Occupational Therapy (13:30 ～16:00 Lecture Room 4)
Session chairs: Prof. Yuji Sawada
Prof. Eun Young Yoo
Prof. Kunifumi Suzuki

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Overview of Occupational therapy in JapanITO Emi (Occupational Therapist, PhD)
Department of Occupational Therapy, School of Health Sciences,
Nagoya University, Nagoya, Japan

This short lecture will focus on Occupational Therapy (OT) in Japan. Contents of the lecture are as follows. Firstly,a brief history of OT will be introduced: 1) precursors of OT, 2) the establishment of ‘the law of PT and OT’, 3)
paradigms. Secondly, the characteristics of Occupational Therapists (OTs) and their practical areas are shown: 1)
physical dysfunctions, 2) mental disorders, 3) pediatric and developmental disorders, 4) geriatric disorders.

Thirdly,

educational systems for OTs are informed: 1) schools, 2) educational criteria, 3) post graduate and lifetime education.
Finally, the future of OT will be discussed.
The first school for OTs was established as a three year diploma course in 1963. The first national examination forthe license of OT was held and Japanese Association of Occupational Therapists (JAOT) was formed in 1966. JAOT
joined WFOT an associate member in 1970 and then, became a full member in 1974. According to the roster of OTs
registered in 2010 (JAOT, 2010), there are 53,080 OTs in Japan. There are more female OTs than male – the ratio is
two to one - and almost a half of OTs are under 30 years old (JAOT, 2010).
Seventy percent of OTs are working in clinical settings (hospitals and clinics) and the rest of them are working at
geriatric facilities or welfare institutions in their communities (JAOT, 2010). Major practical fields are physical (36%),
geriatric (25%), mental (15%), and developmental (7%) areas (AJOT, 2005). OT is covered by both national healthinsurance and national long-term care insurance.
There are now 171 schools (187 courses) with around 7,000 OTs graduating each year.

Various kinds ofschools are being founded, such as 3 year diploma course, 4 year diploma course, 3 year associate degree course, and 4
year degree course. In addition, 32 Master courses and 22 doctorate courses have been firmly established (JAOT,2009).
In recent years, we are striving for increasing OT in the community including private homes, group living,
institutions as permanent living places, public schools, health centers, and local government beyond hospitals. Super
aged society (aged proportion: 22.7% in 2009), and the philosophy of independent living and normalization, encourage
us to move into the community where we will be able to contribute further to expanding aspects of OT: not only aiding
the recovery of functional components, but also helping clients engage in meaningful occupations, assisting with home
modifications, supporting accommodation to own environment, adapting devices and aids, and collaborating with otherprofessions.
The ultimate purpose of OT is for all the people who require OT to live their lives in hope and with value.
References
The journal of Japanese association of Occupational Therapists Vol.25, Suppl. 2006
The journal of Japanese association of Occupational Therapists Vol.28, N04, 2009
The journal of Japanese association of Occupational Therapists Vol.29, N04, 2010
http://www.jaot.or.jp/
Author address

E-male: emiito@met.nagoya-u.ac.jp

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The Beginning and Development in the Field of Occupational Therapy in Korea

Yoo, Eun-Young, Ph.D. OT
Department of Occupational Therapy, College of Health Sciences,
Yonsei University, Kangwon-do, Korea

The field of occupational therapy in Korea began in 1950 for the purpose of treating injured persons during the Korean
War. Western missionaries took a primary role in providing the foundation of occupational therapy in Korea. The national
licensure examination system was implemented in 1969 and has been given yearly to the present time with an average
passing rate of 78%.
Undergraduate education of occupational therapists began in 1979 at Yonsei University and currently, there exist 27 3year colleges and 21 4-year colleges and universities that provide education in occupational therapy. Currently,
approximately 1,000 college graduates are being admitted as first-year college students each year, with a total of 5,403
registered occupational therapists. The average employment rate for occupational therapists between 2007 and 2009 stands
at 85%.
In regards to the gender distribution of occupational therapists, 82% are female and 18% are male. With the rapid
installment of occupational therapy departments across the nation, the average age group of occupational therapists has also
declined such that 69% of occupational therapists are currently in their 20's. Occupational therapists are working in diverse
locations such as rehabilitation hospital, medical centers, local clinic, welfare facilities, and institutes. A majority ofoccupational therapists (67%) are employed in rehabilitation hospitals and medical centers, working primarily withindividuals with physical disabilities and only a minority working in the mental-health field.
The Korean Association of Occupational Therapist (KAOT) was established in 1993 and has been responsible forsecuring members' professional rights, entry into diverse professional fields, and continuing education of its members.
KAOT and a number of occupational therapy undergraduate programs have received accreditation from the World
Federation of Occupational Therapy (WFOT) in 1998. Currently, there are 5 colleges whose curriculum has been accreditedby the WFOT. The Korean Society of Occupational Therapy began its journal publication in 1993 for the purpose ofqualitatively improving research in the field of occupational therapy in Korea and is being published quarterly. The Journalof Korean Society of Occupational Therapy has been accepted into the Korea Research Foundation citation index, the mostprestigious journal evaluation institute in Korea.
The KAOT is currently putting in all of its effort into passing appropriate federal regulations that will open doors foroccupational therapists to enter the field of mental health, in addition to collaborating with other disciplines and working toprovide and implement policy guidelines and systems to meet the growing elderly population similar to Japan.

