■ORIGINAL ARTICLE

Associated Movements of the Little Finger during
the Precision Grip with the Thumb and Index Finger
Mitsuo Nakamura1, Mariko Nakamura1, Yuji Sawada2
1
2

Department of Occupational Therapy, Graduate School of Health Sciences, Sapporo Medical University
Department of Occupational Therapy, School of Health Sciences, Nagoya University

Abstract: We studied the relationship between the coordinated precision grip force of the thumb and index finger andthe positions and associated movements of the little finger. Subjects (n = 10) pinched the pinch-meter and followed thetarget wave, which was made by a triangular wave and two horizontal waves. When following the target wave (TW)with precision grip, subjects preformed two tasks: changing the little finger positions to neutral, flexion and extension(Task-1) and performing flexed and extended movements (Task-2). The errors between TW and the following wave resulting from precision grip with the thumb and index finger were recorded. We found that the change of the little finger
position and joint movements influenced the coordinated precision grip force. Furthermore, we found a relationshipbetween the plus or minus directions of error, and the direction of the little finger’s joint movements and little finger
positions. This study indicates that the little finger position influences coordinated precision grip force, but showed no
involvement between the thumb and the index finger.
Keywords: power coordination, little finger, precision grip

(Asian J Occup Ther 11: 1−8, 2016)

Introduction
In our daily living, we can grasp and operate manifold objects appropriately. For this to be accomplished,
we coordinate both a complex system of sensory-receptors and motor skills with the object’s properties. Finding normal finger functions and coordinating fingers arenecessary for occupational therapists when providing
therapy for the loss of finger functions in orthopedic andcerebral vascular disease patients. There are two prehension synergies used when holding an object in static
tasks by individual digits. The first is to change the handshape and configuration according to the object’s shape,
weight, friction and center of gravity, and the second is
to grasp and operate the objects. According to Napier(1956), even though we have grasped the same object,prehensile activities can be classified into the two categories of ‘power grip’ and ‘precision grip’. Power grip is
Received: 20 January 2015, Accepted: 10 December 2015
Corresponding to: Mitsuo Nakamura, Department of Occupational
Therapy, Graduate School of Health Sciences, Sapporo Medical University, west 17 south 1, chuo-ku Sapporo, 060-8556, Japane-mail: micchan@sapmed.ac.jp©2016 Japanese Association of Occupational Therapists

used to fix objects in the hand with the palm. Precisiongrip is used for the purpose of fine control of prehensile
forces on a manipulated object, which is usually held by
the tips of the fingers and opposing thumb. Kamakura(1978) found that the shape of the hand while grasping
an object was decided by the purpose and operation of
the grasp; furthermore, the contact positions between
the object and hand when grasping a large number ofobjects were classified. This classification indicated thatthe contact positions varied by individual. However,Kamakura also revealed that the characteristic contact
positions were derived from the physical properties ofobjects according to the intent of the grasp and operation. The second synergy is to coordinate the grip andpinch power to accomplish the smooth grasp and operation of the object. Previously, power coordination wasmeasured using the precision grip between thumb andindex fingers, which is the minimum unit of grasping.
According to Johansson & Westling (1984), an appropriate amount of grip and pinch power was provided whenpeople grasped objects depending on the object’s material and weight, so that the object would not to slide out.
They found that the precision grip power when holding
an object in space consisted of two elements: minimum
pinch power requirements, and redundant power (safety

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Associated Movements of the Little Finger during the Precision Grip

margin). Furthermore, Nakamura (1993) reported that
subjects provided 5~7% of maximum precision grip
force during perturbation when vertical load force wasapplied suddenly to the grip apparatus. Goto (2003)
found that fixing the wrist joint influenced the finger
joint’s motion during precision grip between the thumband index finger. In terms of operating environment,
Nakajima (2012) indicated that an obstacle’s position
influenced the trajectory and velocity of precision grip.
Yamashita (2005) found that the thumb and index finger
each have a functional role during this precision grip.
When EMG amplitude was measured using graded
increases of precision grip force, the thumb took on a‘fixed’ role (FR) and index finger had the ‘role of gradual power coordination’ (GPC) showing no change in the
thumb’s precision amplitude but a gradual change in theindex finger. Coordinated precision grip force and thefunctional role between the thumb and index finger has
been reported. However, many kinds of object-dependent tasks are carried out in daily life that require skilled
manipulations with not only a thumb-index finger pinch
but also whole-handed manipulations involving all five
digits. Recent studies on whole-hand grasping haveshown that the force of individual digits is related tothe direction of rotational torque in the rotational equilibrium for hand-held objects (Zatsiorsky et al., 2003).
According to Taguchi (2002), when rotating a circularcylinder, it was found that the little finger used a highly
coordinated movement. The results of chaos analysisof the trajectory of the five fingers showed that theindex and middle fingers were highly chaotic, while thethumb and little finger showed little chaos (8). Hence,each finger assumed a functional role during graspingand operation, the middle, ring and little fingers taking
on a functional role during a precision grip between
the thumb and index finger. This study investigated thelittle finger’s functional role during a precision grip
between the thumb and index finger. If the little finger
is not directly engaged in prehension, but is involved in
the coordinated precision grip force between the thumband index finger, it may be necessary to consider thatthe functional unit is not each finger but the whole hand,with all fingers influencing one another.

University.
Apparatus and experimental setup
A pinch meter (PM) was used (Fig. 1) which was
horseshoe shaped and consisted of two parallel stainlessbars and a strain gauge, and which was attached to a
baseboard. Amplified electric signal waves measuring
grip between the thumb and index finger were producedon the PM, and shown on the oscilloscope (DL1640,
Yokogawa, Japan). The oscilloscope was set at the subjects’ eye level, and its display preferences were fixed toa vertical axis of electric voltage 2.0 v/div, and horizontal axis of recording time 500 ms/div. Additionally, thetarget wave (TW) was projected onto the oscilloscope.
The TW was made by a functional generator (FG-272,
KENWOOD, Japan). The TW consisted of a triangularwave and two horizontal lines. The triangular wave was
0.2 Hz and the amplitude was set at 10% of maximum
voluntary contraction (MVC). The two horizontal lines
were drawn in both the upper and lower regions of thetriangular wave in the oscilloscope. We temporarily
recorded the TW and following wave, which were madefrom the PM in the oscilloscope by a data-recorder(RD-135T, TEAC, Japan). The recorded waves wereanalog-digital converted with a sampling rate of 1,000
Hz by an A/D converter (AND-1400, canopus, Japan).
After A/D conversion, the digital wave data wererecorded using a PC (PC9821Ne, NEC, Japan) and analyzed with Microsoft Excel 2000 software on a standard
EPSON Type-VF computer.
Tasks
To determine whether the little finger is related tothe coordinated precision grip force between the thumband index finger, subjects were asked to match the target

MethodParticipants
Ten right-handed male and female volunteers(average age 25.8 ± 4.80 years old) were selected as
subjects for this study. None had previous histories ofneuropathies or trauma in the upper limbs. All volunteers gave informed consent according to the procedures
approved by the ethics committee of Sapporo Medical

Fig. 1. Pinch Meter (PM).

Asian J Occup Ther 11: 1−8, 2016

wave with the following wave made by precision grip
force. In this study, two task variations were set (Task-1,
Task-2) to investigate the power coordination between
the motion position of the joints’ of the little finger andprecision grip force.
Task-1In Task-1, subjects pinched the PM with the thumband index finger (Fig. 2a). On the oscilloscope display,three lines emerged: a triangular wave and two fixedhorizontal lines in the upper and lower axis. When thesubjects held the PM with minimum pinch power, thefollowing wave line descended to the lower line. Whenthe triangular wave descended to match the lower horizontal line, subjects estimated the timing of when to
start the task, and the subjects would start following the
TW. Upon applying pressure to the PM, the following
wave line ascended. Subjects would have to follow theascending TW. After reaching the maximum amplitudeof the TW, subjects would have to maintain the upperhorizontal line position. After 1 up and down cycle ofthe triangular wave, subjects estimated the timing ofwhen to start the descent when TW was at the upperhorizontal line. Subjects then followed the TW fromthe upper horizontal line to the lower horizontal line. In
Task-1, 3 positions of the little finger were purposelyset (neutral, flexion and extension of MP, PIP and DIP
joints). Trial 1 was completed after two cycles. Subjects
did 3 trials with each of the little finger positions (2 × 3
× 3 = 18 trials).
Task-2
Task-2 investigated the influence of muscle contraction and movements of the joints of the little finger
during the coordinated precision grip force between
the thumb and index finger (Fig. 2b). The timing toNakamura M et al.

3start the following in Task 2 was identical to that of
Task 1. At the start of following, the position of little
finger remained in a neutral position. Upon applying
pressure to the PM, the wave line to be followed wasraised, and subjects had to follow it. After reaching
the maximum TW amplitude, subjects maintained theposition of the upper horizontal line and move the little
finger joints while maintaining the position. Upon one
ascending-descending cycle after the TW arrived at theupper horizontal line, the subjects flexed the little finger
joints from the neutral position to an extended position.
With flexion of the little finger, subjects coordinated theprecision grip force for one period. Then the subjects
flexed their little fingers, closing them back to the neutral position. After remaining in the neutral position for
one period, subjects extended the little finger joints fromthe neutral position, and extended the precision grip for
1 period. In the next period, subjects changed their little
fingers’ position from extension to neutral, and followed
the TW from the upper horizontal line to the bottom
line. Subjects repeated the process in 3 trials.
Procedure
Subjects were given an orientation session before
the experiment to become familiar with the experimental
apparatus and to ensure that they were able to accomplish the tasks. Before the experiment, subjects washedtheir hands with soap to normalize their skin, and sat
in a chair with the elbow joint rested on an armrest andflexed at 90°. The right forearm was placed in an intermediate position to facilitate a natural grasping position
for the hand. The pinch meter was fixed in a horizontal
position on vertical beams of the armrest and set infront of the subjects’ forearm, and the distal side of theFig. 2a. Experimental Task-1.
Task-1 was to find whether the change of little finger position (joint angle) influence the power coordination. Dottedline shows upper and lower parameters of waves made from functional generator. Dashed line shows triangular waves
displaying period lengths and spacing. Solid line was the target wave (TW) which subjects had to follow.

4

Associated Movements of the Little Finger during the Precision Grip

Fig. 2b. Experimental Task-2.
Task-2 was to find the influence for the power coordination of little finger joint movements with precision grip. Dottedline shows upper and lower parameters of waves made from functional generator. Dashed line shows triangular waves
displaying period lengths and spacing. Solid line was the target wave (TW) which subjects had to follow. “b”, “c” and“h” periods were neutral positions of little finger. “d” period was little finger flexed period and “f ” period was little
finger extended period. “e” and “g” periods were neutral positions including the rapid time of changing fingers position.

subjects’ wrist joint was left unobstructed. The oscilloscope was set in front of the subjects, and the subjects
monitored the electric wave on the oscilloscope monitor
by holding the pinch meter. After the subjects practiced
the tasks to ensure smooth performance, the experimentcommenced and subjects performed Task-1. Following
a short rest to prevent fatigue, subjects performed Task2. During Task-1, the order of the positions of the little
finger was arranged randomly in order to prevent alearning effect.
Data processing and statistics
Data processing was performed using a datarecorder, and statistics were calculated using SPSS10.
All statistical analyses were performed at a significancelevel of p < 0.05. Data from two waves (TW and following wave) and data from the two horizontal lines(upper and lower) were collected by the data-recorder,
then converted using an A/D converter from analog todigital (A/D) with a sampling rate of 1,000 Hz. After
A/D conversion, the digital wave data were recorded in
the PC and analyzed by Microsoft Excel 2000. 90 data
entries from Task-1 and 30 data entries from Task-2
were analyzed. The error between TW and following
wave were calculated as follows: Raw Error = following
wave – TW.
Both plus and minus types of errors emerged, andwere computed. Total errors was calculated as follows:
Error = Σ | Raw Error (following wave – TW). If theerror was minor, the level of ability of the coordinatedprecision grip force between the thumb and index
finger was high. During data collection, the time thetriangular wave took to travel from the bottom to theupper horizontal lines was 1.25 seconds and the time it
took to maintain the force at the upper horizontal line
was 2.5 seconds. Therefore, the measurement of data
per unit of time was calculated. In Task-1, mean errors
were calculated for the three periods of ‘compression’,‘holding’ and ‘decompression’, and then comparedusing ANOVA for post hoc test. In Task-2, mean errors
were calculated for each of the ‘compression’, ‘neutral’,‘flexion’, ‘extension’ and ‘decompression’ periods, andthen compared using ANOVA for post hoc test. Testingfor significant difference between Task-1 and Task-2
was done using the Tukey-Kramer test performed at asignificance level of p < 0.05.

Results
Relationship between little finger position and power
coordination
Fig. 3 shows the errors between TW and following
wave at each of the periods: compression, holding anddecompression in each little finger position (neutral,
flexion, and extension) in Task-1. The errors of the three
periods proved to be similar in all little finger positions.
The errors of the reduced zone were the largest and thoseof the holding zone were the lowest of the three periods.

Asian J Occup Ther 11: 1−8, 2016

The error of each period was significantly different
by ANOVA (p < 0.05), so the Tukey-Kramer test wasused. The error of the continuous holding period wassignificantly lower than both the compression period
and the decompression period (p < 0.05). Compared to
the little finger positions, the neutral position of the little
finger had the lowest tendency of error of the three little
finger positions. Fig. 4 shows the characteristic errorsof the holding period in the three little finger positions.
The two errors were separated from raw errors. The
plus error of the following wave was greater than that of
the TW, and the minus error of the following wave waslower than that of the TW. When comparing the plus andminus errors, the plus error was significantly larger thanthe minus error in the flexed position of the little finger(p < 0.05). When comparing the plus and minus rates

Nakamura M et al.

5of the little finger in the flexed position, the plus errors
were significantly larger than the minus errors (p < 0.05).
Furthermore, the minus rate errors of the little finger inthe extended position were significantly larger than theerrors of little finger in the flexed position (p < 0.05).
Relationship between voluntary movement of little finger
and power coordination
Fig. 5 shows the difference in errors due to changing the little finger positions from neutral to flexion
to extension in Task-2. We computed the mean dataof each little finger position for the compression anddecompression periods. ANOVA tests confirmed thatthe difference in errors of each little finger positionand power coordination over the compression, neutral,
flexion, extension, and decompression positions were

Fig. 3. Error Difference of the Three Little Finger Positions During the Three Conditions(Compression, Hold, and Decompression) in Task-1.

Fig. 4. Differences in Error of the Little Finger Positions During Holding Period (Task-1).

6

Associated Movements of the Little Finger during the Precision Grip

Fig. 5. Difference in Error by Changing Little Finger Positions (Neutral, Flexion, Extension) in theTask-2.

Fig. 6. Difference in Error Among the Three Little Finger Movements (Task-2).

statistically significant (p < 0.05). The results of the
Tukey-Kramer test were significant between the periodsof neutral position and flexion, and between the periodsof the neutral position of the little finger and extension(p < 0.05). Furthermore, the differences in errors among
all periods and the decompression period were statistically significant (p < 0.05). Raw errors were separated
into plus and minus errors during flexion of the little
finger (Fig. 5d), extension of the little finger (Fig. 5f ),and neutral position of the little finger (Fig. 5b, c, h).
The errors were then compared after separation. Regard­
ing plus errors, the errors of the flexion of the little
finger were the largest of the two periods. For minus
errors, the errors of the extension of the little finger werethe largest, and the difference of errors between theextension of the little finger and the errors of flexion of

the little finger was statistically significant (p < 0.05)(Fig. 6).

Discussion
Task-1 and Task-2 experiments showed that keeping the little finger in a neutral and relaxed position produced the most coordinated force, and that a relationshipexisted between the plus or minus direction of error, andthe direction of the little finger’s joint movements andposition. Regarding the characteristics of the little finger,
the flexor muscles of the little finger were the flexor
digitorum superficialis (FDS) and the flexor digitorum
profundus (FDP), which were the same for the index
finger. In this study, the coordinated precision grip force
between the thumb and the index finger was performed

Nakamura M et al.

