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Promoting Community Recreation and Leisure

Thomas, Amy D. MPT; Rosenberg, Angela DrPH, PT

doi: 10.1097/01.PEP.0000097489.01233.D7
RESEARCH REPORT
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SDC

Purpose The aim of this study was to investigate the nature and level of involvement a cross section of pediatric physical therapists (PTs) and pediatric occupational therapists (OTs) have achieved in promoting community recreation and leisure participation for their clients with disabilities.

Method Using the current Internal Classification of Functioning and Disability, a hierarchy of skills required to promote community recreation and leisure was constructed and a survey was developed based on items contained in the hierarchy. Items represented three potential types of barriers to participation in community recreation and leisure for individuals with disabilities: (1) physical, (2) social, and (3) resource. One hundred fifty-two therapists were surveyed regarding their knowledge and awareness of potential barriers to their clients’ participation in community recreation and leisure and were asked questions related to promotion of recreation and leisure to their pediatric clients.

Results Eighty-two surveys were completed and returned. Data revealed that therapists were practicing below an “optimal” level regarding the promotion of recreation and leisure for their clients with disabilities. No significant differences were found between PTs and OTs other than a slightly greater tendency for PTs to consider cost as a barrier to client participation in recreation and leisure pursuits.

Conclusions More research is indicated to establish the factors contributing to what may be inadequate promotion of community recreation and leisure participation among pediatric therapists.

The authors developed a conceptual model and a survey to measure PTs and OTs level of involvement with promotion of recreation and leisure for their clients. They conclude that therapists can expand upon their traditional training and move toward a health promotion, disability prevention model for intervention.

University of North Carolina at Chapel Hill, Chapel Hill, NC

Address correspondence to: Amy Thomas, 9207 Laurel Springs Drive, Chapel Hill, NC 27516. Email: athomaspt@yahoo.com

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INTRODUCTION

Over the past decade, efforts to increase Americans’ participation in recreation and leisure pursuits have been made by allied health professionals, healthcare organizations, and federal and state governments. One’s overall health is a function of both physical and mental health. Research relating fitness level to morbidity and mortality has shown that even moderate amounts of regular physical activity can provide tremendous health benefits. 1,2 Regular exercise may take many forms, including recreation. Furthermore, recreation and leisure activities pursued within a social context provide advantages beyond those pursued in solitary environments. 3 Among the physical benefits of a regular exercise regimen are the reduction of the risk of osteoporosis and improved outcomes associated with arthritis, diabetes, cardiovascular disease, and pulmonary function. 4–13 In addition, improved mental health, positive attitudes toward people with disabilities, and friendships among individuals of all abilities develop when recreation and leisure are pursued within inclusive community settings. 14–16

On a national level, health goals have grown from simply encouraging average Americans to maintain their health and well-being by improving fitness levels to include the particular challenges faced by individuals with lifelong developmental disabilities. A wealth of literature documents that many complications of disability such as depression, loss of independence, incontinence, musculoskeletal impairment, pain, and social inadequacies occur secondary to disability in young adulthood and may be largely preventable. 17–19 National goals are regularly modified to incorporate the findings of such research. The prevention of secondary conditions often associated with primary disabilities is integral to the objectives of initiatives such as Healthy People 2010. Healthy People 201019 recently published an entire chapter devoted to addressing the health and well-being issues of people with disabilities. In that chapter, prevention of secondary conditions was outlined as a primary objective. Healthy People 2010 also includes definitions of health indicators to be used to measure the overall health of the nation during the next decade. Indicators include exercise, a healthy diet, weight and stress management, and injury prevention habits. All these health promotion objectives focus on health behaviors over a lifetime. Other publications have focused on the successful achievement of goals such as removal of health disparities, promotion of access to health services, and advocating for the health of children by 2010. Although it is unclear how and to what extent particular environmental factors affect the outcomes of children with disabilities, 20 the premise that one’s environment coupled with specific disability characteristics play important roles in shaping those outcomes is well supported. 21 It follows, then, that early childhood intervention and regular participation in physical and social activity are crucial to optimizing the quality of life of individuals with disabilities as they age.

