At one point, the Terrain Park at San Francisco's California Pacific Medical Center (CPMC) Davies Campus was just an idea in the mind of a local community member.

It was at a community advisory council meeting when a former patient, who had an amputation below the knees, approached Scott Rome, MD, chief of physical medication and rehabilitation about his idea.

"He came up to me and said, 'You know, Scott, you have a great program at the hospital in the physical therapy gym that teaches patients how to walk on a prosthetic limb or how to regain walking after a stroke, but we live in the bay area and people need to walk on the beach and over cable car tracks,'" remembered Dr. Rome.

"What do you think about developing a park where people can actually practice that in a safe and controlled environment?" he recalled the man asking.

Dr. Rome thought it was a fantastic idea, and as it would turn out, one that would forever change the way patients re-learned to walk after stroke or injury.

Money Matters

Dr. Rome took the idea of a real-life terrain park to the hospital administrators at CPMC who gave him the green light-but told him to first figure out how much money the project would cost.

The California Pacific Medical Center Foundation helped Dr. Rome raise $1.6 million to build the terrain park. Among others, Kenneth Archibald, MD, previous chairman of the physical medication and rehabilitation at CPMC, made a generous gift, as did the Davies Guild.

The money raised brought the terrain park one step closer to reality. And with the help of MPA Design, the landscape architect, the terrain park was finally under construction. A group of clinicians from CPMC's rehabilitation services, spearheaded by Cathy Kennedy, PT, teamed up with MPA to help with the design.

"We literally sat down with the architect and our team of clinicians, which consisted of PTs, a therapy supervisor, myself and others," said Dr. Rome. "The landscape architect would say, 'We can make this really flat over here.' And we'd say 'No, we really want it to be a steep grade so people can practice climbing hills.' It was an incredibly collaborative effort."

The biggest challenge was getting all of the ideas to fit into the allotted space. But somehow the space was found. Today nearly 30 features that present real-world challenges fill the terrain park.

Authentic Activities

Most of the terrain challenges are contained in a covered, heated and well-lit garden setting making it useable year-round, despite the weather.

The terrain park includes different elevations-as high as a 7 percent grade in some places-and various surface areas, such as sand, cobblestone, wood-chip, granite and rubber. The different terrain is meant to replicate the real-life surface challenges that patients are likely to encounter. Ramps and curb cuts are used for wheelchair navigation and ambulation.

An area designed for automobile transfer training allows therapists to use the individuals' own automobiles. The stoplight and 50-foot crosswalk provide an obvious real-life skills area. Safety, divided attention and temporal adaptation are addressed there.

Leisure activities are also addressed in the terrain park. To start, the basketball station is ideal for visual scanning, reaction time training, arm and hand coordination and movement, and rapid direction changes for high-level balance activities and conditioning.

The putting green is designed to present a firm and rolling terrain that challenges the systems involved in balance and postural control. Putting involves weight shifting, cognitive planning, visual-perception training and coordination.

"There's a hiking trail and several other paths and curb cuts with various surfaces and grade changes that challenge strength and mobility," noted Richard Bookwalter, MS, OTR, supervisor of outpatient occupational, physical and speech therapy. "The garden-like setting and fountain provide a non-clinical area for patients to enjoy."

Specifically, the horticulture stations provide opportunities for seated and standing gardening activities. Broad weight-bearing surfaces were designed to promote strength, postural control and normalization of tone, said Bookwalter.

"As you can imagine, most gardens wouldn't be very conducive to people who are in wheelchairs, but we have a place that is wheelchair accessible and you can actually pull your wheelchair up under an overlay," explained Dr. Rome.

Healing Horticulture

The wheelchair-accessible horticultural stations are beneficial to stroke patients, as most of them are in wheelchairs at least in the beginning of their recovery, noted Dr. Rome. The raised garden beds allow equal accessibility for both patients in wheelchairs and those who are able to ambulate.

"Multi-step tasks such as gardening allow therapists to evaluate and challenge each patient cognitively and psychosocially as part of the rehabilitation program," said Bookwalter.

The garden is an ideal place for safe, graded activities that build visual-perceptual and motor skills as they provide relief from the depression common among people recovering from strokes.

However, Bookwalter is quick to point out that rehabilitation is also about personal goals. If a patient didn't garden before his injury, chances are he's not going to be interested after the injury. "But if you loved gardening, then there's nothing as important as getting back to a real-life setting in the rehabilitation process as soon as possible," he said.

Any real world and non-institutional interaction that stroke patients can have-whether it is making meals or gardening-is really a great part of people's recovery, especially from the emotional standpoint, Dr. Rome added.

"Instead of pretending what it would be like to walk on the beach, the terrain park gives patients the ability to actually practice and find out if they are able to return to the seaside or work harder with a therapist to get there," he said.

The reason this terrain park better prepares patients for life after rehab than a gym may come as a surprise: A gym is an ideal place to try and walk; the terrain park is not.

Dr. Rome explained. "Everything is level and made for the optimal vision and the optimal balance at the gym. The terrain park is a place where, on purpose, we're simulating terrains out in the environment that are much more difficult," he said.

Bookwalter agreed. "It's a safe environment that provides clinical oversight in another step in the transition process back to home. It's something that our community asked for and we provided it."

Beyond Beautiful

To date, the terrain park has received rave reviews.

"They love it," Dr. Rome said of the patients. "We actually had a ceremony to thank the donors, and a few of our former patients said they wished this was here when they were patients."

As a doctor, Dr. Rome doesn't usually get to hear the type of feedback he receives about the terrain park-that it's really beautiful. He credits the landscape architect for making it such an aesthetically pleasing place where people feel like they can heal.

But the terrain park has provided more than just a picturesque place to provide rehabilitation. Bookwalter gave an example of how it helped one, otherwise non-engaged, patient.

"One of our physical therapists was treating a teenage boy with a significant weight problem contributing to various orthopedic issues. Our therapist tried several approaches to engage this teenager in exercises and strengthening activities to address his biomechanical problems, but his poor motivation for exercise was a huge obstacle," he said.

"The PT took him out to the terrain park and learned quickly that basketball was the ideal exercise for this teen-he was fully engaged, active for an extended period of time and motivated to follow the recommendations of the therapist for the first time. His family was thrilled-and the Terrain Park made it happen."

Beth Puliti is associate editor and Web editor at ADVANCE. She can be reached at epuliti@merion.com