30

Japanese Journal of Comprehensive Rehabilitation Science (2017)

Original Article

Activities of daily living and quality of life assessment during homebased rehabilitation― A multi-institutional study
Kazunori Kojima, RPT,1,2 Taku Nakayama, OTR,3 Asami Watanabe, RPT,3
Shiro Yoshimura, RPT,4 Tomonori Yamaya, OTR,4 Konomi Sato, OTR,5 Ari Doi, OTR,5
Takako Ogino, RPT,6 Noriko Moriyasu, RPT,7 Susumu Watanabe, RPT, DMSc8
Visiting Care Kojima, Kurashiki, Okayama, Japan
Department of Rehabilitation, Faculty of Health Science and Technology, Kawasaki University of Medical
Welfare, Kurashiki, Okayama, Japan
3
Kurashiki Central Home visit Nursing Care Station, Kurashiki, Okayama, Japan
4
R-CARE, Tamano, Okayama, Japan
5
Soushinkai co.,Ltd, Kurashiki, Okayama, Japan
6
Kurashiki Heisei Hospital, Kurashiki, Okayama, Japan
7
Visiting Nurse Station Tanpopo, Okayama, Okayama, Japan8
Department of Rehabilitation, Faculty of Health Science and Technology, Kawasaki University of Medical
Welfare, Kurashiki, Okayama, Japan1

2

ABSTRACTKojima K, Nakayama T, Watanabe A, Yoshimura S,
Yamaya T, Sato K, Doi A, Ogino T, Moriyasu N,
Watanabe S. Activities of daily living and quality oflife assessment during home-based rehabilitation – A
multi-institutional study. Jpn J Compr Rehabil Sci
2017; 8: 30-36.
Objective: The purpose of this study was to examine
the relationship between activities of daily living(ADL) performance and quality of life (QOL) in
participants in a home-based rehabilitation program,and to assess the associated changes during the
program.
Methods: The subjects were participants newly enrolled
in home-based rehabilitation in six facilities. The
Functional Independence Measure motor subscore
was used to evaluate the current ADL performance.
We used PGC-MS to evaluate the emotional aspect of
QOL, and ADL satisfaction for the cognitive aspect.
Results: Participants were divided into two groups:<1 year from onset and >1 year from onset; ADL
satisfaction had significantly improved in the lattergroup (p = 0.008). A strong correlation between ADL
performance and ADL satisfaction was found. On the
Correspondence: Kazunori Kojima, RPT
Visiting Care Kojima, 1-4-23 Kojima-ajino, Kurashiki,
Okayama 711-0921, Japan.
E-mail: kojikojikojikazu@hotmail.co.jp
Accepted: January 30, 2017.
The authors report no conflict of interest in this study.
©Kaifukuki Rehabilitation Ward Association 2017
doi.org/10.11336/jjcrs.8.30

other hand, the correlation between ADL satisfaction
and PGC-MS was weaker.
Conclusions: The ‘cognitive aspect’ of QOL improved
due to the rehabilitation staff’s approach in explaining
the participants’ ADL abilities and motivating themto accept their limitations. It is considered that the‘emotional aspect’ of QOL is difficult to change with
only three months of home-based rehabilitation.
Key words: home-based rehabilitation, QOL, ADL
Introduction
In home-based rehabilitation, the therapist visits thehome of the individual with a disease or disorder toprovide instruction in muscle strength training, joint
range of motion exercise, and activities of daily living(ADL). Home-based rehabilitation allows us toincorporate the environmental and social aspects of
the individual’s life, including family status and housing
situation, which we find increasingly important as amediator connecting the primary medical facilities andnursing home care and associated facilities [1, 2].
In domestic and foreign studies involving homebased rehabilitation, ADL is investigated extensively,
mainly reporting the effect of home-based rehabilitation
on ADL ability [3-5]. It is said that the purpose ofhome-based rehabilitation is to improve quality of life
(QOL) as well as maintain or improve motor function
and mental and physical capacity [6]. In general, ADL
evaluation is used to improve QOL. However, one
study that did not include home-based rehabilitation
Jpn J Compr Rehabil Sci Vol 8, 2017