Author address
E-Mail: splash@yonsei.ac.kr

IL-2

BIOLOGICAL OBSERVATION DURING THE DAYTIME OF ELDERLY PATIENTS WITHADVANCED DEMENTIA CARED FOR WITH AND WITHOUT ARTIFICIAL NUTRITION
BY PERCUTANEOUS ENDOSCOPIC GASTROSTOMY
Kaori Yamaguchi
Program in Physical and Occupational Therapy, Nagoya University
Graduate School of Medicine, Nagoya, Japan
Introduction
One of the interventions for patients with a poor oral
intake has been enteral tube feeding by percutaneousendoscopic gastrostomy (PEG). [1] Although the potential
benefit of PEG to improve a patient’s nutritional condition
has been emphasized, the role of treatment in patients withadvanced dementia has recently been debated, [2] and thenumber of systematic studies on demented patients treatedwith PEG is still limited.
The objectives of the present study were to overview theactivity of elderly patients with advanced dementia cared forwith and without artificial nutrition by PEG in a care facility.
Focusing on awake and sleep states and oral movement of
the patients, we continuously recorded and quantified theawake/sleep states and spontaneous swallowing movement
during daytime in demented patients.
Materials and Methods
Twenty-six subjects participated in the present study.
Thirteen demented patients (one male and twelve females,mean age: 84.0 ±6.2 (years, ±SD) years) received artificial
nutrition by PEG (PEG-patients), and 13 patients (one maleand twelve females, mean age: 80.2 ±4.7 with dementia took
meals orally (OR-patients). PEG- and OR- patients all
suffered from advanced dementia.
PEG-patients could not answer any question in the minimental state examination (MMSE), while the mean MMSE
score was 7.8 in OR-patients with statistically difference
from that in PEG-patients (t-test, p<0.01).
We selected Wednesday as the day of the experiment,
since bathing and outside activities were not scheduled forthat day. We carefully observed and described each subject’s
behaviors every 10 min, such as eating, talking, andattending activities.
EEG signals were recorded from two scalp areas, Oz
and C3, with referential electrodes of linked earlobes, using
surface electrodes, which were 7-mm silver-silver chloride
disc electrodes. Those recording areas were selected toobserve alpha basic activity and sleep-specific responses, thevertex potential and sleep spindle. EMG signals fororopharyngeal movements were recorded using a pair ofsurface electrodes. Recording and reference electrodes wereplaced on the thyroid cartilage and chin along the midline,
respectively, and an earthing electrode was positioned on the
midpoint of the left clavicle. EOGs were recorded from theright eye, placing electrodes 2 cm below the infra-orbicularedge and 2 cm lateral to the lateral canthus of the right eye.
The Biological signals were evaluated every 5 min.
Awake and sleep states, i.e., being awake or asleep, were
investigated based on EEG signals. Awake/sleep states were
evaluated, but we partially modified the score with EOG data.
The period of time in awake/sleep states was expressed as apercentage of the recording period, since the total recording
period varied in each subject, as described in the results.
From EOG signals, the period of time spent blinking or
showing step-wise rapid (saccadic) eye movement,
corresponding with the full-awake state, was measured.

