and hands on approach.

Theoretical Foundation

Practice models support the practice of occupational therapy to ensure that therapists are

implementing treatment and using assessments that are appropriate, useful, as well as improves

occupational performance and participation. These models also inform therapists of the expected

changes that should result, recommended populations, and suggestions for therapeutic
HOLISTIC CONSULTATIVE PROGRAM 33

intervention. Three models have been identified to guide intervention and the development of

this program.

The Person-Environment-Occupation (PEO) model emphasizes the importance of

creating an environment that allows a person to improve their occupational participation.

Individuals with neurological conditions often have trouble participating in recreation because of

environmental barriers. Individuals may also experience dissatisfaction with their occupational

performance because of personal and/or activity barriers that do not meet the person’s functional

abilities (Law et al., 1996). By changing the participant’s environment through adaptive

equipment design and/or adapting the activities provided, one can increase their congruence in

desired occupations. The Model of Human Occupation (MOHO) focuses on sustaining a

person’s motivation through participation in occupation. Individuals who experience a life

changing injury often lack the desire to face new challenges and demonstrate decreased

adaptability to their new environment. This model also includes the creation of an occupational

identity and being able to perform competently within this identity in various settings and

situations (Kielhofner, 2009). The COPM as mentioned previously is an assessment which

involves a semi-structured interview to identify current challenges and goals for clients. This will

be used to identify barriers and priorities to be addressed by the program. By focusing on the

biopsychosocial components, TRAILS will be able to identify additional barriers to participation

in adaptive recreation and adjust their services accordingly.

The Occupational Adaptation (OA) model attends to individual’s ability to adapt within

their environment despite the physical and/or cognitive limitations they may experience (Schultz,

2014). Individuals with neurodisabilities often experience challenges leading to social regression,

physical inactivity or limitations, and environmental barriers. By providing a program that offers
HOLISTIC CONSULTATIVE PROGRAM 34

a variety of recreational opportunities and adapting the equipment and logistical necessities,

participants will have an opportunity to learn how to adapt their personal surroundings to meet

their needs and improve their occupational performance.

These theories will be manifested through the social peer-mentorship program as

participants are encouraged to interact with another person with a similar condition. It will also

be shown through the development and design of adaptive equipment based on individual needs

and abilities to increase the person’s capacity to participate in recreational activities, sport and

non-sport related. Additionally, these models will be used to discover the barriers and challenges

to engage in occupation and to create changes to overcome the challenges.

Goals and Objectives

Goal 1: TRAILS will incorporate volunteer education and equipment design to meet the

functional needs of participants through engagement in adaptive recreation.

Objective 1: Within 2 months, TRAILS staff members will independently collect 80% of

participant profiles to be used to create a community document.

Objective 2: Within 4 months, 75% of participants will independently meet with a

TRAILS volunteer to discuss their personal needs, deficits, barriers, and abilities to

increase awareness and understanding.

Goal 2: TRAILS participants will engage more fully in adaptive recreation activities by

increasing their social relationships with other members.

Objective 1: Within 2 months, 75% of participants will independently engage in one

social interaction with their assigned peer measured by self-report.

Objective 2: Within 4 months, 80% of participants will independently get involved in

more than 2 group recreational activities monthly per self-report.

HOLISTIC CONSULTATIVE PROGRAM 35

Program Specifics – A Holistic Consultative Program in Adaptive Recreation

The consultative program will be provided in addition to the current services provided by

the TRAILS program. Three specific areas will be the focus to improve social relationships

among participants, continued involvement in adaptive recreation, and volunteer/staff education

related to the needs of those they are serving. Criteria for participants will include those who are

eligible for current programs provided by TRAILS; 16 years and older, individuals with

neurodisabilities, men and women.

The first area of focus will address volunteer education and equipment design.

Participants who are already involved in TRAILS will be invited to complete an interview,

approximately 30 mins with the occupational therapist to complete the COPM and establish

goals. Those who are receiving inpatient services through the University of Utah hospital will

complete this with their occupational therapist before discharge. Any new participants, not

affiliated with University of Utah health will complete this interview at the beginning of

attending any TRAILS programs. By completing the COPM, the occupational therapist will

begin to gather data on individual barriers, function, and goals. The therapist will work with each

client to narrow down and choose two to three goals that he or she feels is most important for the

participant to achieve through participation in adaptive recreation.

