An upward slope: therapeutic recreation and downhill skiing.

When it comes to meeting the needs and goals of pediatric rehabilitation, Shriners Hospital for Children in Chicago has transformed downhill skiing into a team sport. In recent years, a group of interdisciplinary team members have joined forces to create a downhill ski trip for adolescents with orthopedic and neurological impairments. The results? Patients receive creative and innovative treatment, while rehabilitation professionals transcend ordinary approaches to therapy, stretch boundaries and help to recreate the health care paradigm.

This interdisciplinary program--which includes physical therapy, occupational therapy, recreation therapy, social work and volunteers--annually takes a group of adolescents, all with various physical disabilities, to Chestnut Mountain Resort in Galena, Ill. During the weekend, they spend the majority of time learning adaptive skiing techniques. The participants return home with a sense of accomplishment, new friends and a newfound belief in their abilities.

Pediatric Rehabilitation Goals

The overall goal of pediatric rehabilitation is to help maximize children's abilities to interact with and manipulate their environment. In adolescent development, the most important element is forming a group identity. Therefore, therapies with this population are maximized when they focus on integrating the client into peer situations. In combination, outdoor adventure programs are not only gaining tremendous popularity among the general population, but are also becoming a recognized treatment modality in hospitals. A team-driven and peer-oriented recreation opportunity, such as downhill skiing, has great potential for improving quality of life.

The specific goals of the downhill ski program are comprehensive and diverse, and thus best met by an interdisciplinary team. For example, physically oriented goals include working on strength, fitness, balance and coordination. Social-emotional goals include becoming involved with group activities, enhancing feelings that accompany success in a challenging activity and getting a chance to experience independence away from parents and caregivers. The ability to comprehensively work on multiple goals with a number of clients in one program is not only holistic, but potentially a cost-effective approach to treatment.

Selection of Participants

The selection of participants is the key to the success of any program. For downhill skiing, a small group is recommended for increased cohesion and the ability to control participant outcomes. Participants are required to be independent in all self-care and activities of daily living (ADLs). Equipment options need to be assessed, as availability may also dictate participant selection. If participants will be attempting upright skiing, they will need to be at least therapeutic or household ambulators and have fair standing balance.

For this program, participants needed to be between the ages of 1 and 19 and willing to attempt skiing both days. The program has had adolescents with the following diagnoses: upper extremity amputations, below-knee amputations, myelomeningocele, spinal cord injury and residual brain injury. The participants were selected through means such as chart reviews and recommendations from a variety of team members.

Staffing

Downhill skiing programs for individuals with disabilities are staff-intensive. For patients who are ambulatory, either a one-to-one or one-to-two staff-to-client ratio is suggested, depending on ability level. For the participants who use any type of sit-ski, a two-to-one staff-to-client ratio is recommended. With six participants, the program at Shriners Hospital for Children used five staff members from the various disciplines and two volunteers, thus ensuring an adequate staff-to-participant ratio.

Using an interdisciplinary team brought diverse specialties to an assorted client population, thus enhancing each participant's likelihood of success. Physical therapy and occupational therapy were able to complete an activity analysis and integrate each participant's physical abilities into the sport. Recreation therapists were responsible for programmatic leadership and adaptive equipment utilization and instruction. Social work was able to set the framework for cohesive group dynamics and concentrate on social-emotional needs. Volunteers were flexible with their responsibilities and stayed focused on the tasks assigned to them.

Funding

Funding for the program comes from two sources. The Recreation Therapy Department at Shriners Hospital absorbs the cost for non-exempt staffing and travel. The other costs include ski rental, lessons, lift tickets, hotel accommodations and meals, and are covered by a single donor. This donor annually receives thank-you letters from the participants telling about their experiences on the trip. This enhances the participants' social awareness while allowing the donor to have a unique perspective on the experience, promoting continued interest in the program.

Equipment

People with physical disabilities may require the use of adapted equipment when downhill skiing. Which equipment is used depends on the participants' ability levels, and may be available at many ski resorts. There are several pieces of gear for participants who are ambulatory but lack adequate balance, coordination or the ability to shift weight. This equipment includes tall outriggers and ski stabilizers. Tall outriggers resemble forearm crutches with the addition of a small ski attachment at the base. Participants are able to use these outriggers to assist with balance while skiing down the slope. Pulling the grip cord attached to the handle of the crutch allows the participant to change the ski attachments from a horizontal to vertical skiing position. When in the vertical position, the outriggers serve the same function as regular ski poles.

Another piece of adaptive equipment for the ambulatory participant is a ski stabilizer. This is for the athlete who doesn't possess adequate gradation of control, lower extremity strength or coordination to keep the skis parallel. A ski stabilizer is clipped to the toe of each ski and holds the front of the skis a safe and manageable distance apart. The ski stabilizer can easily be attached and detached for training. Participants are still able to flare the back of the skis to assist with slowing down and stopping.

Participants who use a wheelchair for mobility require a ski that allows them to tackle the slopes in a seated position. Several types of adapted skis are available, including a sit-ski, a bi-ski and a mono-ski. Each ski is progressively more advanced and requires more balance and skill to maneuver than the next. The sit-ski resembles a sled or toboggan with a seat back for stability and a cover that can be zipped over the participant's legs. The sit-ski is steered with a short ski pole that digs into the snow. This type of ski is excellent for a participant with a more significant physical disability, as it provides the most balance and support. The sit-ski, however, doesn't allow for the range of movement and independence that other models provide.

The next step up from the sit-ski is a bi-ski. This has an elevated bucket seat positioned on two skis using a suspension system. Using a pair of short outriggers for stability, skiers lean side to side for steering. The mono-ski is the ultimate in adaptive skiing, and uses the same concept as the bi-ski, but with only one ski. With these types of skies, an able-bodied skier can instruct and offer hands-on assistance to the student in balancing or maneuvering the ski.