We showed comparisons of values recorded between ORand PEG- patients. The time period of awake/sleep states wascompared between the groups using one-way analysis ofvariance (ANOVA) with a post-hoc test (Fisher’s protected leastsignificance test, Fisher’s PLSD test). The swallowing
frequency was compared between PEG- and OR-patients using
a t-test. Since the dementia score, MMSE, was zero in all PEGpatients, the effect of MMSE score on the awake state andswallowing frequency was tested. Correlations between the
MMSE score or BI and amount of time in an awake state, andbetween the MMSE score or BI and number of spontaneous
swallowing movements were tested in OR-patients, using
Bartlett’s test. P-values less than 0.05 were considered to besignificant.
The awake/sleep score was determined every 5 min as: FA: 3,
RA: 2, Sleep (S1 or S2): 1. The mean awake/sleep score every
20 min from 7:40 to 17:00 was calculated in each subject, andthe value every 20 min was compared between PEG- and ORpatients, using the t-test.
Results
EEG, EMG, and EOG signals were successfully obtained
from all patients. Some periods were omitted from analysis dueto physical intervention, such as transferring, toilet, etc., and thetotal recording period was 412 (6 hours and 52 min) ± 42 min(SD). Since a light-sleep state (S2) was defined by spontaneous
sleep spindles, it was difficult to identify the onset and end of
S2 during the recording period. Thus, FA, RA, and sleep(S1+S2) states underwent to statistical analysis.
There was a significant main effect (F (5, 72), p < 0.001) of
the sleep state, and there was a significant difference in theamount of time in FA (p = 0.0041) and S1 (p = 0.0013) states
between PEG- and OR- patients (Fig. 1).
The spontaneous swallowing frequency was alsosignificantly lower in PEG-patients (0.1 ±0.3, times per hour)than in OR-patients (3.4 ±5.2, p<0.001). There was no
significant correlation between the MMSE score or BI andperiod of time in an awake state (MMSE: r = 0.227, p = 0.465,
BI; 0.406, p = 0.173), and between the MMSE score andnumber of spontaneous swallowing movements (r = 0.435, p =0.140) in OR-patients. However, the BI and number of
spontaneous swallowing movements correlated significantly in
OR-patients (r = 0.863, p < 0.001).
Sequential changes in the awake/sleep score during the day
for all subjects are shown in Fig. 2. The score was significantly
greater, i.e., more awake, in OR-patients from 7:40-8:40, 9:4010:00, 11:20-11:40, 12:00-13:00, and 16:40-17:00 (Fig. 2).
Discussion
The present study investigated actual awake/sleep states andthe swallowing frequency in demented patients with andwithout artificial nutrition in a care facility during the day. To
our knowledge, such detailed observations have not hitherto
been reported. Besides decreased physical and mental activities
in patients with advanced dementia, present study showed: 1)
shorter awake and longer sleep states, 2) the frequency of
spontaneous swallowing was markedly lower in PEG-patients,

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while the value correlated with BI in OR-patients; 3) The
length of time in an awake state and swallowing frequency
were not always related with the MMSE score in ORpatients; 4) the awake/sleep pattern during the daytime wasvariable in PEG-patients, and meal times were the limited
periods keeping OR-patients awake consistently.

Figure 1: Length of awake/sleep states during the recording period indemented patients undergoing artificial nutrition by PEG (PEG) andpatients with dementia who took meals orally (OR). The value wassignificantly different in the full-awake state (FA) and sleep states (S1and S2) between OR- and PEG-patients (* p < 0.01). There was nodifference in the value for the rest-awake (RA) state. A solid square( ■ ) and vertical bar indicate the mean and standard deviation,
respectively in each patient group.

patients during period between meals. For those patients withadvanced dementia, meal times could be the only time keeping
them awake, but there was no such opportunity for PEGpatients. Apart from nutritional cycles, the awake/sleep
rhythmicity was important regarding the cognitive function inpatients with and without dementia. [3] Due to the lack of
daytime rhythmicity set by meals, another intervention tomaintain the awake/sleep rhythmicity might be considered for
PEG-patients.
Concerning the spontaneous swallowing frequency, He et al.
[4] reported that a high-risk group for aspiration pneumonia
showed a depressed swallowing function. Since spontaneous
swallowing movements convey oral bacteria into the stomach
and regulate the quality and quantity of oropharyngeal
secretions in the pharynx, such movements are an importantmechanism for pneumonia prevention. [5] Most of the ORpatients and all PEG-patients in the present study were within
the high-risk range for aspiration pneumonia, and some of themhad a history of it. Although oral intake was prevented,
aspiration pneumonia remained as one of the major problems in
PEG-patients. [6] It is of no doubt that pneumonia has been aleading cause of mortality among patients in care facilities,
especially demented patients with a poor oto-pharyngeal
function, [7] and PEG intervention seems to prevent a direct
risk of poor nutrition. However, frequency of spontaneous
swallowing more decreased as lower score of BI, and it almost
diminished in PEG patients with zero of BI. From the aspect of
the spontaneous swallowing frequency, we considered that therisk of pneumonia could never be reduced in PEG-patients.
Conclusions
We reported awake/sleep states and spontaneous
swallowing movements during the daytime in demented patientscared for with and without PEG intervention. In the present
study, serial recording of biological activity could give us
precise knowledge of what happens in patients with advanced
dementia and those after PEG intervention. It also gave us andinformation regarding actual sleep pattern and temporalcharacteristic of a risk factor of aspiration pneumonia,
spontaneous swallowing, and their relationship with MMSE and
BI in those patients.
References

Figure 2: Sequential changes in the awake/sleep score (Full-awake: 3,
Rest-awake: 2, and Sleep: 1), and spontaneous swallowing movement(times per hour, solid bars) for PEG- and OR- patients during thedaytime. Gray areas indicate the time period in which the sleep score
was significantly higher in OR- than in PEG-patients (p<0.05, t-test).
Values for each patient are linked by lines. Each value for swallowing
was average value for all subjects. Swallowing movements during
meals were omitted.