Changes in legislation and healthcare policies have supported the results of current studies by acknowledging that health promotion, disease prevention, and involvement in community activities are equally important to improving both quality and span of life. 19,22,23 For children, recreation and leisure activities often take place within the school environment. Since the passage of the Individuals with Disabilities Education Act (IDEA) in 1973, there has been an increase in physical education participation by children with disabilities in public schools. 21,24 The school environment, however, is only one venue for improving the physical fitness and mental health of children with disabilities. Other settings in which children of all abilities can participate in meaningful, healthy activities are essential to establishing lifelong patterns of community participation, physical fitness, and mental well-being.

According to the most recent publication of the International Classification of Functioning and Disability compiled by the World Health Organization (WHO), participation may be characterized as “the outcome or result of a complex relationship between an individual’s health condition and personal factors, and of the external factors that represent the circumstances in which the individual lives.”25 Given this definition, there is a large segment of America’s children currently not being afforded opportunities to experience the same health and wellness benefits that the remaining population enjoys and are, thus, not “participating” in important facets of community life. 26,27 Individuals impaired by either extrinsic (eg, social environment, physical environment, the legal system) or intrinsic (eg, specific health conditions, fitness level, education) factors, or a combination of both, make up the greatest proportion of those who are limited in their involvement in community activities. 19 The extent to which these factors exist and interact with each other ultimately determines the level and type of enablement or disablement that is experienced by any child throughout his or her lifetime.

Currently, large gaps exist between children with disabilities and their non-disabled peers on all quality of life indicators, including access to recreation. 28 Lepage et al 29 noted that the greatest disruptions in life habit categories for children with cerebral palsy occur in the areas of recreation, mobility, and community. The barriers to recreation and leisure experienced by children with disabilities are numerous, complex, and often interrelated. Among the most consistently recurring barriers cited in the literature are societal, attitudinal, and environmental. 30 Specifically, transportation issues, lack of knowledge of resources on the part of health professionals, and the cost of participation are a few of the most frequently cited barriers to community participation. 31–33 In fact, these barriers are as disabling to individuals as their physical or mental impairments. 34,35 Misunderstandings and misinformation are often the greatest barriers to be overcome by anyone with a disability. Unfortunately, such obstacles are typically the most difficult to eliminate. Identification and rectification of potential physical, social, and resource barriers are necessary for children with disabilities to successfully participate in community activities.

Pediatric physical therapists (PTs) and occupational therapists (OTs) are in a unique position to act as strong community participation advocates for their clients with disabilities and their families. As skilled professionals trained to evaluate, assess, and provide education regarding the activities required for healthy, independent living, therapists can enable their clients to fulfill lifelong health goals. Today, health promotion within the variety of environments in which children live is especially critical. Disability rates for children and adolescents younger than the age of 18 years have risen throughout the mid-1990s, whereas activity limitations have increased for adults aged 18 to 44 years. 31 To successfully promote healthy community habits throughout a lifetime, therapists need a broad, multilevel base of knowledge regarding the variables that interact to either hinder participation in or inspire people to pursue inclusive recreation and leisure activities. Healthcare providers have a professional responsibility to educate the public, dispel myths surrounding disability, and promote client participation in community pursuits in the course of their practice.

The purpose of this study was to begin to understand the nature and level of involvement that a sample of pediatric PTs and OTs has achieved with respect to the recommendation of community recreation and leisure activities to their pediatric clients with disabilities. The specific goals of this study were to assess pediatric PTs’ and OTs’ knowledge of potential barriers to community participation by their clients with disabilities, awareness of resources available to their clients with disabilities with respect to community recreation and leisure, application of training and knowledge to community recreation and leisure venues, and perceptions related to what barriers(s), if any, may account for their clients’ participation or nonparticipation in community activities.

We hypothesized that PTs and OTs as a group would tend to cluster below the optimal level presented on a hierarchy of terms that we developed to describe therapists’ promotion of inclusive community participation. Some differences in responses between PTs and OTs were expected as a result of differences in “traditional” academic training. For instance, the focus of physical therapy education has traditionally been aimed at restoration of strength and mobility as well as injury prevention. Occupational therapy education has been focused on assisting people to regain skills that are necessary for them to function independently within their respective occupations.