With the use of these goals and detailed information on functional abilities, a community

document will be created for volunteers to refer to for participant information. This document

will include relevant information such as name of participant, goal(s), diagnosis or condition(s),

current function (ex: able to transfer from floor to equipment), and steps the client needs assist

with during recreational activities; the details of this form are highlighted in appendix B. This

document will be created prior to each activity for the scheduled day by the program director and
HOLISTIC CONSULTATIVE PROGRAM 36

will be given to the volunteers who are assisting the participants. This information will provide

education to volunteers in what the client may require help with and what the participant is able

to do independently. By understanding this information, participants will feel that they have the

support they may need to engage in the activities, but also can learn to adapt and complete parts

of the task without unnecessary interference from others.

Education forums will be provided by the occupational therapist for both volunteers and

staff members that relate to the needs of TRAILS participants. Topics may include discussion on

symptoms of common conditions, environmental considerations (weather, equipment set-up,

etc.), and/or communication with participants. Volunteers and staff will have an opportunity to

vote on topics they feel are most valuable and interesting to provide adequate services to

participants. These forums will be held once a month, on the first Saturday, from 1pm-3pm. The

forums will provide an opportunity for the team to ask questions, discuss ideas, and make

changes or plans to improve the delivery of services. Additionally, a weekly meeting will be held

twice a month to discuss logistics of the program including sign-ups for volunteer time,

equipment needs, and other situations that arise.

Equipment design is coupled with education as it is vital that volunteers understand the

equipment adaptability, function, and use, to set it up for a user to be as independent and

functional as possible. The occupational therapist will meet with the engineering team twice a

week to design and create new ways to be able to adapt one piece of equipment to meet the needs

of many participants with varying levels of function. This will decrease the amount of expenses

required to create one piece of adaptive equipment for only a couple of users. Additionally, it is

vital that volunteers are educated on how to change the equipment, such as the handles, seat

height, leg extension, etc. to make it useable for the participant according to their physical needs.
HOLISTIC CONSULTATIVE PROGRAM 37

The second area of focus will be the development of two additional activities that address

tasks that are more commonly a part of daily living. The two activities that participants and staff

have stated the most interest in are gardening and cooking. The decision to include additional

activities among the many services already provided was based on the importance of attending to

the needs of those with severe injuries. TRAILS wants to provide services primarily to those

with complex disabilities, however, these individuals are not showing up on a consistent basis to

the current activities provided. After conducting a needs analysis, it was determined that this may

be due to a decrease in adaptability in the activities provided, requiring staff or volunteers to help

these individuals more than they want. There are many steps involved in both gardening and

cooking which allows participants with varying levels of injury to get involved using their

current function. These activities will also challenge and improve skills to be used outside of

adaptive recreation participation but rather in everyday tasks.

Gardening will be set-up at Wasatch Community Gardens which is a local facility that

provides access to gardening plots for purchase to the public. An initial step that needs to be

considered before setting up a garden is making sure that the location is accessible. Accessibility

will include working with staff at the community garden to ensure that the entrance is wide

enough for wheelchairs, the ground is level and smooth, and the garden plots are at varying

heights for standing and sitting participants. Adaptive gardening equipment will also need to be

designed and created to ensure that individuals can get involved. Equipment will be developed

by the engineering team in collaboration with the occupational therapist. Job tasks for

participants to take part in include but are not limited to choosing what is planted, going to the

store with staff/volunteers to purchase needed items, and planting, watering, or picking the

chosen food items. One day a week will be designated to having those who are interested attend
HOLISTIC CONSULTATIVE PROGRAM 38

the gardening activity, however, staff, volunteers, and participants will need to sign-up for

additional days and times to sustain the garden.