[1] Mitchell SL, Teno JM, Roy J, Kabumoto G, Mor V. Clinical andorganizational factors associated with feeding tube use among nursing
home residents with advanced cognitive impairment. JAMA. 2003; 290:
73–80.
[2] Garrow D, Pride P, Moran W, Zapka J, Amella E, Delegge M. Feeding
alternatives in patients with dementia: examining the evidence. Clin
Gastroenterol Hepatol. 2007; 5: 1372–1378.
[3] Oosterman JM, van Someren EJ, Vogels RL, Van Harten B, Scherder EJ.
Fragmentation of the rest-activity rhythm correlates with age-related
cognitive deficits. J Sleep Res. 2009; 18: 129-135.
[4] He M, Ohrui T, Azumi M, Ida S, Sasaki H. Depressed involuntaryswallowing and risk of pneumonia. J Am Geriat Soc. 2004; 52: 1032-1033.
[5] Yamasaki M, Ebihara S, Ebihara T, Yamanda S, Arai H, Kohzuki M.
Effects of capsiate on the triggering of the swallowing reflex in elderly
patients with aspiration pneumonia. Geriatr Gerontol Int. 2010; 10: 107109.
[6] Kitamura T, Nakase H, Iizuka H. Risk factors for aspiration pneumonia
after percutaneous endoscopic gastrostomy. Gerontolog.y 2007; 53: 224227.
[7] Easterling CS, Robbins E. Dementia and dysphagia. Geriatr Nurs. 2008;
29: 275-285.

An awake state was maintained during breakfast andlunch times in OR-patients, significantly differing from theawake/sleep states in PEG-patients. However, in other words,
awake/sleep states were not different between PEG- and OR-

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OCCUPATIONAL THERAPY AS A CAREER: KOREAN UNDERGRADUATE OTSTUDENT’S PREFERENCES AND CONCERNS REGARDING THEIR FUTURE AS
OCCUPATIONAL THERAPISTS
Joo-Hyun Lee1)
1) Department of Occupational Therapy, College of Health Sciences, Yonsei University, Kangwon-do, Korea

Introduction
With the growing number of newly graduating occupational
therapy students, there has been recent concern regarding thefuture job market for occupational therapists and emphasis on
the need to reorganize the areas of OT service in Korea. The
present study analyzed Korean undergraduate occupational
therapy (OT) students' preferences and concerns regarding their
future as occupational therapists using a survey method. The
primary purpose of this study was to examine (1) OT students'
reasons for choosing occupational therapy as their major, (2)their thoughts and beliefs concerning their future as
occupational therapists, and finally (3) to contribute to thedevelopment of the field of OT in Korea by providing
information regarding students' preferred fields of employment
and their professional interest areas.
Materials and Methods
The participants in the study were 1,666 Korean
undergraduate OT students from 19 universities and colleges
across Korea. A packet of questionnaires was given to students.
The questionnaire was made up of three different areas: (1)students’ demographic characteristics in addition to reasons forselecting OT as their major, (2) concerns and anxiety regarding
their future, and finally (3) their current preferred field of
employment and professional interest areas. Demographic
variables included variables such as year in college, student
group type, gender, age, and religion. Students were asked tochoose among 7 reasons that led them to choose OT as theirmajor. 16 items on a 4-point Likert scale were created toaddress students’ concerns regarding their future as
occupational therapists. Lower score indicated greater future
career concerns. Students also responded to a question
regarding their preferred field of employment. Data wasanalyzed using SPSS 12.0.
Results(1) Demographic Characteristics
A total of 723 universities and 606 colleges that had
departments of occupational therapy were represented in thepresent study. The sample consisted of 352 (26.5%) male and977 (73.5%) female students. The sample consisted of483(36.3%) freshmen, 457 (34.4%) sophomore, 335 (25.2%)
juniors, and 54 (4.1%) seniors. The student group typeconsisted of 1139 (85.7%) currently enrolled students, 133(10%) students returning to school after taking time off, 28(21%) transfer students, and 27 (2%) readmission students.
(2) Reasons for Selecting OT as their Major
The results indicated that 675 (50.8%) OT students chose
OT as their major following recommendations made by others(parent, teacher, sibling). 654 (49.2%) OT students replied thatthey chose the major on their own. The principle reason forrecommendation and selection was to work in a professional
field or to secure employment. 476 (70.4%).