Asian J Occup Ther 11: 1−8, 2016by using the FDS and the FDP. Yamashita found thatthe thumb and index finger each have a functional role
during precision grip (5). When the little finger was in
the flexed position, a plus error occurred which waslarger than the other positions of the little finger. This
indicates that the flexed position was an easy position
for the index finger muscles (FDS and FDP), which assumes that coordinated precision grip force between the
thumb and the index finger provides the force, making it
difficult for subjects to coordinate the fine adjustment of
FDS and FDP. Also, when the little finger was in the extended position, a minus error occurred that was larger
than the other positions of the little finger. It is believedthat it was difficult for subjects to finely coordinate
the adjustment of FDS and FDP force as the FDS and
FDP were extended. Therefore, subjects couldn’t raise
the following wave to the TW. Furthermore, when thelittle finger was performing joint movements, the flexor
muscle contracted during a flexed movement. The flexor
muscle contraction of the index finger influenced thecoordinated precision grip force between the thumb andthe index finger. In the little finger extension, the digitalextensor muscle and the extensor digiti minimi muscle
contracted. Like the flexion muscles (FDS and FDP), thedigital extensor muscle was the common muscle duringindex and little finger extension. Hence, when pinching
using the precision grip between the thumb and theindex finger, the concentric contraction of radial digits
and the efferent contraction of ulnar digits occurred
simultaneously in the FDS and FDP. Furthermore, theconcentric contraction of the little finger and the efferent
contraction of the index finger occurred simultaneously
in the digital extensor muscle. This suggests that theposition of the little finger and the contraction of flexorand extensor muscles in the little finger, which had no
involvement in precision grip between the thumb andthe index finger, influenced power coordination. It may
be that the little finger has a functional role in coordinating the grip force, even if the little finger isn’t directly
engaged in the grasping action. When the little finger
joints’ position were in a relaxed position, the contraction of FDS and FDP was neutral in the little finger,
thus suggesting that keeping the muscle contraction of
the little finger neutral was important for the fine-tuningof the precision grip force between the thumb and theindex finger. The results point to the little finger having
a functional role when coordinating grip force even if
the little finger isn’t directly engaged in the grasping
action. In previous studies, the functional roles of thethumb and fingers have been found to take a directpart in prehension and manipulation. Taguchi (2002)
suggested that each finger had a functional role in therolling manipulation of a circular cylinder. This study

7

indicates that the little finger position influences thecoordinated precision grip force, which was not directly
involved with the thumb and the index finger. Thus, toengage in prehension and manipulation of the digits, thethumb and digits may be related in all prehension andmanipulation actions. It is necessary to consider not only
the movement of every individual finger, and the movements of the whole hand which operate as a functional
unit, but also where and how each finger influences
another. The results of this study were obtained underlimited conditions and parameters of the experiment.
Thus, broader generalizations regarding the strategies
of coordinated precision grip force from our study weredifficult to make. Further research will investigate thecoordinated precision grip force under many varying
conditions.
Acknowledgements: The authors would like to give
special thanks to all the participants and staff who facilitated in the data collection. This paper was supportedby the Sapporo Medical University Graduate School of
Health Sciences.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible forthe content and writing of paper.

References
Goto, M., & Nakamura, M. (2003). The effect of wrist joint
position for the pinch tasks. The Hokkaido Journal of
Occupational Therapy. 20, 9–14 (in Japanese).
Johansson, RS., & Westling, G. (1984). Roles of glabrousskin receptors and sensorimotor memory in automatic
control of precision grip when lifting rougher or more
slippery objects. Experimental Brain Research. 56, 550–
564.
Kamakura, N., Omura, M., Ishii, H., Mitsuboshi, F., & MiuraY. (1978). Positional patterns for prehension in normalhands. The Japanese Journal of Rehabilitation Medicine.
15, 65–82 (in Japanese).
Nakajima, R., Shibata, K., Yoneda, M., Inumaru, T., Nishi­
mura, S., Chiba, K., & Shimizu, J. (2012). Adjustment ofupper-limb and finger motions for grasping a peg –Influences of obstacle positions on joint angles, trajectory andvelocity–. Japanese Journal of Occupational Therapy
Research. 14, 1–7 (in Japanese).
Nakamura, M., Sawada, Y., & Tsubota, S. (1993). The Influence of Lord Force Perturbation on the control of precision grip during lifting tasks. Japanese Occupational
Therapy Research. 12, 259–268 (in Japanese).
Napier, JR. (1956). The prehensile movements of the humanhand. Journal of Bone and Joint Surgery B Nov., 38-B,
902–913.
Taguchi, H., Hase, K., & Maeno, T. (2002). Analysis of the
motion pattern and the learning mechanism for manip-

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Associated Movements of the Little Finger during the Precision Grip

ulating objects by human fingers. Transactions of thejapan society of mechanical engineers, 68, 1647–1654 (inJapanese).
Yamashita, T., Kasai, T., Takahashi, M., Kurumatani, H.,& Murakami, T. (2005). Motor adaptation learning ofrepetitive precision grip task: motor behavioral and neurophysiological analysis. Japanese Journal of Clinical
Neurophysiology. 33, 131–140 (in Japanese).

Zatsiorsky, VM., Gao, F., & Latash, ML. (2003). Prehension
synergies: Effects of object geometry and prescribed
torques. Experimental Brain Research. 148, 77–87.
Zatsiorsky, VM., Gao, F., & Latash, ML. (2003). Finger
force vectors in multi-finger prehension. Journal of Biomechanics. 36, 1745–1749.

■ORIGINAL RESEARCH

Effect of Education Programs for Caregivers
with the Provision of the Elderly with Mental
and Cognitive Impairments
Sayo Harada1, 2, Hiroshi Yamane3
1

Faculty of Nursing, SeisenUniversity
Doctoral Course, Department of Human Health Science, Graduate School of Medicine
3
Human Health Science, Graduate School of Medicine, Kyoto University
2

Abstract: Authors provided education programs for certified caregivers to cope with elderly care recipients’ behaviors
caused by mental and cognitive impairments. Thirty-three participants enrolled in all of the programs consisting of lectures and case studies about the features of mental and cognitive functions among elderly people. Authors administeredself-rating questionnaires about “feeling care difficulties” three times as follows: before and after the basic training, andafter the follow-up training. Authors used Friedman’s Test and Bonferroni multiple comparison of analyses for levelsof difficulties. The levels of items for ‘understanding mental symptoms and anxiety’, ‘communication skills’ and ‘dealt
with life disabilities’ were reduced significantly. The participants could better deal with care recipients because they
understood the factors causing their behaviors. However, authors should clearly teach how to deal with behaviors suchas silence. Furthermore, medical staff with mental patients should actively collaborate with certified caregivers to deal
with deviant behavior.
Keywords: Aged, Caregiver, Education, Mental disorders(Asian J Occup Ther 11: 9−17, 2016)

Introduction
Japan is a rapidly aging society. The morbidity rateof dementia in people over 65 years has reached over
14% (Shimokata, 2004), and the coping skills of certified caregivers who have provided the majority of careto those with behavioral and psychological symptoms ofdementia (BPSD) are insufficient (The project team ofdementia measures of the Mental Health of the Ministryof Health, Labour and Welfare 2012). Meanwhile, depression and anxiety patients consult psychiatric clinics
frequently (Saito, 2009).The morbidity rate of mental
and cognitive impairment in people over 65 years old
who were provided with primary care was 48.1% (Watts,
SC., Bhutani, GE., Stout, IH., Ducker, GM., Cleator,
PJ., McGarry, J., & Day, M., 2002), and 10% of elderly
people had anxiety, while the rate of anxiety coexisting
Received: 18 June 2013, Accepted: 1 November 2013
Corresponding to: Sayo Harada, Faculty of Nursing, Seisen University,
720 Hida-cho, Hikone, Shiga 521-1123, Japane-mail: harada-s@seisen.ac.jp©2016 Japanese Association of Occupational Therapists

with depression was high. Moreover, previous studies
reported that the rates of depression, agitation andpsychotic symptoms in Alzheimer’s disease in homecare patients were 80%, 80%, and 70%, respectively(Tractenberg, RE., Weiner, MF., Patterson, MB., Teri, L.,& Thal, LJ., 2003). The number of elderly people withmental and cognitive impairments due to a decline inphysical and mental functions with aging is increasing.
Issues regarding general physicians’ skills to diagnose
depression and prescribe medication have been reported(Mellor, D., Davison, T., McCabe, M., & George, K.,
2008a; Nakano et al., 2011) and it is necessary to construct a system of consultation by psychiatrists about
residents’ mental problems at institutions for the elderly(Loebel, JP., Borson, S., Hyde, T., Donaldson, D., Van
Tuinen, C., Rabbitt, TM., & Boyko, EJ., 2008).
Long-term care insurance was introduced in 2000 in
Japan to improve the care of elderly people with mental
disorders, and care workers who are not mental healthcare specialists have provided the majority of care. In
2013, education for dementia care was included in the
training programs of first grade caregivers, but a large
number of certified caregivers providing care at present

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EFFECT OF EDUCATION PROGRAMS FOR CAREGIVERS WITH THE PROVISION OF THE ELDERLY

are second grade home helpers (HH). They received
education in a short period to get the license and did notstudy dementia.
Authors investigated HH regarding the actual careof elderly people with mental disorders, and found that
HH could not consult any medical professionals if they
had trouble, and that they were experiencing problems(Harada & Yamane, 2013a). HH understood the need forcollaboration with mental health care medical staff tocope with emergency correspondence regarding suicidal
tendencies and sexual behaviors, but HH did not consult
them about dealing with hallucinations, delusions andhypochondria that HH experience in daily care, even if
they experienced difficulties because they thought thatthe difficulties in dealing with symptoms were causedby their lack of knowledge about the features of mental
and cognitive functions among elderly people. Therefore, the education for certified caregivers is necessary(Harada, 2013).
Important research indicated that a comprehensive
behavior-management-skills training program for certified nursing assistants who provide care for cognitively
impaired nursing home residents reduced the residents’agitation levels (Burgio, LD., Stevens, A., Burgio, KL.,
Roth, DL., Paul, P., & Gerstle, J., 2002; McCallion, P.,
Toseland, RW., Lancey, D., & Banks, S., 1999,). As fordepression, some previous research reported that skills
for dealing with people with depression increased amongcare workers who attended depression training programs(Mellor, D., Davison, T., McCabe, M., & George, K.l.,
2008a; Mellor, D., Russo, S., McCabe, MP., Davison,TE., & George, K., 2008b; Mellor, D., Kiehne, M.,
McCabe, MP., Davison, TE., Karantzas, G., & George,K., 2010).The fundamental position of Japan’s Ministryof Health, Labour and Welfare initiated training systems and programs for dementia patients in 2012, andpromoted care skills for dementia patients for certified
caregivers; however, there is little research evidence
about the programs.
Therefore, authors framed and implemented
programs for certified caregivers that provide careservices for elderly people with mental and cognitive
impairments. The purpose of this study was to clarify
the effects and durability of these effects, and examine
issues involved when teaching care skills to certified
caregivers.

Methods
Participants
The participants in this study were certified caregivers working in long-term care insurance community
care offices in an area with a population of 320,000

and a 17.9% elderly population. Authors explained the
purpose of this study to the managers of 12 home care
offices introduced to the authors by community comprehensive service centers or home visit nursing stations.
The authors recruited over 50 participants, but the homecare offices were small, and there were a few officesthat had meetings among certified caregivers. Finally, 2
offices consented to the proposal. There were 14 people
working in the home visiting care offices linked to home
visit nursing stations offices and 19 people working inhome visit care and day service care offices linked togroup homes for people with dementia. Both offices
were managed by a social welfare corporation and the
managers of the offices were professional care workers
who provided care to elderly people with mental disorders and dementia.
Interventions
The program looked at the way in which participants grappled with studying actively and consistedof lectures about the features of mental and cognitive
functions among elderly people and case studies for
dealing with elderly people with mental and cognitive
impairments (Amata, 2004; Hotta, 2012; Yamane, 1994;
Takenaka, 2000; Japan Dementia Communication Con­
ference, 2011). The basic program was done twice.
The first time, authors provided a lecture about the
behaviors of elderly people with mental and cognitive
impairments, and the contents were based on previous
research in which home care recipients were perceived
by certified caregivers as creating difficulties in terms ofcare and coping. In the programs, participants studied aprocedure for considering how care recipients behaved.
After 1−2 months, authors provided a second program with a review of the first lecture and case studies
were provided by participants. The program lasted fromone- to one-and-a-half hours, and the authors provided it
three times; two groups consisted of 7 members and one
group consisted of 19 members. After 6 months, the authors provided a follow-up program with a review of thebasic program. In particular, communication skills andcase studies were provided by participants. The program
was carried out from August 2012 to March 2013 (Fig.
1).
Ethical concerns
Authors obtained approval from the participants
after explaining that they would participate in thisstudy of their own free will, that the records would be
kept safely, and that they would not be used outside
the auspices of this study in either oral or written form.
The study protocol was approved by the Medical Ethics
Committee at Kyoto University.

Harada S et al.

Asian J Occup Ther 11: 9−17, 201611

Session

The aim of the program

The study contents

The basic program
the first time
(Lecture)

Understanding the characteristics of elderly people withmental and cognitive impairments• Confirmation of the program rules• Taking an active part in the programs, analyzing cases that the participants
found difficult, and guaranteeing freedom of speech and ideas• Studying elderly people’s environments by talking about their experiences ofloss, isolation and solitude, and personality changes• Studying the peculiarities of mental symptoms in the elderly such as hallucinations, delusions and anxieties• Considering tactics to deal with care recipients• Considering the reasons for care recipients’ silence and ignorance of social
norms

1 to 2 months later
the second time
(Brief lecture and case study)

Focusing on communication
skills and collaboration withmedical staff on case studies• Confirmation of the program rules• Considering why caregivers could not develop a good relationship with thecare recipients• Considering the recipient’s point of view
• Understanding elderly people with schizophrenia• Considering the meaning of care recipients talking about suicide• Case studies about dealing with care recipients who could not limit theirdrinking or eating and those who are focused on social norms

6 months later
the follow-up program(Lecture and case studies)

Focusing on communication
skills and collaboration withmedical staff on case studies• Confirmation the rules of the programs• Considering why caregivers could not develop a good relationship with thecare recipients• Considering the recipient’s point of view
• Understanding communication disorders in dementia• Case studies about dealing with care recipients’ refusals, aggression andagitation

Fig. 1. Overview of the education program contents

Data collection
Authors administered self-rating questionnaires
survey to participants three times as follows: before
and after the basic training and after the follow-up
training. Authors distributed and collected the self-rating
questionnaires to participants directly at the time oftraining. Authors asked participants to write code numbers for personal identification so they could identify
who wrote questionnaires and analyze the difference
between before and after the basic training and after
the follow-up training. The self-rating questionnaires
asked about participants’ attributes and “feeling caredifficulties”. The authors collected data of participant’s
attributes regarding age, sex, and number of experiences of care for recipients with mental and cognitive
functional disorders: schizophrenia, depression, homecare or day service in the first questionnaire before thebasic training. The authors collected data regarding“feeling care difficulties” before and after the basic
training and after the follow-up training, as well as data
regarding impressions about the programs, and a freedescription after the programs regarding experiencesof “feeling care difficulties” before the basic training
and the follow-up training. There were 24 items about“feeling care difficulties” grouped as follows: dealing
with psychiatric symptoms, depression, anxiety, refusal

and aggression, communication skills, and dealing withcognitive impairments, which authors referred to in previous research (Harada, 2013). Feeling care difficulties
were assigned levels from 1−4 on the Likert Scale.

Analysis
Authors analyzed the rates of the participants’characteristics, experiences and feeling of difficultylevels of the 24 items. Authors used Friedman’s Test andBonferroni multiple comparison of analyses to compare
each pair with levels of difficulty as follows: before andafter the basic training and after the follow-up training,and Mann-Whitney U test for the relations between
experiences and feeling of difficulty levels.IBM SPSS
Statistics (Statistical Package for Social Sciences v20
for Windows) was used for the statistical analyses, andthe significance level was p < 0.05.Regarding feelingof difficulty, authors processed data excluding missing
values for every feeling of difficulty level item.
Authors classified free descriptions into categories
according to the contents of participants’ comments
on care and coping. In the following sections, double
quotes and square brackets enclose categories andspoken contents, respectively.

12

EFFECT OF EDUCATION PROGRAMS FOR CAREGIVERS WITH THE PROVISION OF THE ELDERLY

Results
1. Characteristics and experiences of the participants’care
The participants were comprised of 2 male and 31
female individuals, and they were aged 46.8 ± 9.7; eightparticipants were regular workers employed full-timeand twenty-five participants were part time workers.
Their average number of years of experience as certified
caregivers was 5.82 and the range was 1.2 to 13 years.
Fourteen participants were professional care workers.
The participation rates of whose who attended the training with dementia and mental disorders were 42.4% and12.2%, respectively. The rates for giving care to patientswith schizophrenia, depression, and others, were 15.5%,
33.3% and 21.1%, respectively (Table 1).
2. Participants’ experience for items of care difficulties
Regarding having had experience of the 24 items,
over 50% of items both before the basic training andbefore the follow-up training had been experienced by
54.5% and 66.7%, 78.8% and 63.6%, 66.7% and 57.6%,
57.6% and 57.6%, 78.8% and 66.7%, 66.7% and 54.5%(1, 2, 7, 10, 12 and 22, respectively). Over 50% of items
before the basic training or before the follow-up training
were experienced at rates of 3, 15 and 17, respectively.
Items at low rates were experienced at rates of 5, 8, 11,
19 and 24, respectively (Table 2).