Cooking class will be conducted at the Salt Lake Institute of Culinary Education where a

kitchen is already provided and private groups are instructed by a chef to complete a full meal

with a variety of recipes for the starter, main course, and dessert. This class will be held twice a

month and individuals will be allowed to sign up and attend one of the available times to provide

an opportunity for everyone interested to take part. Cooking will allow for individuals with both

cognitive and/or physical limitations to learn ways to adapt in the kitchen. Again, prior to

beginning this activity, it is vital that the engineering department designs and creates equipment

suitable for the needs of participants. The occupational therapist and staff members will

coordinate with the chef for each event to briefly discuss the participant’s conditions, ensure the

environment is accessible and set up accordingly, as well as get an overview of what the

individuals will be cooking. This will allow the therapist to select certain individuals based on

their function to complete a specific step of the cooking process. Each week, prior to attending

the cooking class, participants will be given their assigned task with an explanation of what is

expected and how it will be adapted to meet their needs. Some of the job tasks will include

reading out the steps of the recipe, organizing groups for the various courses, gathering needed

items, mixing ingredients, and setting the table. Each participant will be encouraged to

participate in all these responsibilities and will be provided with adaptive equipment to support

the clients.

The third area of focus will attend to the social connections and relationships among

participants to create an environment where one feels comfortable and increases their willingness

to try something new or different. Currently, individuals attend many of the provided activities
HOLISTIC CONSULTATIVE PROGRAM 39

and participate in the sports and services independently without much interaction with others.

Through the development of a peer-mentorship program, individuals will have the opportunity to

learn from others with similar experiences and be able to share their own story, challenges, and

successes. As previously mentioned, peer-mediated intervention often increases a person’s

motivation to participate due to a feeling of relatability.

The peer-mentorship program will begin with those who are receiving care at the

inpatient rehabilitation center at the University of Utah. These individuals are often the first to be

informed about the services provided by TRAILS. If interest is expressed, the person will be

paired with someone who is currently and consistently participating in the adaptive recreation

programs. Individuals will be paired based on their condition and/or function to allow for more

common traits and shared skills. It will also be ideal to pair up an individual who is motivated

with someone who may be less sure, anxious, or hesitant to participate in the activities. Social

opportunities will be embedded within current activities/programming. An example of this may

include pairing up individuals who require extra assistance such as safety during cycling with

someone well experienced, rather than pairing them up with staff or a volunteer. A list of

pairings will be kept on record and individuals will be rotated monthly to allow for participants

to build relationships with others both alike and different from them.

Additionally, through the peer-mentorship program, individuals will be paired up based

on vehicle accessibility. If a person drives and can transport other individuals, these members

will be put in contact with one another to coordinate rides to weekly events. Transportation is

one of the primary barriers to getting to the variety of activities and staying engaged in

participating in the services provided. However, with the assistance of those who drive, these

individuals will be able to enjoy the activities without the hassle of public transportation and/or
HOLISTIC CONSULTATIVE PROGRAM 40

reliance on others for travel. The proposed program addresses the physical, cognitive, and social

health needs, educational disparities, community integration, and social systems relevant to

individuals with neurodisabilities. Participants of TRAILS will take part in the enhanced services

to receive benefit to be able to live a well-rounded life.

Time Requirements

The occupational therapist will spend approximately 8 hours a week offering consultant

services that focus on the three areas mentioned previously including volunteer

education/equipment design, development of additional activities, and peer-mentorship.

Consultant services will be provided for a total of 6 months to establish a foundation and allow

time for the initial development of the added services. There are many different activities and

programs that TRAILS offers throughout the week and therefore the time that clients spend

participating will vary. However, the adaptive gardening and cooking class will take up

approximately 5 hours a week.

Staff Involvement

It is important that staff and volunteers are involved as much as possible as they will

continue to carry out the program after the occupational therapist provides the consultant

services. The staff will be responsible for the development of the community document of

participant’s needs that the volunteers will use to determine set-up of the activity. Staff will also

be involved in the creation of the additional gardening and cooking activities. Their role will be

to coordinate the schedule of events, delegating duties to participants, and organizing

transportation, equipment, and other logistics. Staff will refer clients to the occupational therapist

for initial interview if the participant is not currently receiving services through University of
HOLISTIC CONSULTATIVE PROGRAM 41

Utah Inpatient Rehabilitation. Staff will resume their typical roles with the addition of these tasks

which may require delegation to reliable volunteers to complete some of the less involved duties.

