Architectural [Physio]therapy: An Assisting Healing Process

ARCHITECTURAL [PHYSIO] THERAPY AN ASSISTING HEALING PROCESS

OLIVIA LAUREN FERGUSON-LOSIER

ARCHITECTURAL [PHYSIO] THERAPY AN ASSISTING HEALING PROCESS

OLIVIA LAUREN FERGUSON-LOSIER

Entry for the Azrieli Scholarship Competition 2015 Carleton University Thesis Advisor - Federica Goffi

Table of Contents Introduction

6-9

Chapter 1 - the body and well-being The body Complete well-being Qualities of healing spaces

11 11-12 12-13

Chapter 2 - traditional physical REHABILITATION Transitional care Physical therapy Equipment The aspect of time

15 15-17 16-17 19

chapter 3 - case studies Bridgepoint Active Healthcare Woy Woy Rehabilitation Unit Laban Dance Centre

4

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20-25 26-27 28-29

Chapter 4 - DYNAMIC REHABILITATION Benefits of exercise Therapeutic walking Levels of healing Way-finding Conceptual Ideas

31 31-32 32 33 34-35

Chapter 5 - a new rehabilitation facility for Dartmouth History of Dartmouth Site Analysis Zoning + Movement Program Design idea

Endnotes Image sources Bibliography

41-42 43-47 48-51 52-53 54-59 60-61 62 63-64

5

3.8 million canadians in 2012 13.7% of the population

obstructive physical disabilities dexterity pain

mobility flexibility

2012 reported illnesses Alzheimers 118, 043 Parkinson’s 12, 514 Stroke 39, 795 Brain Injuries

5, 504

Multiple Sclerosis Spinal Cord Injuries Muscular Dystrophy

6

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3, 831 1, 187

496

Introduction Physical rehabilitation is the active process by

and reflect upon the surrounding world. Often,

which those disabled by injury or diseases work

achieving this goal proves to be difficult for those

with specialists towards full recovery, or, if a full

with mobile disabilities. As a result, the built

recovery is not possible, to an optimal physical,

environment can sometimes act as an inhibitor

mental and social state. Through exercise and

and instead of helping with physical healing, it

physical activity, patients are re-taught basic

interferes and discourages any progress.

movement functions until proven fit to cope on their own. The main objective of this therapy

Mobility issues, physical injuries and movement

is for the patient to eventually be re-integrated

disorders are becoming increasingly more

into society. As such, physical therapy is an

common in Canada. In 2012, 1 in 10 Canadians

important component of one’s healing process,

aged 15-65 reported having at least one

especially since the ability to move correlates

disability that obstructed their everyday

with one’s level of independence. Movement

activities.3 Statistics show that for those over the

is an integral part of a person’s life because it is

age of 65, mobility is in the top 3 most prevailing

how we experience the world. Finnish architect

disabilities.4 Senior citizens are becoming

Juhani Pallasmaa supports these theories in

the fastest-growing age group within Canada.

many of his publications.

Consequently, debilitating illnesses/injuries

1

are going to increase over time. The design of Pallasmaa has written about the importance of

transitional care facilities and its use of traditional

combining all five senses within architectural

care techniques, helping patients with their

design. He states that our perception is

physical needs to return to a mobile society,

formed through our body interacting with the

needs to be re-evaluated. For example, specific

world.2 Pallasmaa describes the importance

rooms are been assigned for physical therapy,

of movement within our built environments,

yet it is argued that these spaces often do little

which allows one to reconnect with oneself

to promote movement and invigorate the body

Introduction | 7

“Our bodies and movement are in constant interaction with the environment; the world and the self inform and redefine each other constantly.�

Juhani Pallasmaa, The Eyes of the Skin

8

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and mind of individuals in healing. Using the

incorporate elements of well-being and human

connective system of health facilities, such as

movement to create engaging spaces for their

corridors or stairwells, would allow the therapy to

users.

expand throughout the building. These spaces could provide stimulating, interactive and safe

From these investigations, the remaining

areas for patients to gradually improve their

chapters will examine how architectural design

physical health. Additionally, it could encourage

can promote movement and allow physical

patients to incorporate feasible physical

therapy exercises to be practiced fluidly

activities in their daily life, in the hopes of leading

throughout health care facilities. By studying

healthier lifestyles.

notions of traditional physical therapy, and incorporating elements that enhance one’s

The first chapter of this thesis will discuss the

state of well-being, this thesis will propose a

importance of incorporating elements of well-

design that provides healing environments to

being into our built environment. Well-being

patients with physical and mobility dysfunctions.

is defined as the state of being happy, healthy

By establishing the project in Dartmouth, Nova

and prosperous. In order to design spaces that

Scotia, this design project will be providing a

promote the physical healing process, we must

community with a much-needed health centre

investigate how other areas of one’s health can

for patients with mobile dysfunctions. Through

be positively affected. The second chapter of the

the design of a transitional rehabilitation centre,

document will examine traditional care methods

I will explore how the circulatory system of a

and the current ways physical therapy assists

building can be designed as a therapeutic tool

patients during rehabilitation. The third section

to promote exercise and social interactions for

will present case studies of contemporary

patients.

5

rehabilitation centres and buildings that Image : Robson Square stairs and ramps, Arthur Erickson, Vancouver, B.C.

Introduction | 9

CHAPTER 1 The body and well-being

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THE bODY The human body is an integral element to the creation of space. Our understanding of the surrounding environment is done entirely via our physical self and its ability to form connections between sensorial experiences and spatial awareness. Perception of space, as defined by French philosopher and phenomenologist Maurice MerleauPonty, is the human body’s proficiency to engage with its surrounding environment.1 He firmly believed that the body ‘synchronizes’ with the world’s architectural and environmental elements through sensory or motility means. What is important to retain from Merleau-Ponty’s work is that perceptual experience is continually shifting via the aspects that we encounter through our lived body. The mobility of a being should not be solely perceived as visual, but instead should be understood as a more complex sensory exchange between all senses. The human body is much more than an object in space; the body is a vessel through which our connections to the surrounding world can occur simultaneously.2 Thus, translating these phenomenological notions into physical conditions that allow for sensorial and dynamic interactions between body and space through motion are essential within healing environments.

