Walter Reed National Military Medical Center
Bethesda Maryland
Mission: Walter Reed Bethesda leads military medicine through outstanding patient-centered
care, innovation, and excellence in education and research. We provide comprehensive care to
prevent disease, restore health and maximize readiness.
Vision: We are the Nation’s Medical Center. We create extraordinary experiences for patients,
families and staff while driving tomorrow’s healthcare advances.
Military Advanced Training Center (MATC)
Department of Orthopedics and Rehabilitation - Amputee Clinic
Mission & Vision: From injury to independence. Dedicated to the care and rehabilitation of
America’s sons and daughters recovering from injuries sustained in service, the Military
Advanced Training Center (MATC) is a state-of-the-art facility located at the Walter Reed
National Military Medical Center. Wounded, Ill and Injured Service Members, Retirees and
Family Members use sophisticated prosthetics and cutting-edge athletic equipment to confirm
pre-injury capabilities as they restore their sense of selves.
The total focus of MATC’s expert staff is to match the drive and determination of these service
members— build their strength, skills and confidence and return them to the highest level of
physical, emotional and psychological functional ability. A major goal of the MATC is to enable
the Service Members to make their own choices and not let their futures be dictated by the
injuries sustained.
Population: We serve active duty, retired and family members of all ages suffering from
physical, mental or cognitive disabilities. Appointments are made by referral from the Amputee
Clinic held by the Physical Medicine and Rehabilitation Service.
MATC Professional Services:
Amputee Physical Therapy and Occupational Therapy:
 The MATC is setting world-class standards of care and providing the leading edge in
rehabilitative as well as prosthetic care. The comprehensive effort of rehabilitation is
where physical and occupational therapists follow the Service Members from their initial
evaluations through their discharge from the hospital, course of outpatient rehabilitation
and return to active duty or civilian life.
The Prosthetics Service, offering a full range of prosthetic and orthotic services, uses
state of the art advanced prosthetic limb technology for design, milling, and production of
prosthetic devices. Prosthetic devices are manufactured and fit and adjusted in the
Orthotics and Prosthetics Service which is adjacent to the MATC to enable the
Prosthetists to work closely with the physical and occupational therapists to ensure the
best possible fit and utilization of the prosthetic devices.
Recreational Therapy & Adaptive Sports:
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
Walter Reed recognizes the importance of recreational ad adaptive sports to well being
and recovery. The Recreational Therapy staff coordinates a community re-integration
program that offers a wide variety of experiences outside the clinic setting including trips
to public venues like shopping areas, movie theaters, restaurants and museums.
The program provides adaptive sports activities such as scuba diving, therapeutic
horseback riding, basketball, cycling, running and golf which allow the patients to be
challenged and helps provide meaning and purpose. Additionally the MATC offers a
Service/Therapy Dog program, which is coordinated for the facility to make referrals for
patients who request a service animal.
Computer Assisted Rehab Environment (CAREN):
 One of ten of its kind in the world, the CAREN provides a safe, controlled setting where
patients can work on balance, coping with stress, using new prosthetics and other skills
necessary to achieve functional real-life goals. Using specialized cameras and computers
linked to sensors on their bodies, recovering Service Members interact with a virtual
world projected onto a life-sized curved screen by shifting their weight on a motion
platform with an embedded treadmill. More than 70 scenarios enable recovering Service
Members to perform virtual activities such as steering a boat through buoys in a lake or
replicate running up and down trails in woods, or walking through city streets without
fear of falling.
Center for Performance and Clinical Research (CPCR):
 The Gait Lab of the Center for Performance and Clinical Research (CPCR) uses
sophisticated motion analysis equipment (27 infra-red cameras, reflective markers and six
force plates) to quantify the patients’ movement. The information gained through motion
analysis helps care providers to evaluate or modify physical therapy programs and
prosthetic and orthotic components. The ultimate goal is to facilitate improvement of
functional tasks such as walking, running and jumping.
MATC Treatment Services:
Firearms Training Simulator:
 A weapon simulation program that allows for progression from basic target shooting to a
complex shoot/no-shoot environment. Emotional, physical, and cognitive aspects of a
patient’s performance can be assessed and remediated in this safe environment.
