THERAPEUTIC RECREATION'S ROLE IN MEETING THE NEEDS OF HEART TRANSPLANT PATIENTS.What does therapeutic recreation have in common with the Tin Man Tin Man may refer to: In television:
reaches and departs from Oz in circus balloon. [Children’s Lit.: The Wonderful Wizard of Oz] See : Ballooning Wizard of Oz false wizard takes up residence in Emerald City. [Am. Lit. ? Therapeutic recreation joined him in a search for a heart, and found that there are many people currently waiting for a heart transplant heart transplant Procedure to remove a diseased heart and replace it with a healthy one from a legally dead donor. The first was performed in 1967 by Christiaan Barnard. who can use and need our services! In the classic movie, The Wizard of Oz, the Tin Man is in search of a new heart. The Tin Man feels he is anxious and insecure without a heart. He so eloquently stated, "I pray I beg; I request; I entreat you; - used in asking a question, making a request, introducing a petition, etc.; as, Pray, allow me to go s>. See also: Pray you to give me a heart, that I may be as other men." The Tin Man's search for a heart continues today as people waiting for a heart transplant experience similar feelings of insecurity and anxiety. A new and exciting area of service for therapeutic recreation is heart transplantation Heart Transplantation Definition Heart transplantation, also called cardiac transplantation, is the replacement of a patient's diseased or injured heart with a healthy donor heart. . Although not extensively utilized in the past, therapeutic recreation is now being provided as a treatment service in numerous heart transplant units throughout the U. S. Many psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects. psy·cho·so·cial adj. Involving aspects of both social and psychological behavior. issues, such as depression, anxiety, boredom, and the need for perceived freedom arise during the waiting period for a heart transplant. Therapeutic recreation services are perfectly suited to assuage as·suage tr.v. as·suaged, as·suag·ing, as·suag·es 1. To make (something burdensome or painful) less intense or severe: assuage her grief. See Synonyms at relieve. 2. these issues. This article will provide an overview of heart transplantation and the role of therapeutic recreation for patients waiting for a heart transplant. Heart Transplantation Persons with chronic, or long-term heart failure, or cardiomyopathy Cardiomyopathy Definition Cardiomyopathy is a chronic disease of the heart muscle (myocardium), in which the muscle is abnormally enlarged, thickened, and/or stiffened. who have not responded to conventional methods may be candidates for heart transplantation (American Heart Association American Heart Association (AHA), n.pr a national voluntary health agency that has the goal of increasing public and medical awareness of cardiovascular diseases and stroke, and thereby reducing the number of associated deaths and disabilities. , 1999). Persons with end-stage heart failure End-stage heart failure Severe heart disease that does not respond adequately to medical or surgical treatment. Mentioned in: Heart Transplantation usually have a prognosis of less than one year to live. Numerous studies have identified that heart transplantation is now the treatment of choice for end-stage heart disease. Heart transplantation is the process of removing the sick or diseased dis·eased adj. 1. Affected with disease. 2. Unsound or disordered. heart and replacing it with a healthy, human heart from a deceased donor. United National Organ Sharing (UNOS UNOS United Network for Organ Sharing Transplant surgery A database dedicated to optimizing the use of transplantable organs; according to UNOS statistics–1995, ± 20,000 major organs and tissues are transplanted/yr; since successful survival of ) (2000) reported that currently 4,118 people are listed as waiting for a heart transplant. They also report that in 1999, 2,185 heart transplants were performed. The one-year survival rate for a heart transplant is 87%. The roster of potential heart transplant candidates is maintained nationally by UNOS. Hospitalized heart transplant candidates are ranked as ambulatory class III or class IV on the New York Heart Association Functional Classification The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying the extent of heart failure. It places patients in one of four categories based on how much they are limited during physical activity: NYHA CLASS of Heart Disease scale (see Table 1). After successful transplant, the recipient is listed as class I or class II. UNOS (2000) identified 77% of heart transplantation patients are male, 54.9% have type O blood, 53.8% are 50-64 years old, and 78% are Caucasian.