Complete Well-Being When designing spaces that impact the human recovery process, it is important to consider the complete well-being of patients. Healing is multidimensional in the sense that it impacts physical, biological, mental, emotional and societal aspects of a person.3 In fact, the correct definition of health, according to the World Health Organization Image : The National Gardens Athens, Greece

Chapter 1 | 11

(WHO) is “a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity.”4 In The Enigma of Health, Hans-George Gadamer describes being ill as “lacking from health,” or missing something from the entirety. He states that illness is associated with a loss of equilibrium between the body and the mind, supporting his theory with a passage written by Plato : “... the body cannot be treated without at the same time treating the soul. It is further suggested that perhaps even this is not enough, that it is impossible to treat the body without possessing knowledge concerning the whole of being.”5 This statement indicates that we must understand ourselves as a whole in order to heal.

Unfortunately, many of our health facilities are still concerned with ‘curing the disease’ instead of tending to the well-being of individuals. It is only when we are aware of our full well-being that we can begin to treat the affected parts.6 Being healthy includes balancing the interconnected relationships between the physical body, the mind, and the spirit.7 When we fall ill, the main goal is to find balance and return to a stable state of health.

QUALITIES OF HEALING SPACES The process of getting well incorporates multiple factors,. It combines physical healing, with mental, spiritual, emotional and social care, thereby creating a complex system of relationships that all need to be treated.8 Looked at from this perspective, healing is multidimensional and needs to be reflected in the spaces that architects create for

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patients. Especially with physical rehabilitation, there must be spaces that address all aspects of one’s health. These environments are critical to the recovery phase of patients before being returned to society. To be reintroduced into the fast-paced schedule of everyday is not a simple task, as aspects of the self may heal at various tempos and speed. There is no denying the importance of positive environments to a patient’s recovery, however, this understanding is relatively new. During the late 20th century, hospital design placed emphasis on housing advanced medical equipment rather than helping patients. Hospitals were treated as machines aiming to cure the masses.9 Over the past few decades, there has been a shift in health design. . As a result, architects now focus on creating pleasant environments for both patients and staff that contribute to healing. In fact, Gesler firmly states that “healing and place are inseparable.”10 Creating a sense of place - focusing on the experiential qualities of space - gives patients a sense of belonging, comfort, identity and security within hospitals and clinics.11 Looking at subtle humanistic elements that enhance a patient’s space can make a big difference. Successful healing spaces are characterized by the combination of various environments, each focusing on different aspects of healing, but all contributing to the well being of patients.12 This includes a mixture of natural environments, the built environment and social environments resulting in positive overlaps.

Chapter 1 | 13

CHAPTER 2 Traditional PHYSICAL REHABILITATION

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Transitional Care As patients move from hospital to home environments, there is a period of time in which their health is in a state of in between : they are well enough to leave the hospital, yet they are incapable of living independently. This phase requires transitional care, where patients are provided with the necessary treatments and recovery time as they transfer between different environments or levels of health.1 Typically, transitional care is based on a plan of progressive care, designed by health care practitioners and tailored to a patient’s situation. In certain cases, transitional care encompass rehabilitation, in which recovering patients are treated with the expectation of achieving their optimal potential.

The main objective in this case is preparing individuals for an independent life when they return to society. Therapies offered within rehabilitative medicine include psychology, occupational therapy, recreational therapy and physical therapy (among others). Each branch focuses on an aspect of human health, and ensures that it reaches a satisfying level of recovery before a patient is discharged. Through clear communication between patient, therapists, family members and care givers, the needs and limitations of the patient can be addressed. The focus of this thesis is the profession of physical (physio) therapy and how it is used to improve human movement.

Physical Therapy A significant aspect of being healthy is one’s capacity to move independently within society. In situations where motion and functional abilities of the body have been affected, medical professionals prescribe physical therapy. The role of this type of Image : Physiotherapy Room Bridgepoint Active Healthcare, Toronto, Ontario

Chapter 2 | 15

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therapy is to provide the necessary services to injured individuals in order to develop and restore maximum movement and capacity.2 Often, physiotherapists use a mixture of stretches, postures and exercises to evaluate the severity of an injury. Objectives of physical therapy exercises aim to improve strength, endurance, coordination, flexibility and balance of an individual.3 The exercises are typically subdivided into active and passive movements. Active movements are performed by the patient’s muscular effort while passive require an external force, such as a physiotherapist or pulley system.4 Physical therapists use their knowledge to ensure the appropriate interventions and equipment are applied in order to restore integrity to the body’s systems essential to movement and reinforce a patient’s quality of life.

Equipment The types of equipment used during physical therapy are important tools that aid patients improve physically. The purpose of these devices is to give support to patients during exercises and prevent potential falls. In this way, physiotherapists can increase the difficulty of exercises, gradually healing the patient’s injury. Equipment also allows patients to practice exercises with multiple benefits. For example, instead of solely focusing on strength, a therapist encourages exercises that also incorporate elements of coordination and balance. Light weight training and resistance exercises, to illustrate one practice, are particularly beneficial to improving strength, joint mobility and coordination.5 Aerobic and low-impact exercises are important exercises that increase an individual’s heart rate which consequently improves one’s endurance, balance, coordination and cardiovascular capacity.6 Many studies have demonstrated that regular 30-45 minutes of aerobic exercise decreases the risk of numerous diseases and Images: Left: Different pieces of equipment used within physiotherapy.

increases psychological health results.7 Chapter 2 | 17

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The Aspect of Time For some, recovery is not about healing completely, but rather about learning to adapt to an illness in order to regain independence and reintegrate into society. Every person heals differently depending on the injury and other external factors. Hospital environments, especially rehabilitation centres, must understand the challenging aspect of reintegration and respect the gradual process it can take when designing healing spaces. The aspect of time is relevant to rehabilitation when addressing impacts of aging; the necessary time it takes to heal; and the gradual process that is healing.