OT Involvement

As stated prior, the occupational therapist will be responsible for completing the COPM

assessment and initial interview with each participant to establish individual goals. The

occupational therapist will also be the speaker for some of the educational forums provided for

staff and volunteers. However, some of these will be conducted by a specialist in the specific

chosen topic area. The occupational therapist will collaborate with the engineering department

and be involved in the design of adaptive equipment and tools to assist participants in engaging

in adaptive recreation opportunities, specifically with the new activities (gardening & cooking).

All the stated services and schedule is highlighted in appendix C. The occupational therapist will

be very involved toward the beginning of the consultant services, however, she or he will begin

to delegate some of these tasks to staff and volunteers to allow for transfer of responsibilities

throughout the course of six months.

Community Resources

TRAILS values their collaboration with community facilities as it allows them to expand

the services they offer and provide a unique group of recreational activities. With limited funding

and staff members, it is important for this organization to reach out to other programs who

already have an established service and collaborate with their leaders to make accommodations

for individuals with neurodisabilities. The gardening activity and cooking class will also utilize

other organizations and the resources that they have in place, with the addition of some adapted

changes, to allow for individuals with varying disabilities to participate in wholesome recreation.

Space Requirements
HOLISTIC CONSULTATIVE PROGRAM 42

Fortunately, the TRAILS program has recently gained access to a new, renovated, and

large space at the Imaging & Neurosciences Center (INC). This space is currently being utilized

for the office area for staff, storage of equipment, and for hosting various events. With the

addition of this program and added services, this space would be used for volunteer meetings,

educational forums, office space to work on peer-mentorship assignments and community

document, and fundraising opportunities. The meetings, forums, and fundraising events would

require approximately 60” x 40” or 240 sq ft of space provided, while the office space would

require 10” x 4” or 40 sq ft. The INC has chairs and tables available for events held at the INC,

however, the occupational therapist will require a chair and table for workspace to be set up in

the office. Interviews with participants will take place at varying locations depending on what is

convenient for the individual; these may occur at the INC or at the location of the recreational

activity. Any storage space needed will be provided by the INC in the storage sheds and/or

cabinets available in the office. Outdoor space will include Wasatch Community Gardens as well

as where the interviews are held.

Budget

Implementation of the proposed program will require funding to support the needs of

equipment design and the addition of the gardening and cooking activities. Start-up costs will

consist of items including a computer, work station with chair and desk, and marketing. Direct

costs will cover expenses such as the education and consultative services provided by the

occupational therapist, COPM assessments, and office supplies. Adaptive equipment design will

be the largest direct cost as the material is of high value. Adaptive equipment costs will cover the

expenses needed to support the new development of the gardening and cooking activities as well

as the re-innovation expenses of current equipment needs (kayaking, skis, sail boat, etc.). Labor
HOLISTIC CONSULTATIVE PROGRAM 43

costs for the engineering department will also be included in direct costs to pay for services and

time to design and create needed equipment. The last direct cost will be mileage reimbursement

for those who provide transportation through the peer-mentorship program. Indirect costs will

include expenses for use of the Wasatch Community Garden space and utility expenses at the

INC.

Due to TRAILS having access to a large space for events, office with printer, and

volunteers, these services are considered in kind contributions. Participants are not required to

pay for the services provided by TRAILS, therefore, income is limited. Charity and fundraising

events will be held once a month to fulfill the need for ongoing expenses. For additional details

on the proposed budged, see appendix D.

Program Marketing

To increase community awareness and market the TRAILS program, with added

services, channels already in place will be used such as the inpatient rehab center to notify

patients of the program’s changes and to inform new patients of what is available. It would be

relevant to use community events such as educational forums that are held at the INC for specific

neurodisability populations (neuro auto immune conditions, etc.). It is important to also

implement educational forums to the public to inform them of the barriers these individuals face

and the opportunities available to them through adaptive recreation. As the details and

knowledge gets spread, the community may be able to identify someone they know personally

who could benefit from the services provided.

The services would follow the same philosophy and focus already in place by the

TRAILS program which includes older adolescent to adults with neurological conditions,

specifically those with complex, severe symptoms, or physical impairment. However, other
HOLISTIC CONSULTATIVE PROGRAM 44

populations that should be targeted through marketing are those who are willing and able to

volunteer. Additionally, those who currently volunteer will also be informed through marketing

outlets to understand the new aim of the program which is to increase volunteer education on the

various conditions that individuals who participate in TRAILS have.