Kojima K et al.: ADL and QOL during home-based rehabilitation

reported that there was no significant relationshipbetween ADL evaluation and QOL [7, 8]; others
that also did not include home-based rehabilitation
indicated that it is relevant [9-12]. It has also beensuggested that ADL independence is important forenhancing the subjective QOL of the elderly withdisabilities [13-15].
To our knowledge, previous studies on home-based
rehabilitation have not evaluated both ADL and QOL,
and therefore, did not examine their relationship. On
the other hand, there are various rating scales forevaluating QOL. The term QOL has a rather abstract
meaning, and, consequently, different interpretations.
Although QOL is divided into objective and subjective
aspects, the term often refers to subjective QOL [16].
In this paper, the term ‘QOL’ refers to subjective QOL.
Many studies have mentioned two aspects of QOL
assessment, ‘emotional aspect’ and ‘cognitive aspect’[17-19]. The ‘emotional aspect’ refers to psychologicalaspects such as an activity being fun and otheremotional responses; the ‘cognitive aspect’ refers to
the subjective degree of satisfaction in assessing one’s
own living conditions. Diener states that it is importantto evaluate QOL with regard to both the ‘emotional
aspect’ and ‘cognitive aspect’ [20].
The Philadelphia Geriatric Center Morale Scale(PGC-MS) evaluates well-being in old age as
represented by the ‘emotional aspect’ of QOL
exclusively [21]. On the other hand, as a rating systemrepresented by the ‘cognitive aspect’ of QOL, themeasure of ADL satisfaction is obtained using the
Functional Independence Measure motor subscore(mFIM) [22, 23]. Evaluating QOL in the ‘emotional
aspect’ and ‘cognitive aspect’ separately will allow fora detailed analysis of the effect of home-based
rehabilitation, and help establish an ideal QOL
evaluation method within the home-based
rehabilitation setting.
Here, we examined ADL performance in participants
over the age of 65 who had recently starting using
home-based rehabilitation services in six facilities(Okayama home-based rehabilitation research group).
We used PGC-MS as an indicator of the ‘emotional
aspect’ of QOL and used ADL satisfaction as anindicator of the ‘cognitive aspect.’ We evaluated theparticipants at initiation, and at three months, sixmonths, and one year. We assessed the change in andthe relationship of the variables during the homebased rehabilitation program.
Methods
1. ParticipantsParticipants evaluated were those newly enrolled in ahome-based rehabilitation program in six facilities
within the Okayama home-based rehabilitation researchgroup. Participants were 65 years of age or older;
those without aphasia or issues in comprehension and31

expression as well as those scoring 21 points or moreon the revised Hasegawa Dementia Scale with nocognitive issues and with accurate answers to thequestions were included. Individuals with progressive
neurological disease and malignant tumors were also
excluded because of an expected significant decreasein ADL capacity. This study was conducted with theapproval of the Ethics Committee of the Kurashiki
Central Hospital (Approval number 1037).
2. Evaluation
The mFIM was used as an evaluation of current
ADL performance [9, 24]. The visiting therapist
scored participants on the mFIM. We also used
PGC-MS [21, 25] and ADL satisfaction to evaluate
QOL. The PGC-MS consists of 17 question items in
the following three categories: agitation, lonely
dissatisfaction, and attitude toward own aging.
ADL satisfaction evaluation was based on themethod proposed by Uehara et al. [23]. We used anevaluation with a 10-point scale for the 13 individual
items of the mFIM. A score of 10 points indicated“fully satisfied,” and 0 points, “not at all satisfied;” thetotal calculated score represented ADL satisfaction.
Regarding the interview method, we used the
Numerical Rating Scale (NRS) orally in considerationof participants with difficulty in expression due tophysical disabilities, such as visual impairment.
We performed evaluations at the initial evaluation
for the home-based rehabilitation program and threemonths after starting. The initial evaluation was
conducted within one month from the start date of thehome-based rehabilitation program, and the threemonth evaluation was conducted within three to fourmonths or more after starting the program.
The statistical software SPSS Statistics 20 (IBM
Corporation) was used for statistical analysis. We
established normal distributions in the respective
evaluations using the Shapiro-Wilk test. Spearman’srank correlation coefficient was used to determine
correlations between each evaluation. A comparisonof the initial and three-month evaluations was
performed using the Wilcoxon signed rank test witheach evaluation. Upon evaluation, participants wereclassified into the following two groups: “less than one
year since onset” and “at least one year since onset or
onset unknown.” These participants were also divided
into the following two groups: “using day careservices” and “not using day care services.” Thestatistical significance level was set at p < 0.05.
Results
The characteristics of the participants are shown in
Table 1. Among the 42 individuals who completed theinitial evaluation and agreed with the study protocol,
and after excluding those with problems during
the evaluation such as hospitalization with state
Jpn J Compr Rehabil Sci Vol 8, 2017