The age of an individual indicates a certain level of skill, maturity and development. As a result, the therapy prescribed must alter according to the person. As we get older, there is an increasing concern of illnesses, weakness, and fragility to the physical mind and body. Healing takes longer due to decreased function within the body such as muscle fibres, motor units or neurons.8 Establishing a gradient of therapy exercises, increasing in difficulty, is useful because it can be applied to patients of all ages and levels. Aging also emphasizes the limits of the human body after years of overuse and exploitation.

More specifically, the brain and its associated nervous system’s activities decrease due to dying brain cells, causing repercussions to our body’s ability to perform certain tasks.9 Examples of this include physical pain in joints, thinning muscle tissues, fragility in the skeletal system, hearing loss, visual impairments, slower cognitive skills, and a declining neuromuscular system (resulting in gait and instability).10 Alternatively, there are ways to decrease, if not eliminate, some of these symptoms by adopting an active lifestyle, gradually exercising to keep the physical body alert while treating the mind.

Physiotherapy aims to do so by providing exercises that individuals can practice daily.

Chapter 2 | 19

Part 3 Case Studies These projects have been studied, and in one case visited, in order to understand how design accommodates physical rehabilitation and how movement can be emphasized within buildings. 3 out of 5 case studies will be presented.

Bridgepoint Active Healthcare Woy Woy Rehabilitation Laban Dance Centre Rehabilitation Centre Groot Klimmendaal Vandhalla Egmont Rehabilitation Centre

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Bridgepoint Active Healthcare Architects: Stantec Architecture; KPMB Architects; HDR Architecture; Diamond Schmitt Architects Location: Toronto, Ontario, Canada Area: 51,076 square meters Year: 2013 Bridgepoint is a large rehabilitation facility, specialising in long-term, chronic care, it is centrally located within the city of Toronto. In 2013, the original building was destroyed and replaced with a new design. The new facility is twice the area and four times the volume of the previous rehabilitation centre. With an augmented program, improved quantity and quality of space, as well as a variety of social activity spaces (indoors and outdoors), the new design claims to have a very positive impact on the well-being of patients and staff. Touring the building with a practicing physiotherapist gave insight into the spaces as well as their functionality and qualitative nature all while being critical to the building’s layout, benefits and innovation.

Each floor contains one therapy gymnasium located in a corner of the building, thereby granting the space panoramic views. The gyms, used daily by various physiotherapy and occupational therapists with their patients, often become cramped due to overcrowding.

The layouts of the gymnasiums vary slightly from one to another, mostly in regards to the specialized equipment used by each unit. In regards to the designs, medical professionals were not consulted in its creation, thus resulting in smaller rooms with the possibility of overcrowding. When this occurs, hallways, exterior spaces and stairwells often become impromptu areas for therapy sessions. With assistance from railings found throughout Bridgepoint, patients can navigate and practice certain exercises with aid from their therapists using the built environment. Surprisingly, this design ‘flaw’ could Image : Hallway within the Bridgepoint Active Healthcare Toronto, Ontario

potentially lead to a new positive, architectural idea regarding the layout of stairs, ramps and corridors assisting physical therapy.1 Chapter 3 | 21

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Bridgepoint

Image : Left : Exterior shot Bridgepoint Active Healthcare Toronto, Ontario Right : Base map taken from Bing.com

Chapter 3 | 23

1

2

3 1

2

3

4

5

6

4 5 6

Bridgepoint’s new facility provides many spaces for care, yet the connective spaces often feel stale and bare. Providing larger hallways and stairwells is a positive feature, but there are ways to make them more comforting and useful for physical therapy and physical exercise.

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These stairs are a great example of creating more human scale environments: they reduce the size of the area, making it more compact for the user; they implement additional safety features such as double railings; and they include spaces wide platforms for breaks. All of these help decrease the overwhelming feeling patients may experience during physical therapy.

Chapter 3 | 25

1

1

2

3 26 | Architectural [Physio]therapy | an assisting healing process

4

Woy Woy Rehabilitation Unit Architects : Woods Bagot Location : New South Wales, Australia Area : 2200 square meters Year : 2013 This new rehabilitative wing is an extension of the Woy Woy Hospital, and specializes in providing interdisciplinary restorative care for a range of injuries, surgeries and illnesses.

The facility contains 30 sub acute inpatient beds, with each room housing one or two beds. Staff members work with current inpatient facilities and outpatient support services in order to provide a continuation of care for the patients.

This facility attempts to assist patients in their recovery by implementing gardens and natural elements throughout the design, creating intimate spaces that blend the exterior with the interior. “Home in the Park” is the central theme. The interior spaces use comfortable materials, textures and colours that give the feeling of being in a residential house. Through landscaping, outdoor courtyards and ample daylight, the boundaries between exterior and interior are blurred. Small therapeutic gardens have been incorporated into the design, creating sanctuaries that nurture the patients by removing the feeling of being within a hospital. As written by the architects, “the patient’s journey extends into the existing groves of eucalypts and native grasses.”2 This centre attempts to remove the stigma of health institutions, generally perceived as negative and Images : 1. North facade facing gardens 2. Interior hallway with outdoor connection 3. Exterior ramps and stairs for therapy 4. Floor Plan

daunting spaces, by incorporating calming elements of nature, which creates healing environments. Through connections to the outdoor and by providing adequate daylight within the interior spaces, patients are able to enjoy their rehabilitation without feeling institutionalized.3 Chapter 3 | 27