To locate more individuals who qualify for the services provided by TRAILS, it will be

beneficial to coordinate with community programs which may work with similar populations

(vocational rehab, Independent living center, adult day cares, etc.). This would allow these

facilities an opportunity to inform their participants of the services provided by TRAILS.

Collaboration with these programs may also allow for more opportunities for these individuals to

engage in the community and to expand their participation in occupations.

Several types of promotion will be utilized to increase awareness of the program. Direct

marketing will be implemented by speaking to potential participants, family members, and/or

volunteers about the services provided. Advertising using flyers and handouts with details of

when the program services are available (days, times, etc.) will be presented at various events

and provided to the community agencies listed prior. Furthermore, there will be scheduled open-

house opportunities for individuals to get a tour of the INC facility and receive an overview of

the activities and services provided. Current participants will also have an opportunity to share

their experience with the new addition of services offered by TRAILS.

Marketing is a vital role in the development of a new program as it is the means of

providing information to the public and gathering those who could receive benefit from the

services provided. By offering multiple methods of marketing, this program will reach potential

participants, volunteers, and community agencies. Marketing allows for the services to be
HOLISTIC CONSULTATIVE PROGRAM 45

explained and presented in such a way that encourages others to get involved in something that is

interesting and/or meaningful to them.

Funding Options

The TRAILS programs relies on the use of grants and in kind donations to support their

financial and physical needs as they do not require payment for services. These grants support

items such as basic office supplies, adaptive equipment needs, utilities to use the buildings, and

staff salaries. Currently, TRAILS applies for approximately 20 grants ongoing to support their

goals and philosophy. To support the addition of services with this proposed program, two grants

provided through The Good Fund & May and Stanley Smith Charitable Trust will be utilized to

receive extra funding.

The Good Fund provides support for many health and human services and provides a

large portion of funding to aid adaptive recreation and sport programs. To locate grants provided

by this organization, the audit trail consisted of keywords such as, adaptive recreation, adaptive

sports, adults, neurology, and people with disabilities. The May and Stanley Smith Charitable

Trust has a mission that focuses on providing opportunities for individuals with disabilities to

improve their “quality of life, promote self-sufficiency, and assist individuals in achieving their

highest potential” (May & Stanley Charitable Trust, 2018). The audit trail used to locate these

resources included the following keywords: adaptive recreation, people with disabilities, adults,

and Utah. Both grants support the finances required to fund this program with offering amounts

between $50,000 - $75,000. These grants will be utilized to expand the current services provided

by TRAILS to offer a more holistic approach to community re-integration.

Program Evaluation
HOLISTIC CONSULTATIVE PROGRAM 46

Evaluation is a vital part of program development as it is helpful in determining what is

going well and addresses areas of needed improvement. Having various types of evaluation also

offers a unique way to gather data on identified barriers and benefits of the program services.

Throughout delivery of services, the occupational therapist will seek for ongoing feedback and

opinions about the services from staff, volunteers, and participants to gauge the value of the

program and to make necessary changes in the moment. Both qualitative and quantitative

evaluative measures will be utilized to collect information on the outcomes of the enhanced

TRAILS services.

A summative interview will be conducted by the occupational therapist with each

participant and volunteer at the end of the six-month contract after implementation of the

program. This meeting will take place formally at the INC if individuals are able to attend, or

will be conducted over the phone. Individuals identifying information will not be shared,

however, participants will be asked to state how often he or she attended the services weekly and

this data may be used in later reports. This interview will inform the occupational therapist of the

level of commitment, effectiveness of services, and give insight into the person’s motivation or

interest to participate. The interview will provide qualitative data including the following five

open-ended questions: 1) Which part(s) of the program are you most satisfied with, Why, 2) In

what ways has the program increased your motivation to participate in adaptive recreation, 3)