Community Reintegration Programs:
 Designed by a CTRS to help patients reintegrate back into various life tasks and roles in
their community.
Adaptive Sports Programs:
 Offer patients the opportunity to excel in their rehabilitation through the introduction to
adaptive sports and adaptive instruction. Participation in innovative programs and
adaptive equipment may allow a continuation of an active lifestyle.
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Theoretical Foundation and Service Delivery Model
For Walter Reed Medical Advanced Training Center
Shannon Drysdale
PRT 3360 Assessment and Documentation
University of Utah
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Leisure Ability Model
The Leisure Ability Model was developed by Carol A. Peterson and Scott L. Gunn in 1984
with the “belief that the end product of therapeutic recreation services for clients was improved
independence and satisfying leisure functioning”.(Stumbo & Peterson, 1998). This model was
build on the foundation of four concepts, which are (1) leaned helplessness vs. mastery of selfdetermination; (2) intrinsic motivation, internal locus of control, and causal attributions; (3)
choice; and (4) flow. These fours concepts will be discussed, with more depth, later on.
Why use the Leisure Ability Model? “A therapeutic recreation specialist who utilizes the
Leisure Ability Model as the basis for service
delivery helps reduce clients’ barriers to
leisure involvement through the provision of
functional intervention, leisure education,
and recreation participation services”.
(Stumbo & Peterson 2009) By reducing a
client’s barriers, it allows them the freedom
and the choice to participate more fully in
Figure 2.1 Leisure Ability Model (Stumbo &
Peterson, 1998)
leisure experiences. This in turn helps the
recreational therapist meet the ultimate goal
of recreational therapy services which is “improved ability of the individual to engage in a
successful, appropriate, and meaningful independent leisure lifestyle that, in turn, leads to
improved health, quality of life, and well-being.” (Stumbo & Peterson 2009)
The Leisure Ability Model contains three major categories or service, as shown in figure 2.1,
these include: (1) Functional Intervention, (2) Leisure Education, and (3) Recreation
Participation. Each of these categories, or services, is based specifically on the client’s needs and
their intended goals and objectives. Now one thing to know is that this model illustrates the idea
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of a continuum, which means that there is constant movement between the categories.
Movement, within the model, is based on programs and the client’s needs. “The model itself only
represents those services that would be designed and implemented under the auspices of various
agencies involved in the delivery of therapeutic recreation services. The ultimate goal of
independent leisure involvement and lifestyle is beyond the parameters of the model.” (Stumbo
& Peterson 2009)
Functional Intervention
Functional intervention is the first section of the Leisure Ability Model. “Functional
intervention addresses functional abilities in physical, social, emotional-affective, and/or mentalcognitive domains that are prerequisites to leisure experiences and participation in other areas of
life.” (Carter & Van Andel, 2011) The functional intervention category is where the recreational
therapist is the “therapist”, because the outcome is to improve the client’s functional abilities and
provide a foundation for the other two sections. As the clients move further through the model
the degree of control by the specialist will decrease as their degree of freedom in leisure
participation increases.
Leisure Education
The second stage of the Leisure Ability Model is leisure education. “Leisure education, a
priority component of this model, focuses on developing attitudes, knowledge, and skills so
clients have a border capacity to participate in leisure of their choice that positively impacts
health, well-being, and quality of life.” (Carter & Van Andel 2011) It is all about teaching clients
the skills and helping them acquire knowledge about leisure. The Recreational Therapist uses the
title of instructor, advisor, or counselor. The amount of responsibility between the client and the
therapist is relatively equal during this stage.
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The leisure education category has its own
model, figure 2.2, which is divided into four
components. The first is leisure awareness. “An
important aspect of leisure lifestyle and
involvement appears to be a cognitive
awareness of leisure and its benefits, a valuing
of the leisure phenomenon, and a conscious
Figure 2.2 Leisure Education Content Model
(Stumbo & Peterson 2009)
decision-making process to activate
involvement.” (Stumbo & Peterson 2009)
Within the leisure awareness section are four areas that are necessary in developing and
expressing an appropriate leisure lifestyle. These four areas are: (1) knowledge of leisure, (2)
self-awareness, (3) leisure and play attitudes, and (4) related participatory and decision-making
skills.
