78

Japanese Journal of Comprehensive Rehabilitation Science (2020)

Case Report

Utilizing the self-training handouts creation system “Pattore !”:a report of two cases
Motoki Tanaka, RPT,1 Kazuyo Oguchi, MD, DMSc,2 Motoo Sakai, RPT,2 Shinichiro Goto, OTR,2
Takashi Hoshino, RPT, PhD,2 Ryuichi Ino, RPT,2 Riyo Katafuchi, RPT,2 Nagisa Asai, RPT,2
Shiho Takatsu, RPT,2 Reona Naito, RPT,3 Suzuna Sonoda, OTR4
Department of Rehabilitation, Kariya Toyota East Hospital, Kariya, Aichi, Japan
Department of Rehabilitation, Kariya Toyota General Hospital, Kariya, Aichi, Japan
3
Medical Technology Room, Takahama Toyota Hospital, Takahama, Aichi, Japan
4
Nursing home for the elderly Habilis Hitotsugi, Kariya, Aichi, Japan1
2

ABSTRACT
Tanaka M, Oguchi K, Sakai M, Goto S, Hoshino T, Ino
R, Katafuchi R, Asai N, Takatsu S, Naito R, Sonoda S.
Utilizing the self-training handouts creation system“Pattore !”: a report of two cases. Jpn J Compr Rehabil
Sci 2020; 11: 78-84.
Objective: To report two cases of utilizing the selftraining handouts creation system “Pattore !” (“Pattore !”hereinafter).
Methods: In two patients, handouts were created using“Pattore !” which is a system to compile self-training
menus tailored individually for each patient on paper.
The handouts were updated at appropriate timing, and thetime required for creation was measured. Each patient
made entries in the self-training record, and the therapist
confirmed the implementation status. A questionnaire on
patient satisfaction and self-efficacy was conducted
before discharge from hospital. The same procedures
were also conducted in a group of patients for whom thehandouts were developed without utilizing “Pattore !”.
Results: The average time required to prepare thehandouts was shortened by using “Pattore !”. Case 1
rated good patient satisfaction and self-efficacy, while
Case 2 was not able to achieve high self-efficacy. The
implementation rate was 100% for Case 1 and 85% forCase 2.
Conclusion: Effective use of “Pattore !” enhances thequality of self-training and contributes to implementationand continuation of training. Updating the handouts at
Correspondence: Motoki Tanaka, RPT
Department of Rehabilitation, Kariya Toyota East Hospital,
1-101, Noda shinmachi, Kariya, Aichi 448-0862, Japan.
E-mail: t_mo_pt_1006@yahoo.co.jp
Accepted: April 19, 2020.
COI: The authors have no conflicts of interest directly
relevant to the content of this article.
©Kaifukuki Rehabilitation Ward Association 2020
doi.org/10.11336/jjcrs.11.78