Discuss the benefits you feel you receive from the program, 4) Please describe what encourages

you to get involved in adaptive recreation, and 5) What changes do you feel would positively

improve the program. The results from this interview will be coded to find themes and

commonalities among responses and will be used to adjust the services to better meet the needs

of participants.
HOLISTIC CONSULTATIVE PROGRAM 47

A quantitative survey will be given to only participants which will address satisfaction,

motivation, social interactions, confidence, independence, and holistic needs. The survey will be

provided in the last month of consultative services provided by the occupational therapist to

allow time for completion. Individuals can receive an e-mail if he or she is unable to meet in

person to get the form. The survey will provide options on a Likert scale from strongly disagree

to strongly agree and will include the following five statements: 1) I am satisfied with the new

changes to the TRAILS program (peer-mentorship, volunteer education, additional activities -

gardening, cooking, and equipment design), 2) I am motivated to participate in more adaptive

recreation, 3) The new services have increased my desire to socialize and interact with others

who participate in TRAILS, 4) I feel that I can do more things independently and with

confidence as a result of the new education and services provided by TRAILS, and 5) The new

services have met both my physical and functional abilities; see appendix E for details of

interview questions. Both means of data collection will offer greater insight of the usefulness of

services to determine what changes should be made to improve the delivery of services for all

involved.

Expected Outcomes

The goal of the development of this program is that individuals with neurodisabilities,

volunteers, and staff will participate in an adaptive recreation program (TRAILS) that improves

all areas of health. A specific outcome for participants are that individuals will increase their

motivation and desire to participate in TRAILS through making social connections with other

members. Participants are also expected to get involved in activities that meet the needs of those

with complex injuries through the development of appropriate equipment. An expected outcome
HOLISTIC CONSULTATIVE PROGRAM 48

for volunteers is that they will receive adequate education to support the physical and cognitive

needs of participants through adaptive recreation services.

Summary

Offering a holistic consultative program in an adaptive recreation setting for individuals

with neurodisabilities will attend to the physical limitations, cognitive impairments, and social

needs that participants with these conditions experience day to day. TRAILS provides a variety

of services that focus primarily on physical function and mobility. With the addition of the

services described in this proposal, individuals will have an opportunity to expand their

knowledge and gain skills through participating in an occupation based program that is set up

based on their individual needs and functional abilities.

HOLISTIC CONSULTATIVE PROGRAM 49

Appendix A

Interview Questions

Client Questions:
What do you like about the services offered by TRAILS?
What are the biggest challenges you face when participating in the TRAILS program?
Is there anything you would change or add to enhance the TRAILS program?
What do you feel you gain from participating in this program?
How were you informed about the TRAILS program?
What is your relationship like with other clients who attend the TRAILS program?
Do you have a favorite program offered by TRAILS? If so, why?
What are the everyday challenges that you experience?
What does a typical day look like for you?
What occupations are most challenging for you to participate in?

Staff/Administration Questions:
What is the purpose of the TRAILS program?
What services are provided by the TRAILS program?
What is the process for someone that is interested in joining the TRAILS program?
Are there qualifications for someone to participate in TRAILS?
Is the program only limited to those with spinal cord injury? If so, why?
Are there any programs you wish you could implement?
What are the strengths of the current services?
What are the weaknesses of the current services?
How are the services/programs funded?
How did you decide what adaptive sports to include?
What are your plans for the future of the TRAILS program?
Based on what you know about OT, are there any services you think could be added by an
occupational therapy practitioner?
 HOLISTIC CONSULTATIVE PROGRAM 50

Appendix B

Community Document

Name of Goal(s) Diagnosis/Condition Able to Needs Assist With:

Participant Transfer?
Y/N
 HOLISTIC CONSULTATIVE PROGRAM 51

Appendix C

Occupational Therapist Schedule

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

8am–9am Create
Community
Participant
Document;
Make Peer
Assignments
9am-10am
10am-11am Equipment Equipment
Design Design
Meeting Meeting
11am-12pm Cooking
12pm-1pm Class: 2x
month (every
other
Saturday)
1pm-2pm
2pm-3pm Adaptive
3pm-4pm Gardening:
4pm-5pm Organize
supplies, set-up
equipment, etc.
5pm-6pm
6pm-7pm
7pm-8pm Volunteer
weekly
meeting- 2x
month
(education
on neuro
conditions;
needs, sign-
up, etc.)
HOLISTIC CONSULTATIVE PROGRAM 52