32

Kojima K et al.: ADL and QOL during home-based rehabilitation

Table 1. Characteristics of participantsParticipant

GenderAge

DiseaseDiabetes
Lumbar compression
fractureHip dislocation
Pelvic contusion
Cerebral infarction
aftereffects

1

Female

69

2

Male

89

3
4

Female
Male

79
65

5

Female80

Onset dateVisitstarting date

5/5/2012

6/21/2012

4/10/2012

6/19/2012
7/9/2012

Female81

Left thalamic
hemorrhage

7

Male

83

Multiple cerebral
infarction

8

Female90

Cerebellum infarction
aftereffect

9
10

Male
Female76
83

AnginaLeft hip osteoarthritis

11

Female71

Cerebral infarction

3/20105/1/2012

12

Female70

Cerebral infarction

12/31/2011

7/2/2012

13

Female69

Cerebral infarction

3/16/201210/12/2012

14

Female72

Right putamen
hemorrhage

6/14/2012

8/25/2012

15

Male

76

Cerebral infarction

2/17/2012

6/22/201216

Female93

Lumbar compression
fracture

4/1/2012

8/7/2012

17

Female83

Cerebral infarction

2010

7/16/201211/2011

9/6/2012

18

Female71

Periaortic fibrosis

19

Female76

Spinal canal stenosis

20

Female85

21

Female81

22

Female78

Aplastic anemia
Lumbar compression
fracture
Lumbar compression
fracture

23

Male

77

4/2003

10/9/2012

4/11/2013
7/2/2013
8/6/2013

9/10/201210/12/2012
10/201212/29/2012

5/11/2011

9/18/2012

Cerebral infarction

7/23/2009

8/21/2012

5/24/2012

7/9/2012

24

Female77

Left fibula fracture(Guillain-Barre
Syndrome)

25

Male

76

Cerebral infarction

1990

5/15/2013

26

Female88

Hematoma of knee
joint

5/10/201310/11/2013

deterioration and rejection, we finally analyzed 26
participants with complete three-month evaluationdata.
An investigation with evaluation at six months ormore would have rendered a very small sample size;
thus, we determined that this would have been
unreliable and conducted the investigation using thethree-month evaluation.
The participants were 7 men and 19 women with anaverage age of 78.4 ± 7.2 years who were at thefollowing levels of nursing care: 7 participants at Care
Level 1; 6 participants at Care Level 2; 3 participants
at Care Level 3; and 4 participants at Care Level 4.
Jpn J Compr Rehabil Sci Vol 8, 2017

3

40

1,440

No

1

60

720

Yes

1
1

60
60

720
720

No
Yes

2

40

960

No

1

40

480

No

2

40

1,320

No

1

40

660

No

1
2

60
60

720
1,440

No
No

2

40

960

No

3

40

1,440

Yes

2

40

960

Yes

2

40

960

No

1

40

480

Yes

2

40

960

No

2

60

1,440

Yes
Yes

About 1
month

About
114
months

11/6/2012

8/3/2005

Visit timein 3
months(minutes)

