Cover Story: The Secret Garden

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June 2004

By C.A. Wolski

Nancy Chambers, HTR, director of the Glass Garden (left), and Joan Gold, MD, clinical director of rehabilitation services at the Rusk Institute.

Hidden in the concrete and steel of Manhattan is a bit of greenery that seems more at place in a storybook than nestled in the shadows of skyscrapers. Bathed in a pastel wash of rainbows, and filled with butterflies and flowers, the 5,500-square-foot Glass Garden at the Rusk Institute of Rehabilitation Medicine, New York University Medical Center, New York, serves both as a center of play and as a means to conduct pediatric rehabilitation in a natural, interactive setting.

"It's extremely useful," says Karen Vonnegut, MSPT, MPH, supervisor of pediatric physical therapy at the Rusk Institute. "When we're in physical therapy, we want the children to be as functional as possible in as many different environments as possible, so it's nice to bring them into an outdoor setting....You want them to be able to apply [therapy] to their environment, and the playground is definitely an environment for children."

NATURAL THERAPY
The therapy outcomes that Vonnegut and her staff of 11 physical therapists are trying to accomplish in this patch of nature are completed as much through natural play as through structured therapeutic tasks. The equipment on the playground, which includes a slide-Vonnegut's favorite-a sand pit, paths, a child-sized house, water features, and a hammock, is designed to appeal to the children in the Rusk inpatient and outpatient programs while aiding their therapy.

According to Nancy Chambers, HTR, director of the Glass Garden, there are several ways it aids the children in their therapy. The garden provides a safe place for the children to learn how to move and navigate through the world. It is full of sensory stimulation including wind chimes and grass that crunches when the children walk and roll on it; and it gives the kids a chance to interact with one another or find quiet corners to spend time by themselves or with their families. "[A typical playground has] a huge piece of equipment that spreads out and has slides and climbing things and tunnels attached. For children with disabilities, it's scary because it's filled with children, and they are much more cautious about getting into the fray," says Chambers. "The equipment we have built into the garden is spread out. It is meant to be explored individually, to get children out of their wheelchairs and down on the ground somehow and let them wander around at their own pace." Physical therapy sessions in the garden range from 30 to 60 minutes each day.

Having a play garden as a component of rehabilitation makes sense to Joan Gold, MD, clinical director of rehabilitation services. "Play is a child's work, and they have to hone it in order to be successful as a child," she says. "Our children have come from being very ill-either from birth, or from having surgery or life-threatening accidents-so for them to have a hiatus in an area that is not strictly clinical is a psychological relief. Since the garden is within a therapeutic setting, it's therapeutic recreation."

In addition to its 35-bed inpatient pediatric unit, Rusk also runs an early intervention preschool for children with disabilities and has an active outpatient program. In 2003, Rusk had a total of 20,000 inpatient and outpatient physical therapy visits, and 10,000 occupational therapy visits. The children in the rehab program have a range of conditions from cerebral palsy and traumatic brain injury to simple fractures.

Therapy involves the parents at every level, which reflects the team approach of rehabilitation at Rusk. "We're one of the very few facilities that have cross-certification for family and child-based pediatric programs, and what that means is that the parents are involved from the beginning," says Gold. When the children are in the hospital, parents can sleep over, take part in therapy, and attend team meetings. Siblings are also involved, with programs including sibling support groups. There are other support and counseling services available as well.

Getting the family, particularly the parents, involved in treatment is a key element of success. "I think the ultimate goal is to always have the parents involved because they are the ones who will be home with the child," says Vonnegut. "Even if we start the program here and we have the child for intensive rehab, the parents are going to need to carry through with it once they are home. So it is very important to train the parents. We want the children to be as independent as possible in their own environment."

This holistic approach to treatment means that it is highly individualized, taking into account the needs and lifestyle of the family and the child. "We look at the children's goals, and the parents' goals, and we look at the goals they would need, if [for example] they are going back to school," says Vonnegut.

The Glass Garden allows the children to be less inhibited, in some cases, leaving the therapist behind and going to a favorite piece of equipment. Many times, this "child directed" therapy coincides with the therapy plan. Chambers adds that the garden almost becomes a silent partner in the therapy. "Gardens become the third component of the therapeutic relationship," she says. "When the PTs walk the patients through the garden for their ambulation class, they're not focused so much on the person who is getting the therapy, and their walk, they're looking at the garden and talking about other things. It is easier and nicer for the therapist and the patient, and the same things are getting done. It just enhances the therapy."