Table 1. Characteristics of the participants

N = 33n (%)

Sex
Employment
LicenseAttended the Training
programs

Care Experience

Male
FemaleRegular worker
Part time worker
Professional care worker
Home helper
Mental disorderyesnoDementia
yesnoSchizophrenia
yesnoDepression
yesnoOther mental diseaseyesno2( 6.1)31(94.9)8(24.2)25(75.8)
14(42.4)
19(57.6)4(12.1)29(87.9)
14(42.4)
19(57.6)
5(15.2)28(84.8)
11(33.3)
22(66.7)
7(21.2)26(78.8)

3. The scores for feeling care difficulties (Table 3)
There were missing values before the basic training, so authors processed data excluding missing values
every feeling of difficulty levels of items. Eighteen
items’ rates showed significant results between the scorebefore after training.
The items’ rates that showed significant results
between the score before the training and after the basic
training, and between the score before the training andafter the follow-up training included 6 items as follows:

Table 2. Participants’ experience of difficulty with each item

N = 33
before basic training

1. Hallucinations and delusions
2. Fluctuations in care recipient’s mood
3. Hallucinations in which someone steals
4. Sexual behaviors
5. Threatened by care recipients
6. Causing care recipients anxiety about being dirty
7. Talking about suicide
8. Suicidal ideation
9. Care recipients not speaking and being silent
10. Mentioning anxiety about life
11. Many phone calls
12. Symptoms of hypochondria
13. Certified caregivers scolded by care recipients, but not understanding why
14. Care recipient’s violence
15. Refusal of care that certified caregivers could not understand
16. Care recipients cannot dump trash
17. Ingnorance of social norms
18. Insufficienct care time
19. No sense of the value of money
20. Difficulties understanding life skills
21. How to maintain appropriate distance from care recipients
22. Hurting care recipient’s pride
23. The appropriate way to speak to care recipients
24. Care recipients forget when certified caregivers will visit

before follow-up training

yes
n (%)

no
n (%)

yes
n (%)

no
n (%)

18(54.5)26(78.8)
13(39.4)
7(21.2)4(12.1)11(33.3)
22(66.7)4(12.1)14(42.4)
19(57.6)2( 6.1)26(78.8)
11(33.3)
15(45.5)20(60.6)
10(30.3)
16(48.5)
14(42.4)
3( 9.1)16(48.5)
14(42.4)
22(66.7)
14(42.4)8(24.2)15(44.5)
7(21.2)20(60.6)
26(78.8)29(87.9)22(66.7)
11(33.3)
29(87.9)19(57.6)
14(42.4)31(93.9)7(21.2)22(66.7)
18(54.5)
13(39.4)23(69.7)
17(51.5)
19(57.6)30(90.9)17(51.5)
19(57.6)
11(33.3)
19(57.6)25(75.8)22(66.7)21(63.6)
18(54.5)8(24.2)010(30.3)
19(57.6)2( 6.1)16(48.5)
19(57.6)2( 6.1)22(66.7)9(27.3)10(30.3)
14(42.4)
12(36.8)
17(51.5)
12(36.8)5(15.2)6(18.2)8(24.2)18(54.5)
7(21.2)5(15.2)11(33.3)
12(36.4)
15(45.5)25(75.8)33( 100)
23(69.7)
14(42.4)31(93.9)17(51.5)
14(42.4)31(93.9)
11(33.3)24(72.7)23(69.7)
19(57.6)
21(63.2)
16(48.5)21(63.2)
28(84.8)27(81.8)25(75.8)15(45.5)26(78.8)28(84.8)

Harada S et al.

Asian J Occup Ther 11: 9−17, 2016

2, 7, 12, 17, 18, 22 and 24. The items before the basic
training, after the basic training and after the follow-up
training of items were experienced by 3.06 ± .61 to 2.24
± .61 to 2.15 ± .57 ( χ2 = 25.47, p < .000), 3.03 ± .77 to
2.13 ± .82 to 2.15 ± .57 ( χ2 = 16.69, p < .000), 2.83 ±.70 to 1.97 ± .62 to 1.70 ± .53 ( χ2 = 28.23, p < .000), 2.67
± .82 to 1.87 ± .68 to 1.84 ± .63 ( χ2 = 15.39, p < .000),
2.96 ± .83 to 2.26 ± .83 to 2.18 ± .53 ( χ2 = 15.57, p <.000), 2.27 ± .59 to 1.93 ± .46 to 1.70 ± .64 ( χ2 = 26.44,
p < .000) and 3.16 ± .83 to 2.21 ± .86 to 1.97 ± .65 ( χ2 =15.96, p < .000), all of df = 2, with average scores of 2,

13

12, 17, 18, 22 and 24, respectively.
Items experienced with significant results only between the score before the training and after the followup training included 6 items as follows: 1, 10, 14, 15,
20, 21 and 23. The items’ rates before the training andafter the follow-up training were experienced by 2.54
± .51 to 1.81 ± .58 ( χ2 = 14.83, p = .001), 2.64 ± .91 to
1.76 ± .50 ( χ2 = 15.64, p = .001), 3.12 ± .90 to 2.45 ±.67 ( χ2 = 7.80, p = .020), 3.31 ± .74 to 2.28 ± .63 ( χ2 =12.43, p = .002), 2.77 ± .87 to 1.97 ± .53 ( χ2 = 13.35,
p = .001), 2.57 ± .90 to 1.96 ± .71 to 1.76 ± .61 ( χ2 =Table 3. The scores for items before and after the basic training and after the follow-up training
Mean

SD

χ2-ScoreP-value

1. Hallucinations and delusions (n = 25)

beforebasicfollow-up

2.54
2.00
1.81

.51
.67
.58

14.83

.001

2. Fluctuations in care recipient’s mood (n = 27)

beforebasicfollow-up

3.06
2.24
2.15

.61
.61
.57

25.47

.000

3. Hallucinations in which someone steals (n = 18)

beforebasicfollow-up

2.91
2.17
2.00

.85
.72
.67

8.97

.011

4. Sexual behaviors (n = 12)

beforebasicfollow-up

2.27
2.22
2.13

1.07
.88
.66

3.50

.174

5. Threatened by care recipients (n = 9)

beforebasicfollow-up

3.00
2.36
2.42

1.34
.92
.61

2.14

.343

6. Causing care recipients anxiety about being dirty (n = 16)

beforebasicfollow-up

2.75
1.95
1.82

.97
.76
.68

9.52

.009

7. Talking about suicide (n = 26)

beforebasicfollow-up

3.03
2.13
2.15

.77
.82
.57

16.69

.000

8. Suicidal ideation (n = 14)

beforebasicfollow-up

3.07
2.60
2.67

1.28
.28
.65

4.48

.107

9. Care recipients not speaking and being silent (n = 17)

beforebasicfollow-up

2.86
1.86
2.10

.79
.66
.72

13.56

.001

10. Mentioning anxiety about life (n = 21)

beforebasicfollow-up

2.64
1.88
1.76

.91
.53
.50

15.64

.000

11. Many phone calls (n = 12)

beforebasicfollow-up

2.67
2.20
2.06

1.18
.68
.62

1.27

.529

12. Symptoms of hypochondria (n = 24)

beforebasicfollow-up

2.83
1.97
1.70

.70
.62
.53

28.23

.000

multiplecomparison
P-value
**

**

*

**

**

**

**

**

**

(continued)

14

EFFECT OF EDUCATION PROGRAMS FOR CAREGIVERS WITH THE PROVISION OF THE ELDERLY

12.16, p = .002) and 2.65 ± .88 to 1.76 ± .56 ( χ2 = 11.31,
p = .004), all of df = 2, with average scores of 1, 10,
14, 15, 20 and 23, respectively. The scores of 3 and 6
items experienced with significant results between thescores before the training and after the basic training,
but results of Bonferroni multiple comparison were notsignificantly, 3.03 ± .77 to 2.13 ± .82 to 2.15 ± .57 ( χ2 =8.97, p = .011) and 2.75 ± .97 to 1.95 ± .76 to 1.82 ± .68( χ2 = 9.52, p = .009) all of df = 2, with average scores of
3 and 6, respectively. The score of 9and16 items experi-

enced with significant results between the scores before
the training and after the basic training, but the scores
after the follow-up training deteriorated. Items were notsignificantly included 6 items as follows: 4, 5, 8, 11, 13
and 19.
The scores of 22 items after follow-up training
showed significant differences between the participants
who had experience before follow-up training and theparticipants who had no experience, 1.91 ± .725, 1.40 ±.27, z = −2.204 ( p = .044, with average scores of 22.

Mean

SD

χ2-ScoreP-value

13. Certified caregivers scolded by care recipients, but notunderstanding why (n = 16)

beforebasicfollow-up

2.74
2.26
2.33

.93
.73
.69

1.27

.531

14. Care recipient’s violence (n = 21)

beforebasicfollow-up

3.12
2.71
2.45

.90
.87
.67

7.80

.020

15. Refusal of care that certified caregivers could not understand (n = 20)

beforebasicfollow-up

3.31
2.42
2.28

.74
.81
.63

12.43

.002

16. Care recipients cannot dump trash (n = 17)

beforebasicfollow-up

2.63
1.68
1.81

1.01
.48
.73

9.70

.008

17. Ignorance of social norms (n = 21)

beforebasicfollow-up

2.67
1.87
1.84

.82
.68
.63

15.39

.000

18. Insufficienct care time (n = 20)

beforebasicfollow-up

2.96
2.26
2.18

.83
.73
.53

15.57

.000

19. No sense of the value of money (n = 10)

beforebasicfollow-up

2.54
2.31
2.03

1.13
.63
.54

.55

.761

20. Difficulties understanding life skills (n = 19)

beforebasicfollow-up

2.77
2.23
1.97

.87
.61
.53

13.35

.001

21. How to maintain appropriate distance from carerecipients (n = 18)

beforebasicfollow-up

2.57
1.96
1.76

.90
.71
.61

12.16

.002

22. Hurting the care recipient’s pride (n = 25)

beforebasicfollow-up

2.72
1.93
1.70

.59
.46
.64

26.44

.000

23. The appropriate way to speak to care recipients (n = 17)

beforebasicfollow-up

2.65
2.05
1.76

.88
.61
.56

11.31

.004

24. Care recipients forget when certified caregivers will visit(n = 16)

beforebasicfollow-up

3.16
2.21
1.97

.83
.86
.65

15.96

.000

multiplecomparison
P-value

**

**

*

**

**

**

**

**

**

**

**

**

*

**

before: before the basic training; basic: after the basic training; follow-up: after the follow-up training
The Likert scale of feeling care difficulties (can handle with no feelings, can handle without feeling difficulties, can handle, but feel difficulties, and cannot handle and feel difficulties) were assigned from levels 1–4
Friedman’s test, df = 2, Bonferroni multiple comparison: significant at **p < .01, *p < .05

Asian J Occup Ther 11: 9−17, 2016

4. The contents of the free descriptions
There were 47 descriptions after the follow-up
training. “How to deal with care recipients” was experienced by14: [We should provide care service to respectcare recipients’ feelings], “exchange information in theoffice” was experienced by 9: [It is important to behave
jointly with other staff care recipient’s behaviors which I
felt difficulties to deal with], “multidisciplinary collaboration” was experienced by 10: [It is necessary to reportand consult the mental medical staff the difficulties ofdealing with care recipient’s behaviors and request medical judgment], [It is necessary to exchange opinionswith other professional staff], and “impressions of thisprogram” was experienced by14: [I studied the casestudies about cases with which the other staff deal with],[The way in which participants grappled with studying
actively was good].

Discussion
In a comparison of “care difficulties” between
before the training and after the basic and follow-up
training, authors investigated the effects of this education program and other issues related to the education ofcertified caregivers.
1. Concerning the items for which the levels difficulty
were reduced
Both after the basic and follow-up trainings, theaverage scores of the care items with respect to dealing
with anxieties such as ‘fluctuations in care recipient’s
mood’ and ‘symptoms of hypochondria’, ‘ignorance ofsocial norms’, ‘insufficient care time’ and ‘hurting thecare recipient’s pride’ decreased. The participants could
understand that care recipients’ anxieties were caused by
the feeling of loss and loneliness elderly people experience; therefore, they could develop inner reserves anddeal with care recipients with composure. Regarding‘hurting the care recipient’s pride’, the scores of theparticipants who had care experience were significantly
higher than those who had no experience. The authors
assume that the participants were confident having experienced mistakes; therefore, it is desirable that certified
caregivers have training as soon as possible after they
are employed.
Furthermore, the care difficulties of care recipient’s
regarding the rules of life caused differences in thevalues between certified caregivers and care recipients(Harada & Yamane, 2013b). Authors included the experience of the care recipients’ feelings as if it had been
the participants’ own in the program, so the certified
caregivers could understand care recipient’s sense ofvalues and thinking, and consider care recipients’ feel-

Harada S et al.

15

ings. It is easy for certified caregivers to understand carerecipients’ anxieties and the rules of life.
The average scores of the care items with respect
to ‘hallucinations and delusions’, ‘the appropriate way
to speak to care recipients’, ‘refusal of care that certified
caregivers could not understand’ and ‘care recipient’s
violence’ decreased. The care items with respect tounderstanding psychiatric symptoms, the assessment of
disabilities in life and communication skills were effects
experienced after the follow-up training. If certified
caregivers received acknowledgment and understandthe recipients’ mental disease, it is easy for them to deal
with psychiatric symptoms and mental disabilities inpractice. The participants should understand care recipients’ communication disabilities and study them, thenacquire communication skills to address this problem.
In the implementation of case studies in this program,
authors selected care recipients’ behaviors whichcaused difficulties for participants in practice. Authors
had shared differences with care recipients’ responses,
integrated our information and clarified how to deal
with care recipients’ behaviors which caused difficulties
for participants. Consequently, the care difficulties forcertified caregivers improved. The rate of experience of
the items for which the levels of difficulty were reduced
was high, meaning certified caregivers have a lot of experience of care; consequently, they can make the mostof their opportunities.
2. Concerning the items for which the levels difficulty
deteriorated after the follow-up training
The average scores of items ‘care recipients not
speaking and being silent’ and ‘care recipients cannot
dump trash’ deteriorated after the follow-up training.
The certified caregivers have to finish care services after
a limited length of time for care-plans under Long-termcare insurance .Also, certified caregivers need to confirm
care recipients’ wishes in order to provide appropriate
care services; they were sometimes hasty in reacting tocare recipients’ silence. The dissatisfaction with the behavior ‘cannot dump trash’ indicates the certified caregivers cannot clean rooms and provide the care services
in the care-plan. Therefore, the authors assume that theparticipants thought they could deal with the care recipients’ behaviors immediately after the basic program,but could not deal with them easily in practice. The
follow-up programs supplemented the basic programs
to clarify the factors that caused the behavior and why
the care recipients behaved in that way. Consequently,‘feeling care difficulty’ about these items could not beeasily reduced. Previous research reported that skills toclearly deal with BPSD were taught in communication
skills training for nursing assistants for the care for

16

EFFECT OF EDUCATION PROGRAMS FOR CAREGIVERS WITH THE PROVISION OF THE ELDERLY

dementia patients (Spore, DL., Smyer, MA., & Cohn,
MD., 1991; McCallion, P., Toseland, RW., Lancey, D.,& Banks, S., 1999; Hukaya, Y., Suzuki, K., & Shitita, K.,
2004; Cankurtaran, ES., Kutluer, I., Senturk, M., Erzin,GB., Gursoy, D., & Tombak, E., 2008; Levy-Storms, L.,
2008; Roue, FP., Ortiz, KZ., Araújo, MSC., & Bertolucci, PHF., 2009; Burgio, LD., Stevens, A., Burgio, KL.,
Roth, DL., Paul, P., & Gerstle, J., 2002). Concerning
care recipients ‘not speaking and being silent’ and ‘carerecipients cannot dump trash’, it is necessary to teachboth awareness of the background factors and how topractically deal with these issues in practice.
3. Concerning items for which the difficulty level did notchange before the training and after follow-up training
The difficulty level for deviant behaviors suchas ‘sexual behaviors’ and ‘suicidal tendencies’ were
not improved. Thesis items were characterized as towhether or not certified caregivers could resolve them.
It is necessary that certified caregivers consult medical
staff who deal with mental patients and help them copein multidisciplinary collaboration. However, certified
caregivers hesitate to consult medical staff who deal
with mental patients and have issues about this (Harada& Yamane, 2013a). Certified caregivers were undecided
whether they should consult medical staff who deal withmental patients and worried that medical staff who deal
with mental patients would not respond to their consultations. The item “multidisciplinary collaboration”
was experienced as [It is necessary to report and consult
medical staff who deal with mental patients about thedifficulties in dealing with care recipient’s behaviors andrequest advice] in the free descriptions. The participants
could understand that it is necessary to consult medical
staff who deal with mental patients about the care recipients’ behaviors with which they could not cope withthrough multidisciplinary collaboration and case studies.
Medical staff who deal with mental patients shouldcollaborate with certified caregivers actively and supply
information about how to deal with care recipients’deviant behaviors.
4. Limitations
This study consisted of examinations conductedin one area with a small number of participants, so
the effects of this program are inconclusive. Authors
could not set up a control group because authors could
only select a few offices as the subjects of the research.
Six participants left during the research period, so theauthors did not have many participants to confirm thedurability of the effects of the education program. As
a result, the authors could not clarify the difference indistribution of the levels of difficulty by the participants’characteristics such as age and number of experiences ofcare for recipients. Furthermore, the authors examinedthe care difficulties for certified caregivers, but they
did not evaluate the index of outcome measures suchas care recipient’s QOL (Quality of Life); therefore, theeffects of this program have limited explanatory power.
However, the programs provided by this research areconsistent in the number of times, as well as the timerequired to fit in the working shifts of staff in home care
offices, so other offices could easily introduce a similar
program. The staff in the offices to which the authors
provided the programs exchanged information after the
program. Thus, the effects of our programs are ongoing.
Furthermore, it is necessary to do future studies withmore participants and examine the results quantitatively,
as well as construct systems to implement education
programs.

Conclusion
The following 3 points were the effects and issues
related to the programs:
1) The difficulty levels of the items ‘understanding
mental symptoms such as hallucinations, delusions,anxiety and hypochondria’, ‘understanding life skills
such as ignorance of social norms’ and ‘communication skills such as the appropriate way to speak tocare recipients’ were reduced significantly.
2) Concerning the levels of items ‘care recipients not
speaking and being silent’ and ‘care recipients cannot
dump trash’, authors should teach caregivers how todeal with practically deal with them.
3) The levels of items for deviant behaviors were
not effective. Medical staffs who deal with mental
patients should collaborate with certified caregivers
actively and deal with deviant behaviors throughmultidisciplinary collaboration.
Acknowledgements: Authors appreciate the cooperation of the managers and certified caregivers of theparticipating home visit care offices. Authors declarethat authors have no conflicts of interest.