Visitsperweek

9/1/2012

6

Visit time(minutes)

Followup period

About 92monthsAbout 26
monthsAbout 6monthsAbout 6monthsAbout 2monthsAbout 4monthsAbout 4monthsAbout 30monthsAbout 10monthsAbout 2monthsAbout 16monthsAbout 37
monthsAbout 1
month
About
280
monthsAbout 5monthsDay careservices

3

40

1,440

1

40

480

No

2

60

1,440

No

2

60

1,440

No

1

40

480

No

1

40

480

No

1

60

720

No

2

60

1,440

No

3

40

1,440

No

Note

60 minutes
from
11/30/2012
60 minutes
from
5/1/2013

The participants requiring support on Support Level 2
included 6 people.
The results comparing the initial evaluation with thethree-month evaluation are shown in Table 2. ADL
performance did not follow a normal distribution, andADL satisfaction and PGC-MS were found to benormally distributed. The average value of ADL
performance and PGC-MS was nearly unchanged,
whereas ADL satisfaction tended to improve by threemonths (p = 0.065). Furthermore, participants in the“at least one year since onset or onset unknown” group
had significantly improved ADL satisfaction(p = 0.008). When classifying participants regarding

Kojima K et al.: ADL and QOL during home-based rehabilitation

33

Table 2. Changes in each evaluation between initial evaluation and after 3 months.
Evaluation

Initial evaluation

After 3 months(Mean ± SD)(Mean ± SD)p

1. Participants (n = 26)
ADL performance
69 ± 1969 ± 20
ADL satisfaction
93 ± 22101 ± 23
PGC-MS
9.8 ± 3.6
9.7 ± 4.5
2a. Participants less than a year from onset (n = 10)
ADL performance
78 ± 1278 ± 12ADL satisfaction
109 ± 15105 ± 23
PGC-MS
8.5 ± 4.4
8.9 ± 3.8
2b. Participants except those less than a year from onset (n = 16)
ADL performance
63 ± 2063 ± 21
ADL satisfaction
83 ± 18
98 ± 21
PGC-MS10.6 ± 2.6
10.1 ± 4.6
3a. Participants using day care services (n = 7)
ADL performance
59 ± 1861 ± 19
ADL satisfaction
87 ± 2785 ± 25
PGC-MS10.4 ± 5.5
9.9 ± 4.3
3b. Participants not using day care services (n = 19)
ADL performance
73 ± 1872 ± 19
ADL satisfaction
95 ± 18
106 ± 18
PGC-MS
9.6 ± 2.5
9.6 ± 4.4

0.98
0.065
0.76
0.83
0.48
0.35
0.86
0.008**
0.93
0.27
0.61
0.40
0.50
0.022*
0.43

PGC-MS, Philadelphia Geriatric Center Morale Scale.
*p < 0.05, **p < 0.01.

Table 3. Correlations between ADL performance, ADL satisfaction and PGC-MS at initial
evaluation.
ADL performance
ADL performance
ADL satisfaction

ADL satisfaction

PGC-MS

0.71*

0.050
0.15

*p < 0.05.
Table 4. Correlations between ADL performance, ADL satisfaction and PGC-MS after 3
months.
ADL performance
ADL performance
ADL satisfaction

ADL satisfaction

PGC-MS

0.63*

0.10
0.25

*p < 0.05.

the use of day care services, ADL satisfaction
significantly improved in those not using day careservices (p = 0.022). There was no significant
difference when comparing the initial evaluation andthree-month evaluation with other evaluations.
The correlation coefficients between each measureare shown in Table 3 and Table 4. The correlation

coefficients between ADL performance status and
ADL satisfaction were r = 0.71 at the initial evaluation(p < 0.05) and r = 0.63 (p < 0.05) at the three-monthevaluation, which are both strongly correlated. On theother hand, the correlation coefficients between ADL
satisfaction and PGC-MS were r = 0.25 at the initial
evaluation and r = 0.15 at the three-month evaluation.
Jpn J Compr Rehabil Sci Vol 8, 2017