However, this third component, which seems, on the face of it, to be a natural part of therapy, is a relatively new addition to the Rusk menu of pediatric services-which also include standing programs, an adaptive bike program, and on-site hydrotherapy.

CREATING XANADU
More than 30 years ago, the space that is now the Glass Garden was the site of what was then considered a state-of-the-art playground, one which Chambers believes was not only a failure, but ugly. "When [the playground] was built 30 years earlier, it had been very creative, very innovative. And it was built specifically for the preschool program that is housed at the Rusk Institute," she says. "It was built by the then-director of the preschool, and 25 years later everything of course changed in how you treat children with disabilities and how independence has become the keyword now." She adds that, unlike the nature-dominated garden, the old playground was covered by asphalt.

That changed in 1998, when a $10,000 grant secured by a volunteer allowed Rusk to hire landscape architect Sonja Johansson to clean up the disused, dirty, littered, and unsafe site and turn it into the urban eden that it has become. The design process was collaborative including Johansson, Chambers, the PT and OT staffs, and others at the hospital.

Since the Glass Garden is part of Rusk's horticultural program, nature is literally intertwined in every element. "I didn't want a playground, I wanted a garden, and all the pieces of equipment that we do have, we've tried to integrate nature into all of it," says Chambers. "Over the top [of the hammock swing] there is a vine that is filled with flowers. In the summertime you don't have a sense that a big piece of metal is stuck out there. Everything is softened by plants and flowers."

In addition to the typical playground equipment-swings, slide, climbing bars, sandbox-Rusk added a prism sculpture that turns in the wind and bathes the sunny bit of urban wilderness with rainbows. Though older children and even adults use the garden, it was designed primarily for children under six.

Chambers says that learning about nature is as much a part of the rehab process as using the various pieces of playground equipment. "The children are learning about science and nature for the first time," she says. "They're manipulating the environment. They're playing with soil. And they're playing with plants. They're looking under rocks and seeing what's under there. They're seeing butterflies, and worms, and bees, and all kinds of things. They can explore all of that."

The therapists, with the help of Chambers' staff, create a sense of wonder in these explorations. For instance, the occupational therapy staff had a set of discovery boxes set up in the garden. Each box is opened using a different kind of locking or latching device. Inside-courtesy of Chambers-the children will find a different kind of rock, flower, or other reward every day. "It's part of the therapy, but it's also fun," says Chambers. "It has to be fun, it has to be a game. As soon as you try to plan it, it's not so good. The play garden is the motivator. It's not like you have to do anything to have the kids learn from it and grow and develop in healthy ways."

The Glass Garden is only one of several gardens available to both adult and pediatric patients at Rusk. There is a greenhouse that adjoins the play garden, and a perennial garden that is used for parties and celebrations and for horticultural therapy. The Rusk horticultural therapy program is, according to Chambers, the oldest in the country. There is no doubt that Johansson's design for the Glass Garden has been successful. Her work has been acknowledged by her peers several times, most recently with an award in excellence in universal design: great places fit for people, which was given by Adaptive Environments/Boston Society of Architects/AIA New York.

For Chambers, the park's accessibility to everyone-patients, their families, and even adults-has been a pleasant surprise. "The physical therapists now use it for the adults in their ambulation classes, practicing balance, and going up and down hills," she says.

But there was one other surprise that the Rusk staff did not anticipate. With no advertising, invitation, or encouragement, shortly after the park opened, neighborhood children began using the Glass Garden. These children-who are welcomed by Rusk administrators and Chambers-refer to the play garden as "our park."

The play garden even has its regulars. Chambers says that every Wednesday-when the weather is good-the same group of mothers and their children convene for a weekly play group. The phenomenon may have been inevitable since the garden was designed as a meeting place for Rusk families in addition to being a therapy space. "The hospital kids have families come to visit them in evenings and on weekends, and they might be disabled but their brothers and sister aren't necessarily," says Chambers. "So we knew we were going to be designing for families of the disabled kids."

Ultimately, however, the garden is a tool for therapists, who are the real reason that Rusk stands out, says Gold. "The staff is well versed in their subspecialty and they're very well trained-but that's not enough," she says. "They fall in love with the children and they have a look on their faces that says there is no place else that they would rather be, and they advocate and work for these children, as if they were their own. We're culturally and ethnically and religiously diverse, but everybody comes together to help the children. It's sort of a microcosm of what the world should be."

C.A. Wolski is associate editor of Rehab Management.

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June 2004