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■NEW OCCUPATIONAL THERAPY APPROACHES

Facilitating Transfer of Skills and Strategies
in Occupational Therapy Practice:
Practical Application of Transfer Principles
Ganesh M. Babulal1, 2, Erin R. Foster1, 2, Timothy J. Wolf1, 2
1
2

Program in Occupational Therapy, Washington University School of Medicine
Department of Neurology, Washington University School of Medicine

Abstract: In Occupational Therapy (OT) practice, practitioners assume that the skills and strategies taught to clientsduring rehabilitation will transfer to performance and participation in everyday life. Despite transfer serving as apractice foundation, outcome studies conclude that this assumption of transfer is not occurring and it often results indecreased efficacy of rehabilitation. This paper investigated key aspects of transfer and found concepts in the psychology literature that can support transfer of skills and strategies in OT. Six key principles proposed from educational psychology can serve as a guide for practitioners to better train for transfer. In this paper, we discuss the six principles andapply concepts from psychology. Each principle is supported with examples of how they may be incorporated into OTpractice. If occupational therapists understand these principles and implement them in treatment, the efficacy of treatment may improve for many populations.
Keywords: Clinical reasoning, Occupational Therapy practice, Rehabilitation services(Asian J Occup Ther 11: 19−25, 2016)

Occupational therapy (OT) practice may be conceptualized as a learning process, where therapists serveas teachers, facilitating the learning process for clients
working towards becoming more independent in everyday life activities. Learning is defined as a relatively
permanent change in behavior as a result of experienceor having the capacity for skill or knowledge acquisition(Berkeland & Flinn, 2005). As facilitators of learning,
occupational therapists assist clients in a variety oflearning processes including, helping clients learn or
relearn skills, developing strategies to perform activities, and teaching caregivers skills that will help themcare for or support clients with disabilities (Glogoski,
Milligan & Wheatley, 2006). As a result, transfer seems
to be a critical component in the domain of teaching andlearning.
The purpose of teaching clients skills and strategies
during occupational therapy is to support performance
Received: 20 September 2013, Accepted: 30 November 2013
Corresponding to: Ganesh M. Babulal, Program in Occupational Therapy, Washington University School of Medicine, Campus Box 8505,
4444 Forest Park, St. Louis, MO 63108
e-mail: babulalg@wusm.wustl.edu©2016 Japanese Association of Occupational Therapists

and participation in the broader contexts of everyday
lives. It is not feasible to teach a client all the skills or
strategies for every situation he or she might encounter
when returning to home and community. Moreover,as many clients resume daily activities, is it unlikelythat continuous support or a structured setting will beavailable to assist in using newly learned skills andstrategies. Therefore, the skills and strategies must be
acquired during therapy in a way that permits them to
be independently applied by clients across a variety ofsituations that may differ from the initial learning event(Toglia & Kirk, 2000). This phenomenon, the use orapplication of prior learning in new contexts, is often
termed “transfer” or “generalization” of learning (Flavel,
1979; Woodworth & Thorndike, 1901). For this paper,
we treat transfer and generalization as overlapping
constructs and use the following definition. Transfer isthe degree that a skill learned in one context can be performed in another context, and transfer of training refers
to the potential that learning one skill will influence theability of the learning of another skill (Geusgens et al.,2007). Context refers to internal (emotion/mood state)or external (physical/social environment) circumstances
associated with the learning or performance event(Roediger, Dudai & Fitzpatrick, 2007). These two defi-

20

TRANSFER OF SKILLS CAN BE A GOAL FOR LEARNING IN OCCUPATIONAL THERAPY

nitions are replete in the psychology literature (Guthrie,
1935; Hull, 1943; Perkins & Saloman, 1989; Thorndike,1932). Transfer that is defined in this article is not tobe confused with the term transfer used in OT to define
how a person physically moves from one surface toanother. Further, transfer can occur across environmental contexts, such as techniques to complete a modified
cooking task learned in inpatient setting to use in thehome. Transfer can also occur across tasks, for example
when an individual who has learned to eliminate distraction (e.g., turn off the television) while paying bills, also
does this while cooking a new recipe (Haskell, 2001;
McKeough, Lupart & Marini, 1995).
According to Hammel and colleagues, social
participation is increasingly becoming a core goal forrehabilitation as a whole (2008). Transfer of skills is one
means to achieving this goal; however evidence is limited to support the occurrence of transfer in rehabilitation(Geusgens, Winkens, van Heugten, Jolles & van den
Heuvel, 2007). In educational psychology, the conceptof transfer has been rigorously studied. Transferring oflearned skills is not expected to occur automatically,
except in rare conditions when the transfer distance(the similarity between a learned skill and the newskill) is very near (or skills are very similar) (Perkins& Salomon, 1988). Transfer seems to be inconsistent
in rehabilitation practice and research (Geusgens et al.,2007). One common assumption among researchersand practitioners is that skills and strategies taught toclients during therapy will be seamlessly and automatically implemented in various contexts of everyday
lives (Geusgens et al., 2007). For example, in stroke
populations, efforts primarily target remediation offunctional impairment (e.g., upper extremity movement
and strengthening/endurance) with the assumption that
this will result in gains in everyday life activities (e.g.,dressing, working) (Teasell, Foley, Salter & Jutai, 2008).
Numerous follow-up studies with individuals withstroke demonstrate that this transfer is not occurring andfunctional outcomes remain poor, once individuals withstroke return to their premorbid activities (Murray &Lopez, 1997; Teasell et al., 2008). This limitation may
stem from the failure to explicitly “teach for transfer”(Butterfield & Nelson, 1989; Perkins & Salomon, 1988)
during the process of intervention.

PurposeIn a recent review of educational psychology literature, Geusgens and colleagues (2007) offered a list of“prerequisites for the occurrence of transfer” (p. 426).
They argue that the adoption of these principles (seeTable 1) during the therapeutic process may enhance thelikelihood that skills learned would be retained and appropriately implemented by the clients across activities
and environments upon discharge. However, discussionis lacking on how the principles may be understood andadopted by rehabilitation, specifically OT. The purposeof this paper is to provide a descriptive summary on thesix principles proposed by psychology (Geusgens et al.,2007) and discuss their potential application to OT. We
apply concepts from educational psychology to support
each principle and provide examples of how each may
be operationalized in the context of occupational therapy
practice.

Transfer in OT Practice
The educational psychology literature has determined a number of specific, evidence-based principles
related to teaching for transfer. As a caveat, these principles are discussed in general terms, as they would relate
to clients who are capable of cognitive, goal-directed
learning. For clients with neurological injury (i.e., TBI,
CVA), practice guidelines for OT stress the importanceof generalization and present it as a central tenet of cognitive rehabilitation (Cicerone et al., 2000). However,
the research and outcomes on how transfer applies toclients with cognitive deficits (i.e. executive function) is
limited but emerging (Geusgens et al., 2007). Therefore,
we emphasize that application of these principles in
populations with neurological injury may be different
when compared to clients without cognitive deficits.

Six principles to support transfer of skills in
occupational therapy
Principle I. A person should know what transfer isand how it works (Geusgens et al., 2007, p. 464).
While the definition of this concept is somewhat
self-evident, it is often not addressed in OT. In essence,
this principle states that therapists should explain toclients what transfer is and the process of how transfer
works. For example, when working with a client on alight meal preparation, the occupational therapist should
point out that the goal of the treatment is to transfer the
strategies and processes they are learning in completing
this exercise to meal preparation in their home. Thisshould facilitate a discussion about the similarities anddifferences between the two contexts and a discussion
about the application of the activity to their home. The
underlying educational psychology principle associatedwith this principle is the concept of “teaching for transfer” (Butterfield & Nelson, 1989; McKeough, Lupart &Marini, 1995; Perkins & Salomon, 1988). Teaching fortransfer is simply structuring the learning environment

Asian J Occup Ther 11: 19−25, 2016

Babulal GM et al.

21

Table 1. Prerequisite principles to promote occurrence of transfer
1
2
3
4
5
6

A person should know what transfer is and how it works
A person should be aware of one’s own functioning before he or she will acknowledge that a strategy is needed to improve it
A person should be able to judge when and where transfer can be applied
General knowledge should be taught, as this type of knowledge is easier to transfer than specific knowledge
The connection between what is learned and the situation in which it is learned should be broken by practicing a strategy orskill while varying the practice situation as much as possible
Transfer should be addressed during learning, as it cannot be expected to occur automaticallyand the activity to promote transfer. This concept ofteaching for transfer is the foundation for the remaining
principles.
Principle II. A person should be aware of one’s ownfunctioning before he or she will acknowledge that a
strategy is needed to improve it (Geusgens et al., 2007, p.
464).
Clients must understand they have a problem before
they may be willing and able to adapt existing or new
behaviors to address it. Intuitively, this principle is also
supported by studies that show that impaired self-awareness is associated with poor outcomes (Fleming, Strong& Ashton, 1998; Prigatano & Wong, 1999; Sherer et al.,1998). Cognitive psychology and therapeutic models(e.g., Barco et al., 1991; Toglia & Kirk, 2000) describe
two main aspects of awareness: (1) pre-existing knowledge or beliefs regarding one’s abilities, task demands
and how to compensate for limitations (termed “metacognitive knowledge” [e.g., Toglia, 1991] or “intellectual
awareness” [Barco et al., 1991]) and (2) knowledgeof performance acquired during task execution via
self-monitoring processes (termed “on-line awareness”[Toglia, 1991] or “emergent awareness” (Barco et al.,1991). In the context of learning and transfer, reduced
self-awareness of deficits may result in decreased motivation to engage in the initial learning of skills or strategies; if the client does not understand that a problem
exists, he or she might view strategies as unnecessary(Toglia, 1991). Reduced self-awareness may also resultin the inability to appropriately recognize situations inwhich learned skills or strategies should be used (Toglia& Kirk, 2000).
The importance of awareness in the therapeutic
process and to functional outcomes seems to be recognized by OT’s, particularly in populations with brain
injuries (Radomski & Latham, 2008). As such, there are
a number of suggested ways to improve clients’ selfawareness during the course of OT, and randomized controlled trials are emerging to support them (Goverover
et al., 2007; Schmidt, Fleming, Ownsworth, Lannin &Khan, 2012). The general perspective is that awarenessinterventions, rather than focusing on improving awareness in isolation, should occur in the context of im-proving a functional ability and should use real-life andfamiliar activities and settings (Fleming & Ownsworth,
2006; Toglia & Kirk, 2000). This “occupation-based”
awareness training is thought to best facilitate theemergence of awareness because it allows clients tocompare their stored knowledge and expectations of
performance with their current performance, thereby
permitting error-recognition and the eventual restructuring of knowledge and beliefs about their abilities.
This is accomplished via direct feedback regarding task
performance and structured self-evaluation. For example, a therapist working with a client on community
reintegration could set up a structured shopping experience that incorporates awareness-training techniques.
In a practical approach, the therapist would provide an
introduction to the task and its goals, after which theclient would predict his or her task performance, estimate the level of difficulty or how much time or effort
it will take, and pre-plan for any problems. Actual task
performance should be videotaped so that the client canevaluate his or her performance and compare it with hisor her initial predictions. Following this, the therapist
and client would compare and discuss their observations
and perceptions of task performance, including how
consistent the client’s performance was with his or her
predictions and expectations. The video would be used
to support this discussion as well as to review errors,
positive aspects of task performance, and potential
opportunities for compensatory strategy use. Such experiences would continue in the service of improving pretask metacognitive knowledge, while techniques to improve online-awareness, such as periodic self-checking
during task performance, would be introduced gradually.
The therapist may begin by participating in or verbally
guiding the client through the process, and would reducethe verbal guidance as it becomes habitual for the client.
Occupation-based approaches recognize the importance of providing opportunities for clients to implement
the same learned awareness strategies in varied tasks
and environments (Toglia & Kirk, 2000; Tsaousides &Gordon, 2009). For example, the client could start by
applying the evaluation process in a simulated grocery
store in the clinic, and then move to a small neighborhood grocery, to a larger grocery store or a clothing store

22

TRANSFER OF SKILLS CAN BE A GOAL FOR LEARNING IN OCCUPATIONAL THERAPY

in the mall and then to other non-shopping activities (e.g.,
meal preparation, laundry). Many features of occupation-based awareness interventions are consistent withthe teaching strategies thought to enhance the likelihoodof transfer including reducing the transfer distance byembedding learning in contexts in which it will later berequired, teaching general skills and strategies which
can applied in a range of contexts, and varying the practice/learning situation (Toglia & Kirk, 2000; Tsaousides& Gordon, 2009).
Principle III. A person should be able to judge when
and where transfer can be applied (Geusgens et al.,2007, p. 464).
Once a client acknowledges performance deficits
and learns skills or strategies to address them, he or sheneeds to be able to realize the occurrence of situations inwhich the skills or strategies should be used. Researchin healthy adults show that individuals do not spontaneously recognize everyday situations to which learned
material can be applied (Gick & Holyoak, 1983; Perkins& Salomon, 1988; Roediger, Dudai & Fitzpatrick,2007), therefore it is unrealistic to expect that clientswith disabilities can do this automatically. Instead, therapists should assume that spontaneous transfer is not thenorm and incorporate methods into treatment that will
facilitate a client’s ability to recognize and anticipate
situations which might prove difficult and thus requirelearned skill or strategy use. This is particularly relevantin situations that require “high-road transfer,” which
depends on deliberate mindful abstraction of skill or
knowledge from one context for application in anothercontext (Salomon & Perkins, 1989). When contexts(environments) are very different and fail to trigger
automatic associations, then cognitive effort is required
to discover or extract generic qualities that two contexts
possess to make connections based upon common elements. For example, driving a car vs. driving farm tractor are different contexts but contain similar elements
for abstraction (e.g. functional operation).
Salomon and Perkins (1989) describe two modes ofhigh-road transfer, “forward reaching” and “backward
reaching.” Therapists can incorporate teaching methods
into their interventions to facilitate both of these modes.
Steps to promote forward reaching high-road transfer
occur during the learning process and involve abstracting learned skills (acquired ability) or strategies (plans)in preparation for application elsewhere in the future.
An example of forward reaching transfer is where thetherapist simply tells the client how to apply cooking
skills for meal preparation learned in the clinic to meal
preparation in his or her home. Once the client understands the general idea of transfer, the therapist may ask,

“How might you apply these skills in a friend’s kitchen?
Or camping?” This would exercise and strengthen theclient’s own forward reaching capability. In addition,
after learning a particular skill or strategy, the client
could be asked to brainstorm different daily life situations to which it could be applied.
In contrast, backward reaching high-road transfer
is required when one experiences, or anticipates experiencing, a performance problem. He or she must identify
the key problematic characteristics of the situation anddraw upon (“reach backward into”) past experience forknowledge, skills or strategies that could be applied tosolve the problem. To strengthen this type of problem
solving ability, therapists can place their clients in novel
situations that require the application of previously
learned strategies. If a client wants to be independentin shopping, the therapist could take the client to an unstructured context (e.g. mall) and, if the client becomesoverwhelmed by distractions, the therapist would cue
the client to think about what he or she has been practicing in therapy and implement some strategy to help
him or her feel more in control of the situation. Therapy
sessions could also involve homework assignments thatguide clients to become more aware of everyday situations which may be problematic or to which strategies
can be applied.
In essence, high-road transfer requires the client
to develop the skills to perform basic “task analysis” toidentify, summarize and organize common elements or
demands of various situations and then map them onto
their strengths, limitations, and the skills or strategies
learned during OT. Clients will need a high level of
support from their therapist to initially perform theseabstractions, but the process may become habitual withrepeated practice (Siegler, 2004).
Principle IV. General knowledge should be taught,
as this type of knowledge is easier to transfer than specific knowledge (Geusgens et al., 2007, p. 464).
In OT, there is a tendency to be task-oriented or
focused on a specific activity—therapists work withclients to address a specific skill or provide them withspecific strategies for improving their performanceof a task (Toglia, 2005). According to this principle,
however, a different approach may be required whentrying to promote transfer (Geusgens et al., 2007). Task
specific knowledge does not transfer as well as generalknowledge. The educational psychology principle
underpinning this principle is the concept of “transfer
distance”. Transfer distance refers to how similar thelearning environment and activities are to the transfer
environment and activities (Butterfield & Nelson, 1989.
General knowledge has greater similarity to multiple

Asian J Occup Ther 11: 19−25, 2016activities and contexts than task specific knowledge andis therefore easier to transfer. For example, instead of
discussing specific strategies to reduce fatigue while
cooking a meal, the occupational therapist should focus
on teaching the concepts that support conservation ofenergy and general strategies such as pacing and planning. Transfer distance also involves the concept of “highand low road transfer” (Salomon & Perkins, 1989). Low
road transfer is transfer that occurs between two very
similar activities (e.g., driving a car vs. driving a truck)
whereas high road transfer is the general abstraction
and application of a strategy between two different
contexts (e.g., energy conservation techniques to dressing) (Salomon & Perkins, 1989). Low road transfer
can occur fairly automatically and relies on long-term
memory [Salomon & Perkins, 1989] whereas high roadtransfer involves multiple cognitive processes, but has
a far broader range of applicability in the real world.
Teaching general knowledge or strategies will promotehigh road transfer. In OT for example, teaching general
metacognitive strategies to help clients identify goals,
create a plan, implement a plan, and evaluate their work
can have broad application across multiple performanceareas (Toglia & Kirk, 2000). While high road transfer
may ultimately be the goal, this principle is dependent
on the ability of the client (e.g. clients with severe brain
damage have more limitations).
Principle V. The connection between what islearned and the situation in which it is learned should be
broken by practicing a strategy or skill while varying thepractice situation as much as possible (Geusgens et al.,2007, p. 464).
As mentioned earlier, a context is defined as asituation where an event occurs; it can be an internal
state (feeling a particular way, e.g. being happy whenseeing friends) or an external state (physical environment where something occurs) (Roediger, Dudai &Fitzpatrick, 2007). This principle links a specific task
or strategy and the context in which it is learned; thislink is influenced by how much the task or strategy
is practiced and the various situations in which it ispracticed (Schneider & Shiffrin, 1977). Further, this link
is supported by consistent mapping (initial practice in
one context) and varied practice (practice in different
contexts). Consistent mapping involves sustained task
performance in a static context across time—there will
be differences in performance in the beginning, but
automaticity will develop across hundreds to thousandsof trials (Schneider & Shiffrin, 1977). For example,
reading is not an automatic skill but requires time andpractice to recognize and comprehend letters, words
and sentences, and to understand how the words may be

Babulal GM et al.