The second section of the Leisure Education Content Model is social interaction skills which
is a major aspect of leisure living. “In many situations, the social interaction is more significant
and important to the participants than the activity itself. The activity may be the reason to be
together, but it is the social interaction that has real meaning for the people involved.” (Stumbo
& Peterson 2009) The social interaction skills addressed within the Leisure Education Model are:
(1) communication skills, (2) relationship-building skills, and (3) self-presentation skills.
The third section in the model is leisure activity skills. Leisure activity skills allows for a
choice and a sense of freedom when involved in leisure activities. These include traditional
leisure skills and nontraditional leisure skills. What is the difference between traditional and
nontraditional leisure skills? Traditional leisure skills are “activities that are commonly identified
as recreational and sanctioned by the society.” (Stumbo & Peterson, 2009) Examples are: sports,
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drama, outdoors, music, expressive arts, mental games and hobbies. Nontraditional activities “are
less likely to require a specific amount of time or time scheduled by someone else.” (Stumbo &
Peterson, 2009) Nontraditional activities include things like: social interaction, education,
shopping, home improvement, eating, and intimacy.
The fourth, and final, section of the Leisure Education Content Model is leisure resources.
“Leisure resources teach both the knowledge of the resource and skills about how to use the
resource for future leisure involvement.” (Stumbo & Peterson, 2009) Having the knowledge and
the ability to utilize leisure resources is incredibly important in a leisure lifestyle. Being able to
participate in a specific activity, knowing how to look up a number in the phone book, or
understanding how to use an ATM are all examples of leisure resources. The content within the
leisure resources section is: (1) activity opportunities, (2) personal resources, (3) family and
home resources, (4) community resources, and (5) state and national resources.
Recreation Participation
Recreation participation is the third and final category of the Leisure Ability Model.
“Recreation participation services provide a structured and organized program that allows the
client to practice and apply the knowledge and skills acquired through functional intervention
and leisure education.” (Carter & Van Andel, 2011) This portion of the Leisure Ability Model
takes the knowledge and a skill developed during functional intervention and leisure education
and allows the client to engage in a fun, organized recreation opportunity. In this stage the
client’s degree of freedom is at the highest point and the role of the specialist is that of leader,
facilitator, or supervisor.
Military Advanced Training Center (MATC)
The Military Advance Training Center (MATC) is located within Walter Reed National
Military Hospital in Bethesda, Maryland. MATC offers many different services to assist in the
rehabilitation of their patients. These services include: Physical, Occupational and Recreational
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Therapy, adaptive sports programs, computer assisted rehabilitation, and the center for
performance and clinical research.
The training center is “dedicated to the care and rehabilitation of America’s sons and
daughters recovering from injuries sustained in service. Wounded, ill and injured service
members, retirees, and family members use sophisticated prosthetics and cutting-edge athletic
equipment to confirm pre-injury capabilities as they restore their sense of self.” (Walter Reed,
2014)
Now that we have a general understanding of the Leisure Ability Model, I want to discuss
how it will be used as a framework for the Recreational Therapy Program in the Advanced
Training Center at Walter Reed. To do so I want to go back to the foundation of the Leisure
Ability Model. As mentioned earlier, the Leisure Ability Model stems from four concepts, which
are: (1) learned helplessness vs. mastery of self-determination; (2) intrinsic motivation, internal
locus of control and causal attributions; (3) choice; and (4) flow. By relating these four concepts
to the RT population, this will provide a better understanding of the recreational therapy
programs placement within the Leisure Ability Model. The Recreational Therapy population at
the MATC includes active duty, retired and family members with physical, mental and/or
emotional disabilities. However, the Recreational Therapy and adaptive sport programs are
mainly used by military personnel using prosthetics.
The thought of having to learn how to use a limb all over again can be an overwhelming and
traumatic experience. The concept of learned helplessness can develop during this life-altering
situation. “Learned helplessness is the perception by an individual that events happening in his or
her life are beyond his or her control, and therefore, the individual stops trying to effect changes
or outcomes with his or her life.” (Stumbo & Peterson, 1998) This is where Recreational
Therapy can help. “The role of the therapeutic recreation specialist, in order to reverse the
consequences of learned helplessness, is to assist the individual in: (1) increasing the sense of
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personal causation and internal control, (2) increasing intrinsic motivation, (3) increasing the
sense of personal choice and alternatives, and (4) achieving the state of optimal experience”.