TABLE 1. NEW YORK ASSOCIATION FUNCTIONAL
CLASSIFICATION OF HEART DISEASE
Classification Description
CLASS I Patients with cardiac disease but without
resulting limitations of physical activity
Ordinary physical activity does not cause undue
fatigue, palpitation, dyspnea, or anginal pain
CLASS II Patients with cardiac disease that results in a
slight limitation of physical activity
Patients are comfortable at rest, but ordinary
physical activity results in fatigue, palpitation,
dyspnea, or anginal pain
CLASS III Patients with cardiac disease that results in a
marked limitation of physical activity
Patients are comfortable at rest, but
less-than-ordinary physical activity results in
fatigue, palpitation, dyspnea, or anginal pain
CLASS IV Patients with cardiac disease that results in an
inability to carry on any physical activity without
discomfort; fatigue, palpitation, dyspnea, or
anginal pain may be present; if any physical activity
is undertaken, symptoms increase
(Sadowsky, 1996, p. 501)
To be accepted as a heart transplant candidate, the person must have end stage cardiac disease, and must have failed more conservative treatment measures (Rauch & Kneen, 1989). UNOS allocates organs on the basis of medical need, geographical distance from the transplant center, length of time on the registry, and acute disease versus chronic illness. Functional Abilities in Heart Transplant Candidates Heart transplant candidates experience numerous functional disabilities related to advanced heart failure. Adjusting to the functional disabilities that accompany end-stage heart disease is not an easy task. As Shapiro (1996) noted, impairments in sexual functioning, loss of work, and being separated from their families may decrease the self-esteem of the heart transplant candidate. The literature also indicates that heart transplant patients perceive recreation as one of their highest functional disabilities (Jalowiec, Grady, White-Williams, 1994; Muirhead et al, 1992; Walden et al., 1989). Heart transplant patients perceive their physical functional status and ability to perform social and leisure activities to be worse than heart transplant recipients (Walden et al., 1989). In a study of heart transplant candidates, Muirhead et al. (1992) found 89.8% of participants identified the inability to participate in sports and athletic activities, and 74.4% identified the inability to participate in recreation and leisure activities as a significant physical disability. Obviously, recreation and leisure functioning are significant functional disabilities for heart transplant candidates. Psychosocial Issues in Heart Transplant Candidates Hospitalized patients waiting for heart transplants have difficult and unusual psychosocial needs. A unique aspect to transplantation is that "pre-transplant, many patients ... face the mutually opposing tasks of preparing to live and preparing to die" (Abbey & Farrow farrow see farrowing. , 1995, p. 165). Coping with these contradictory tasks is very difficult, and presents many psychosocial obstacles for the heart transplant candidate. In addition, patients are intimately of the fact that another person must die so they can live. This awareness causes the heart transplant candidate considerable stress, and feelings of guilt. On one hand, they hope for a heart so they can return to their previous lifestyle with good health, and on the other hand, knowing that someone must die causes the heart transplant candidate to experience stress and guilt. "Metaphorically, as well as physiologically, the heart is crucial to one's identity and social function" (Shapiro, 1996, p. 618). In society, we identify that our heart is the center of our emotions. We commonly use phrases such as "I am broken-hearted," or, "he wears his heart on his sleeve." Therefore, it is easy to see why so many people waiting for a heart transplant experience psychosocial difficulties, as it is difficult to imagine having someone else's heart in their bodies. The time spent waiting for a heart transplant often causes the candidate to experience a myriad of emotions which range from stress and depression to appropriate well-being (see Table 2). Depression and anxiety are common in heart transplant candidates (e.g., Fisher et al., 1995; Joshi & Kevorkian, 1997; Shapiro, 1996; Shapiro et al., 1996). It is important to address the depression that is evident so that functioning can improve, and so the candidate can work with the treatment disciplines (i.e., physical therapy, occupational therapy, exercise physiology exercise physiology n. The study of the body's metabolic response to short-term and long-term physical activity. , recreation therapy) more effectively (Shapiro et al., 1996).