34

Kojima K et al.: ADL and QOL during home-based rehabilitation

Discussion
1. 
Changes after three months of home-based
rehabilitation
In this paper, we report our multi-institutional study
on participants enrolled in a home-based rehabilitation
program with two types of QOL evaluations involving
ADL performance, and our investigation of theassociated changes during the program. We usedmFIM as an evaluation of ADL performance. No
improvement was seen after comparing the initial andthree-month evaluations. Previous reports haveindicated an improvement in ADL performance after
home-based rehabilitation [4, 5]. However, it isdifficult to compare these studies with ours because
they vary in terms of the participants’ condition andage. Generally, ADL performance is considered todrop suddenly in advanced age [26]. The challenge of
future studies is to investigate the effect of age on ADL
performance in a larger sample.
Currently, QOL evaluation in home-based rehabilitation
has not yet been studied. In our study, we classified
QOL into ‘emotional aspect’ and ‘cognitive aspect.’The ‘emotional aspect’ refers to the individual’s
emotional and psychological state, such as being
happy or sad. For example, the individual may havedepressive thoughts such as “I can’t live like this.”
They will objectively judge themselves with thoughts
such as “I worry about small things.” On the other
hand, the ‘cognitive aspect’ refers to an individual’ssatisfaction such as with their self-assessed living
conditions. It reflects their satisfaction with their living
conditions and environment. A specific example is theindividual’s satisfaction with their current ability tomove around in the restroom.
We used the PGC-MS as an indicator of the‘emotional aspect’ of QOL, and used ADL satisfaction
as an indicator of the ‘cognitive aspect’ following theprevious evaluation method of life satisfaction. The
results showed that there was no difference in the
PGC-MS after three months of home-based
rehabilitation. This evaluation is considered to be along-term assessment that includes the individual’s
conventional life [27]; it is considered that the‘emotional aspect’ of QOL is resistant to change after
only three months of home-based rehabilitation. Nojiri
et al. classified the life rebuilding process duringhome-based rehabilitation into four phases [28]. They
state that it starts with a ‘set-up phase,’ indicating the
beginning of life at home, followed by an ‘adjustment
phase,’ indicating the need for readjustment andadditional help. The ‘maintain phase’ involves social
support to maintain a continued stable life. The lastphase is the ‘step-up phase,’ where we plan to improvetheir QOL and expand their sphere of life into
participation in community activities. Considering thisprocess, we assumed that because we did not yetchange their inner emotions and psychological aspects
Jpn J Compr Rehabil Sci Vol 8, 2017

in the period of three months, we did not improve their‘emotional aspect’ of QOL. On the other hand, ADL
satisfaction tended to improve during three months of
home-based rehabilitation. This evaluation candetermine the satisfaction level for each category indaily life, focusing on items that are not satisfied,
which can then be changed easily by home-based
rehabilitation to allow for a comparison with threemonths prior to rehabilitation. This may be useful as ashort-term evaluation. Kikkawa emphasizes thefollowing three viewpoints on rehabilitation to
improve the quality of life for the elderly [29]: (1)activating their mind by maintaining relationships,
roles, and responsibilities; (2) addressing social
participation and independence; and (3) emphasizing
informed consent. Thus, while home-based
rehabilitation includes sufficient informed consent
depending on the situation, we encourage social
participation and independence, thereby creating andmaintaining their relationships. As a result, it isconsidered that ADL satisfaction was improved, whichis the ‘cognitive aspect’ of QOL. This improvement
becomes remarkable in the participants who continued
living at home for a longer term of one year or morefrom the onset (Table 2); thus, it is considered thatthree months of home-based rehabilitation affected thesatisfaction of the participants who had been living at
home before participating in a rehabilitation program.
Further examination should be conducted for
repeatability and reliability of this evaluation.
It is believed that the improvement in ADL
satisfaction by three months of home-based
rehabilitation despite an unchanged ADL performance
was because of the assent and acceptance of thepresent living conditions through explanation and an
appeal by the home-based rehabilitation staff, even if
ADL performance did not change.
In addition, it is believed that PGC-MS did notchange despite an improvement in ADL satisfaction
because most of the categories of PGC-MS evaluate
the personal character and general feelings and it ischallenging to change these with home-based
rehabilitation in the short term.
However, it is necessary to consider factors otherthan the home-based rehabilitation, including whether
the participant used day care services, given that ADL
satisfaction significantly improved in participants who
did not use day care services (p = 0.022). The difference
was not statistically significant in other evaluations at
the time; however, because of the small sample size,
future study should have more participants for detailed
analysis. In addition, we did not know if participants
were previously enrolled in rehabilitation before
starting home-based rehabilitation or the period after
they began their home life. Therefore, further study isneeded to conclude that home-based rehabilitation
was the sole cause of the outcomes.