Initially, these skies require two staff members to assist the participant on and off the ski lift. Some of the more advanced skis have a mechanism that helps to elevate the bucket seat, thus making it easier for staff to raise the participant onto the lift or allowing for complete participant independence. Exiting the lift may require a push from each staff member, and all three glide off the lift. For the beginner, the staff holds onto either side of the participant until coming to a stop.

Outcomes

The outcomes of this program have been significant in numerous aspects. Potential for involvement in the downhill ski trip has motivated adolescents to become independent in self-care (i.e. bowel and bladder programs). In fact, many have become more active as they regularly partake in their home exercise programs. It has also helped several adolescents take strides toward overcoming the learned helplessness they may have acquired with their disability. Last but not least, the participants bonded with their peers, helping to create a support system, which contributed to their success in downhill skiing.

Letters to staff and donors have reflected this success:

   "Before going on the trip, I did not
   know if I would be able to ski at all.
   Amazingly, I was able to ski just like
   any other beginner. I came back with
   many bumps and bruises, but also with
   a renewed sense of accomplishment,
   that I can do anything I set my mind
   to."

   "I had such a great time, and can't wait
   to go skiing again soon. I was amazed at
   the fact that I could actually get up on
   skis. I cannot wait to drag my family
   out to ski again."

Case Highlight

One of the participants of this downhill ski program was a 14-year-old female with an incomplete C6 spinal cord injury caused by a diving accident in 1999. In July 2001, the spinal cord injury team at Shriners Hospital for Children evaluated her. At the time, she wasn't fully independent in her self-care and ADLs, had limited strength throughout upper and lower extremities, and had difficulties with balance and coordination. Although she was ambulatory with an assistive device, she was able to walk limited distances and only over even surfaces. This patient struggled with having the confidence and initiative needed to independently perform many of the above skills. Despite this, she and her family were interested in pursuing activities to challenge her to reach her full potential.

After an evaluation by the spinal cord team, including a pediatrician, nurse, social worker, recreation therapist, occupational therapist, physical therapist and psychologist, it was recommended this client be admitted to Shriners Hospital for Children, Chicago, for a rehabilitation stay to increase her independence. During her stay, she was identified as a potential candidate for the ski program. Owing to the criteria necessary to be a participant, she gained the motivation to work on many of her self-care skills. To make the ski trip a success, upper and lower extremity strength, upright balance and coordination were essential. The team utilized a collaborative approach.

This approach included the spinal cord injury medical director, who, in addition to involvement on all levels, was able to address her spasticity and dysesthetic pain by putting her on appropriate medication. The client, her family, the spinal cord injury nurse and the occupational therapist problem-solved the difficulties surrounding self-catheterization and completion of her bowel program independently. Fine motor skills, ability to achieve appropriate positioning and variations available on toileting equipment were assessed. The social worker also became involved with the nurse and the occupational therapist to address comfort level and motivation necessary to become independent with these tasks. In addition, the social worker provided the patient with numerous teaching materials regarding spinal cord injury that involved body image and self-esteem. As part of a peer-mentoring program, the patient worked with a social work student who had a C5-6 level injury. He discussed numerous spinal cord injury issues as well as overall adjustment to disability. The recreation therapist was able to involve the patient in a variety of activities, including wheelchair basketball, scuba diving and a teen cooking group. These opportunities improved her ability to engage with peers and gave her the confidence to explore new leisure activities.

This patient was seen twice daily by physical and occupational therapy to address upper extremity and lower extremity strengthening, ADLs, ambulation and fine motor skills. She continued with outpatient therapy before the ski program to further her strength and abilities specific to skiing. All of these goals were integrated into a home-exercise program.

While at Chestnut Mountain, a variety of options were tried, including a bi-ski, bilateral outriggers and a ski stabilizer. After building confidence and receiving handling cues while skiing, she was able to ski down the hill in an upright position on regular skis with bilateral outriggers, a ski stabilizer and standby assistance. She continued to require maximal assistance with turning and loading and unloading from the lift.

The team effort and collaboration with this participant before the ski trip to increase her independence in all areas made the ski trip a success for her. She was encouraged to pursue new activities using the knowledge and skills that she gained during the trip. In her own words, "This ski trip was great! I fell a lot at first, but I got the hang of it and it was really cool and a lot of fun! It was great to be away from my parents and try something new that I've never done before. If there is something you really want to do, then just keep trying. There will always be a way to do it!"

In today's health care environment, a paradigm shift must occur to meet the changing needs of our clients. Transforming downhill skiing into a team sport has allowed many young people with disabilities to experience the unexpected while gaining invaluable life skills. The spirit of team collaboration enhanced the experience for all who participated, and ensured that goals in the physical, emotional, social and recreational realms were all met. Interdisciplinary programs, such as this downhill ski trip, represent an anomaly in rehabilitation. Yet creativity and innovation are often the hallmarks of success. We hope this program will encourage other clinical facilities to examine current practices, expand traditional services and implement creative, team-driven programs.

Leah Bent, OTR/L, is an occupation therapist at Shriners Hospital for Children, Chicago. Sara Klaas, LSW, C-ASWCM, is director of care coordination at the hospital. Shannon Rathsam, CTRS, is a recreation therapist at the hospital. Jennifer Schottler, MPT, is a physical therapist at the hospital. Kristen Johnson, MS, CTRS, is an assistant professor in the Recreation Administration Department at Aurora University, in Aurora, Ill. For more information about the downhill skiing program, contact Johnson at [e-mail].