(Stumbo & Peterson, 1998)
The Recreational Therapists at MATC can assist clients in increasing intrinsic motivation and
internal control by providing programs and activities where clients can experience competence
and self-determination. “Individuals seek experiences of incongruity or challenges in which they
can master the situation, reduce the incongruity, and show competence”. (Stumbo & Peterson,
1998) It is also important for the Recreational Therapist to provide choices to their clients.
Choice not only allows clients to feel more in control of their leisure experiences, but “choice
implies the individual has sufficient skills, knowledge, and attitudes to be able to have options
from which to choose, and the skills and desires to make appropriate choices”. (Stumbo &
Peterson, 1998)
Recreational Therapists at MATC must also be able to provide programs and activities that
help clients in achieving the state of optimal experience or flow. Therapists can do this by
adequately assessing their clients and implementing programs where the challenge level of the
activity and the client’s skill level are balanced.
Recreational Therapy Programs
The Military Advanced Training Center has many different recreational therapy and adaptive
sports programs, all of which fit in one, or more, of the three categories in the Leisure Ability
Model. The Recreational Therapy program at MATC uses “treatment, education, and recreation
programs to help people with disabilities and other conditions develop and use their leisure in
ways that enhance their health, functional abilities, independence and quality of life” (Walter
Reed, 2011). Within the Recreational Therapy department there are four other programs that are
involved in client’s functional intervention, leisure education, and recreation participation. These
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programs are: an adaptive sports program, service dogs/specialized facility K9s, firearms training
simulator, and community reintegration programs.
The adaptive sports program provides clients with the necessary knowledge and skill needed
to participate in recreational activities. “Adaptive sports programs offer patients the opportunity
to excel in their rehabilitation through the introduction to adaptive sports and adaptive
instructions. Participation in innovative programs and adaptive equipment may allow a
continuation of an active lifestyle”. (Walter Reed, 2011) The MATC adaptive sports include:
adaptive skiing/snowboarding, swimming, basketball, volleyball, cycling, yoga, hockey,
triathlons, and so much more.
The Recreational Therapy department at MATC also provides a service dog and specialized
facility K9 program. “Service Dogs and Specialized Facility K9s assist in the service of members
physical, emotional, and psychological well-being” (Walter Reed, 2011) which is necessary in
improving clients functional ability. The Specialized Facility K9s are part of the Recreational
Therapy department, but are used throughout the entire medical facility to assist in patients’
rehabilitation.
The Firearms Training Simulator (F.A.T.S.) is also a part of the Recreational Therapy
Department. This program can be a part of both the leisure education and recreation participation
categories. F.A.T.S is “a weapons simulation program that allows for progression from basic
target shooting to a complex shoot/no-shoot environment. Emotional, physical, and cognitive
aspects of a patients performance can be assessed and remediated in this safe environment”.
(Walter Reed, 2011). This program teaches clients, with prosthetics, how to properly handle and
use firearms. It also allows clients to participate in adaptive hunting trips.
The final program within the Recreational Therapy department is the Community
Reintegration Program. This program can be represented in every category of the Leisure Ability
Model, because it teaches clients basic functions like orientation and memory, while at the same
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time allowing them to get out of the hospital setting and learn how to function within the
community. The purpose of the Community Reintegration Programs purpose is “to help these
patients reintegrate back into various life tasks and roles in their community. Therapeutic
rehabilitation goals include: increased independence, decreased vulnerability, increased safety,
and improve prevocational skills” (Walter Reed, 2011)
Conclusion
The reason I chose the Leisure Ability Model for the Recreational Therapy Program, in the
Military Advanced Training Center at Walter Reed National Military Medical Center, is because
the Leisure Ability Model is based solely on the client’s need and increasing their overall quality
of life through leisure experiences. That outcome goes hand in hand with the Recreational
Therapy programs overall goal of, “helping people with disabilities and other conditions develop
and use their leisure in way that enhance their health, functional abilities, independence and
quality of life”. (Walter Reed, 2011)
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Works Cited
Carter, M., & Van Andel, G. (2011). Becoming a Member of a Profession. In Therapeutic
Recreation: A Practical Approach (4th ed., p. 545). Long Grove, IL: Waveland Press.