(3) Thoughts Concerning their Future
The results indicated that 693 (52.1%) OT students havehigh career confidence, 504 (37.9%) OT students have average
career confidence and 117 (8.8%) OT students have low careerconfidence when they first entered the department. However,362 (27.3%) OT students reported high career confidence, 603(45.4%) OT students average career confidence and 352(26.4%) OT students low career confidence presently. Such
results indicate that career confidence is lower in the present
than in entering school. Female students reported greater future
career concerns than male students. Freshmen reported greater
future career concerns than sophomores, juniors, seniors. 831(62.5%) OT students hoped to transfer to another academic
department.
(4) Preferred Field of Employment and Professional Areas ofInterest
The results indicated that most 1157 (36.4%) OT students
were most interested in the areas of mental health, physicaldisability, and autism-spectrum disorders, respectively. The
most desired place of work following graduation was in a
medical center / teaching hospital (n=908; 68.3%). Thispreference held true in students' response to the question,"Where would you like to be working in 10 years?". OT
students indicated that would prefer working with the children(n=792; 40.6%), followed by the adult population (n=632;
32.3%) and elderly (n=425; 21.7%).
(5) Additional Analysis: Relationship between OT Students'
Demographic Characteristics and Preferences and Concerns
Regarding their FutureFirst of all, there was a meaningful effect of gender on
future career concerns. Female students reported greater future
career concerns than male students (t = 3.46, p < .05). Second,
there was a meaningful positive correlation between year incollege and career concerns. More specifically, the higher theyear in college, students reported greater future career concerns(r = -.126, p < .01).
Conclusions
In conclusion, the results of the present study indicate that
Korean OT undergraduate students’ degree of future careerconcerns is affected by factors such as gender and year incollege. This suggests the need for departments in OT to tailor
their education and student mentoring depending on students'
gender and year in college. Also, this study indicates that thepreferred interest or work field of Korean OT undergraduate
students was mostly limited to medical institutions. Therefore,
further guidance is required to expose OT students to morediverse areas of interest and work field.

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Memo

ALTERATION OF TIME PERCEPION IN YOUNG AND ELDERLY PEOPLE
DURING JIGSAW PUZZLE TASKS WITH DIFFERENT COMPLEXITIESY. Iwamoto
Program in Physical and Occupational Therapy, Nagoya University
Graduate School of Medicine, Nagoya, Japan
Introduction
Recent studies have suggested that subjective timeperception is strongly linked to the quality of activity
performed. [1] Thus, time perception is an important factor
during occupational therapy, which might promote clients’positive experiences. [2]Abnormal time perception has been reported in patientswith dementia, [3] but little is known regarding theneuropsychology and pathophysiology of time perception.
Contrarily, the time perception of clients may give us
information regarding their physical and mental states. We
suggest that time perception is informative to evaluateclients’ psychological and pathological conditions. Previous
studies reported time perception among ages and tasks, [4]but the results were not consistent.
In the present study, focusing on healthy people, weinvestigated time perception in young and elderly people
during tasks. We discussed the psychological mechanismsof time perception during tasks based on the hypothesis of
Larson and von Eye. [2] The objective of this study was toclarify the characteristics of time perception in the clinicalsituation of occupational therapy (OT), along with theperformance of a globally well-known jigsaw puzzle tasks.
Materials and Methods
Twenty-eight elderly (8 men and 20 women, mean age:
69.9 ±6.2 (SD) years, range: 60-85) and thirty-one young (8men and 23 women, mean age: 21.9 ±1.4, range: 18-24)
participants were involved in the present study.
Allparticipants had no motor, sensory, or cognitive symptoms,
and no history of neurological diseases. The elderly subjects
had no behavioral or clinical symptoms of dementia or mild
cognitive impairment, and their scores in the mini-mental
state examination were in the normal range over 28 points.
They had no detectable visual, auditory, or speech
disturbance on performing jigsaw puzzle tasks, and they had
no speech disturbance on answering questions asked byexaminers.
Participants were asked to complete two jigsaw puzzles
with different complexities, and a time estimation test wasapplied during the puzzle tasks. All tasks were performed ina quiet room in the afternoon.
Time estimation tests were performed during the two
puzzle tasks. One was a simple task with 24 pieces, and theother was a complex task with 54 pieces. Participants wererandomly divided into two groups; those who performed the24- or 54-piece puzzle first (cross-over design). They were
specifically instructed to concentrate to complete the puzzle
tasks. Examiners told participants to start a puzzle task onhearing a beep sound and to stop the task 17 minutes and 17
seconds after the onset on hearing another beep sound. The
fixed duration of the tasks, 17 min and 17 sec, was chosen as
an unpredictable time.
Just after stopping the puzzle task, participants wereasked to verbally answer how long in minutes and seconds
they thought they had spent on the task. After the two puzzle
and time estimation tasks, subjects were asked to answer aquestionnaire regarding interests and feelings during the puzzle
tasks.
We measured the time required to complete each puzzle taskand, then the ratio of the subjective to absolute duration of time,the duration judgment ratio (DJR), [6] was calculated for eachtask A DJR of 1.0 indicates that the participants estimated time
was equal to the actual time, whereas a DJR of less than andgreater than 1.0 indicates under- and overestimation of time,
respectively. The values of tasks obtaining groups performing
the 24- or 54-piece task first were averaged. The time required
to complete the puzzles and DJR values were compared using
two-way (groups and tasks) analysis of variance with TukeyKramer’s tests for multiple comparisons.
For subjective
feelings, the DJR values were compared among the four gradesof interest and among the four different feelings employing
Mann-Whitney tests. A p-value less than 0.05 was consideredsignificant.
Results
Twenty-six and two elderly subjects completed 24- and 54piece jigsaw puzzles, respectively, and all young subjects
completed both puzzles.
Excluding subjects who did notcomplete the puzzle, the elderly group took 486.14 ±209.87(mean ±SD) and 1,035.32 ±6.24 sec, and the young groupneeded 127.29 ±33.77 and 466.65 ±115.28 sec for the 24- and54-piece jigsaw puzzles, respectively (Fig. 1). The elderlygroup required significantly longer time than the younger group(F [1, 114] = 444.5, p < 0.001, ANOVA). The DJR values areshown in Fig. 1. Both elderly and young subjects estimatedthat tasks took a longer time than they actually did, i.e., the DJR
value was more than 1.0. The effect of group on the DJR was
not significant in each task (F [1, 114] = 0.75, p = 0.385).
However, the effect of the task on the DJR was significant (F [1,114] = 31.75, p < 0.001), and the value was greater in the 24than in the 54-piece task in both groups (p < 0.01, TukeyKramer’s test).
The number of subject, who felt the task was difficult was
higher in the elderly group than in the young group in each task
(p < 0.05, Mann-Whitney tests). The number of young subject
who answered that the task was interesting was greater than in
the elderly subjects for the 54-piece task (p < 0.05).
Among the sub-groups of each grade of interest, the DJR
was smaller in the group with “much interest” than in that with“little interest” for the 24-piece task (p < 0.05, Mann-Whitney
tests), but there was no difference for the 54-piece task.
Subjective feelings of “engaging”, “difficult”, and “enjoyable”
had no effect on the DJR
Discussion
The present results can be summarized as: 1) subjects
estimated that tasks took a longer time than they actually did, 2)
subjects estimated a longer time for the 24- than 54-piece task,
3) there was no difference in the time estimation between young
and elderly groups, although the feeling of difficulty wassignificantly different between the groups, and 4) subjects
interested in the task estimated a time shorter than those notinterested in both the young and elderly groups. The present