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METHODS

Hierarchy and Survey Development

The measure used for this study consisted of a survey developed over a period of one year. First, we created a hierarchy of dimensions required for pediatric PTs and OTs to be successful in evaluating clients’ recreation and leisure habits, intervening, and promoting community participation. This was deemed necessary to generalize, define, and categorize the wide range of skills and knowledge that therapists possess. Creation of the hierarchy made it possible to make measurable skill and knowledge comparisons. An extensive literature review was conducted to generate critical elements of the hierarchy. Concepts and definitions from the July 1999 WHO Internal Classification of Functioning and Disability (ICIDH-2) 25 as well as the Guide to Physical Therapy Practice36 were used to structure the hierarchy. The ICIDH-2 outlines three categorical domains of body functions and structures, activities, and participation. When combined with environmental and personal factors, these domains form an interactive format necessary to classify and qualify all aspects of human functioning and disability (Fig. 1). The Guide to Physical Therapy Practice identifies a number of salient roles and responsibilities of PTs that are important for enabling their clients to achieve optimal outcomes. The hierarchy was divided into four 4 levels and dimensions were defined within each level. The dimensions themselves were included based on an extensive review of the literature and input from therapists with at least 10 years in the field of pediatrics. Hierarchical dimensions and associated levels are represented in Figure 2 and provide a framework for the dimensions delineated in Appendix 1.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

After constructing the initial hierarchy, a second literature review was conducted to determine the dimensions that were most likely to have a specific, significant impact on individual participation in recreation and leisure. It is important to note that although the hierarchy is depicted level by level and bottom to top, it is a dynamic, fluid model. Several dimensions may just as easily assume a more inferior or superior position. For instance, one could argue that preemptory attitudes, values, and beliefs must be in place for adequate resources to be pursued rather than the reverse. The base level, body functions and structures, was purposely excluded because it was our assumption that all practicing PTs and OTs have basic knowledge in these areas as a result of their formal training and practical experience.

Once the hierarchy was developed, a set of dimensions was used to construct a battery of pilot survey questions. Dillman’s 37 methods were relied on for survey design. The dimensions included were judged by the researchers to be crucial to the promotion of community recreation and leisure as gathered from literature reviews. Three PTs, one OT, and one medical doctor reviewed the pilot survey. Their draft comments were reviewed, and the survey was revised. Data gathered from the therapists completing the pilot survey were not included in final survey results. Additional assistance with survey content and design was provided by statisticians. Final survey questions focused on the hierarchical dimensions depicted in Figure 2.

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Participants

Names and addresses of pediatric PTs and OTs in five local counties were obtained through the American Physical Therapy Association (APTA) and the American Occupational Therapy Association (AOTA). The counties were chosen because of their adequate numbers of PTs and OTs meeting research criteria and for their contrasting rural and urban localities. Search criteria yielded names and mailing addresses for 50 PTs and 102 OTs. Two mailings, three weeks apart, resulted in a total of 82 returned surveys. The response rate for PTs was 60% and 51% for OTs. The average number of years of pediatric experience was 13.7 for PTs (range = 0–37.5 years) and 6.6 for OTs (range = 0–25 years). Other characteristics and demographics of respondents are listed in Table 1. Various local organizations contributed funds to a nonprofit therapeutic horseback riding facility based on the number of surveys returned, thus providing an incentive for survey completion.

TABLE 1

TABLE 1

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Analyses

Using information provided on returned surveys, data sets were created and analyzed with the Statistical Package for the Social Sciences (SPSS) version 6.0. The extent to which both therapist groups indicated that they were able to identify and assist in minimizing the impact of potential barriers to community participation was measured by analyzing the response frequencies presented in tabular form in this paper.

Survey items addressing physical barriers yielded information about facility accessibility, transportation, and adapted equipment. Questions pertaining to social barriers focused primarily on professional and community member attitudes surrounding disability and inclusive recreation. Awareness of community program costs and other issues related to funding were examined in survey items concerning resource barriers.

To quantify subjective data, two scales were developed (α level = 0.83) to determine at what level therapists were currently functioning in the hierarchy as a whole. These scales allowed us to apply numerical values to groups of subjective responses and associate a hierarchical level with each of them. For both scales, a value was assigned to each possible response to survey questions and an overall range of scores was obtained. Values ranged from 6 to 14 for one scale and from 0 to 8 for the other. The frequencies of scores falling into each of three hierarchical categories (intermediate level I, intermediate level II, and optimal) were tabulated for each scale (Table 2).