Appendix D

Line-Item Budget Detail

Source of Specific costs or sources of income Cost
Start-up Costs Computer $800
Work Station (Chair & desk) $400
Marketing: $600
- Flyers, website design ($100/month x 6
months)

Total= $1800

Direct Costs Education & Consultative Services $5760

$30/hr x 8 hr x 24 weeks (6 months)
Supplies:
- Computer-Based COPM Assessments (100/3 $27.58
months)
- Paper and Ink cartilage ($50 every 2 months x $150
3 = $150/6 months)
Adaptive Equipment Design Material (6 $30,000
months):
- Cycling, skis, kayaks, sail boat, etc.
- Handles, sip & puff, straps
- Kitchen (cooking supplies-stove, sink,
counters, cabinets), adaptive gardening

$5,000/1 month x 6 months = $30,000

Cooking/Adaptive Gardening Supplies:
- Food ($60/event x 12 events) $720
- Gardening-seeds, dirt ($50/one time cost) $50
Labor Costs For Students (Engineer school/OT) $4800
$20 x 10hr x 24 weeks (ongoing)
Peer – Mentorship (Ride Share Program) $3600
- Mileage Reimbursement (.50 x 20miles x 24
weeks x 15 drivers =

Total= $49, 347.58

Indirect Costs Wasatch Community Gardens (Adaptive $240

Gardening)
$40/month x 6 months (ongoing)
Utilities at Imaging & Neurosciences Center $2400
$400/month x 6 months (ongoing)

Total= $2640
HOLISTIC CONSULTATIVE PROGRAM 53

In Kind Use Imaging & Neurosciences Center:

- Space available 60” x 40” (240 sq ft) $0
- Build equipment
- Install kitchen for cooking recreation
- Chairs for educational seminars/volunteer
collaboration
- Office space available
Volunteer Hours:
- Volunteers contribute 4hr/week
Printer (In Kind) $0

Total = $0

Income No cost for participants $0

Donations: $12,000
- Hold charity events 1x/month (goal of $2,000)
x 6 months
Total= $12,000

Total costs $53,787.58

Total income or $12,000

in-kind
contributions
Net cost of $41,787.58 To be covered by grants and fund-
program raising/donations
HOLISTIC CONSULTATIVE PROGRAM 54

Appendix E

Qualitative Interview

1.) Which part(s) of the program are you most satisfied with? Why?

2.) In what ways has the program increased your motivation to participate in adaptive
recreation?

3.) Discuss the benefits you feel you receive from the program?

4.) Please describe what encourages you to get involved in adaptive recreation.

5.) What changes do you feel would positively improve the program?
 HOLISTIC CONSULTATIVE PROGRAM 55

Quantitative Interview
(Circle one of the choices)

1.) I am satisfied with the new changes to the TRAILS program (peer-mentorship, IADL
participation, and equipment design).

Strongly disagree Disagree Slightly disagree Slightly agree Agree Strongly agree

2.) I am motivated to participate in more adaptive recreation.

Strongly disagree Disagree Slightly disagree Slightly agree Agree Strongly agree

3.) The new services have increased my desire to socialize and interact with others.

Strongly disagree Disagree Slightly disagree Slightly agree Agree Strongly agree

4.) I feel that I can do more things independently and with confidence as a result of the new
education and services provided by TRAILS.

Strongly disagree Disagree Slightly disagree Slightly agree Agree Strongly agree

5.) The new services (volunteer education, equipment design) has met my physical needs
and functional abilities.

Strongly disagree Disagree Slightly disagree Slightly agree Agree Strongly agree
HOLISTIC CONSULTATIVE PROGRAM 56

References

AdminiTrust LLC (2018). May & Stanley Smith Charitable Trust. Retrieved from

http://www.adminitrustllc.com/may-and-stanley-smith-charitable-trust/.

Barone, S., & Waters, K. (2012). Coping and adaptation in adults living with spinal cord injury.

Journal of Neuroscience Nursing, 44(5), 271-283.

Blauwet, C., Yang, H., Cruz, S., Collins, J., Smith, K., Losina, E., & Katz, J. (2017). Functional

and environmental factors are associated with sustained participation in adaptive sports.