3

1

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2

4

Laban Dance Centre Architects : Herzog de Meuron Location : London, England Area : 8,203 square meters Year : 2000 – 2003 The Trinity Laban Dance Centre is a distinguished dance facility located within an industrial area in southwest London. The building houses many amenities, including several studios, a large theatre, library, cafeteria, administrative offices and production facilities. The main performance theatre is centrally situated within the building with circulation moving around it. The activities are distributed over two open levels, encouraging the intermixing of tasks and creating social interactions.4 This dance facility can be identified for its wonderful use of human movement within, and around, the building.5 Designed as a public building, the centre incorporates a complex interior of avenues, streets, winding lanes, spiral stairs and courtyards. The openness of the centre allows for social encounters, spontaneous dance practice and an overall feeling of connectedness. Two large, black winding staircases anchor the space at either end, all while being large enough for gatherings. Through the use of translucent and transparent walls and windows, the boundaries are blurred between exterior and interior. The reflection or shadow of dancers along the translucent panels playfully interact with observers and contribute to the building’s identity as a consequence. Soft colours are used as way-finding tools both inside and outside the building with large Images : 1. Gathering space beside stair 2. Entrance to building 3. Hallway with exterior ramp 4. Main route around theatre

windows assisting in orienting those within. Nicknamed “the rainbow building,” its colourful, translucent polycarbonate cladding truly allow the building to stand out within the city fabric.

Chapter 3 | 29

Part 4 Dynamic REHABILITATION

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Benefits of Exercise Physical therapists often use exercise as an effective treatment during rehabilitation.

According to Duncan Mason in Tidy’s Physiotherapy, exercise uses “voluntary muscle activity produced by the integration of higher centres, cardiovascular, pulmonary and neuro-musculoskeletal components to rehabilitate these systems.”1 Physical activity has been proven to reduce and prevent certain debilitating health conditions such as obesity, type 2 diabetes, cardio vascular disease, chronic pain, osteoporosis, and many more.2 As such, it is essential to one’s physical, emotional and mental health . Additionally, the hormones released during exercise have been known to improve one’s mood and help in mental illnesses such as anxiety and depression.3 Despite knowing the benefits and overall positive effect of exercise, the habit of physical activity is typically forgotten or ignored with adults.4 This trend leads to inactive older adults with increased chances of obesity, cardiovascular health issues and falls. As we age, our physical capacities decline : maximum oxygen intake begins to decrease from 8 to 16% each decade after thirty ; muscle strength declines by 10 to 15% and chances of falling increase substantially.5 Exercise can be delivered in numerous ways by physical therapists: in a clinical setting, by teaching home exercises, as an individual, in a group setting, in water, etc.6 All approaches need to be considered to select the most appropriate for the individual requirements of each patient. With this in mind, it is important for rehabilitation environments to provide conditions that encourage different types and levels of physical activity.

Therapeutic Walking Image : The Canterbury Labyrinth University of Kent, Canterbury, England

In regards to the importance of exercise, walking, especially for older citizens, is known to improve cardiovascular health and muscle strength.7 Furthermore, moderate walking Chapter 4 | 31

done regularly has been proven to enhance moods, as well as boost the body’s immune system.8 As explained by Esther Sternberg in Healing Spaces, walking can be meditative: you focus your attention on the rhythm and speed of your breathing during every bodily movement. It becomes a soothing ritual, where each step is an effective way to manage stress.9 Furthermore, this inexpensive form of exercise can be done everywhere as it gives people small moments of activity during long sedentary days. Labyrinths are an interesting way to create therapeutic environments that involve walking as stress relief. Once popular in many European gardens, labyrinths are now often included in health care designs. Using many features of Tai-Chi, a system of exercises practiced for health and relaxation, labyrinths encourage physiological relaxation through controlled

1

breathing.10 This spatial intervention and form of exercise can be used not only by patients, but also by staff members and visitors experiencing stress.

Incorporating Levels of Assistance An important element of physical therapy is incorporating exercises of varying difficulty.

Gradual learning must be incorporated as it decreases feelings of frustration and increases positive results. This can be done through different iterations of exercises, or using equipment for additional support. Handrails, for instance, are helpful optional devices that facilitate movement throughout the building by aiding in stability and guidance. They allow patients with mobility issues to travel at a personal pace without fear of falling. By implementing a gradient of activity levels, objectives appear more realistic and less overwhelming to someone re-learning a basic function.11 Stairs and ramps are also helpful interventions to decrease the difficulty of walking, requiring

2

patients to use additional strength, coordination and balance. Physiotherapists often use small stairs and ramps before demanding patients to practice on actual staircases within buildings. Decreasing the scale of architectural elements, such as stairs and ramps, is an effective way to help patients regain their physical confidence.

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Way-finding Hospital design is infamously known for its confusing spatial organization, disorienting hallways and poorly explained layout. Patients and visitors consistently find themselves getting lost when navigating the corridors of hospital facilities. If we are to encourage these environments to be interactive and social places, a proper configuration and system must be addressed. Way-finding is a technique that uses the physical environment to navigate from one location to another.12 When walking, our brains perceive objects and then place them in sequences, consequently forming a memory of the places we experience.13 One technique to make way-finding simpler is to position specific markers on pathways. Connecting these familiar sights forms a mental map that people become acquainted with the area. Additionally, placing a recognizable object entices curiosity of the mind and encourages our bodies to move towards it.14 Using this strategy, spatial organization becomes a discovery, seducing human movement rather than directing it.15 Proper way-finding can offer patients and visitors an enjoyable procession through health facilities, making unfamiliar aspects of health centres more comforting. It is important to note that including elements to those with disabilities is essential. Visual, spatial, auditory or textural proprioceptive cues (these are signals that occur when moving through space16) are various ways that improve patient’s wayfinding abilities. It is through practice and repetitive movement that spaces become more familiar, thus making way-finding easier. As explained in Brain Landscape: “motor skills are embedded in procedures which are expressed through performance.�17

Images : 1. Assisting handrail 2. Parallel bars enabling a range of motions.