23

rearranged to form sentences, paragraphs and stories. In
time, recognition of words becomes automatic with constant exposure and practice; however, comprehensionof the material read always requires effort to processeach new piece of information (Logan, 1997). In OT,
a therapist working with pediatric clients on reading
may encounter fluctuations in their performance due tointernal contexts (feeling sad), external contexts (noisy
therapy gym) or both. Consistency in performance isrequired before practice may be varied.
Similarly, varied practice refers to allowing
practice to occur in a variety of similar contexts. Thispermits retaining and adapting certain pieces of information from one context to the next, which is thought
to increase the chances that the task or strategy willtransfer from the initial context of practice into the application of novel contexts (Salomon & Perkins, 1989).
An example of varied practice in OT might include
assessing and ‘fitting’ a new vehicle for a client. In the
new car, the controls for operation may be similar but
may vary in location and shape. These slight variations
in context require re-adaptation of prior knowledge andstrategies to reorient in order to use skills to operate thenew vehicle. Repeated exposure will eventually fostertransfer of skill. By practicing in varying contexts, theclient increases the likelihood of successful performancein future novel contexts.
This principle of transfer is critical for OT. The
continuum of consistent mapping and varied practicepresents how therapy should structure a context tofacilitate transfer. A client should first gain mastery overa strategy or skill in one context and demonstrate consistent performance before moving to different contexts
and transferring that strategy/skill over.
Principle VI. Transfer should be addressed during
learning, as it cannot be expected to occur automatically(Geusgens et al., 2007, p. 464).
If the intention of teaching a skill/strategy is foruse in daily performance, then this intention should be
explicitly stated and concentrated on throughout the process. Assuming a skill or strategy taught to a client willautomatically transfer and be used is a misconception.
For example, in the context of education, the objectivesof a teacher’s lesson plan are typically stated before alecture, instantiated through the lecture and revisited at
the end to ensure the content was covered (Salomon &Perkins, 1989). While this example is pertinent to education, it would be efficacious to apply this basic approachto OT.
Transfer appropriate processing and bridging are
two concepts that support transfer in learning. Transfer
appropriate processing is categorized as a type of24

TRANSFER OF SKILLS CAN BE A GOAL FOR LEARNING IN OCCUPATIONAL THERAPY

memory dependent learning where the memory of anevent is typically best retrieved under similar or original
circumstances in which it was encoded. Additionally,
the amount of information recorded and the initial context of encoding directly impacts performance based on
degree of similarity or dissimilarity of the context of retrieval (Morris, Bransford & Franks, 1977). Practitioners
can utilize this concept to improve the performance of aclient on a specific task. For example, therapists working on dressing with a client who has hemiplegia may
want to evaluate how the client performs in their homesince it is the most appropriate and relevant context forcompleting the activity. Bridging is another concept thathighlights teaching a specific condition or resembling
condition in order for specific transfer (high or lowroad) to occur in the context of OT. If a client with aknee replacement wants to dress and sequence througha morning routine, it would be recommended to use theclient’s own clothes and practice dressing where the clients typically completes activity (e.g. at bedside insteadof bathroom). Both TAP and bridging are requisites fortransfer in order to maximize the probability of the skills
and strategies being used in various contexts.
The advantage of using transfer appropriate
process, bridging and this final principle in OT may
seem intuitive, and it is often glossed over. However,transfer has far reaching implications for therapists andclients. For example, a client with a right below knee
amputation is being taught to use a new prosthesis for ameal-prepping task. The therapist should first work withthe client to state goals and expectations for OT. The
overall goals might include having the client don theprosthesis independently and ambulate with a cane in
the kitchen without any loss of balance. Before, during
and after a cooking task, there should be discussion of
overall goals, specific strategies for movements, taskpriorities and safety. More importantly, there should bea discussion of the differences and similarities between
the practice environment in therapy and home environment in relation to the cooking task. This might include
an evaluation of the client’s home environment, having
the client complete the same cooking task, discussing
the client’s performance and what needs to be altered to
improve transfer. It is important for therapists to limit
our assumptions about transfer occurring automaticallyand instead, clearly address it in the context of OT.

Conclusion
One expected outcome of OT and rehabilitation isthat skills or strategies acquired by clients will be readily accessible for use in their daily activities and environments. In other words, what is learned in a clinical set-ting will transfer or generalize to everyday life for eachindividual client. Evidence for the occurrence of transfer
in practice is lacking as suggested by a recent reviewof transfer in cognitive rehabilitation (Geusgens et al.,2007). We propose that this may stem from a fundamental disconnect on how to promote transfer in OT. The
six principles and their supporting concepts previously
described are borne from educational psychology; yet,they bear significant implications for OT practice. Thesesix principles apply to existing OT practice models andsupport the work of therapists as they teach skills andstrategies to clients in order to support and maintainperformance and participation. To our knowledge, theseprinciples have not been formally tested in structured
experimental research studies; however, the concepts
supporting them have been extensively studied in psychology. We recommend practitioners and researchers
to begin to use these principles and assess the impact on
the functioning of their clients. Research on transfer isa new field of inquiry that may bear great significanceon evaluating the efficacy of OT interventions. Onceoccupational therapy begins to view practice as a type oflearning and the benefits of training for transfer, we may
augment our interventions and practice frameworks toinclude principles of transfer.

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■ORIGINAL ARTICLE

Correlation of the Hand 20 with the International
Classification of Functioning, Disability, and Healthand comparison of the results with those of
the Disability of the Arm, Shoulder and Hand
Terufumi Iitsuka, Tomoko Ohura, Takashi Fujita
Division of Occupational Therapy, Faculty of Care and Rehabilitation, Seijoh University

Abstract: The present study aimed to determine the correlation of the Hand 20, a patient-based outcome evaluation
widely used in Japan, with the International Classification of Functioning, Disability, and Health (ICF) and compare
the results with those of previous studies on the Disability of the Arm, Shoulder and Hand (DASH) score. As a result of
the study, it was found that the Hand 20 includes 5 items in the chapters of Body Functions, 23 items in the chapters of
Activity/Participation, and 2 items in the chapters on Personal Factors in the ICF. The results show that the Hand 20 has
a larger number of assessment items categorized into the muscle function (b740) and hand dexterity (d440) than that of
DASH. The present study concludes that the Hand 20 is a measurement method suitable for assessing hand functions
and performance. These findings provide insights to select appropriate outcome assessment methods and interpret outcomes between the two different methods.
Keywords: ICF, Hand20, DASH

(Asian J Occup Ther 11: 27−33, 2016)

Introduction
In the recent approaches for outcomes evaluation oforthopedic rehabilitation, not only objective outcomes
focusing on functional or biological aspects but alsopatient-based outcomes have come to play an importantrole in determining the impacts of disease or effects ofintervention on psychosocial aspects (Dawson & Carr,
2001). Health-related quality of life (QOL) is the mostcommon patient-based outcome of medical care. Its
assessment system includes comprehensive, diseasespecific, and body region-specific scales (Mcdowell,2006).
The Disabilities of the Arm, Shoulder, and Hand
(DASH) score has been widely used as a body regionspecific scale for outcomes evaluation in the field ofhand surgery. The DASH questionnaire consists of 30
Received: 5 December 2013, Accepted: 4 March 2014
Corresponding to: Terufumi Iitsuka, Division of Occupational Therapy, Faculty of Care and Rehabilitation, Seijoh University, 2-172
Fukinodai, Tokai, Aichi 476-8588, Japane-mail: iitsuka@seijoh-u.ac.jp©2016 Japanese Association of Occupational Therapists

questions pertaining to disability/symptoms and 4 pertaining to work and participation in sports/performing
arts. Each item is scored by each patient using a Likert
scale (Hudak, Amadio & Bonbardier, 1996). The questionnaire has been translated into each patient’s native
language, and its reliability, validity, and responsivenesshave been verified (Christina, Isam & Charlotte, 2003;
Imaeda, Toh, Nakao, Hirata & Ijichi, 2006; Offenbäacher, Ewert, Sangha & Stucki, 2003; Padula et al.,2003). However, the scope of the DASH questionnaire
was reported to be limited to the 18- to 65-year-old age
group (“The DASH outcome measure”, n.d.) and somequestions are difficult to respond to because of cultural
background, except in the United States (Lee et al.,2004, 2005).
The Hand Frontier, a nonprofit organization, developed the Hand20 questionnaire, which takes into consideration the Japanese cultural background, and reported
its reliability, validity, and responsiveness, as well as
its concurrent validity with the DASH version by theJapanese Society for Surgery of the Hand [DASH-JSSH](Suzuki et al., 2010). Considering that the DASH-JSSH
consists of questions that elderly respondents tend not to
respond to, such as those pertaining to the item “Having

28

Correlation of the Hand 20 with the International Classification

sexual life,” the Hand20 was designed to exclude suchitems. Moreover, the Hand20 reinforces 19 of the 20
questions with illustrations for the convenience of elderly respondents to further avoid unanswered items, which
if missing could affect the overall score (Fig. 1). Additionally, the Hand20 has some particular items which
ask about activities using the affected hand, facilitating
effective intervention. These advantages have led to thewide acceptance of the Hand20 in Japan (Yoshida et al.,2011; Iwatsuki et al., 2011).
Thus, in Japan, either the DASH or Hand20 isprimarily used as a patient-based evaluation tool in thefield of hand surgery. However, when comparing theusefulness of the 2 scoring systems in determining theeffects of intervention, it is important to know the characteristics of each evaluation tool and judge them appropriately. Thus, adequate consideration of the subjective
difficulties in measuring specific aspects of a patient’s
health condition by each evaluation system is important.
Cieza et al. (2002, 2005) proposed to consider
the association of an assessment instrument with theInternational Classification of Functioning, Disability

Fig. 1. Hand20

and Health (ICF) score because the ICF is necessary
to achieve a consensus on the appropriate functional
outcome parameters and is useful for comparing study
results or choosing the appropriate assessment system.
In addition, given that determining which outcome
parameters should be evaluated and how they shouldbe evaluated are important in outcomes assessment, theinstrument’s scope of scoring functional aspects should
be based on the ICF score, thereby elucidating the relationship between intervention and its outcome.
The concurrent validity of the Hand20 with the
DASH was previously reported. As suggested by Ciezaet al. (2005), further determining the correlation of anassessment tool with the ICF may reveal the characteristics in each scope of scoring and may be useful in comparing outcomes. Furthermore, Drummond, Sampaio,
Mancini, Kirkwood & Stamm (2007) reported on the
DASH score and clarified its association with the ICF.
In conforming with the guidelines proposed by
Cieza et al., the present study aimed to determine thecorrelation of Hand20 with the ICF and compare the results with those of previous studies on the DASH score.

Iitsuka T et al.

Asian J Occup Ther 11: 27−33, 2016

Methods
Determining correlation with the ICF
In the ICF (World Health Organization, 2008),
information is classified into 2 parts: Functioning andDisability as Part 1 and Contextual Factors as Part 2.
Along with these parts, the ICF code expresses regionswith lower case letters as follows: in Part 1, “b,” “s,”and “d” represent body functions, body structures, andactivities and participation, respectively; in Part 2, “e”
represents environmental factors. Furthermore, 2 to 4
numbers are added for individual classification. The
classification into the “activities and participation”
category was common. Although they should have been
fundamentally expressed as “a” (activities) and “p” (participation) (Ueda, 2010), it was decided to code them as“d” for comparison with previous studies.
The Japanese version of the Hand20 was used inthis study. However, the codes written in English provided by previous studies (Suzuki et al., 2010) were used inthis paper. We complied with the guidelines proposed by
Cieza (2002, 2005). The correlation guidelines consist of
8 items to correlate with the appropriate ICF codes that
correspond to all the concepts that might be considered
as applicable to the second-level items in the evaluationtable. The classification into either “other specified” or“unspecified” was not performed; instead, the coding forthe relatively lower level was applied. Personal factors
were coded as “pf.” Factors that were not defined in the
ICF code were coded as “nd.”Consequently, 2 researchers (T.I. and T.O.) acquired adequate prior knowledge of the ICF, correlation
guidelines, and Hand20 and performed the correlation
analysis independently. Subsequently, they comparedeach other’s classifications. When a consensus on anassessment tool was reached between the 2 researchers,
that instrument was adopted, as well as its correspondingclassification codes. When no consensus was achieved,a third researcher (T.F.), who had been a lecturer on the
ICF to the undergraduates in the university, made thedecision.

Analysis
According to the above-mentioned correlation
guidelines, the Hand20 was evaluated using the ICF
codes. The rate of concordance of the final code after
having reached an agreement (T.I and T.O) was expressed by the kappa coefficient. The coding of Hand20
was subsequently compared with that of the DASH.
Although the DASH was classified into the second level
including the “disability/symptom,” “work,” and “sports/
performing arts” categories, the Hand20 could not be

29

appropriately classified; therefore, we compared thescores from the “disability/symptom” category only. We
also compared the differences in the number of codes
and the rate of concordance of each ICF code between
the DASH and the Hand20.

Results
1. Linking to the ICF in Hand20 (Table 1, 2)
As a result of having classified the items according
to the ICF codes, 20 questions in the Hand20 werecorrelated with 30 ICF codes, covering 6 chapters:
Sensory Functions and Pain, Neuromusculoskeletaland Movement-related Functions, General Tasks and
Demands, Mobility, Self-care, and Community, Social,
and Civic Life. These correlation codes included 5, 23,
and 2 items pertaining to body functions, activities andparticipation, and personal factors, respectively. None of
the items was classified as a body function/structure oran environmental factor.
For the body functions, 2 items were classified
as sensation of pain (b280), 2 items were classified asmuscle function (b730), and 1 was classified as muscle
endurance function, respectively (b740).
For the “activities and participation” category, 2
items were classified as “carrying out daily routine”(d230) in Chapter 2 (General Tasks and Demands); 1,
4, and 7 items were classified as “lifting and carrying
objects” (d470), “fine hand use” (d440), and “hand andarm use” (d445), respectively, in Chapter 4; 3 and 1
items were classified as “washing oneself” (d510) and“caring for body parts” (d520) in Chapter 5; 1 item wasclassified as “preparing meals” (d630) in Chapter 6; and1 item was classified as “caring for household objects”(d650) in Chapter 7.
Question no. 17 “Do you experience difficulties
in recreational activities? (e.g., painting, knitting, andsports)” was most frequently linked to the classification
items, including “recreation and leisure” (d920), “sports”(d9201), “art and culture” (d9202), and “handicrafts”(d9203).
The kappa coefficient indicating the rate of concordance of the final code after a consensus was reached
was substantial (Kappa index = 0.69, P = 0.02) (Landis& Koch, 1977). Items 11 (“Push a heavy object up andonto the shelf overhead using both hands; approximately
5 kg”), 14 (“Turn over pages of a newspaper with theaffected hand”), and 15 (“Do manual work without too
much difficulty?”) in the Hand20 questionnaire required
discussion with the third person to obtain an agreement.

30

Correlation of the Hand 20 with the International Classification

Table 1. Linking between the Hand20 and the ICF
No.

Item Hand20

Meaningful Concept

ICF code/ICF category

Additional Information1

wash your face with both hands

washing oneself

d5100 washing body parts

face

2

cut all 10 nails on the digits of both
hands properly. (using a nail cutter)caring for body parts

d5203 caring for finger nails

using a nail cutter

3

Do up shirts buttons with both hands.

fine hand use

d440 fine hand use

do up shirts buttons
with the affected hand4pick up coins out of a purse with theaffected hand.

picking up

d4400 picking up

coins
out of a purse

5

turn on/off the faucet with theaffected hand.

turning/twistingd4453 turning or twisting the hands or arms

the faucet
with the affected hand

6

open a milk curton with both hands.

fine hand use

d440 fine hand use

a milk curton

7

open a PET bottle.

opend4453 turning or twisting the hands or arms

a PET bottle

8roll up and squeeze a towel hard.

turning/twistingd4453 turning or twisting the hands or arms

a towel9peel an apple using a knife.

cooking

d6300 preparing simple meals

10

operate a door knob and open aheavy door with the affected hand.

turning/twisting
opening/pushingd4453 turning or twisting the hands or arms
d4451 pushingdoor knoba heavy door

11

push a heavy object up and onto theshelf overhead using both hands.
(about 5kg)

putting downreachingmuscle power function

d4305 putting down objects
d4452 reachingd730 muscle power functions

overheadabout 5kg

12hang wet clothes on a clip hanger.

housework

d6400 washing and drying clothes andgarments

wet clothesa clip hanger

13

wash your hair with both hands.

washing oneself

d5100 washing body parts

hair

14

turn over pages of a newspaper withthe affected hand.

fine hand use
hand and arm use

d440 fine hand use
d445 hand and arm use

a newspaper

15

do manual work without too muchdifficulty.

muscle power functions
muscle endurancefunctionsd230 caring out daily routines
b730 muscle power functions
b740 muscle endurance functions

manual workwith the affected hand16

do you hesitate to show people youraffected hand for cosmetic reasons?