TABLE 2

TABLE 2

The first scale measured therapists’ perceptions of their alignment of client interest in community participation with their promotion of participation. The survey questions used to develop this scale were as follows: (1) Generally, how would you rate satisfaction with your facilitation of participation in community recreation or leisure activities by your clients with disabilities? (2) How would you rate your own satisfaction with your facilitation of participation in community recreation or leisure activities for your clients with disabilities? (3) Overall, how often do you feel you are able to link the skill requirements of community recreation/leisure activities with your clients’ abilities? (4) Overall, how often do you feel you are able to link the skill requirements of community recreation/leisure activities with your clients’ interests? For the first scale, the hierarchical level intermediate level I was set equal to the reported responses of “dissatisfied” or “rarely,” intermediate level II was set equal to “somewhat” or “sometimes,” and optimal level was set equal to “satisfied” or “often.”

For the second scale, an effort was made to gauge therapists’ interest in pursuing education related to promoting community activities among their pediatric clients. Frequency of item selection was used to create scale values in response to the question “Would you be interested in a continuing education series that provided information about any of the following in relation to community recreation and leisure participation for all children regardless of ability?” Options listed were funding, community training, accessing resources, modifying activities, using adaptive equipment, creating accessible facilities, self-assessment, and other (Appendix 2). Score ranges were based on the number of positive responses and were assigned to one of the three categories of intermediate level I, intermediate level II, and optimal level. Distributions of responses falling into discrete categories were analyzed to determine whether a particular group or pair of groups of the three types of potential barriers (physical, social, and resource) appeared to account for the greatest perceived limitation(s) to community recreation and leisure participation.

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Validity

Using the definitions and concepts suggested by the WHO, a literature review, experts in the pediatric field, and our hierarchical framework, content validity was established for the measurements used to test each research goal.

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RESULTS

Physical Barriers

Response frequencies to survey questions representing the degree to which therapists were aware of and identified the influence of potential physical, social, and resource barriers to their clients’ community participation are listed in Tables 3, 4, and 5. Questions relating to therapists’ perceptions of the influence of physical barriers were designed to sample the primary hierarchical dimensions of access/environmental factors, transportation, and community (Appendix 2, questions 23, and 25). Therapists most often answered “never” or “no” (52.1%–87.9%) when asked if they were aware of or identified facility accessibility, activity modification, adaptive equipment provisions, or facility location as criteria for assessing community programs (Appendix 2, question 23). Similarly, therapists most frequently indicated that these potential barriers were not considerations when either suggesting or not suggesting community activities to their clients with disabilities (Appendix 2, question 25). The majority (90.1%) of all therapists responding to questions pertaining to transportation indicated that they identified transportation used by their clients for less than 25% of their clients (Table 3).

TABLE 3

TABLE 3

TABLE 4

TABLE 4

TABLE 5

TABLE 5

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Social Barriers

Questions relating to therapists’ perceptions of the influence of potential social barriers to their clients’ recreation and leisure participation were based on the hierarchical dimensions of independence, motivation, and choice and attitudes, values, and beliefs. The most frequent responses were “sometimes” (34.8%–43.5%) and “never” (17.4%–24.6%) when therapists were asked whether social information was requested during evaluations. However, “supportive” was checked most often as being descriptive of attitudes surrounding disability held by healthcare professionals and the therapists themselves (68.1% and 94.6%, respectively) compared with “tolerant” regarding community member attitudes (38%). Survey questions (Appendix 2, questions 16, 16a, 16b, 17) and corresponding responses are listed in Table 4.

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Resource Barriers

Questions pertaining to therapists’ perception of potential resource barriers prohibiting their clients’ participation in community recreation and leisure focused on the hierarchical dimensions of funding and resource channels. Of therapists who completed these questions, approximately half (45.5%) cited cost as a reason for either suggesting or not suggesting particular community activities. In addition, therapists indicated that they asked colleagues or looked up information pertaining to community recreation and leisure programs rather than maintaining a personal list. Response results related to resource barriers (Appendix 2, questions 23, 25) are listed in Table 5.

The preponderance of therapist responses distributed in the middle (eg, 50% or “sometimes”) to low-end (eg, 0–25% or “never”) ranges were consistent with respect to each potential barrier group (physical, social, and resource). These results indicated that no single group or pair of groups was outstanding as a perceived primary impediment to community participation by therapists surveyed.