Chapter 4 | 33

Conceptual Sketches Idea of circuit circulation with marked pathways/ markers that bringing users back to their initial spot.

conceptual circuit walking throughout building

x meters 34 | Architectural [Physio]therapy | an assisting healing process

Conceptual Sketches Illustrating ideas of incorporating safety, privacy and passive / active elements that enable human movement.

Active assisting (track walking)

Double railing ( safety )

Rest station

Exercise area off main path

Private areas ( screened ) Passive assisting (railings)

Chapter 4 | 35

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A serious problem Many of the beds in the Dartmouth General Hospital are occupied by patients who have stable health, but require additional physical care in order to be independent. Due to lack of inpatient physical therapy facilities, these patients are kept within the institution, confined to their rooms and beds. Movement and exercise are required to strengthen the musculoskeletal system, improve the cardiovascular system and decrease the risks of other health issues. When patients do not receive the necessary movement, health complications such as bedsores, falls and blood clots. Moreover, these beds are being occupied by patients that could be treated elsewhere instead of the hospital. Providing a facility that focuses on offering physical therapy services can be beneficial not only for patients, but also for the main Capital Health District.

easing the transition The population for this new transitional rehabilitation facility would be individuals who have been discharged from the hospital setting with stable health, but require additional care for their mobile or physical difficulties. This rehabilitation centre is the link between the hospital and home: it is the final step patients may experience before fully returning to society. Despite housing several beds for short stays only, individuals can live within their community and receive the necessary physical care. Not only does this facility provide individuals with the movement and exercise they need, but also liberates hospitals beds for those who truly need them.

Chapter 4 | 37

Hospital Patients are dependant on caregivers; Patients’ health is not stable; Mobility is severely limited due to health, injuries, illness, etc.

Patient is bedridden Patient could not support themselves independently

Transitional Rehabilitation Acts as LINK between hospital and home settings Patients’ health is stable, but requires exercise ; Injuries are healed enough, yet requires gradual movement Must receive therapy to address mobility concerns

Home Individual is fully independent; Health is completely stable; Physical issues (if any) do not obstruct living conditions.

Individual is completely mobile

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Time

+

Movement

=

Space

Designing spaces for gradual

Incorporating elements that

Combining the two to create

healing and varying abilities

allow for movement and exercise

engaging and interactive conditions

Chapter 4 | 39

CHAPTER 5 A New Rehabilitation Facility for Dartmouth

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Dartmouth, Nova Scotia The community of Dartmouth is part of the Halifax Regional Municipality (HRM) and is located on the eastern shore of the Halifax City Harbour. Once an individual city, it is now part of a large metropolitan area that combines suburban, rural and urban elements.1 With an approximate population of 373,000, the HRM is the largest and most diverse municipality in Nova Scotia and Atlantic Canada.2 Currently, the average population of Dartmouth (including Cole Harbour) is around 89,200 and covers an area of approximately 58.57 km2.3 The area occupied by present-day Dartmouth was originally used by the Mi’kmaq First Nation for summer fishing and camping trips. In 1750, English settlers sailed across the harbour from the newly created city of Halifax to establish Dartmouth (in honour of the Earl of Dartmouth, William Legge)4. Until the mid 1800s, the area was mostly a small farming and fishing community used by local inhabitants. Dartmouth was transformed into a light industrial and commercial community during the Industrial Revolution, with the addition of shops, small factories, an oil refinery as well as the construction of the Shubenacadie canal system.5 Following World War II, the city experienced a substantial period of growth as a result of industry and new employment opportunities.6 Since then, road construction have sprawled throughout Dartmouth, allowing easy transit between regions, such as Bedford and Sackville. The physical connection between Halifax and Dartmouth is an important element in the lives of many Haligonians. From 1752 to 1954, the only direct trajectory across the Halifax Harbour was by ferry, still in operation today.

In 1955, the Angus L. MacDonald bridge was constructed, facilitating transportation Images : Left : Bing.com image Right : Google images of Dartmouth’s characteristics

between the two cities. A second cross-harbour bridge was built in 1970. Since this time, Dartmouth has become a successful commercial and industrial area for the Atlantic provinces of Canada.7 Chapter 5 | 41

New Brunswick

P.E.I

Sydney

Amherst New Glasgow

Antigonish

Truro

Halifax Regional Municipality

Nova Scotia Dartmouth

Yarmouth

HALIFAX

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Health Care facilities within the area Nursing Homes

Large health institutions

Rehabilitation Centres

Bedford Basin Admiral Long Term Care Site The Berkley Senior Care Parkland at the Lakes Senior Care Oakwood Senior Care

Dartmouth General Hospital

Chapter 5 | 43

Proposed Site manor park

Halifax Harbour

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Medical Area

woodlawn

From Hospital to Physical Rehabilitation time + distance

7 MIN 4.1km

5 MIN 2.9km 6 min 4.3km

Chapter 5 | 45

Current Penhorn Site (empty lot behind the Sobeys)

Sobeys

soccer field + playground

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pedestrian stair / ramp

Penhorn Lake

PEnhorn Mall + Proposed Site Penhorn Mall was a U-shaped shopping mall located in central Dartmouth and was directly accessible from Portland Street. It was the local community’s destination for food (Sobeys, Sunday markets, food court), entertainment (Empire Theatres) and leisure / shopping purposes (Wal-Mart, Sears, many little boutiques). Due the establishment of a large shopping district in Dartmouth, many shops migrated, leaving the mall destitute and empty. It was open from 1974 until 2008, with partial demolition terminating in 2011.8 Currently, the lot is partially vacant with the exceptions of a small strip mall (7 tenants), a Sobeys, Goodlife Fitness Centre, Sears and two large parking lots. Residential, commercial and recreational zones surround the site. Residents in the area range from young families with children to senior citizens. The commercial zones are a mixture of strip malls, restaurants, big box stores, car dealerships, gas stations and grocery stores.