TABLE 2. PHASES OF ADJUSTMENT TO TRANSPLANTATION
Phases of Adjustment Emotional Correlate
Pre-transplant illness Chronic stress; depression;
anxiety
Transplant proposed Anger, denial, disbelief
Pre-operative work-up Anxiety about acceptance into
the program
Waiting for a donor Impatience, frustration
Donor becomes available Readiness, eagerness to proceed
Initial post-operative period Elation, well-being, calm
Post-operative course Anxiety
Rejection of heart Demoralization, fear
Discharge Ambivalence; anticipation; fear
Adaptation Appropriate sense of well-being
(Rauch & Kneen, 1989, p. 50)
Heart transplant candidates are often hospitalized during the wait, which can last up to a year. As the patient's wait becomes prolonged for a heart transplant, boredom can increase (Holt, 2001). Boredom can negatively affect a person's health and has been found to be the cause of serious social and medical problems such as cardiovascular disease Cardiovascular disease Disease that affects the heart and blood vessels. Mentioned in: Lipoproteins Test cardiovascular disease , psychiatric and psychosomatic psychosomatic /psy·cho·so·mat·ic/ (-sah-mat´ik) pertaining to the mind-body relationship; having bodily symptoms of psychic, emotional, or mental origin. psy·cho·so·mat·ic adj. 1. disease (O'Hanlon, 1981). The need for perceived freedom is pervasive in all realms of the hospitalized heart transplant candidate's life, prehospitalization and during hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun) 1. the placing of a patient in a hospital for treatment. 2. the term of confinement in a hospital. (Holt, 2001). Patients hospitalized while waiting for a heart transplant have little ability to choose what they want to do, as there are many restrictions placed on them by the nature of their illness and by the treatment team. For example, they are usually not able to even leave their unit without a nurse with them because of the severity of their heart disease. Thus, the psychosocial issues which need to be addressed when working with heart transplant candidates are boredom, mood, anxiety, and the need for perceived freedom. By acknowledging and addressing these issues, the recreation therapist can enhance the quality of life for the heart transplant candidate. The Role of Leisure in Waiting for a Heart Transplant Leisure and recreation have been shown to decrease stress levels and incidences of boredom, as well as increase life satisfaction (Iso-Ahola, 1994). Neulinger (1974) posited that along with intrinsic motivation, perceived freedom has been determined to be the primary influence on a person's perception of leisure. Numerous studies (e.g., Iso-Ahola, 1979; Neulinger, 1974) have indicated that people feel more positive and happier if they feel that they are in control of their environment and leisure pursuits. Iso-Ahola (1994) reported that people who participated in numerous activities and were fulfilled by their activity pursuits were better able to deal with life stress than people who are less invested in activities and less fulfilled. Recreation involvement enhances quality of life for people who participate in activities or experience leisure by decreasing anxiety, depression, and social isolation, and improving the ability to manage chronic pain and cope with stressors related to hospitalization (Berryman, James, & Trader, 1991). High level of life stress can be buffered by the freedom to choose and engage in leisure activities (Reich & Zantra, 1981). A low level of stress and proficient pro·fi·cient adj. Having or marked by an advanced degree of competence, as in an art, vocation, profession, or branch of learning. n. An expert; an adept. coping are related to higher life satisfaction and a better quality of life (Grady et al., 1995). "Perceived leisure freedom, intrinsic leisure motivation and the avoidance of leisure boredom are important leisure lifestyle dispositions that are believed to be associated with higher health status" (Coleman, 1993, p. 353). Therefore, it seems clear that the treatment team needs to understand the importance of leisure and perceived freedom for heart transplant candidates, and provide appropriate activities that meet the needs of their