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Differences Between Therapist Groups

A t test revealed that PTs were more likely than occupational therapists to consider cost as a potential barrier to client participation in recreation and leisure pursuits by individuals with disabilities (Table 6). For all other survey questions, no significant difference existed between the two therapist groups.

TABLE 6

TABLE 6

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Scales

Responses related to the two hierarchical dimensions of promotion of disability awareness and continued education are illustrated by the frequency data for the two scales created in Table 2. On one scale, therapists identified themselves as practicing in the intermediate level I in terms of their overall abilities and satisfaction in promoting community participation on behalf of their clients with disabilities. On the scale that gauged therapists’ interest in pursuing continuing education programs related to community recreation and leisure participation, responses clustered in the intermediate level II category. However, fully 54.3% of respondents had not attended any relevant seminars within the past three years (Table 1).

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DISCUSSION

The process of creating and promoting inclusive community environments in which all individuals have access to recreation and leisure programs regardless of ability is ongoing and complex. To realize the vision of equal opportunity for all individuals regardless of ability in the arena of community recreation and leisure participation, it is crucial to identify the potential barriers to participation and apply strategies to minimize their impact. Both subjective and objective results from this limited survey indicate that pediatric PTs and OTs may not be practicing at an optimal level in relation to their degree of awareness and consideration of the potential physical, social, and resource barriers that can hinder their pediatric clients’ participation in community recreation and leisure pursuits. Consequently, application of therapists’ knowledge and their promotion of community involvement are seemingly deficient. A greater sampling of pediatric therapists is needed to determine whether they are, as a population, actively promoting community participation. In addition, a refined survey should provide client data related to therapists’ knowledge and chosen interventions as well as information about their specific health conditions and socioeconomic status.

If future focused studies substantiate deficits in therapy practice as they relate to community recreation and leisure, then close attention should be paid to the reasons behind them. Perhaps entry-level academic curricula lack sufficient content in the focus areas of disability prevention and health promotion through community partnerships, client involvement in community recreation and leisure, and applications of local and national legislation. Perhaps employers and third-party payers are reluctant to reimburse the efforts of therapists who wish to avail themselves of current information and strategies regarding community participation promotion. Perhaps therapists view themselves as too busy to obtain information related specifically to community recreation and leisure. These possibilities, among others, should be considered and explored in depth to gain insight into therapists’ performance with respect to promoting community recreation and leisure for their clients with disabilities.

To ensure promotion of lifelong community activities, the development of model continuing education training programs for pediatric PTs and OTs, as well as efforts to enhance current preservice educational programs, is indicated. Training programs can assist therapists to optimally evaluate their clients with disabilities with respect to recreation and leisure habits and use intervention techniques to promote community participation. Ultimately, training can lead to longer, healthier, more productive and satisfying lives for their clients with disabilities. These outcomes are not only desirable but are consistent with national legislation and state health objectives.

In terms of program design, a historical background regarding the gradual recognition of the importance of recreation and leisure in prolonging healthy lifestyles provides a starting point. Specifically identification of (1) potential barriers to participation, (2) the impact of barriers on the type and level of participation an individual experiences, and (3) successful techniques for promoting community participation might be incorporated into a series of targeted training segments. The model of functioning and disability provided by the WHO in the most current ICIDH-2 provides an excellent foundation upon which to construct program content.

Given that the majority of therapists surveyed did not indicate a specific interest in any of the proposed options for continuing education topics, a focused follow-up survey would be useful in determining whether this is due to a lack of interest or alternative reasons beyond the scope of this study. Results illustrated a conflict between interest in and pursuit of continuing education. Although therapists categorized themselves in intermediate level II with respect to interest in continuing education, more than half had not attended any related courses or seminars in the past three years. Whether this was due to reasons suggested earlier (eg, gap in academic training, lack of organizational support and sponsorship, lack of time) was unclear. However, the topic of “resources” was the most frequently selected continuing education topic, despite the fact that it did not emerge as a primary barrier to participation in this study.

Because frequently cited barriers to community participation in the literature include knowledge of resources and transportation, future studies should explore the relationship of these barriers to specific activity selection and whether therapists’ and/or clients’ assumptions about barriers or significant, “real” barriers are most influencing participation choices.