Stumbo, N., & Peterson, C. (1998). The Leisure Ability Model. Therapeutic Recreation Journal,
32(2), pg. 82-96.
Stumbo, N., & Peterson, C. (2009). The Leisure Ability Model. In Therapeutic Recreation
Program Design (5th ed., pp. 27-72). San Francisco: Pearson Benjamin Cummings.
Walter Reed National Military Medical Center. (2011). Therapeutic Recreation & Adaptive
Sports Programs [Brochure]. Department of Orthopedics & Rehabilitation. Retrieved
September 27, 2014 from: http://crsr.org/wp-content/uploads/2012/01/WRNMMCADAPTIVE-SPORTS-BROCHURE_Dec2011.pdf
Walter Reed National Military Medical Center. (2014). Welcome to the Amputee Service –
Military Advanced Training Center (MATC). Retrieved from
http://www.wrnmmc.capmed.mil/Health%20Services/Surgery/Orthopaedics%20and%20
Rehabilitation/Amputee%20Care/SitePages/Home.aspx
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Diagnostic Protocol
Diagnostic Grouping:
Spinal Cord Injuries: “damage to any part of the spinal cord or nerves at the end of the
spinal canal – often causes permanent changes in strength, sensation and other body functions
below the site of injury”. (Mayo Clinic)
Specific Diagnostic:
 Incomplete Spinal Cord Injury: “There is some function below the level of injury –
movement in one limb more than the other, feeling in part of the body, or more function
on one side of the body than the other. Incomplete injuries can occur at any level of the
spinal cord”. (Hopkins Medicine)
 Anterior Cord Syndrome
 Central Cord Syndrome
 Posterior Cord Syndrome
 Brown-Sequard Syndrome
 Cauda Equina Lesion
 Complete Spinal Cord Injury: “There is no function below the level of injury – both
sensation and movement – and both sides of the body are equally affected. Complete
injuries can occur at any level of the spinal cord”. (Hopkins Medicine)
 Complete Paraplegia
 Complete Tetraplegia
 C1-4 Tetraplegia
 C-5 Tetraplegia
 C-6 Tetraplegia
 C7-8 Tetraplegia
Identified Problems:
 Muscle weakness or paralysis in the trunk, arms or legs
 Breathing Problems
 Sexual Dysfunction
 Problems with heart rate and blood pressure
 Muscle Spasticity
 Decreased Activity Level
 Digestive Problems
 Decreased Communication Skills
 Decreased Socialization Skills
 Inability to work or maintain a job
 Depression
 Memory Processing
 Anxiety
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Related Factors or Etiologies:
 PTSD
 Depression
 Anxiety
 Amputations
Process Criteria:
 Community Reintegration Programs
 Aquatic Therapy
 Adaptive Sports Programs
 Sex Education Classes
 Self-Esteem Programs
 Vocational Training
 Socialization Skills
 Family Support Programs
 Self-Care Programs
 Strength Training
 Relaxation Methods
o Adaptive Yoga
 Communication Skills
 Mobility Skills
 Family Focused Recreation Programs
Outcome Criteria:
 Physical: Increase client’s overall strength and functional abilities by 20% from
admission through strength training and other adaptive leisure and recreational activities.
 Emotional/Spiritual: Identify problems linked to client’s depression and provide
meaningful activities and solutions to increase client’s self-esteem and overall coping
skills.
 Social: Increase client’s socialization/communication skills by 30% from admission, by
facilitating group/family activities that require interaction with others either at the facility
or within the community. Also by providing alternative methods of communication if
necessary.
 Cognitive: Increase the client’s memory process abilities by 15% from admission, by
providing memory stimulating activities (recollection programs, memory retaining
activities); also by providing orientation programs within the community.