PMRJ, 9(7), 668-675.

Carswell, A., McColl, M., Baptiste, S., Law, M., Polatajko, H., & Pollock, N. (2004). The

canadian occupational performance measure: A research and clinical literature review.

Canadian Journal of Occupational Therapy, 71(4), 210-222.

Cheung, A., Brawley, L., Wilson, A., Tomasone, J., Arbour-Nicitopoulos, K., Gray, C.,

Prapavessis, H., & Wolfe, D. (2013). Devloping physical activity interventions for adults

with spinal cord injury. Part 2: Motivational counseling and peer-mediated interventions

for peope intending to be active. Rehabilitation Psychology, 58(3), 307-315.

Cunningham, C., Wensley, R., Blacker, D., Bache, J., & Stonier, C. (2012). Occupational

therapy to facilitate physical activity and enhance quality of life for individuals with

complex neurodisability. British Journal of Occupational Therapy, 75(2), 106-110.

Friederich, A., Bernd, T., & Witte, L. (2010). Methods for the selection of assistive technology

in neurological rehabilitation practice. Scandinavian Journal of Occupational Therapy,

17(4), 308-318.
HOLISTIC CONSULTATIVE PROGRAM 57

Jaarsma, E., Dijkstra, P., Geertzen, J., & Dekker, R. (2014). Barriers to and facilitators of sports

participation for people with physical disabilities: A systematic review. Scandinavian

Journal of Medicine & Science in Sports, 24(6), 871-881.

Kielhofner, G. (2009). Conceptual Foundations of Occupational Therapy Practice (4th Ed., Pp. 147-174).

Philadelphia: F. A. Davis Company.

Lape, E., Katz, J., Losina, E., Kerman, H., Gedman, M., & Blauwet, C. (2018). Participant-

reported benefits of involvement in an adaptive sports program: A qualitative study.

Physical Medicine and Rehabilitation Journal, 10(5), 507-515.

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The person-

environment-occupation model: A transactive approach to occupational

performance. Canadian Journal of Occupational Therapy, 63, 9-23.

Lundberg, N., Taniguchi, S., McCormick, B., & Tibbs, C. (2011). Identity negotiating:

Redefining stigmatized identities through adaptive sports and recreation participation

among individuals with a disability. Journal of Leisure Research, 43(2), 205-225.

Schultz, S. (2014). Theory of Occupational Adaptation. In B. A. B. Schell, G. Gillen, & M. E.

Scaffa (Eds). Willard and Spackman’s occupational therapy (12th ed., pp.528-540).

Philadelphia: Lippincott Williams & Wilkins

Tasiemski, T., & Brewer, B. (2011). Athletic identity, sport participation, and psychological

adjustment in people with spinal cord injury. Adapted Physical Activity Quarterly, 28(3),

233-250.

Truelle, J., Fayol, P., Montreuil, M. & Chevignard, M. (2010). Community integration after

severe traumatic brain injury in adults. Current Opinion in Neurology, 23(6), 688-694.
HOLISTIC CONSULTATIVE PROGRAM 58

Turner-Stokes, L., Disler, R., & Williams, H. (2007) The rehabilitation complexity scale: A

simple practical tool to identify ‘complex specialised’ services in neurological

rehabilitation. Clinical Medicine, 7(6), 593-599.

U.S. Department of Health & Human Services (2018). Health Information Privacy. Retrieved

from https://www.hhs.gov/hipaa/.

Utah State Capitol (2018). Voters by Party and Status. Retrieved from

https://elections.utah.gov/party-and-status

United States Census Bureau (2017). Quickfacts Salt Lake County, UT. Retrieved from

https://www.census.gov/quickfacts/fact/table/saltlakecountyutah,ut

University of Utah Rehabilitation Center (2018). TRAILS: Technology Recreation Access

Independence Lifestyle Sports. Retrieved from https://healthcare.utah.edu/rehab/support-

services/trails.php

Warner, G., Desrosiers, J., & Stadnyk, R. (2018). Factors affecting ability and satisfaction with

social roles in persons with neurological conditions: The importance of mobility and

stigma. British Journal of Occupational Therapy, 81(4), 207-217.