As for the small recreational zones found in the area, they are comprised of soccer and baseball fields, playgrounds, as well as tennis and basketball courts. Large and busy roads and highways divide these areas.

The large vacant portion of the lot offers many opportunities for architectural interventions. By rezoning the site and establishing an area that promotes physical activity while also housing a physical rehabilitation facility, a community will be provided with a much needed physical health care centre. In addition, rehabilitating the site will also address an urban eye-sore. Since the site is situated between two residential neighbourhoods, the centre will bring patients closer to their community, rather than forcing them to travel for necessary services.

Chapter 5 | 47

Residential Areas

Commercial Areas

Recreational Areas

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In addition, this location allows a change of environment for patients keeping them within familiar sights instead of near the medical area of Dartmouth. Furthermore, the site is located near many amenities that can benefit a patient’s process of being reintegrated into society. This includes a new green zone for recreational activities and observation; a calm lake for pleasant views and potential trails; easy access off a busy highway while providing shelter from noise; as well as a slow commercial area off the main street providing groceries, home essentials, pharmacy, and restaurants.

New zoning for the site Despite the busy area being filled with mostly vehicular movement, the position of the Sobeys and Sears cut off the unused lot from the street, leaving it stale and ignored.

Although I am proposing a new master plan, the existing commercial area cannot be changed. Movement should be brought back into the site via roads for cars, but also incorporating sidewalks, footpaths and trails that allow pedestrians to meander. The site’s zoning will be reviewed to be a mix use property, containing commercial areas, residential units and recreational areas for physical activity. By rehabilitating the site through movement, adding a park and green spaces, the site will be enhanced and create enjoyable areas for pedestrians. The area between the new park and main commercial area will be used for health and exercise promotion.

Chapter 5 | 49

Penhorn Lake

Site plan - proposed zoning Commercial Zone Residential Zone Recreational Zone Active Promotion Zone Area for new facility

50 | Architectural [Physio]therapy | an assisting healing process

Pedestrian

Fence

Vehicular

Pedestrian trails in park

Main entry

Vehicular

Current movement

Proposed movement

Current circulation for cars are restricted to the south

The new plan keeps the vehicular circulation (and

area of the site only ; the northern part of the site is

parking) towards the south, adding foot paths and

barren despite the random pedestrian traveling the

pedestrian routes near the northern section of the site.

sitezz.

Rehabilitation includes adding landmarks, gathering spaces and landscaping.

Chapter 5 | 51

Therapy Circulation

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Main Circulation

Site Circulation

Program The program of the building will reflect the necessities of physical care. Along with physical therapy, the facility will house spaces for occupational therapy, recreational therapy, social work, psychology and nutrition, all working with one another.

Certain connections must be made between professions, such as physical therapy/ occupational therapy, and should be reflected in the design.These professions require spaces to function properly, such as administrative offices, private offices and meeting rooms, thus these requirements will also be taken into consideration.

For visitors and staff, a cafeteria and eating area will be included. A separate space will be allotted for a pharmacy, supplement store, prosthetic fittings, as well as an orthopedic and fitness equipment store. This will help support the facility financially.

In order to accommodate patients who must stay temporarily, a small inpatient wing will have 10 beds and caregivers to assist them with their rehabilitation.

Movement There are many levels of movement occurring throughout this design. One level addresses the movement at an urban scale, bringing human activity back to a secluded area within the site. A second level addresses how (main) movement between the different professions and staff members takes place in a professional manner. A third level addresses the physical therapy movement that affects the well-being of the users. How these levels interact and overlap will be investigated through the design of the facility.

Chapter 5 | 53

Guidelines Transitional Rehabilitation Centre Elements of Well-being

Rehabilitation

Natural

Occupational Therapy

Soclal

Physical Therapy

Spiritual

Recreational Therapy

Psychological

Psychology

Haptic

Nutrition

Architectural

Social Work Chiropractics / Acupuncture Massage Therapy

Circulation Spaces Beneficial

Gradual

Therapeutic

Interactive

Strength

Levels of difficulty

Walking Paths

Between professions

Endurance

Accessibility

Circuits

Person to person

Balance

Privacy

Way-finding

Person to building

Flexibility

Safety

(materiality, colour, texture,

Coordination

(physical elements,

light, etc.)

Rest

materials, etc.)

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Design This project aims to incorporate some of the mentioned theories (benefits of exercise, therapeutic walking and levels of assistance) into areas within the connective spaces while addressing the way-finding system. These design interventions will permit safe exercises that target one’s strength, endurance, balance and coordination, as well as ensuring enjoyable walking paths to promote an active lifestyle. Additionally, aspects of privacy and safety must be incorporated within the spaces so that the patient’s identity and progress is not compromised.

Although the design has not been completely determined, the approach will organize physical therapy spaces around levels. These levels, ranging from one to four, are based on the amount of difficulty a patient could have with exercises.

For instance, level 1 constitutes a sequence of exercises that could be viewed as difficult for patients with severe mobile dysfunction. In contrast, level 3 revolves around exercises for patients with substantially better mobility. As injuries improve, patients move up a level. By doing so, the therapy spaces eventually become easier for them. These four levels of therapy spaces will flow and occasionally interact with the main circulation of the facility while leading to positive destinations (outside, resting spaces, equipment areas, etc.). These are not secluded rooms, rather they circulate within the building and occasionally overlap and inform other levels. They are organized as explained below :

Chapter 5 | 55

Conceptual sketch - level 1 space

Idea of tight circulation

Patients are able to walk along while being assisted by a track and harness Way-Finding : colours indicate direction of spaces

Beneficial : areas for breaks

Accessibility : circulation spaces are wide enough to accommodate space for wheelchairs, walkers, etc.