S. Drysdale CTRS 10/7/2014
(Student)
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Resources
Mayo Clinic Staff. (2014, January 1). Spinal Cord Injury. Retrieved October 1, 2014, from
http://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/basics/definition/con20023837
Newsome Melton LLP. (2013, January 1). Types of Spinal Cord Injury. Retrieved October 1,
2014, from http://www.brainandspinalcord.org/spinal-cord-injuries/index.html
Spinal
Cord Injury. (2014, January 1). Retrieved October 1, 2014, from
http://www.hopkinsmedicine.org/healthlibrary/conditions/physical_medicine_and_rehabi
litation/spinal_cord_injury_85,P01180/
Spinal Injury Network. (2009, January 1). Complete Spinal Cord Injuries. Retrieved October 1,
2014, from http://www.spinal-injury.net/complete-spinal-cord-injury.htm
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Intervention Protocol
Program Title:
Community Reintegration Program
General Statement:
Community Reintegration Program is designed to assist patients in the reintegration
process by using learned techniques and implementing them into community involvement.
Description of Program:
The Community Reintegration Program includes a diverse group of interventions,
including:
 Community Outings
 Adaptive Sports
 Leisure Education
 Family Focused Activities
 F.A.T.S.
 Weekly Cooking Classes
The Recreational Therapy goals for the Community Integration Programs include the client’s
personal treatment goals and objectives along with:
 Increase in overall independence
 Decreased vulnerability
 Increase in client’s personal feeling of safety when out in the community
 Improve prevocational skills
Client Problems that may be addressed:
 Muscle weakness or paralysis in the trunk, arms, or legs
 Sexual Dysfunction
 Decreased Activity Level
 Decreased Communication Skills
 Decreased Socialization Skills
 Inability to work or maintain a job.
 Depression
 Memory Processing
 Anxiety
Referral Criteria:
Participation in any Recreational Therapy activity requires a referral from the Department
of Orthopaedics & Rehabilitation.
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Contraindicated Criteria:
 Inability to transfer
 Loss of bladder/bowel control
 Anxiety around large crowds
 Doctors orders
Intervention Activities or Techniques:
Staff Training/Certification Requirements
 Certified Therapeutic Recreation Specialist (CTRS)
 Health Insurance Portability and Accountability Act (HIPAA)
 First Aide
 CPR
 Food Handlers
 Behavior Management Training
 Water Safety Instructor Certification
 Firearms Training Simulator (F.A.T.S.)
 Valid Driver License
 Completion of Driver’s Training
 Completion of Patient Transfer Training
 Contracted Out
o Adaptive Yoga Certification
o Scubility Certified Scuba Instructor
o Jiu-Jitsu Certification
Risk Management Considerations:
 Staffing
o Nationally certified as a Certified Therapeutic Recreation Specialist through
National Council for Therapeutic Recreation Certification
o 1 staff member to every 5 client ratio
o Completion of all required training
 Behavior Management Training
 First Aide
 CPR
 Health Insurance Portability and Accountability Act (HIPAA)
 Water Safety Instructor (WSI)
 Food Handlers
 Transportation
o Proper automotive insurance
o Valid driver’s licenses for all staff
o Completion of annual safety and emission inspections
o Completion of driver’s training for all staff
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

o Always at least 2 staff members in the vehicle at all times.
Clients will be outdoors
o Weather
o Sun sensitivity
o Natural disasters
o Safety
Clients may participate in adaptive sport activities
o Safety rules
o Proper equipment
o Staff training
Outcomes Expected:
 Physical: Increase client’s overall strength and functional abilities through different
adaptive sport and leisure programs
 Emotional/Spiritual Identify problems linked to clients depressions and provide
meaningful activities and solutions to increase client’s self-esteem and overall coping
skills
 Social: Increase client’s socialization/communication skills by facilitating group/family
activities, and community outings, that require interaction with others.
 Cognitive: Increase client’s memory processing ability by providing memory stimulating
activities and orientation programs out in the community.
Program Evaluation:
 To ensure that the Community Reintegration Program, at Walter Reed National Military
Hospital, is reaching both the client’s personal treatment goals and the goals of the
program itself, staff will evaluate using:
o Client’s personal treatment goals
o Patient and family member surveys
o Pre and post-tests of patients abilities
o Quality Improvement Programs
o Observations
o One on one and group interviews with clients
o Holding regular staff meetings to evaluate program outcomes
S. Drysdale CTRS 10/23/2014
(Student)