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study clarified behaviors in young and elderly subjects
regarding time estimation, which have been theoreticallyreported. [2]Fig. 1: The mean time required for the puzzle tasks (left). The
elderly group required a significantly longer time than the younger
group for both tasks (p<0.01. ANOVA).
The mean duration
judgment ratio (DJR) during the tasks (right). Both elderly andyoung subjects estimated a time longer than the actual time during
the tasks. The effect of group on the DJR was not significant ineach task, while the effect of the task on the DJR was significant (p< 0.001). The value was greater in the 24- than 54-piece task inboth groups (* p < 0.01, Tukey-Kramer’s test). Each vertical line
indicates a standard deviation.

The DJR value was more than 1.0 in both tasks in bothyoung and elderly groups. This indicated that the subjects
felt that the time passed slower than it actually did during thetasks. Between the tasks, the 24-piece task had a greater
effect on the prolonged time estimation of subjects than the54-piece task in both groups. These results regarding the
subjective estimation of time are generally in line with thosein previous studies. [5]Coelho et al. [4] reported a change in the estimation andproduction of time intervals with aging, suggesting an
association of aging with a faster “internal clock”, which
resulted in a longer subjectively estimated time than theabsolute time, at least over a short duration around 10 sec.
Since our time estimation task required a relatively long time,
17 min and 17 sec, it might not be possible to compare theresults to previous ones.
One explanation concerning the effect of aging in thepresent study may be plausible, based on Larson’s model oftime perception (Fig. 2). [2]Time perception could be
explained by the task content, as well as psychologicalcondition.
When an task during time estimation was
successful, time passed slowly, i.e., a low DJR. On the other
hand, when the task was challenging, subjective time passed
quickly. When the task was difficult being beyond subjects’ability, the estimated time again became long. During the24-piece task, both young and elderly subjects successfully
performed the task. Young subjects were challenged by the54-piece task, and their subjective time estimation was
shorter than for the 24-piece task. However, for elderly
subjects, the 54-piece task was difficult to perform, and thetime estimation was long in the range of “beyond ability”(Fig. 2). We considered that it was important to take into
account not only the absolute complexity of tasks, but also
subjects’ feelings during tasks or how they performed inthem.
Similarly, another novel result in the present study wasthat the subjects’ feelings of interest in the task affected thetime estimation. This result suggested that time perception
during a task, or an occupation, could be modified by one’s