heart transplant population. Therapeutic Recreation's Role for People Waiting for a Heart Transplant With the potential of leisure to substantially decrease boredom, increase mood, facilitate coping with stress, and increase feelings of perceived freedom, recreation therapists and the treatment team need to be more aware of how leisure can affect the psychosocial needs of heart transplant candidates. Some suggestions for recreation therapists to meet the psychosocial needs of heart transplant candidates are: 1. Include leisure education to increase the heart transplant candidates' awareness of the benefits of a healthy and appropriate leisure lifestyle, increase the heart transplant candidates' personal awareness of leisure needs, to assist with learning mechanisms to decrease boredom and increase stimulation, and assist patients in identifying enjoyable activities. Activities such as the Leisure Coat of Arms coat of arms: see blazonry and heraldry. coat of arms or shield of arms Heraldic device dating to the 12th century in Europe. It was originally a cloth tunic worn over or in place of armour to establish identity in battle. and For My Leisure (Stumbo, 1986) help to enhance leisure and self-awareness. Searle and Mahon (1991) found the use of leisure education increased perceptions of perceived competence, which supports this recommendation. 2. Facilitate stress management and relaxation groups to help with alleviating stress, and teach hospital-appropriate coping mechanisms coping mechanism Psychiatry Any conscious or unconscious mechanism of adjusting to environmental stress without altering personal goals or purposes . Hospital-appropriate coping mechanisms could include the use of passive leisure activities to decrease stress, and increase awareness and use of the support system inherent in the hospital unit. Leisure experiences can decrease stress levels and thus can be appropriate coping tools. The use of guided imagery Guided Imagery Definition Guided imagery is the use of relaxation and mental visualization to improve mood and/or physical well-being. Purpose and progressive muscle relaxation are also recommended to decrease stress. 3. Offer a myriad of leisure and recreation options that facilitate and increase personal choice, control, competence, playfulness, arousal arousal /arous·al/ (ah-rou´z'l) 1. a state of responsiveness to sensory stimulation or excitability. 2. the act or state of waking from or as if from sleep. 3. , relaxation and self-determination. Langer (1975) provides support for this by reporting that increasing the illusion of control Illusion of control is the tendency for human beings to believe they can control, or at least influence, outcomes that they demonstrably have no influence over. Experimental demonstration may benefit the psychological well being of hospitalized patients. 4. Provide numerous social interventions to decrease social withdrawal, increase the social interactions and sense of community, as well as facilitate the social support network of the heart transplant candidates. Weekly luncheons for the heart transplant population enhance social interaction and increase feelings of community and belongingness. 5. Provide interventions that facilitate a sense of self-worth and meaning in life through activities that are meaningful and provide an opportunity to leave a legacy. By increasing feelings of self-worth and participation in meaningful activities, the transition to post-transplant may be enhanced and incorporate a healthy leisure lifestyle. Therapeutic recreation has the ability to greatly increase the physical and psychosocial well-being of heart transplant candidates. By understanding that the components of perceived freedom and the avoidance of leisure boredom correspond with higher levels of health, leisure can meet the psychosocial and physical needs of heart transplant patients and recipients. References Abbey, S. & Farrow, S. (1995). Group therapy and organ transplantation The transfer of organs such as the kidneys, heart, or liver from one body to another. The transplantation of human organs has become a common medical procedure. Typical organs transplanted are the kidneys, heart, liver, pancreas, cornea, skin, bones, and lungs. . International Journal of Group Psychotherapy group psychotherapy, a means of changing behavior and emotional patterns, based on the premise that much of human behavior and feeling involves the individual's adaptation and response to other people. , 48(2), 163-184. American Heart Association. (1999). Heart transplants and statistics [on-line]. Available: www.americanheart.org/Heart_and_ Stroke_A_Z_Guide/htrans.html. Berryman, D., James, A., & Trader, B. (1991). The benefits of therapeutic recreation in physical medicine. In C. P. Coyle, W. B. Kinney, B. Riley, & J. W. Shank shank (shangk) 1. leg (1). 