It is notable that we found no significant differences between therapist groups with respect to the promotion of community participation for their pediatric clients in the area of recreation and leisure. Although, overall, professional goals and academic programs continue to be distinct for PTs and OTs, there may be more apparent overlap in actual practice. Recreation and leisure promotion may serve as a useful venue to remind PTs and OTs of their roles as health professionals, working toward a common goal of facilitating practical, holistic services and opportunities for their clients with disabilities and their families. To promote community awareness and participation, we must first be a community unto ourselves.

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CONCLUSIONS

Heightened efforts to encourage participation in and promotion of recreation and leisure pursuits are important to begin to address the chronic health issues that continue to confront many young Americans. Community-based pediatric PTs and OTs, in particular, are in an ideal position to promote healthy community attitudes and behaviors regarding inclusive recreation and leisure. Healthy People 2010 suggests many ways in which health professionals might play a role in improving the nation’s health including establishing community partnerships, sponsoring health fairs, and assessing school health education curricula. There are many additional ways in which therapists can expand on traditional training within a medical model and move toward a health-promoting, disability-preventing model. All therapists must recognize the influences that extrinsic factors, such as physical and social environments, can have on an individual’s physical and mental health status. In relation to this, PTs and OTs must consider the potential physical, social, and resource barriers and facilitators that ultimately determine their clients’ participation in recreation and leisure pursuits. Practitioners must recognize that physical impairment is just one of the myriad of factors that influence the development of healthcare goals. Finally, therapists must be aware of the evolving nature of disability and correspondingly alter their goals and interventions as their clients age.

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ACKNOWLEDGMENTS

We thank the Clinical Center for the Study of Development and Learning in Chapel Hill, NC, for its support of this body of work and sponsorship in its initial phase. We also thank Kathleen Hunter for her assistance in procuring community support in the form of incentives for survey completion. We are very grateful for the financial support from numerous local organizations that not only provided the incentive for therapists to return surveys but also allowed for the provision of hippotherapy services to families in need of financial assistance. We also extend our thanks to Darlene Sekerak from the Division of Physical Therapy at the University of North Carolina at Chapel Hill who recognized the importance of this work and provided additional financial resources for statistical support. Finally, we thank the PTs and OTs who found the time to respond to our survey.