appropriate timing and feedback that allows patient toperceive the exercise effect are expected to enhancepatient satisfaction and self-efficacy.
Key words: self-training, handouts, patient satisfaction,
self-efficacy, system
Introduction
In the rehabilitation setting, self-training guidanceis performed on a daily basis. Since a therapist has
limited time to work with one patient, self-training isimportant for the recovery of physical function. On theother hand, implementation and continuation of selftraining is not easy, and how to encourage patients toengage in self-training is an issue.
Previous reports have shown that adoption of
behavioral science-based theories and models is
effective for exercise continuation, and that high selfefficacy promotes maintenance of exercise behavior[1-5]. Nakayama [6] classified human support for
promoting physical activity of elderly persons into
three categories: information provision, collaboration,and praise, and reported that guidance provided byexperts was particularly effective. Kitawaki et al. [1]have reported the possibility that hospitalized elderly
patients receiving direct guidance from therapists
regarding the purpose and method of self-training
achieve increase in self-efficacy, which may lead tocontinuation of exercise. These reports suggest thatproviding guidance using handouts of self-training
tailored to individual patients compiled on paper(hereinafter, handouts), may be an effective method toenhance the implementation and continuation of selftraining.
However, in our hospital, creation of such handouts
consumed much time [7], with additional problems ofdelay in providing the handouts to patients and
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Figure 1. “Pattore !” Creation screen of handouts: Select 1→ 2 in order, then select 34 for 2.
inability to change the contents at appropriate timing.
In order to prepare the handouts in a short time, wehave developed a self-training handouts creation
system using Microsoft Excel® (hereinafter,“Pattore !”). “Pattore !” has 190 types of menu images
classified by posture and difficulty level. The featureof this system is that by simply selecting an item in the
sheet, the content is reflected as written instructions
that can be printed on paper [7] (Figure 1). In thisarticle, we report two cases of utilizing “Pattore !” in
the convalescent rehabilitation ward (hereinafter,
convalescent ward).
Subjects
1. Case 1
A male patient aged in the 70s had left hemiplegia
due to cardiogenic cerebral infarction. He was admitted
to the convalescent ward on disease day 24. At
admission, Stroke Impairment Assessment Set-motor(SIAS-m) scores were 2-3-3-4-3; Mini Mental State
Examination (MMSE) score was 26; Functional
Independence Measure (FIM) motor subscore was
57 and cognitive subscore was 32. Regarding ADL
in the ward, wheelchair transfer and toileting were
FIM score 5. In rehabilitation setting, he required
minimum assistance with T-cane (without orthosis)
walk. At discharge to home (disease day 52), FIM
motor subscore was 73 and cognitive subscore was 33.
2. Case 2
A 70-year-old female sustained injury to the trochanterof her right femur due to a fall while walking with a cane,and underwent total hip replacement. Because of
intraoperative occurrence of distal femur fracture,complete non-weight-bearing of the affected lower limb
was prescribed. On postoperative day 55, one-third
partial weight-bearing was started and she was admitted
to the convalescent ward on the same day. At admission,
manual muscle testing (MMT) of hip joint flexion on theaffected side was grade 3 and MMT of hip joint extension
was grade 2; numeric rating scale (NRS) of knee painwith weight bearing on the affected side was score 4;
MMSE score was 29; FIM motor subscore was 63 andcognitive subscore was 35. Regarding ADL in the ward,
wheelchair transfer was FIM score 6 and toileting was
FIM score 4; gait training was not conducted. At discharge
to home (postoperative day 121), FIM motor subscore
was 75 and cognitive subscore was 35.
3. Group with handouts created without utilizing“Pattore !” (No “Pattore !” group)This group consisted of nine patients admitted to theconvalescent ward, with mean age of 70.2 ± 9.2 years
and mean MMSE score of 26.8 ± 2.1. The diseases
were cerebrovascular diseases in 4 patients, orthopedic
diseases in 4 patients, and heart disease in 1 patient.
Methods
1. Creation of handouts
Using “Pattore !”, handouts were created for Case 1
and Case 2, and updated at the timing of change indegree of ADL independence or change in weightbearing status. In the no “Pattore !” group, handoutss
were created according to the conditions of individual
patients by manually writing sentences and drawing
figures or by combining multiple parts of menus instandardized sheets. The time required for preparing
each handout was measured with a stopwatch.
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Tanaka M et al.: Two cases of using self-training handouts creation system “Pattore !”2. Confirmation of implementation status of selftraining
Each patient was instructed to make entry in a selftraining record, and the implementation status was
confirmed by the therapist. Based on the record, therate of implementation from the start of self-training
instruction to discharge was calculated.
3. Questionnaire survey
At discharge from hospital, therapists who were notin charge of training conducted interviews on a seriesof self-training. The items on the questionnaire were
the Customer Satisfaction Scale based on Need
Satisfaction [8, 9] and a scale on self-efficacy regarding
implementation of training constructed with reference
to previous studies [10-14]. As shown in Table 1, thequestionnaire was divided into two categories: patientsatisfaction with the handouts and self-efficacy, eachconsisted of three questions. Each question was rated
on a 10-point scale, with 1 point for “not at all” and 10
points for “absolutely true”. The mean score of thethree items in patient satisfaction and the mean scoreof the three items in self-efficacy were calculated.