17

do you experience difficulties inrecreational activities (eg., painting,knitting, sports, etc.)?

recreation
painting
knitting
sportsd920 recreation and leisure(d9201 sports)(d9202 arts and culture)(d9203 crafts)

18

do you experience difficulties in
activities of daily living?

carrying out daily
routined230 carrying out daily routine

19

how much pain do you have in youraffected hand?

painb28014 pain in upper limb
b28016 pain in joints

20

do you feel less confident because ofyour affected hand?

pf

2. The difference of item numbers between Hand20 and
DASH (Table2)
For the DASH and Hand20 questionnaires, theconcordance rate was calculated by dividing the numberof items in the ICF first and then the second-levelclassifications by the total number of items: 2−13% for
the DASH and 3−23% for the Hand20. The ICF code
was concentrated on the “sensation of pain” (b280) and“hand and arm use” (d445) for the DASH and on “handand arm use” (d445) alone for the Hand20. In addition,no item corresponded to “sleep functions” (b134) inthe DASH and to “touch function” (b265), “mobility ofbone functions” (b720), and “sensations related to mus-sportspainting
knitting

affected handpfcles and movement functions” (b780) in the Hand20.
For activities and participation, no item corresponded
to “writing” (d170), “using transportation” (d470),“dressing” (d540), “eating” (d550), “doing housework”(d640), “informal social relationships” (d750), “family
relationships” (d760), “intimate relationships” (d770),and “remunerative employment” (d850) in the Hand20.
For body functions, no item corresponded to “muscle
endurance functions” (b740) in the Hand20. For activities and participation, no item corresponded to “finehand use” (d440) in the DASH.

Iitsuka T et al.

Asian J Occup Ther 11: 27−33, 201631

Table 2. Comparison of the Hand20 with the DASH
Number of items(ratio; %)ICF categories
One-level classification

Two-level classifiacation

DASH

Hand20body function
Chapter 1 MENTAL FUNCTIONS

global mental functions

sleep functions (b134)

1 (2.2)

Chapter 2 SENSORY FUNCTIONS AND PAIN

additional sensory functions
pain

touch sensation (b265)
sensation of pain (b280)

1 (2.2)6 (13.0)

Chapter NEUROMUSCULOSKELTALAND MOVEMENT-RELATED FUNCTIONS

functions of the joints andbones
muscle functions

mobility of bone functions (b720)

1 (2.2)

muscle power functions (b730)
muscle endurance functions (b740)
sensations related to muscles andmovement functions (b780)

2 (4.3)

writing (d170)

1 (2.2)carrying out daily routine (d230)

1 (2.2)2 (6.7)lofting and carrying objects (d430)
fine hand use (d440)
hand and arm use (d445)
using transportation (d470)

2 (4.3)1 (3.3)4 (13.3)
7 (23.3)

washing oneself (d510)
caring for body parts (d520)
dressing (d540)
eating (d550)

1 (2.2)1 (2.2)1 (2.2)1 (2.2)2 (6.7)
1 (3.3)preparing meals (d630)
doing housework (d640)
caring for household objects (d650)

1 (2.2)4 (8.7)
1 (2.2)

1 (3.3)

particular interpersonal
relationships

informal social relationships (d750)
family relationships (d760)
intimate relationships (d770)

1 (2.2)3 (6.5)
1 (2.2)1 (2.2)work and employment

remunerative employment (d850)

1 (2.2)

recreation and leisure (d920)
pf

3 (6.5)
1 (2.2)

movement functions

1 (2.2)2 (6.7)2 (6.7)
1 (3.3)

activities and participation
Chapter LEARNING AND APPLYINGKNOWLEDGE

applying knowledge

Chapter 2 GENERAL TASKS AND DEMANDS
Chapter 4 MOBILITY

carrying, moving andhandling objects
moving around usingtransportation

Chapter 5 SELF-CARE

Chapter 6 DOMESTIC LIFE

household tasks
caring for household objects
and assisting others

Chapter 7 INTERPERSONAL INTERACTIONSAND RELATIONSHIPS

Chapter 8 MAJOR LIFE AREAS
Chapter 9 COMMUNITY, SOCIAL AND CIVIC
LIFE

Discussion
In this study, the difference in the number ofquestions influenced the correlation with the ICF (10chapters and 44 items for the DASH vs. 6 chapters and
30 items for the Hand20). In addition, the ICF code wasconcentrated on “sensation of pain” (b280) and “handand arm use” (d445) for the DASH and on “hand andarm use” (d445) alone for the Hand20, which were considered characteristic of each scoring system. Regarding
the correlation with the ICF, the rate of interrater agreement was significant.
The reliability and validity of the Hand20 werepreviously verified, and its concurrent validity with
the DASH score was 0.91, indicating high correlation(Suzuki, 2010). However, the health-related QOL should

6 (13.0)
1 (2.2)

1 (3.3)4 (13.3)
2 (6.7)

not be interpreted using only the scores, and each scopeof scoring should be prescribed with a common framework. It is important that the scores be considered as oneof the indexes for comparing or choosing an assessment
tool. In this study, the ICF proposed by the WHO (World
Health Organization) was considered as the unifying
framework. The Hand20 was compared with the DASH
in conformity with the correlation guidelines proposedby Cieza et al. (2002, 2005). Regarding the results on
the characteristics of the aspects of body functions in
the Hand20, no item corresponded to the sleep functions
under the mental functions in the first level in Chapter 1.
In the DASH, sleep disorder is considered to be causedby arm pain and supplemented by the question “Howpainful is the affected hand?” in the Hand20. However,items related to touch function are not covered in the32

Correlation of the Hand 20 with the International Classification

Hand20 despite the fact that sensitivity to decreased
touch function is a concern in peripheral neuropathy.
To overcome this limitation, the use of disease-specificevaluation is recommended. For neuromusculoskeletal
and movement-related functions, some differences wereobserved but were not relevant items in the DASH andthe Hand20. It is a common point that items in the ICF
are more focused on aspects of body functions.
For activities and participation, no item corresponded to “writing” in Learning and Applying Knowledge(Chapter 1). Conversely, “fine hand use” was as frequent
as 23.3% in the Hand20. These results might be because
the DASH focuses on disorders in the entire arms,
whereas the Hand20 focuses on hand-specific, healthrelated QOL. Furthermore, the DASH included manyquestions on interpersonal interactions and relationships(informal social relationships, family relationships, intimate relationships, and remunerative employment). Thisdifference in the conceptual framework led to the difference between the 2 instruments. Therefore, the fundamental principles of the Hand20 may be considered
as based on the conceptual framework that disorders of
the hand have a minimum influence on the aspects ofparticipation.
In the Hand20, only few items are associated with
self-care and instrumental activities of daily living suchas dressing, eating, doing housework, and using transportation. These reflect the differences in the conceptual
framework between the 2 assessment tools. The Hand20
is more focused on the hand and skill activities than the
DASH. In contrast, for the personal factors, the DASH
included only 1 item, whereas the Hand20 included 2
items, suggesting that the impact of hand disorder on
personal factors is of particular concern.
Thus, the characteristics of the DASH include
many social aspects such as health-related QOL, on
which whole-arm disorders have an impact, whereas theHand20 includes many performance aspects pertaining
to health-related QOL, on which mainly hand disorders
have an impact. Therefore, although the Hand20 isconsidered sensitive for evaluating performance aspects
in disorders confined to the hand, it was suggested thatit lacks sensitivity to measuring its impact on social
aspects.
To utilize evidence derived from the study results,
it is important to further consider whether an instrument
should be used to guide the decision of appropriate
treatment after having carefully examined the evaluationindex used to measure the effect of intervention. In thisstudy, the characteristics of the DASH and Hand20 were
examined thoroughly. The results of this study will be
useful in deciding which evaluation index should be
used in clinical practice.

Conclusion
In conformity with the ICF correlation guidelines,
as a result of having classified each item of the Hand20
and DASH, we found that the Hand20 is intended
for diseases confined to the hand and that the DASH
consisted of a comprehensive conceptual frameworkthat includes social aspects on which whole-arm disorders have an impact. In addition, the sensitivity of theHand20 for evaluating impaired touch function is unclear. Thus, identifying the differences in the conceptual
frameworks between the 2 instruments is important for
instrument selection and interpretation of results using
the DASH and Hand20, which have been widely used in
the field of hand surgery in Japan.
Acknowledgment: The author would like to thankDr. Hitoshi Hirata, MD, Professor of Department ofHand Surgery at Nagoya University and Chairman ofHand Frontier, for cooperating and accepting the use of
Hand20 English version.

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Arm, Shoulder, and Hand questionnaire (DASH-G). Z
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the Disability of the Arm, Shoulder and Hand (DASH)
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T., & Hirata, H. (2010). Development and validation ofan illustrated questionnaire to evaluate disabilities of theupper limb. J Bone Joint Surg Br. 92, 963–969.
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Yoshida, A., Kisanuki, O., Shimizu, T., Omokawa, S., &Yajima, H. (2011). Toukotsu eni syousoku pure-to batteizenngo no tekansetsukinou no henka [The differenceof wrist function between removing a distal radius volar
plate]. The Journal of Japanese Society for Surgery of theHand. 28, 13–15.

■ORIGINAL ARTICLE

Effects of tendon and nerve gliding exercises
and instructions in activities of daily living following
endoscopic carpal tunnel release
Junya Hirata1, 2, Tetsu Suzuki3, Tomoyo Yamamoto1, Yuka Miyazaki1,
Yoko Ogasahara1, Hiroyuki Hashizume4, Keiko Inoue5
1

Department of Rehabilitation, Kasaoka Daiichi Hospital
Doctoral Program, Rehabilitation Graduate School of Health Science and Technology, Kawasaki University of Medical Welfare
3
Department of Physical Therapy, Shimane Rehabilitation College
4
Department of Orthopedic Surgery, Kasaoka Daiichi Hospital
5
Department of Rehabilitation, Faculty of Health Science and Technology, Kawasaki University of Medical Welfare
2

Abstract: The effects of postoperative therapy on psychological function following endoscopic carpal tunnel release(ECTR) have not been sufficiently investigated. This study investigated the effectiveness of instruction in tendon andnerve gliding exercises and activities of daily living (ADL) as postoperative treatment for 49 patients with carpal tunnel
syndrome. Patients were randomized into 2 groups (intervention and control). After surgery, tendon and nerve gliding
exercises and instruction in ADL were performed only on the experimental group on the day of the surgery. All patientswere examined preoperatively and again 5−13 days postoperatively. Outcomes of pain, numbness, sensation, range of
motion (ROM), anxiety, ADL and quality of life (QOL) were compared between groups. Differences were seen in pain,
static 2-point discrimination, ROM, anxiety, and QOL. Tendon and nerve gliding exercises and instruction in ADL after
ECTR appear likely to accelerate recovery.
Keywords: carpal tunnel syndrome, endoscopic carpal tunnel release, tendon and nerve gliding exercises, ADL-instruction(Asian J Occup Ther 11: 35−41, 2016)

Introduction
Carpal tunnel syndrome (CTS) develops when the
median nerve is compressed at the wrist. Symptoms
such as numbness and sensory impairment of the fingers in the area of the median nerve, failure of thumb
opposition, finger movement disorders, and pain arecharacteristic of CTS (Phalen, 1966). Cutting the transverse carpal ligament is the most effective treatment forCTS (Uchiyama et al., 2009). Open carpal tunnel release(OCTR) (Phalen, 1966) was the choice of surgery until
1987, when endoscopic carpal tunnel release (ECTR)(Okutsu et al., 1987) was introduced as a minimally
Received: 25 December 2012, Accepted: 3 February 2015
Corresponding to: Junya Hirata, Department of Rehabilitation, Kasa­
oka Daiichi Hospital, 1945, Yokoshima, Kasaoka, Okayama, 7140043, Japane-mail: kfmbs599@yahoo.co.jp©2016 Japanese Association of Occupational Therapists

invasive alternative to OCTR using a smaller skinincision. ECTR avoids painful scarring, reduces the duration of hospitalization, and allows earlier recovery of
movement. In addition, because postoperative external
fixation is unnecessary, rehabilitation of patients canbe accelerated (Okutsu, Ninomiya, Takatori & Ugawa,1989).
Studies comparing the postoperative the results of
ECTR and OCTR (Trumble, Diao, Abrams & GilbertAnderson, 2002; Tian, Zhao & Wang, 2007; Atroshi
et al., 2009) showed that ECTR was associated with
better improvements in muscle strength directly after
surgery, but no differences in treatment results for subjective symptoms and activities of daily living (ADL)
were reported. Agee et al. (1992) reported that postECTR tenderness caused a decrease in muscle strength,
delaying ADL improvement. Atroshi, Johnsson, andOrnstein (1998) reported a strong correlation between
ADL and postoperative patient satisfaction. There is
therefore a need to improve early function and ADL

36

Effects of tendon and nerve gliding exercises and instructions in activities

after appropriate therapy.
Patient-perceived disability correlates as much or
more with psychological distress as with objective impairment (Schiphorst Preuper et al., 2008). Correlations
with psychological function are reported using Disabilityof the Arm, Shoulder, and Hand (DASH) scores (Niekel,
Lindenhovius, Watson, Vranceanu & Ring, 2009), andVranceanu, Jupiter, Mudgal & Ring (2010) stated thatintervention for psychological function is important
after surgery for CTS. In terms of psychological interventions, Inoue (2002) stated that a provision of objective and concrete information is effective. For physicalintervention, finger exercises to prevent flexor tendon
and neural adhesions must be prescribed (Yoshida,
Okutsu & Hamanaka, 2008; Narazaki & Hashizume,2008). Intervention effects on physical function havebeen examined, but intervention effects on psychological function have not been sufficiently investigated. The
present study, therefore, sought to clarify the effects ofinterventions for physical and psychological functions
on improvement of function, ADL, and quality of life
(QOL) in patients treated using ECTR for CTS.

Methods
Subjects
From August 2010 until March 2011, a total of 86
patients (106 hands) diagnosed with CTS underwent
ECTR at our institution. The content and purpose of
the study were explained in advance to these patients,
and consent to participate in this study was obtained
from prospective subjects. Patients who had previously
undergone carpal tunnel release (CTR) surgery, who
had a combination of different upper limb disorders, or
who had a medical or surgical history were excluded. In
addition, patients with secondary CTS (caused by hemodialysis, wrist osteoarthritis, rheumatoid arthritis, ordiabetes), upper limb numbness, pain, or sensory impairment (spine and spinal cord disorders, cerebrovasculardisease) were excluded along with those who could notcomplete the questionnaire because of dementia, basedon the judgment of the examiner. Subjects were randomly allocated to an intervention group or control group
after preoperative evaluation according to sex, age,disease duration, severity (Hamada, Ide & Yamaguchi,1985), and type of disorder, starting with patients withthe earliest date of preoperative evaluation. Staff members not involved in the evaluation or treatment of thesepatients rolled a dice. When an odd number was rolled,
the patient was assigned to the control group, and whenan even number was rolled, the patient was assigned tothe intervention group. During the intervention period,
patients who refused to participate in the study, thosewith missing data, and those who were absent on thedate of evaluation were excluded. Consequently, 25 patients were included in the intervention group (34 hands)
and 24 were included in the control group (30 hands).
Mean ages in the intervention and control groups were
59.8 ± 14.2 and 63.2 ± 11 years, respectively. This study
was conducted after approval had been obtained fromthe hospital ethics committee (approval number: 54).
Methods
During preoperative examination, the intervention
and control groups received explanations and precautions regarding the surgery. Patients underwent surgery
on an outpatient or overnight inpatient basis. All surgeries were performed using the Okutsu method (Okutsu
et al., 1987) by a surgeon specializing in hand surgery.
During medical examination on postoperative day 1, thebulky dressing was removed to facilitate free movementof the wrist and fingers. After surgery, intervention was
limited to patients in the intervention group only on the
day of the surgery, as described below. Nothing was
performed besides a medical examination in the control
group. All patients were examined preoperatively andagain at 5−13 days postoperatively (mean, 8.1 ± 1.9
days).
Intervention
An occupational therapist provided instruction on
finger exercises and ADL. Instructions on finger andtendon gliding (Wehbé & Hunter, 1985) and nerve
gliding (Totten & Hunter, 1991) exercises were given topatients in the intervention group. Tendon-gliding exercises consisted of 5 types: finger stretches; hook fist; full
fist; table top; and straight fist. Nerve gliding exercises
included 6 types: 1) finger and thumb flexion with thewrist in a neutral position; 2) finger and thumb stretcheswith the wrist in a neutral position; 3) wrist and finger
stretches with the thumb in a neutral position; 4) wrist,
finger, and thumb stretches; 5) forearm supination while
performing wrist, finger, and thumb stretches; and 6)
thumb stretches with forearm supination. These exercises were performed with the head in the median line,
the shoulder girdle in a neutral position, and the forearm
placed on the table with the elbow flexed at a 90° angle.
Each position was maintained for 5 s. Three sets of exercises were performed 10 times/day and continued until
the first follow-up at 1 week after surgery. To avoid exacerbation of inflammation, patients were instructed tostop the exercises immediately if pain was experienced
in the wound or the palm during exercise.
Taking into account the methods of Okutsu,
Hama­naka, and Yoshida (2008) and Montgomery (1994),
consultations were held between occupational therapists

Hirata J et al.