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REFERENCES

1. Erikssen G, Liestol K, Bjornhold J, et al. Changes in physical fitness and changes in mortality. Lancet. 1998; 352: 759–762.
2. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995; 273: 402–407.
3. Chedd NA. Sports and fitness: meaningful participation. Exceptional Parent. 1996; 26: 30–31.
4. Centers for Disease Control and Prevention. Health-related quality of life and activity limitation—eight states, 1995. MMWR Morb Mortal Wkly Rep. 1998; 47: 134–140.
5. Centers for Disease Control and Prevention. Physical Activity and Health: A Report of the Surgeon General. Atlanta: US Department of Health and Human Services, CDC National Center for Chronic Disease Prevention and Health Promotion, President’s Council on Physical Fitness and Sports; 1996.
6. Kannel W, Sorlie P. Some health benefits of physical activity: the Framingham Study. Arch Intern Med. 1979; 139: 857–861.
7. Morris J, Clayton D, Everitt M, et al. Exercise in leisure time: coronary attack and death rates. Br Heart J. 1990; 63: 325–334.
8. Ward DS, Evans R. Physical activity, aerobic fitness, and obesity in children. Med Exerc Nutr Health. 1995; no. 1057–9354, 3–16.
9. Woolf K, Manore MM. Nutrition, exercise and rheumatoid arthritis. Top Clin Nutr. 1999; 14: 30–42.
10. Stone EJ, McKenzie TL, Welk GJ, et al. Effects of physical activity interventions in youth: review and synthesis. Am J Prev Med. 1998; 15: 298.
11. Barrett-Connor E, Orghard T. Diabetes and heart disease. In: Harris MI, Hamman RF, eds. Diabetes in America. Washington, DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases, NIH publication no. 85–1468; 1985.
12. Drowatsky KL, Drowatsky JN. From the field. Physical activity and bone mineral density. Clin Kinesiol. 2000; 54: 28–35.
13. Fox KR. Physical activity and mental health promotion: the natural partnership. Int J Ment Health Promot. 2000; 2: 4–12.
14. Green FP, Schleien S. Understanding friendship and recreation: a theoretical sampling. Ther Recreat J. 1991; 25: 29–40.
15. Heyne L, Schleien S, McAvoy L. Making Friends: Using Recreation Activities to Promote Friendships Between Children with and without Disabilities. Minneapolis: School of Kinesiology and Leisure Studies, College of Education, University of Minnesota; 1993.
16. Dykens EM, Rosner BA, Butterbaugh G. Exercise and sports in children and adolescents with developmental disabilities. Positive physical and psychosocial effects. Child Adolesc Psychiatr Clin N Am. 1998; 7: 757–771.
17. Campbell SK. Therapy programs for children that last a lifetime. Phys Occup Ther Pediatr. 1997; 17: 1–102.
18. Nagi S. Disability concepts revisited: implications for prevention. In: Pope A, Tarlov A, eds. Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press; 1991: 309–327.
19. US Department of Health and Human Services. Healthy People 2010. Washington, DC: US Department of Health and Human Services, Public Health Service, Office of Disease Prevention and Health Promotion; 2000.
20. Kokkonen J. The social effects in adult life of chronic physical illness since childhood. Eur J Pediatr. 1995; 154: 676–681.
21. Sherrill C. Adapted Physical Activity, Recreation and Sport. Crossdisciplinary and Lifespan. New York: McGraw-Hill; 1998.
22. Americans With Disabilities Act. Public Law no. 101–336(1990). United States Department of Justice, 1990.
23. Report of the Implementation Task Force of the National Commission on Allied Health. Washington, DC: US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions; 1999.
24. Rimmer JH, Braddock D. Physical activity, disability, and cardiovascular health. In: Leon AS, ed. National Institutes of Health. Physical Activity and Cardiovascular Health. A National Consensus. Champaign, IL: Human Kinetics; 1997: 236–244.
25. World Health Organization. International Classification of Functioning and Disability (ICIDH-2): BETA-2 DRAFT, Full Version. Geneva, Switzerland: WHO; 1999.
26. Department of Health and Human Services, CDC National Center for Chronic Disease Prevention and Health Promotion President’s Council on Physical Fitness and Sports; 1996.
27. National Institute on Disability, and Rehabilitation Research. Trends in Disability Prevalence and Their Causes. Proceedings of the Fourth National Disability Statistics and Policy Forum, May 16, 1997, Washington, DC. San Francisco: The Disability Statistics Rehabilitation Research and Training Center; 1998.
28. Lavin D. High performers are driven by vision, values, and mission. In: DePoint B, ed. Reach for the Stars! Achieving High Performance as a Community Rehabilitation Professional. St. Augustine, FL: TRN; 2000: 1–13.
29. Lepage C, Noreau L, Bernard PM, et al. Profile of handicap stuations in children with cerebral palsy. Scand J Rehabil Med. 1998; 30: 263–272.
30. Colon KM. Sports and recreation: Many rewards, but barriers exist. Exceptional Parent. 1998; 28: 56–60.
31. Kane R. Looking for physical therapy outcomes. Phys Ther. 1994; 74: 425–429.
32. Kennedy D, Smith R, Austin D. Barriers to recreation participation. In: Brown WC, ed. Special Recreation: Opportunities for Persons with Disabilities. 2nd ed. Dubuque, Iowa: 1991: 68–79.
33. Peat M. Community based rehabilitation—development and structure: pPart 2. Clin Rehabil. 1991; 5: 231–239.
34. Imrie R. Rethinking relationships between disability, rehabilitation and society. Disabil Rehabil. 1997; 19: 263–271.
35. West PC. Vestiges of a Cage: Social Barriers to Participation in Outdoor Recreation by the Mentally and Physically Handicapped. 1911. Eugene, OR: University of Oregon, 1984 (on microfiche).
36. Guide to physical therapy practice. Part 1: a description of patient/client management. Part 2: preferred practice patterns. American Physical Therapy Association. Phys Ther. 1997; 77: 1160–1656.
37. Dillman DA. Mail and Internet Surveys. 2nd ed. New York: John Wiley & Sons; 2000.
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APPENDIX 1.

TABLE

Table 1

Table 1

Table 2

Table 2

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APPENDIX 2.

FIGURE

Figure

Figure

Figure

Figure

Figure

Figure

Figure

Figure

Keywords:

leisure activities; recreation; physical therapy; occupational therapy; primary prevention

© 2003 Lippincott Williams & Wilkins, Inc.