Results
1. Time taken to create the handouts
The self-training handouts for Case 1 was createdby a physiotherapist (11th year in service) for a total offour times, and the mean time required was 195 ± 26
(range: 152-221) seconds/ handout. The self-training
handouts for Case 2 was created by a physiotherapist(2nd year in service) for a total of four times, and themean time required was 245 ± 29 (195-270) seconds/
handout. For the no “Pattore !” group, handouts werecreated by physiotherapists who had 8.4 ± 6 years ofexperience, and the mean time required was 421 ± 158(220-645) seconds/ handout (Table 2).
2. Case 1
According to the degree of ADL independence, four
self-training handouts were given to the patient at thefollowing timing: (1) wheelchair transfer FIM score 5(disease day 24), (2) wheelchair transfer FIM score 6(disease day 31), (3) T-cane walk in ward FIM score 6(disease day 40), (4) T-cane walk in hospital FIM
score 6 (disease day 47) (Figure 2).
In the first handout, considering the risk of falling,training was started with low-intensity menus that

Table 1. Items of questionnaire.
Questionnaire items
Patient satisfaction
1: Are the explanations and drawings in the handouts easy to understand ?
2: Do you feel that the handouts was custom-made for yourself ?
3: Did you receive a new handouts just when you felt you needed it ?
Self-efficacy
1: Do you feel that your body can move more smoothly by doing self-training ?
2: Do you feel that pain and discomfort are reduced by doing self-training ?
3: Do you think you can continue self-training after leaving hospital ?
Response is scored on a 10-point scale, with a score of 1 for “not at all” and a score of
10 for “absolutely true”. The higher the score, the more highly evaluated is the item.
Table 2. Creation of handouts, self-training implementation rate, patient satisfaction, and self-efficacy.

Creation of handouts
・Clinical experience of therapist in charge (years)
・Mean time required (seconds/ handouts [range])
Results
・Self-training implementation rate (%)
・Patients satisfaction (score)・Self-efficacy (score)

Case 1Case 2

No “Pattore !”
group

11
195±26[152-221]2
245±29[195-270]8±6421±158[220-645]

100
9.7
10

85
7.7
5.7

70±27
6.9±1.96.8±1.2

Patient satisfaction and self-efficacy scores are mean values of three items for the corresponding category.

Jpn J Compr Rehabil Sci Vol 11, 2020

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Figure 2. Case 1: progress and handouts.