Therapeutic elements : views of the exterior park and lake create pleasant environments for exercise

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Level 1 : These spaces will target the issues of patients that require the most assistance in regards to their therapy. For these patients, mobility is extremely difficult. How the level 1 spaces are choreographed is important because it determines how patients get to the spaces with the least amount of difficulty. Thus, level 1 spaces should be organized tightly and in close proximity to the entrance and inpatient area. The sequence should guide the patients through the therapy spaces while providing wheelchair accessibility, lifts, and tracks that permit for walking. The hydrotherapy facility should be a destination within this area.

Level 2 : These spaces will target patients who require moderate assistance thus are slightly more mobile. Handrails walkers, crutches, canes and parallel bars can help with patient stability, balance and strength. Along with areas for stationary exercises, level 2 therapy spaces should encourage walking while providing room for the equipment and allowing for breaks. These spaces should interact with level 1 but should be farther within the building, allowing for more movement.

Chapter 5 | 57

Conceptual sketch - level 3 space

Main circulation pathway Small flight of stair Bench (rest station) Area for stationary exercises Continuous handrail Ramp

58 | Architectural [Physio]therapy | an assisting healing process

Stairs and ramps can lead patients into a sunken area for a stationary exercise zone. Screens and clerestorey windows ensure a private zone. or Patients can use the stairs and ramp to climb to a mezzanine where there are benches and chairs for rest and socializing.

Level 3 : Level 3 spaces target patients who demonstrate significant improvement in mobility.

Patients are able to work with ramps and small stairs in order to improve strength and balance. Longer walking paths through interesting environments should be implemented to address cardio health. Level 3 spaces must incorporate a mixture of walking routes and areas for stationary exercises since such a combination would target the patient’s specific needs at this stage of rehabilitation. Larger equipment such as stationary bikes and treadmills could be used at this stage, and thus should be incorporated as destination points in addition to pleasant areas (exterior spaces, gathering spaces, cafeteria, etc.). This is the final level for patients and should, at times, interact with the main circulation.

Level 4 : This level is for the main circulation and has therapeutic routes for all users. These paths incorporate a clear way-finding strategy with landmarks and colourful coding while providing calming environments through natural elements, materials, and views to the exterior.

Following the hierarchy of levels, this thesis will investigate how to connect the therapy spaces within the functionality of a rehabilitation centre. This will entail establishing how the centre functions professionally, while allowing the levels to transition into one another fluidly, thus allowing patients to heal gradually. Details of the therapy spaces, such as humanistic elements, materials, and organization will be examined to understand how they can help patients during physiotherapy. From this, a new transitional rehabilitation design will be proposed that encourages movement as a healing and engaging tool for patients with physical disabilities.

Chapter 5 | 59

Endnotes [Introduction] 1. Ward, Anthony. “Physical And Rehabilitation Medicine In Europe.” Jvournal of Rehabilitation Medicine. 38.2 (2006): 85.

2. Pallasmaa, Juhani. The Eyes of the Skin: Architecture and the Senses. Chichester: Wiley-Academy, 2005. 44.

3. Statistics Canada - http://www.statcan.gc.ca/dailyquotidien/131203/dq131203a-eng.htm 4. Statistics Canada - http://www.statcan.gc.ca/dailyquotidien/131203/dq131203a-eng.htm 5. Gadamer, Hans-Georg. The Enigma of Health: The Art of Healing in a Scientific Age. Stanford: Stanford UP, 1996. 73.

[Chapter 1] 1. Seamon, David. “Merleau-Ponty, Perception, and Environmental Embodiment:Implications for Architectural and Environmental Studies.” Intertwinings: Interdisciplinary Encounters with Merleau-Ponty.

Albany: State University of New York, 2008. 2.

2. Seamon, 2.

3. Gesler, Wilbert M. Healing Places. Lanham, MD: Rowman & Littlefield, 2003. 3.

4. Armstrong, Pat, and Hugh Armstrong. Wasting Away: The Undermining of Canada’s Health Care System. Don Mills, Ont.: Oxford UP, 2010. 13.

5. Gadamer, 41.

6. Gadamer, 41.

7. Gesler, 3.

8. Gesler, 3.

60 | Architectural [Physio]therapy | an assisting healing process

9. Sternberg, Esther. Healing Spaces: The Science of Place and Well-being. Cambridge, MA: Belknap of Harvard UP, 2009. 4.

10. Gesler, 3.

11. Gesler, 5.

12. Gesler, 6 [Chapter 2] 1. Naylor, Mary, and Stacen A. Keating. “Transitional Care.” Journal of Social Work Education.” 44.0 (2008): 65-73. Web. 2. Definition provided by World Confederation of Physical Therapy, 2012.

3. Hollmann, et al. “Physical Activity and the Elderly.”

European Journal of Cardiovascular Prevention & Rehabilitation. 14.6 (2007): 730.

4. World Confederation of Physical Therapy, http:// www.wcpt.org/policy/ps-descriptionPT. 5. Quaney, et al. “Aerobic Exercise Improves Cognition and Motor Function Poststroke.” Neurorehabilitation and Neural Repair. 23.9 (2009): 879. Web. 6. Quaney, 881.

7. Hollmann, et al., 732.

8. Lieberman, Daniel. “The Story of the Human Body: Evolution, Health, and Disease.” Knopf Doubleday Publishing Group, 2013. Print.

9. Eberhard, John P. “Brain Landscape the Coexistence of Neuroscience and Architecture.” Oxford: Oxford UP, 2009. 131.

[Chapter 3] 1. Cheryl, Atkinson. “Architectural Analysis Report for the POE of Bridgepoint Active Healthcare” June 16, 2014.

2. Description taken from Woods Baggot project website (accessed Dec 2014).

3. Description taken from Woods Baggot project website (accessed Dec 2014).

4. Description taken from Herzog de Meuron project website (accessed Dec 2014).

5. Article written by Jonathan Glancey (The Guardian, 2011) [Chapter 4] 1. Mason, Duncan. “Exercise in Rehabilitation.” Tidy’s Physiotherapy. Edinburgh: Churchill Livingstone/ Elsevier, 2008. 273.