Asian J Occup Ther 11: 35−41, 2016

and doctors regarding the content of ADL instruction
to be provided as part of the postoperative intervention
in this study. The occupational therapist taught thefollowing contents about ADL instruction. Patients were
instructed to start with a light load in the pain-free range
and to gradually increase load. To prevent numbness andpain, patients were instructed to minimize flexion andextension of the wrist. To prevent palmar dislocationin the flexor tendon and nerves and pain, patients wereasked to avoid applying pressure or gripping of heavyloads involving holding a stretch for 1 month after surgery. Patients received an explanation that there may not
be early improvement of ADL, and the disappearanceof numbness and pain could take a relatively long time.
Furthermore, brochures containing instruction on ADL
and exercise were distributed after these consultations.
Evaluation
Occupational therapists not involved in the treatment intervention and blinded to the group allocation
process performed the evaluations before and after
surgery. Mean day of postoperative evaluation was 8± 1.8 days postoperatively (range, 5−13 days) for theintervention group, and 8.3 ± 2 days (range, 5−13 days)
for the control group. The same occupational therapists
performed all evaluations for each subject. Upper limb
function (pain, numbness, perception, and range of
motion (ROM)), anxiety, ADL, and QOL were evaluated.
An 11-point numerical rating scale (Jensen, Turner& Romano, 1994) was used for the evaluation ofpain and numbness. This evaluation method included
quantification of the current stimulation level, with the
maximum stimulation level ever experienced set as 10.
Perception was evaluated using the Semmes-Weinsteinmonofilament test (SWMT) (Aulicino, 2002) and static
2-point discrimination test (s2PD) (Aulicino, 2002)
for the ventral part of the numbest finger. ROM wasevaluated using the total active motion (TAM) assessment scale for the index finger. The Japanese version of
the State Trait Anxiety Inventory (STAI) (Nakazato &Mizuguchi, 1982) was used to evaluate anxiety. Withan anxiety scale created from self-evaluation questionnaires, both the temporary emotional state due to current
living conditions and trait anxiety showing individual
character tendencies can be measured. The present study
only measured state anxiety.
The evaluation of ADL utilized the DASH symptom
scale (Imaeda et al., 2005), published by the JapaneseSociety for Surgery of the Hand. The reliability, validity,
and efficacy of the DASH scale have been confirmed(Imaeda et al., 2005). In this study, only items regarding
disability/symptom were considered. The DASH is a 30-

37

item disability/symptom scale concerning disability of
the upper extremity. Scores for all items are then used to
calculate a scaled score ranging from 0 (no disability) to100 (most severe disability).
The Japanese version of the Euro QOL 5-Dimension scale (EQ-5D) (The Japanese EuroQol Translation
Team, 1998) was used to evaluate QOL. The EQ-5D
visual analog scale (VAS) evaluates health state on ascale from 0 to 100. Respondents indicate how they
feel that day (with 0 as the worst and 100 as the beststate). The EQ-5D describes health status according to 5
dimensions: mobility, self-care, usual activity, pain/discomfort, and anxiety/ depression. Each dimension has
3 levels, namely, “no problems”, “some problems” and“sever problems”. Responses to the 5 dimensions arecollectively expressed in the standard way as an EQ-5D
score using the value set, which ranges from a for perfect health (no problems in any dimensions) to −0.111
for worst health (severe problems in all dimensions).
Statistical processing
SPSS for Windows version 16 (SPSS, Chicago, IL,
USA) was used for statistical analyses. The χ2 test andMann-Whitney U test were used to compare data in theintervention and control groups. Wilcoxon’s signed-rank
test was used to compare data within groups before andafter surgery. The significance level was established at
5% for all measures.

Results
Patient characteristics are shown in Table 1. No significant differences were observed between the control
and intervention groups in terms of these characteristics.
Tables 2 and 3 display the results of clinical parameters
for both groups. No significant differences were evident
in the preoperative comparison of all evaluation items
between groups. Postoperative pain was significantly
lower in the intervention group than in the control
group, whereas TAM and EQ-5D (VAS) scores weresignificantly higher in the intervention group than in thecontrol group (p = .01, p = .02, and p = .01, respectively).
In pre- and postoperative comparisons within eachgroup, a significant increase in pain was only observedin the control group (p = .001). Both s2PD and STAI
scores declined significantly in the intervention group
after the intervention (p = .002, p = .01). The control
group showed no significant change. Likewise, nosignificant change in EQ-5D (5 dimensions) was seenfor either group, whereas the EQ-5D (VAS) score wassignificantly higher only in the intervention group (p =
.03).

38

Effects of tendon and nerve gliding exercises and instructions in activities

Discussion

Table 1. Baseline characteristics of study patientsAge (years)
Height (cm)Weight (kg)
Women, n (%)
Bilateral symptoms, n (%)
Affected side (dominant), n (%)
Disease duration (days)
Baseline-ope (days)
Severity
I
II
III

Intervention(n = 25)

Control(n = 24)

59.8 ± 14.2
155.0 ± 7.1
56.9 ± 10.4
19 (76)9 (36)
18 (72)31.2 ± 40.7
17.3 ± 11.0
26
3
5

63.2 ± 11.0
157.4 ± 6.4
59.9 ± 8.3
18 (75)6 (25)
17 (71)36.3 ± 52.3
18.2 ± 16.5
20
3
7

Values are given as mean ± standard deviation.
*: Significant difference between groups.

Table 2. Comparison of functional status before and after surgery
Intervention(n = 34)

Control(n = 30)
1.7 ± 2.8
3.7 ± 2.2*†

NRS (pain)

Pre
Post

2.3 ± 3.1
2.5 ± 3.0*

NRS (numbness)

Pre
Post

6.7 ± 2.6
3.0 ± 3.0†

6.4 ± 3.0
2.3 ± 2.5

†

SWMT

Pre
Post

3.7 ± 0.6
3.2 ± 0.7†

3.6 ± 0.8
3.4 ± 0.5

†

s2PD

Pre
Post

5.8 ± 2.8
4.4 ± 2.9†

5.6 ± 3.1
4.6 ± 2.7

TAM (°)Pre
Post

220 ± 20.7
218.8 ± 17.2*

213.8 ± 23.5
204.7 ± 22.4*

Values are given as mean ± standard deviation.
*: significant difference between groups; †: significant difference within group.
NRS, numerical rating scale; SWMT, Semmes-Weinstein monofilament test; s2PD, static 2-point discrimination test; TAM, total active
motion.

Table 3. Comparison of STAI, DASH and EQ-5D scores before andafter surgery
Intervention(n = 25)

Control(n = 24)

STAI

Pre
Post

40.2 ± 8.9
34.7 ± 12.2†

38.1 ± 7.4
36.6 ± 9.9

DASH

Pre
Post

24.2 ± 18.1
41.7 ± 20.9†

24.3 ± 19.4
47.2 ± 22.5

EQ-5D
(5 dimensions)

Pre
Post

0.750 ± 0.1
0.75 ± 0.2

EQ-5D (VAS)

Pre
Post

66.6 ± 19.8
77.2 ± 16.9*†

0.77 ± 0.1
0.74 ± 0.1†

68.5 ± 15.6
67.7 ± 16.3*

Values are given as mean ± standard deviation.
*: significant difference between groups; †: significant difference within group.
STAI, State Trait Anxiety Inventory; DASH, Disability of the Arm,
Shoulder and Hand; EQ-5D, Euro QOL 5-Dimension; VAS, visual
analog scale.

This study examined the effects of finger exercises
and instruction in ADL on postoperative improvements
in hand function, ADL, and QOL in patients with CTS
treated using ECTR. Tendon and nerve gliding exercises
are reportedly effective in the prevention and improvement of adhesions affecting the gliding of nerves andtendons in the hand (Cook, Szabo, Birkholz & King,
1995; Burke, Ellis, Mckenna, Bradley & Dubin, 2003;
Butler, 2000). These exercises are recommended as exercise therapy as part of conservative or invasive therapy
in patients with CTS (Nathan, Meadows & Keniston,
1993; Cook et al., 1995). Gliding of the median nervein such patients is decreased because of adhesions tosurrounding tissue (Butler, 2000). Neurolysis is not performed because of technical difficulties and the narrow
surgical field involved in the ECTR procedure (Hashizume, Nagoshi & Inoue, 1998). As a result, performing
these exercises after ECTR may be necessary not only
to prevent postoperative nerve adhesion, but also to
encourage nerve gliding.
Perception tests convey information about nerve
function. In this study, differences between the intervention and control groups were only seen in the resultsof the s2PD among the perception tests. Simsir, Sarsan,
Akkaya, and Yildiz (2011) examined correlations between electrophysiological testing and perception tests
and reported high correlations with s2PD scores, but
not with SWMT scores. Katz, Gelberman, Wright, andAbrahamsson (1994) reported that because the s2PD
reflects dysfunction of the median nerve, it is useful as
a postoperative evaluation method. The results of thes2PD accurately reflect changes in the median nerve andthis intervention may accelerate nerve recovery. Training
in nerve-gliding exercises may therefore have positiveeffects on the recovery of nerves and surrounding tissue
after ECTR.
When tissue is damaged as a result of injury or
surgery, swelling and pain can occur. Mechanical stimulation during acute inflammation can lead to chronic
inflammation and prevent normal healing (Gary, 2005).
ECTR does not require extensive recovery time after
surgery, so use of the hand may begin at an early stage.
However, excessive activity may exacerbate hand dysfunction and delay recovery. Patients require a thoroughexplanation of how to resume postoperative ADL. In
this study, occupational therapists provided individualintervention regarding postoperative ADL to patientsin the intervention group. By instructing patients toincrease the use of their hand in a step-by-step manner
while performing ADL, excessive loads can be decreased and exacerbation of inflammation prevented.

Asian J Occup Ther 11: 35−41, 2016

Postoperative pain was significantly higher in the control group, whereas no significant changes were seen in
the intervention group, suggesting that the postoperative
restrictions on hand usage imposed for the ADL instruction in this study facilitated pain prevention in ECTR
patients. Postoperative limits to ROM were also betterin the intervention group than in the control group, but
this result can be attributed to lower pain levels in theintervention group. Pain relief at an early stage is crucial
to the retention of good postoperative hand function.
Anxiety may also exacerbate pain. Vranceanu et al.
(2010) reported a correlation between acute postoperative pain and preoperative anxiety after minimallyinvasive surgery for CTS. In medical and physiologicalstress models, anxiety represents a psychological reaction caused by stress and perceiving a stressor as a threatcauses anxiety (Spielberger, 1983). Preoperative anxiety
is caused by daily stimuli such as thinking about or experiencing surgery. These feelings then become a stressor and may have large implications on recovery. In thisstudy, anxiety showed no postoperative improvement in
the control group. On the other hand, anxiety did show
postoperative improvement in the intervention group.
Inoue (2002) stated that objective and concrete information must be communicated in order to enhance feelingsof control and alleviate anxiety and tension. Sustaining
an uncomfortable psychological and physical state after
surgery can be stressful. Objective information about thecauses of pain and numbness and receiving instructions
in coping methods can affect perception and may explain the differences in anxiety between the two groups
in this study. When such information was clearly communicated to patients in previous studies (Hall & Stride,
1954; Langer, Janis & Worfer, 1975), pain and anxiety
were alleviated. Instruction on ADL as utilized in thisstudy should thus combine subjective and objective information to effectively alleviate anxiety and avoid thestress that delays complete postoperative recovery.
In this study, a brochure was distributed to patientsin the intervention group to encourage the completion of
postoperative exercises and communicate instructions
for resuming ADL. In a study using a questionnaire on
post-ECTR surgery, Yoshida et al. (2008) stated thatpatients reporting anxiety had received insufficient explanation from the medical staff and had demonstrated
a lack of understanding of their condition. Visualization
through a brochure makes the content of the instructions
easier to understand and facilitates confirmation andrepetition. Patients using the brochure can perform
postoperative exercises and follow instructions on ADL
more effectively. In this study, the intervention had apositive effect on the early improvement of postoperative physical and psychological function.

Hirata J et al.

39

Objective evaluation indices such as the SWMT
and tests of nerve conduction velocity have long beenused to determine the therapeutic effects of interventions for CTS. In recent years, however, the importanceof subjective evaluation indices has also come to berecognized (Itsubo et al., 2009). The present study usedthe DASH scale and EQ-5D as subjective measures toevaluate ADL and QOL.
The DASH scale is a questionnaire that allows
self-evaluation of the symptoms and abilities of thehand, and has been reported as a useful index for evaluating improvement in disorders resulting from CTS(Kameda et al., 2007). A significant decrease in ADL for
both groups was observed both pre- and post-operatively. Mackenzie, Hainer, and Wheatley (2000) reported
that after ECTR, 2 weeks were required for grip andpinch strength to improve to preoperative levels. Muscular strength was not measured, but muscular strength
may not have been sufficiently improved when patientscompleted the DASH scale. The presence of pillar pain
may be another factor influencing postoperative recovery in CTS patients (Feinstein, 1993). Pillar pain has notbeen clearly defined, but pain in the thenar and hypothenar areas of the palm that appeared for 3 months after
surgery is presumably caused by postoperative tendon
synovitis and palmar cutaneous nerve injury (Ludlow,
Merla, Cox & Hurst, 1997). Hunt and Osterman (1994)
reported that pillar pain occurring in the early postoperative period delays the time until reinstatement or reuseof the hand and may result in decreased postoperative
ADL. No differences in ADL were observed between
groups after surgery. Responses to the DASH are supposed to be based on the state in the preceding week,
not on the day of measurement. Good results were seenin the intervention group for physical and psychological
function, but there is a possibility that these were notreflected by the DASH. Further investigation in consideration of the measurement time might therefore be
warranted.
The EQ-5D is a comprehensive scale commonlyused for the evaluation of changes health status. Differences in VAS scores were seen between the two groups
in our study. The VAS score was increased only in theintervention group. Kuroda and Kanda (2007) reported
a high correlation between the 5 dimensions evaluatedon the EQ-5D and VAS scores, but suggested that subjective symptoms and mental state had a considerable
effect on the latter. In this study, pain and anxiety were
improved in the intervention group. These differences inpostoperative pain and anxiety may have influenced the
VAS scores.
This study had several limitations that need to beconsidered when interpreting the results. First, no de-40

Effects of tendon and nerve gliding exercises and instructions in activities

tailed study was performed to determine the complianceof the intervention group with regard to performing theexercises and following the rehabilitation instructions
at home after discharge. Differences in the degree of
implementation of these exercises and instructions thus
remain unclear. Second, the sample size was small.
Third, only anxiety was evaluated among many possible
contributory psychological factors. The connection
between psychological perception and pain must be
evaluated in greater detail and should include factors
such as depression and self-efficacy. Future studies will
focus on these issues.

Conclusion
This study examined whether prescribed tendon
and nerve gliding exercises and instruction in ADL
accelerated improvements in hand function, ADL, and
QOL after ECTR for CTS. Our results suggest that successful encouragement and description of the expectedcourse of improvements in physical and mental function
through tendon and nerve gliding exercises and instruction in ADL can enhance QOL at an earlier stage after
ECTR.

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■ORIGINAL ARTICLE

Visual Axis Analysis during Unassisted Eating
and Robot-assisted Eating
Atsuko Suzuki1, Yui Takahashi1, Mitsuhiro Nito2, Katsuhiko Suzuki1, 3,
Hiromi Fujii1, 4
1

Graduate School of Health Sciences, Yamagata Prefectural University of Health Sciences
Graduate School of Medical Sciences, Yamagata University
3
Department of Physical Therapy, Faculty of Health Sciences, Yamagata Prefectural University of Health Sciences4
Department of Occupational Therapy, Faculty of Health Sciences, Yamagata Prefectural University of Health Sciences
2

Abstract: This study examined differences of the visual axis and pupil diameter between unassisted eating and robotassisted eating in 12 healthy subjects. A digital video camera and an eye tracker were used for synchronous measurements. Subjects carried cereal with a spoon or a meal support robot. The upper extremity position at which the visual
axis was removed from food was designated as the critical visual point (CVP). Pupil diameter and CVP were used as
an index. The results showed a CVP in unassisted eating; the visual axis was centered on the food from the start ofthe motion while eating to the CVP. However, the results for assisted eating showed no CVP, and the visual axis was
located on the food during eating. These findings suggest that a subject with no somatosensory information depends
solely on visual information, and identifies distance from the spoon to the mouth by visual information in robot-assisted
eating.
Keywords: unassisted eating, robot-assisted eating, visual axis, eating(Asian J Occup Ther 11: 43−52, 2016)

Introduction
A registered occupational therapist (OTR) uses
assistive technology (AT) to improve a person’s activities of daily living (ADL) and instrumental activities ofdaily living. In AT, the input system of humans is usedfor visual, auditory, and somatosensory disorders. The
output system of humans is used for upper extremity
motion, finger motion, lower extremity motion, andtrunk motion disorders (Demain et al., 2013; McIntyre& Atwal, 2005). Moreover, AT is used for mental disorders, higher brain dysfunction, and developmental disorders. However, the AT framework is provided according
to its intended purpose. For example, AT support has acommunication board and a speech generating device
for people with speech, language, and hearing disorders
Received: 13 January 2014, Accepted: 16 June 2014
Corresponding to: Hiromi Fujii, Department of Occupational Therapy,
Yamagata Prefectural University of Health Sciences, 260 Kamiyanagi,
Yamagata, 990-2212 Japane-mail: hfujii@yachts.ac.jp©2016 Japanese Association of Occupational Therapists(McIntyre & Atwal, 2005; Pedretti & Early, 2001; Willard et al., 2009).
Eating and toilet hygiene are initial ADL acquisition targets of subjects with disabilities resulting frominjuries such as head or spinal cord injuries. Eating andtoilet hygiene are the goals of early ADL acquisition.
Especially, acquisition of eating is important not only
because of life support, but also for individual andsocial pleasure. A meal support robot (My Spoon, MAR0010; SECOM, Inc., Tokyo) is an electrical eating
device for people who have limited functionality of theirarms or hands, and serves as one AT device (Soyama,
Ishii & Fukase, 2003). A user with rheumatoid arthritis,
cervical cord injury, or muscular dysplasia can operate
My Spoon using a joystick or a button switch. Using My
Spoon, one can choose food in a voluntary order withvoluntary timing. Reportedly, the use of My Spoon improves the quality of life (QOL) and independent ADL.
Because of head and spinal cord injuries, simple
motions such as carrying food from a plate to the mouth
cannot be done smoothly. An OTR must teach proper
eating motions. However, subjects desiring smootheating motion cannot use My Spoon alone. For such

44

Visual Axis Analysis during Unassisted Eating and Robot-assisted Eatingcases, an OTR must offer support when introducing My
Spoon. An OTR must understand the characteristics of
AT when instructing subjects (Goto, Hatakeyama &Katayama, 2008). It is therefore important that the OTR
know the physiological and psychological effects of AT
on the subjects.
This study examines differences of the visual
axis and pupil diameter between unassisted eating androbot-assisted eating in healthy subjects, in addition totheir respective physiological responses.