mental attitude and manner, and that involvement with interestin a tasks shortens a subject’s time perception. Besides relative
factors should be important to manage the time perception ofclients during occupational therapy, since spending a fruitfultime and the quality of daily activities could be linked to timeperception. [2]Fig. 3: Hypothetical explanation of the results for time estimation inyoung (open circles) and elderly (solid circles) subjects of the present
study (the time estimation curve is a modified figure of Larson andvon Eye. [2]For the 24-piece task, both groups performed it
successfully (a and b). For the 54-piece task, young subjects werechallenged (c), while it was too difficult for elderly subjects tocomplete (d).

Conclusions
In conclusion, we investigated the characteristics of timeperception in the clinical situation of occupational therapy alongwith the performance of jigsaw puzzle tasks.
Subjective
feelings modified time perception in both young and elderly
subjects, and a part of the results could be explained by a modelof time perception in an occupation. Occupational therapists
can consider these features. As Larson and von Eye [2] pointed
out, if the client perceives a daily task as disinteresting, there
are shifts in mindfulness during the task or an increase incognitive and emotional involvement. Conversely, if a task ofdaily living is too challenging, the therapist might redesign thetask by reducing the complexity and increasing the client’s skill.
By knowing characteristics of time perception in each client,occupational therapists could use such knowledge to use thetime for interventions effectively, as well as employ it aspersonal information on the client.
References[1] Green A. Freud's concept of temporality: differences with current
ideas. The International Journal of Psycho-analysis. 2008;89:10291039.
[2] Larson E. & von Eye A. Beyond flow: temporality and participationin everyday activities. American Journal of Occupational Therapy.
2010;64:152-163.
[3] Wiener M. & Coslett H. B. Disruption of temporal processing in a
subject with probable frontotemporal dementia. Neuropsychologia.
2009;46:1927-1939.
[4] Coelho M, Ferreira JJ, Dias B, Sampaio C, Pavão-Martins I, CastroCaldas A. Assessment of time perception: the effect of aging.
Journal of the International Neuropsychological Society.
2004;10:332-341.
[5] Druyan S, Dani A, Hadadi G. Effect of complexity of a physical task
on estimation of time to complete. Perception and Motor Skills.
1995;81(3 Pt 1): 707-722.
[6] Block RA, Zakay D, Hancock PA. Human aging and duration
judgments: a meta-analytic review. Psychology and Aging.
1998;13:584-596.

Author address

E-Mail: iwamoto.yuko@c.mbox.nagoya-u.ac.jp

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EFFECTS OF SCHEDULED EXERCISE PROGRAM COMBINED WITH FORCED USE
ON UPPER EXTREMITY FUNCTIONING IN INDIVIDUALS WITH HEMIPLEGIA
Hae-Yean Park 1)
1) Department of Occupational Therapy, College of Health Sciences, Yonsei University, Kangwon-do, Korea