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Tanaka M et al.: Two cases of using self-training handouts creation system “Pattore !”could be implemented in supine and sitting positions.
After the patient achieved independence in transfer,lower limb muscle strengthening and standing balance
exercises such as squat were added. Because themuscle tension of the paretic lower limb (Triceps
surae) tended to increase excessively with increasing
outdoor walking and other activities, instructions ofself-management methods such as stretching were
given before discharge from hospital.
The self-training implementation rate was 100%,
except when the physical condition was poor. The
results of the questionnaire survey were patientsatisfaction score 9.7 and self-efficacy score 10. The
patient’s comments were as follows: “Feel reassured
that I won’t forget the menus because I am given thehandouts promptly on the spot” and “by continuingself-training I was able to feel that I could use mylimbs on the paralyzed side more easily.”
3. Case 2
According to the permited weight bearing on thefoot or the degree of ADL independence, the patient
was given four self-training handouts at the following
timing: (1) one-third weight-bearing (postoperative
day 55), (2) two-thirds weight-bearing (postoperativeday 71), (3) complete weight-bearing with walker
walk FIM score 5 (postoperative day 85), (4) complete
weight-bearing with walker walk in ward FIM score 6(postoperative day 107) (Figure 3).
Training was started with affected hip and knee
joint muscle strengthening in non-weight-bearing
position, and then lower limb exercise under weightbearing was added in a stepwise manner according to
the change in the allowed weight-bearing status. Aftercomplete weight-bearing was allowed, the patient was
instructed to perform weight shifting to the left andright in standing position as well as stepping, and was
encouraged to learn left-right symmetrical movements.
Before discharging from hospital, the menus werechanged to those that can be executed even in theconfined space of the home environment.
The self-training implementation rate was 85%.
The results of the questionnaire survey were patientsatisfaction score 7.7 and self-efficacy score 5.7. The
patient’s comments were as follows: “It was difficult
to understand the effects of self-training” and “I wasworried that exercise will worsen the pain in the lower
limbs”.
4. No “Pattore !” group
The patient satisfaction score was 6.9 ± 1.9; selfefficacy score was 6.8 ± 1.2; and self-training
implementation rate was 70 ± 27%.
Discussion
The utilization of “Pattore !” shortened the timerequired to create self-training handouts regardless
Jpn J Compr Rehabil Sci Vol 11, 2020of the therapist’s years of experience. Patientsatisfaction scores were 9.7 in Case 1 and 7.7 in Case2; both scores were higher than that in the no “Pattore !”group (6.9 ± 1.9). Some of the reasons are as follows:
utilization of “Pattore !” allowed update of handouts
at appropriate timing, and that the layout and drawings
were easily understandable even by elderly patients[1]. According to Tanaka and Tokaji [8], customer
satisfaction promotes internalization of the value andimportance of exercise as well as enhances motivationof self-determination. Therefore, providing handouts
with high patient satisfaction is probably an effective
method to motivate self-training. On the other hand,self-efficacy score was 10 in case 1 and 5.7. in Case 2,
with a difference between the two patients. The selftraining implementation rate was 100% in Case 1
and slightly lower at 85% in Case 2, suggesting a
relationship between self-efficacy and the self-training
implementation rate.
Self-efficacy as proposed by Bandura [3] is definedas one’s belief in one’s capabilities to execute thecourses of action. Self-efficacy is affected by four
major sources of information (physiological andaffective arousal, achievement of actual performance,
vicarious experience, and verbal persuasion). Amongthese four sources of information, physiologicaland affective arousal is defined as self-perceived
physiological state such as physical condition, and isacquired by being aware of changes in everyday life
such as “stopped feeling out of breath when climbing
up the stairs” [5]. In order that patients perceive such
positive effects through exercise therapy, it is importantto provide instructions upon setting the environment,difficulty level, and amount of exercise tailored toeach individual [15, 16].
Case 1 had mild memory impairment and sometimes
forgot the menu. However, he was able to implement
self-training effectively by referring to the handouts.
In the questionnaire, he responded, “By continuingself-training, I was able to feel that I could use mylimbs on the paralyzed side more easily”, indicatingthat he was able to perceive the positive effect of
exercise, which increased his self-efficacy. On theother hand, Case 2 tended to develop knee pain on theaffected side, and she was in a psychological state ofanxiety toward exercise therapy. In the questionnaire,
she responded, “It was difficult to understand theeffects of self-training”, indicating that the she did notachieve perception of the exercise effect, which wasprobably the factor for her inability to achieve highself-efficacy. According to Arita et al. [5], since elderly
persons tend to put priority on emotionally meaningful
goals, it is essential to set goals that are easy to perceive
and understand. In order to increase self-efficacy inCase 2, it would be necessary to design menus that canbe implemented without anxiety, and have easily
perceivable effects such as pain relief and range of
motion improvement [15].

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Figure 3. Case 2: progress and handouts.

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Tanaka M et al.: Two cases of using self-training handouts creation system “Pattore !”“Pattore !” is an effective tool to enhance the qualityof self-training instruction. However, in order to use it
effictively, it is necessary to update the handouts at
suitable timing based on appropriate evaluation, and touse instruction methods such as feedback and praise sothat patients can perceive the training effect. These
approaches are expected to improve patient satisfaction
and self-efficacy, and promote the implementation andcontinuation of self-training.

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