2. crus ( 2). shank n. The part of the human leg between the knee and ankle. (Eds.), Benefits of therapeutic recreation: A consensus view. Ravensdale, WA: Idyll idyll or idyl In literature, a simple descriptive work in poetry or prose that deals with rustic life or pastoral scenes or suggests a mood of peace and contentment. Arbor arbor Garden shelter providing privacy and partial protection from the weather, most commonly a lightweight, latticed framework (trellis) of wood or metal with interlaced branches of vines or climbing shrubs trained over it. . Coleman, D.J. (1993). Leisure based social support, leisure dispositions and health. Journal of Leisure Research, 25(4), 350-361. Corley, M.C., Westerberg, N., Elswick, R.K., Jr., Connell, D., Neil, J., Sneed, G., and Witcher, V. (1998). Rationing rationing, allotment of scarce supplies, usually by governmental decree, to provide equitable distribution. It may be employed also to conserve economic resources and to reinforce price and production controls. organs using psychosocial and lifestyle criteria. Research in Nursing and Health, 21, 327-337. Fisher, D.C., Lake, K.D., Reutzel, T.J. & Emery emery: see corundum. emery Granular rock consisting of a mixture of the mineral corundum (aluminum oxide, Al2O3) and iron oxides such as magnetite (Fe3O4) or hematite (Fe2O3). , R.W. (1995). Changes in health related quality of life and depression in heart transplant recipients. Journal of Heart and Lung Transplant lung transplant Surgery Transplant of a lung allograft into a Pt with failing lungs; 90 US centers perform LT; 35 centers perform ≥ 10/yr Mean wait time 18 months Indications COPD–eg, emphysema due to α1 , 14, 373-381. Grady, K.L., Jalowiec, A., White-Williams, C., Pifarre, R., Kirklin, J.K., Bourge, R.C. & Costanzo, M.R. (1995). Predictors of quality of life in patients in advanced heart failure awaiting transplantation. Journal of Heart and Lung Transplant, 14, 2-10. Holt, A.M.V.P. (2001). Leisure related needs of status one heart transplant candidates. Unpublished master's thesis. University of Florida University of Florida is the third-largest university in the United States, with 50,912 students (as of Fall 2006) and has the eighth-largest budget (nearly $1.9 billion per year). UF is home to 16 colleges and more than 150 research centers and institutes. , Gainesville. Iso-Ahola, S.E. (1979). Some social psychological determinants of perceptions of leisure: Preliminary evidence. Leisure Sciences, 2(3/4), 305-314. Iso-Ahola, S.E. (1994). Leisure lifestyle and health. In: D.A. Compton, & S.E. Iso-Ahola (Eds.). Leisure and Mental Health, pp. 42-56. Utah: Family Development Resources. Jalowiec, A., Grady, K.L., White-Williams, C. (1994). Stressors in patients awaiting a heart transplant. Behavioral Medicine behavioral medicine n. The application of behavior therapy techniques, such as biofeedback and relaxation training, to the prevention and treatment of medical and psychosomatic disorders and to the treatment of undesirable behaviors, such as overeating. , 19, 145-154. Joshi, A. & Kevorkian, C.G. (1997). Rehabilitation rehabilitation: see physical therapy. after cardiac transplantation. American Journal of Physical Medicine and Rehabilitation physical medicine and rehabilitation or physiatry or physical therapy or rehabilitation medicine Medical specialty treating chronic disabilities through physical means to help patients return to a comfortable, productive life despite a medical , 76(3), 249-254. Langer, E.J. (1975). The illusion of control. Journal of Personality and Social Psychology The Journal