Introduction
Although individuals with hemiplegia need continuous
therapy to improve upper extremity functioning, they spend
most of their time alone and not exercising spontaneously
outside the outpatient clinic setting (Bernhardt, Chan, Nicola,& Collier, 2007). The goal of the present study was hence tosuggest the potential effectiveness of an exercise program thatcan encourage client's voluntary participation while minimizing
therapist involvement. More specifically, the purpose of thisstudy was to investigate the effects of scheduled exercise
program combined with forced use in improving upper
extremity functioning in individuals with hemiplegia.
Materials and Methods
Participants: Two males and one female diagnosed withchronic stroke participated in the present study. The inclusion
criteria were as follows: (1) a minimum of 6 months post
single unilateral stroke and currently neurologically stable, (2)no significant cognitive deficits as indicated by a score > 25 on
the Korean Mini Mental Status Examination(MMSE-K)(Kwon& Park, 1989), (3) ability to actively extend at least 10 ° at theaffected metacarpophalangeal and interphalangeal joints and
20 ° at the more affected wrist and (4) no balance problems that
may compromise safety.
Design: A-B-A'-C reversal design was used in the study.
Setting: Home-based.
Intervention: The treatment process consisted of two
conditions: forced use only (B intervention period) andindividual customized scheduled exercise program in addition
to forced use (C intervention period). During the B and C
intervention periods, participants had their healthy arm
immobilized by wearing mittens for 6 hours such that they
were not able to manipulate objects using the non-affected hand.
During the C intervention period, exercise programs wereconducted 14 times along with forced use according to the
fixed schedule. A total 10 activities (5 tasks targeting arm
functioning and 5 tasks of activities of daily living: ADL) wereadopted which differed across the three participants based on
their level of functioning in the affected upper extremity. The
present researcher selected tasks for improving arm functioning
based on individual’s performance with the goal of improving
functioning of the shoulder, elbow, hand, and finger. ADL
tasks were determined based on information gathered fromparticipant and caregiver interviews, with the goal of selecting
tasks that were deemed essential in minimizing other’s help.
Outcome measures: The Box and Block Test
(BBT)(Cromwell, 1976) and the Wolf Motor Function Test
(WMFT)(Wolf, Lecraw, Barton, & Jann, 1989) were used toassess motor function of the upper extremity. Participant’s rateof performance of assigned activities was determined by the
number of assigned acrivities accomplished on a day divided
by the total of 30 activities multiplied by 100. To determine therate of implementation of scheduled exercise activities, thenumber of scheduled exercise tasks implemented on a day
divided by the total of 10 assigned tasks multiplied by 100. The
Motor Activity Log(MAL)(Page, Sisto, & Levine, 2002) wasused to assess ADL. In order to examine the psychosocial
status of the participants, the Self-Esteem Scale (Rosenberg,1965) and the Psychosocial Well-Being Index Short Form (SFPWI)(Chang, Cha, Won, & Koh, 2001) were measured pre- andpost-intervention.
Data analysis: The scores for each participant on theabove-mentioned outcome measures were visually analyzed
using graphs.
Figure 1 Trial Design

Results
The results of the present study can be summarized asfollows:

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1.

Performance rates to measure motor functioning ofParticipant 1, 2, and 3 were 99.0%, 22.1%, and 74.6%,
respectively, on the BBT. Compared to the baseline
period, the number of wood blocks which were moved
during the period of intervention improved. The degreeof performance on the WMFT showed improvement in
the post-intervention period C compared to the baseline
A period and the amount of time needed to complete thetasks also decreased.

2.

Performance rates on tasks of ADL for Participant 1, 2,
and 3 were 57%, 113%, and 48.8%, respectively,
markedly improving from the baseline period. Resultsfrom the MAL indicate improvement in the use andquality of movement in the post-baseline C period
compared to the baseline A period.

3.

During the intervention C period, the implementation
rates of ADL schedule for Participant 1, 2, and 3 were85%, 70%, and 90%, respectively.

4.

On measures of psychosocial status, improvement in
self-esteem was found for Participant 1 and 3, while
their sense of psychosocial stress declined. For
Participant 2, the self-esteem score declined and thepsychosocial stress remained unchanged.

Conclusion
The results of the present study indicate that scheduled
exercise program combined with forced use had positive effects
on improving upper extremity functioning and activities ofdaily living in persons with post-stroke hemiparesis in thehome setting. Such scheduled intervention program also
showed partial effects on improving psychosocial status.
Furthermore, the present study also suggests that chronic stroke
patients can take part in exercise programs on their own within
the home setting and improve upper extremity functioning
without therapist intervention.
Key Words
Activities of Daily Living, Arms Function, Forced Use,
Schedule, Stroke
References[1]Bernhardt, J., Chan, J., Nicola, I., & Collier, J. M. (2007).
Little therapy, little physical activity: Rehabilitation within
the first 14 days of organized stroke unit care. Journal of
Rehabilitation Medicine, 39(1), 43-48.
[2]Chang, S. J., Cha, B. S., Won, J. U., & Koh, S. B. (2001). A
study on the distribution and risk factors for psychosocial
distress, and the development of worksite stress reduction
program. Seoul: Ministry of Health and Welfare.
[3]Cromwell, F. S. (1976). Occupational therapist manual forbasic skills assessment: Primary pre-vocational evaluation.
Altndena, C. A.: Fair Oaks Printing.
[4]Kwon, Y. C., & Park, J. H. (1989). Korean version of MiniMental State Examination (MMSE-K). Journal of Korean
Neuropsychiatric Association, 28(1), 125-135.
[5]Page, S. J., Sisto, S. A., & Levine, P. (2002). Modified
constraint-induced therapy in chronic stroke. American
Journal of Physical Medicine and Rehabilitation, 81(11),870-875.
[6]Rosenberg, L. A. (1965). Rapid changes in overt behavior
reflected in the Draw-a-Person. Journal of Projective
Techniques, 29(3), 348-351.
[7]Wolf, S. L., Lecraw, D. E., Barton, L. A., & Jann, B. B.
(1989). Forced use of hemiplegic upper extremities toreverse the effect of learned nonuse among chronic strokeand head-injured patients. Experimental Neurology, 104(2),125-132.
Author address

E-Mail: libra33@hanmail.net

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