Kojima K et al.: ADL and QOL during home-based rehabilitation

2. Correlation between each evaluation
We estimated the relationship between each
evaluation, and a strong correlation was indicatedbetween ADL performance and ADL satisfaction at
both the initial evaluation and the three-monthevaluation. As a result, we were able to suggest thatADL performance influenced the ‘cognitive aspect’ of
QOL. Granger et al. [9] noted that the FIM score wascorrelated with satisfaction of personal life whencomparing evaluations with the FIM and other QOL
evaluations; our study supports this result. On theother hand, a correlation was not seen between ADL
performance and PGC-MS at both the initial evaluationand three-month evaluation. This result is similar to aprevious report in which Itako et al. studied health carefacilities for the elderly [30], and is also similar to thatin a previous report in which Hori et al. studied day
care users [31]. This evidence supports the notion that
it was impossible for ADL performance to influencethe ‘emotional aspect,’ such as PGC-MS, of QOL not
only in elderly people in facilities but also in homebased rehabilitation users who lived at home. In thisregard, it is revealed that the correlation with ADL
performance varies according to the difference inevaluation of the ‘cognitive aspect’ and evaluation ofthe ‘emotional aspect’ of QOL in home-based
rehabilitation; thus, it is necessary to examine its
contents on the QOL assessment in future studies. In
other words, there are many approaches to evaluating
QOL, but we can interpret an evaluation result more
concretely by clarifying which aspect of QOL theevaluation reflects in detail. Furthermore, it isconsidered that we can use an evaluation properly
depending on the aspect we want to clarify byunderstanding the specifics of the properties ofindividual QOL evaluations.
This study has some limitations. First, we wereplanning to estimate the evaluation at the initiation,
and at three months, six months, and one year after
starting home-based rehabilitation. However, theanalysis of the evaluation after six months became
difficult, because some participants were hospitalized
due to deterioration in state, and others refused anevaluation; the number of participants was thenreduced. Thus, considering future study designs, it isnecessary to include a larger number of facilities toincrease the number of candidates.
Additionally, participants were enrolled in homebased rehabilitation in this study, and they were at alevel where they could be discharged from the medical
institution and live at home, and they were limited inthat they did not have dementia with more than 21
points on the HDS-R. Therefore, it is considered thatthey had a higher degree of ADL independencecompared to ordinary patients, and so it is necessary to
examine how this influences QOL. In addition, certain
clinical details could not be examined, as only basic
information such as the disease state and the age of the




35

participants was available; other information such as
insurance-provided services, family constitution,
health condition, care burden of the family, and type of
rehabilitation program performed for home-based
rehabilitation should be included. Thus, it is necessary
to consider such factors in future studies.
Acknowledgement
We wish to thank the staff members at each facility
who assisted with this research. We are also grateful tothe staff members at Kurashiki Central Hospital for
their advice.

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