of Personality and Social Psychology (often referred to as JPSP) is a monthly psychology journal of the American Psychological Association. It is considered one of the top journals in the fields of social and personality psychology. , 32(2), 311-328. Muirhead, J., Meyerowitz, B.E., Leedham, B., Eastburn, T.E., Merrill, W.H., & Frist, W.H. (1992). Quality of life and coping in patients awaiting heart transplantation. Journal Heart Lung Transplant, 11, pp. 265-272. Neulinger, J. (1974). The psychology of leisure: Research approaches to the study of leisure. Springfield, IL: Charles C. Thomas. O'Hanlon, J. (1981). Boredom: Practical consequences and a theory. Acta Psychologica, 53, 53-82. Rauch, J. B., & Kneen, K. K. (1989). Accepting the gift of life: Heart transplantation recipients' post-operative adaptive tasks. Social Work in Health Care, 14(1), 47-59. Reich, J.W. & Zantra, A. (1981). Life events and personal causations: Some relationships with satisfaction and distress. Journal of Health and Social Behavior In biology, psychology and sociology social behavior is behavior directed towards, or taking place between, members of the same species. Behavior such as predation which involves members of different species is not social. , 40, 1002-1012. Sadowsky, H. S. (1996). Cardiac transplantation: A review. Physical Therapy, 76(5), 501. Searle, M.S. & Mahon, M.J. (1993). The effects of a leisure education program of selected social psychological variables: A three month follow-up investigation. Therapeutic Recreation Journal, first quarter, 9-21. Shapiro, P.A. (1996). Psychiatric aspects of cardiovascular disease. The Psychiatric Clinics of North America North America, third largest continent (1990 est. pop. 365,000,000), c.9,400,000 sq mi (24,346,000 sq km), the northern of the two continents of the Western Hemisphere. , 19(3), 613-629. Shapiro, P.A., Levin, H.R., Oz, M.C. (1996). Left ventricular assist devices left ventricular assist device Cardiology A mechanical device to ↑ force and volume of blood flowing through the heart. Cf CABG, Jarvik-7. : Psychosocial burden and implications for heart transplant programs. General Hospital Psychiatry, 18 (Suppl. 6), 30S-35S. UNOS. (2000). Transplant patient data source [on-line]. Available: www.unos.org/frame_ Default.asp. Walden, J., Stevenson, L., Dracup, K., Wilmarth, J., Kobashigawa, J., & Moriguchi, J. (1989). Heart transplantation may not improve quality of life for patients with stable heart failure. Heart Lung, 18(5), 497-506. If you are interested in the reference list, please contact: Marieke Holt, PO Box 118208, Gainesville, FL 32611-8208, Marieka@ufl.edu Marieke Holt, MSRS MSRS Minnesota State Retirement System MSRS Maine State Retirement System MSRS Manic State Rating Scale MSRS Metalsmith Ship Repair Sheet (US Navy rating) MSRS Micro Surgery Robotic System MSRS Molecular Sieve Regeneration System , CTRS CTRS Centers (street suffix) CTRS Containers CTRS Certified Therapeutic Recreation Specialist CTRS Conventional Terrestrial Reference System CTRS Center for Technology Risk Studies (University of Maryland) and Candace Ashton-Shaeffer, Ph.D., CTRS, are with the Department of Recreation, Parks, and Tourism at the University of Florida, Gainesville. Holt is currently a Ph.D. student at the University of Florida. She began working on the heart transplant unit at Shands Hospital at UF as a research assistant when she started her Master's degree master's degree n. An academic degree conferred by a college or university upon those who complete at least one year of prescribed study beyond the bachelor's degree. Noun 1. . Her previous therapeutic experience in rehabilitation and psychiatry provided her with an excellent background for working with patients waiting for heart transplants. Her recently completed Master's thesis, Leisure Related Needs of Status One B Heart Transplant Patients, directed by Candace Ashton-Shaeffer, affords new insights into this population and provides the foundation and framework for efficacy research currently being conducted by Dr. Ashton-Sheaffer and Holt. Their article, "TR's role in Meeting the Needs of Heart Transplant Patients". |
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