2. 1. Kerr, J., D. Rosenberg, and L. Frank. “The Role of the Built Environment in Healthy Aging: Community Design, Physical Activity, and Health among Older Adults.” Journal of Planning Literature 27.1 (2012). 42.

3. Frontera, Walter R., David M. Slovik, and David M. Dawson. Exercise in Rehabilitation Medicine.

Champaign, IL: Human Kinetics, 2006. 20.

4. Rosenberg, 43.

5. Rosenberg and Frank, 44.

6. Mason, 273.

7. Rosenberg and Frank, 44.

8. Sternberg, 121.

9. Sternberg, 120.

10. Sternberg, 119.

11. Emily Balcetis (Ted Talk) “Why some people find exercise harder than others.”

12. Brain Landscape, 55.

13. Sternberg, 138.

14. Sternberg, 153.

15. Zumthor, Peter. Atmospheres: Architectural Environments, Surrounding Objects. Basel: Birkhäuser,

2006. 39-41.

16. Sternberg, 138.

17. Brain Landscape, 124.

18. Imperfect Health, 26.

[Chapter 5] 1. http://www.halifax.ca/newcomers/Documents/ NewcomersGuide_July2011.pdf (viewed on November 17, 2014) 2. http://www.halifax.ca/newcomers/Documents/ NewcomersGuide_July2011.pdf (viewed on November 17, 2014) 3. http://www.thecanadianencyclopedia.ca/en/article/ dartmouth/ (viewed on November 17, 2014) 4. http://downtowndartmouth.ca/images/uploads/ DDBC_Final_LowRes_Revised.pdf (viewed on November 17, 2014) 5. http://downtowndartmouth.ca/images/uploads/ DDBC_Final_LowRes_Revised.pdf (viewed on November 17, 2014) 6. http://downtowndartmouth.ca/images/uploads/ DDBC_Final_LowRes_Revised.pdf (viewed on November 17, 2014) 7. http://www.thecanadianencyclopedia.ca/en/article/ dartmouth/ (viewed on November 17, 2014) 8. http://thechronicleherald.ca/business/35214-cityplanners-see-big-future-penhorn-mall-site (viewed on November 5, 2014).

Endnotes | 61

62 | Architectural [Physio]therapy | an assisting healing process

Image Sources [Introduction] Page 8 image : google images : https://www.flickr.com/photos/jianweiyang/7648628130/ (Dec 2014) [Chapter 1] Page 10 image : google images : http://www.discovergreece.com/ (Dec 2014) [Chapter 2] Page 14 image : photograph taken by Olivia Ferguson-Losier (Oct 2014) [Chapter 3] Page 20 image : photograph taken by Olivia Ferguson-Losier (Oct 2014) Page 22 image : photograph taken by Olivia Ferguson-Losier (Oct 2014) Page 23 : base image taken from Bing.com Pages 24-25 : all photographs taken by Olivia Ferguson-Losier (Oct 2014) ; drawing taken from report.

Page 26 : drawing and images taken from Woods Baggot website (Dec 2014) Page 28 : images taken from Herzog de Meuron website (Dec 2014) [Chapter 4] Page 30 : handrail - google images : www.asiwallprotection.com/files/1653804/page/handrail.jpg

parallel bars - google images : www.livestrong.com [Chapter 5] Page 40 : base image taken from google maps Page 41 : thumbnail photographs : google images ‘Dartmouth Nova Scotia�

Page 43 : base images taken from Bing.com Page 46 : base images taken from Bing.com Page 50 : photocollage images taken by Olivia Ferguson-Losier (Dec 2014) Image Sources | 63

Bibliography [Books] Gadamer, Hans-Georg. The Enigma of Health: The Art of Healing in a Scientific Age. Stanford: Stanford UP, 1996.

Print.

Seamon, David. “Merleau-Ponty, Perception, and Environmental Embodiment:Implications for Architectural and Environmental Studies.” Intertwinings: Interdisciplinary Encounters with Merleau-Ponty. Albany: State University of New York, 2008. Print.

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Body and Building: Essays on the Changing Relation of Body and Architecture. Cambridge, MA: MIT, 2002. Print.

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Gesler, Wilbert M. Healing Places. Lanham, MD: Rowman & Littlefield, 2003. Print.

Sternberg, Esther M. Healing Spaces: The Science of Place and Well-being. Cambridge, MA: Belknap of Harvard UP, 2009. Print.

Sternberg, Esther M. The Balance Within: The Science Connecting Health and Emotions. New York: W.H. Freeman, 2000. Print.

64 | Architectural [Physio]therapy | an assisting healing process

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Imperfect Health: The Medicalization of Architecture.

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Frontera, Walter R., David M. Slovik, and David M. Dawson. Exercise in Rehabilitation Medicine. Champaign, IL: Human Kinetics, 2006.

Armstrong, Pat, and Hugh Armstrong. Wasting Away: The Undermining of Canada’s Health Care System. Don Mills, Ont.: Oxford UP, 2010. Print.

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and embodiment” Architecture and Ideas. 18-37, 2013.

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Journal of Social Work Education. 44.0 (2008): 65-73.

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Tagarakis, and Gerard King. “Physical Activity and the Elderly.” European Journal of Cardiovascular Prevention & Rehabilitation. 14.6 (2007): 730-39. Web. Quaney, B. M., L. A. Boyd, J. M. Mcdowd, L. H. Zahner, Jianghua He, M. S. Mayo, and R. F. Macko. “Aerobic Exercise Improves Cognition and Motor Function Poststroke.” Neurorehabilitation and Neural Repair. 23.9 (2009): 879-85. Web.

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Carleton University Mini Thesis Submission 2015

66 | Architectural [Physio]therapy | an assisting healing process