Methods
Subjects
Subjects were 12 healthy volunteers (5 males, 7
females) from 20−26 years old (mean 22; standard
deviation 2). All subjects had visual acuity necessary toobtain a driver’s license, color sense, right-handedness,
and affiliated psychic function. None had any disease or
injury that would impair ADL. All subjects gave theirinformed consent to the experimental procedures, whichwere approved by the Ethics Committee of Yamagata
Prefectural University of Health Sciences, Yamagata,Japan.
Instrumentation and Data Acquisition
Exploratory eye movements were recorded using
an eye tracker (EMR-8B; nac Image Technology Inc.,Tokyo) with a sampling frequency of 30 Hz, which
detects infrared reflections from the cornea. EMR-8B
consisted of an eye camera head unit attachment and acontroller. The eye camera head unit includes a pupil
camera and a field camera. A visual axis position was
attached to a picture from the field camera with the controller. The field camera of the head unit did not have askewness of lens and used lens of diameter 62 degrees(deg) that a wide image was obtained. The detection
precision of upper extremity motion on the desk of thesubjects was 0.2 deg of 40 deg inside the circle of thecycloduction axis. A digital video camera (30 frames
per second, NV-GS320; Panasonic Inc., Osaka) was set
outside the subjects. Data were recorded using a digitalmotion picture waveform real-time synchronous recording system (The Teraview; Gigatex Co. Ltd., Osaki).
Meal tools were a spoon (stainless steel, 180 mm fulllength) and a My Spoon.
My Spoon has the following characteristics; a base,an arm and a hand part (with the spoon and fork). My
Spoon dimensions are 370 mm deep, 280 mm wide,and 250 mm high, with a weight of 6.0 kg. My Spoon
has a plate (245 mm deep, 245 mm wide, 58 mm high)divided into four sections. A user can easily operate My
Spoon with the joystick. There are three types of oper-

ation modes; automatic, semi-automatic, and manual.
This experiment used the manual mode of My Spoon
with the joystick.

Procedures
Illumination in the test room was 652 lux, and the
air temperature was about 24°C. The subjects sat on achair (400−450 mm height) and put the forearm on atable (800 mm deep, 1,200 mm wide, 700 mm high)with the shoulders flexed to 0−20 deg of flexion andthe elbow flexed to 70−90 deg of flexion. The subjects
held the spoon or the joystick for the eating task prior totask commencement (Fig. 1). The respective distances
between the mouth and the plate during unassisted
eating and robot-assisted eating were 338−471 mm and321−577 mm. The food used in the experiment was adoughnut-type cereal (Kokokun-no-chocowa; Kelloggs
Co., Tokyo) 15 mm in diameter. The eyes of the subjects
were masked to prevent the intervention of prior visual
information. Visual masking was removed at the startof the eating task. When food was in the mouth of thesubjects, the task was finished. Subjects were allowed tospit out the food from their mouths if they did not wantto swallow it. A bowl for this was prepared beside thesubjects. The eating tasks were unassisted eating androbot-assisted eating.
Unassisted eating procedure
For unassisted eating, subjects were instructedto eat food in the same way as in daily life. Types of
motion, speed, and accuracy were not instructed to any
subject.
Robot-assisted eating procedure
My Spoon was set at about 300 mm in front of thesubjects. The center of the My Spoon plate was alignedwith the midline of the subjects. The spoon tip of My
Spoon was set to stop at about 50 mm to 100 mm fromthe mouth of each subject. When the spoon of My
Spoon neared the subjects’ mouths, the subjects showedsome anxiety. Each subject set a distance of 50−100 mm
for which it was easy to eat without anxiety. Next, thesubjects performed three to five practice exercises to test
the joystick operation of My Spoon. The subjects chosethe food from any of four sections using the joystick,and the robot arm moved the section chosen by the
subject. The subjects then maneuvered the hand part of
My Spoon to the food. The robot caught the food in the
spoon which was attached to the hand part, and moved it
toward the mouth. Finally, the subject ate the food fromthe spoon. The subject operated the joystick during thestart of task, while controlling the spoon position on theAsian J Occup Ther 11: 43−52, 2016

Suzuki A et al.

45

Fig. 1. Experimental setup
EMR-8B denotes the eye tracker. DVC denotes a digital video camera. The Teraview
denotes digital motion picture waveforms real-time synchronous recording system.

plate, and while picking up the food.

Data Analysis
1. Motion Phases
Unassisted eating
Phases of each eating task were divided into threephases using video data. During phase 1 (P1), the spoon
began moving and reached the food. During phase 2 (P2),the spoon picked up the food. During phase 3 (P3), thespoon moved from the plate to the mouth of the subjects(eating motion).
Robot-assisted eating
During P1, the spoon attachment of My Spoon
moved and arrived on the plate. During P2, the spoon
attachment controlled the spoon position and picked up
the food. The phase ended before My Spoon began tomove the spoon to the mouth of the subjects. During P3,
the spoon attachment moved the spoon to within 50−100
mm of the front of the mouth, arrived at the mouth, andthe subjects put the food into the mouth.
2. Classification of eye movement
The position of the visual axis was fed to a picturefrom a field camera, and pursued during the eating task.
Furthermore, the eye movements were classified into
three types; saccadic eye movements (SEM), smooth
pursuit eye movements (SPEM), and fixation. SEM
were determined to be eye movement of an angle speed
greater than 50 deg/s. SPEM were determined to be eye
movements which follow the food at an angle speedof less than 50 deg/s (Fukushima & Fukushima, 2004;

Tazaki & Saito, 2013). Fixation was defined as inactive
eye movements which continued longer than 0.10s(Manor & Gordon, 2003). Therefore, the eye mark waspaused at the same position for more than three fieldcamera images under these conditions.
3. Visual axis position and upper extremity motion
The visual axis position was divided into three categories; showing a plate and section with food; showing
the spoon on the spoon bowl without the food, andshowing the food. Other positions showed blinking and/or no placement of the plate, the spoon, the food. The
Critical Visual Point (CVP) was defined as the upper
extremity position at which the visual axis was removed
from the food in P3.
4. Pupil diameter
The pupil diameter was measured at 30 Hz using
Eye mark data analysis software (EMR-dFactory; nac
Image Technology Inc. Tokyo). The pupil diameter of
each subject was measured before and after the nearreflex test. The reference of pupil diameter used the difference of the before and after the near reflex test (Tazaki& Saito, 2013). Judgment of three types of change in P3
was made; increase, decrease, or no change. The pupil
diameter change in all trials included each type. The
quantity of change of the pupil diameter was calculated
the difference between the maximum and the minimum(min-to-max or max-to-min) of P3.

46

Visual Axis Analysis during Unassisted Eating and Robot-assisted Eating

Results
Fig. 2 shows the respective transitions of the visual
axis and the pupil diameter during unassisted eating
for subject A. The spoon arrived at the food within 0.9
s from the task start (end of P1). The visual axis of
the subject was on the food. Furthermore, the subject
picked up the food with the spoon in 3.0 s (end of P2).
During P2, the visual axis changed in order of the food,the spoon, and back to the food. Next, the spoon began
to move toward the mouth and arrived at the mouth
within 4.8 s from the task start (end of P3). In P3, CVP
occurred at 3.9 s from the task start. CVP was 0.9 s fromstart of P3. The spoon at this time was located 221 mmfrom the left eye of the subject.
The order of the visual axis position with other trial
was different. However, the eye movement patterns weresimilar to those shown by this subject. Furthermore, allsubjects showed the same visual axis positions and eye
movement patterns.

The visual axis of P1 was fixed on the food fromtask start to 0.3 s later. The visual axis was fixated on
the food thereafter for 0.6 s. At that moment, the pupil
diameter increased 0.5 mm; from 2.8 mm to 3.3 mm.
During P2, the eye movement pattern changed in orderof fixation (0.2 s duration), SPEM (0.6 s), fixation (1.0 s),
and SPEM (0.3 s). In addition, SEM occurred between
fixation and SPEM. The pupil diameter increased 0.7mm; from 3.3 mm to 4.0 mm. During P3, the eye movement pattern changed in order of SPEM (0.6 s), SPEM
(0.4 s), fixation (0.5 s), others (0.2 s), and fixation (0.1s). The pupil diameter did not change. In the subject, thepupil diameter showed changes similar to other trials
in P1-P2. However, this subject showed an increase inpupil diameter among five trials, a decrease in two trials
and no change in three trials in P3 (Table 3).
Fig. 3 shows the respective transitions of the visual
axis and the pupil diameter during robot-assisted eating
for subject A. The spoon of the hand attachment arrived
at the plate at 7.9 s from the task start (end of P1).

Fig. 2. Transition of visual axis and the pupil diameter during unassisted eating in the subject A
The figure shows digital video camera images (DVC), field camera images (FC), the position of visual axis (VA) andpupil diameter (PD). Slash line boxes of FC show fixation of eyes. Dotted boxes of FC show smooth pursuit eye movement. Black color boxes show saccadic eye movement. When the visual axis was located in the blank part in all phases,
it was others. DVC and FC show the start of task, end of Phase 1, end of Phase 2, critical visual point (CVP), and end oftask sequentially from the left. Left dotted line shows the task start. Dotted lines of P1, P2, and P3 show the end of eachphase. The broken line shows CVP. Abbreviations are the same as those shown in Fig. 3.

Suzuki A et al.

Asian J Occup Ther 11: 43−52, 2016

During P1, the visual axis position shuttled back andforth among the plate, the spoon, the food, and otherobjects. Furthermore, the subject controlled the spoon
to accommodate the food, and picked up the food withthe spoon in 14.7 s (end of P2). During P2, the visual
axis position changed in the following order; the spoon,
the food, the plate, the spoon, the food, other objects,
the food, the spoon, and the food. Next, the spoon began
to move toward the mouth and arrived 97 mm fromthe mouth front within 23.4 s from the task start. The
subject put the food in the mouth within 25.9 s from thetask start (end of P3). The visual axis position was fixed
only on the spoon during P3. The spoon at this time was
located 152 mm from the left eye of the subject.
The order of the visual axis position differed fromthose of other trials. However, the visual axis positions
and the eye movement patterns were similar to thoseshown by this subject. During P3, the visual axis position was on the spoon and the plate in some of the trialsof the 10 subjects. Furthermore, all subjects showed thesame visual axis position from P1 to P3 as that of thissubject.
The visual axis of P1 was fixed on the food fromthe task start to about 0.3 s later. During P1, the eye
movement fixation times were 0.1−0.3 s on the plate and0.3−1.8 s on the food. Moreover, the eyes were fixated47

on the spoon at 0.5−0.6 s, and 0.9 s of SPEM. During
this time, the visual axis position shuttled back andforth among the plate, the spoon and the food. At thatmoment, the pupil diameter increased 0.9 mm; from 3.0
mm to 3.9 mm. During P2, the eye movement patternshowed only fixation, which occurred eight times. Eachfixation time was 1.1 s on the plate, 0.3−1.6 s on the
spoon, and 0.2−0.7 s on the food. The pupil diameterincreased 0.8 mm; from 3.7 mm to 4.5 mm. During P3,
the visual axis position was only on the spoon. The eye
movement patterns were fixation, SPEM, and SEM. The
fixation time showed 0.2−0.8 s. Furthermore, the SPEM
time showed 0.3−1.2 s only on the spoon. The pupil
diameter decreased 1.7 mm; from 4.5 mm to 2.8 mm,
which was similar to that of other trials for this subject.
In all trials, this subject showed a decreased pupil diameter in P3 (Table 4).
Table 1 shows the elapsed times in respective
phases and CVP times for unassisted eating in all subjects. The range of total elapsed time was 2.2−4.0 s inall subjects. The elapsed times of each phase were 0.8−
1.3 s, 0.5−1.1 s, and 0.9−1.8 s. All trials of all subjects
had a CVP in P3. The range of CVP times from the startof P3 was 0.5−1.1 s.
Table 2 shows the elapsed times in respective
phases for robot-assisted eating in all subjects. The range

Fig. 3. Transition of visual axis and the pupil diameter during robot-assisted eating in subject A.

48

Visual Axis Analysis during Unassisted Eating and Robot-assisted Eating

Table 1. Elapsed time in respective phases of unassisted eating
Subject
A
B
C
D
E
F
G
H
I
J
K
L

Total

P1

P2

P3

Elapsed time

Elapsed time

Elapsed time

Elapsed time

CVP time

3.9 ± 0.7
3.3 ± 0.4
2.9 ± 0.3
2.5 ± 0.2
3.2 ± 0.4
2.8 ± 0.2
3.1 ± 0.3
2.2 ± 0.3
2.7 ± 0.2
4.0 ± 0.3
2.4 ± 0.1
3.7 ± 0.3

1.1 ± 0.2
1.0 ± 0.1
0.9 ± 0.1
0.9 ± 0.2
1.2 ± 0.1
1.0 ± 0.1
1.3 ± 0.1
0.8 ± 0.2
0.9 ± 0.1
1.3 ± 0.2
0.9 ± 0.1
1.2 ± 0.2

1.0 ± 0.4
1.1 ± 0.4
0.8 ± 0.2
0.6 ± 0.1
1.0 ± 0.4
0.9 ± 0.2
0.7 ± 0.1
0.5 ± 0.1
0.7 ± 0.2
1.1 ± 0.1
0.6 ± 0.1
1.1 ± 0.3

1.8 ± 0.3
1.2 ± 0.1
1.2 ± 0.1
0.9 ± 0.1
1.0 ± 0.1
1.0 ± 0.1
1.1 ± 0.3
1.0 ± 0.1
1.1 ± 0.1
1.6 ± 0.2
1.0 ± 0.0
1.4 ± 0.1

0.9 ± 0.2
0.7 ± 0.2
0.6 ± 0.1
0.5 ± 0.1
0.6 ± 0.1
0.6 ± 0.1
0.7 ± 0.1
0.5 ± 0.1
0.6 ± 0.1
1.1 ± 0.1
0.5 ± 0.1
0.9 ± 0.1(s)

Table 2. Elapsed time in respective phases of robot-assisted eating
Subject

Total
Elapsedtime

P1
Elapsedtime

P2
Elapsedtime

P3
Elapsed
time

A
B
C
D
E
F
G
H
I
J
K
L

25.5 ± 1.1
27.2 ± 2.2
26.4 ± 0.7
26.4 ± 0.9
25.9 ± 1.0
25.4 ± 0.7
26.2 ± 1.4
25.3 ± 1.5
24.7 ± 1.0
25.2 ± 1.3
26.6 ± 0.9
26.4 ± 1.8

8.4 ± 0.5
8.4 ± 0.2
8.2 ± 0.1
8.3 ± 0.4
7.8 ± 0.1
8.5 ± 0.1
8.8 ± 0.3
8.3 ± 0.6
8.1 ± 0.1
8.5 ± 0.6
8.2 ± 0.3
8.9 ± 0.8

5.4 ± 1.1
6.8 ± 2.0
5.6 ± 0.7
6.8 ± 0.8
5.5 ± 0.9
5.5 ± 0.7
6.9 ± 1.0
6.6 ± 0.9
5.5 ± 0.8
5.3 ± 1.3
5.5 ± 1.1
5.0 ± 1.1

11.7 ± 0.4
12.0 ± 0.4
12.6 ± 0.3
11.3 ± 0.6
12.6 ± 0.3
11.3 ± 0.2
10.5 ± 0.6
10.4 ± 0.8
11.2 ± 0.5
11.5 ± 0.2
12.9 ± 0.5
12.4 ± 1.0(s)of total elapsed times was 24.7−27.2 s. Furthermore, theelapsed times of each phase were 7.8−8.9 s, 5.0−6.9 s,
and 10.4−12.9 s. In all subjects, CVP disappeared completely from all trials in P3.
Table 3 shows the min-to-max or max-to-min pupil
diameters, differences, and changing counts for unassisted eating in all subjects of P3. For subject A, the min-tomax or max-to-min pupil diameters increased from 3.8
to 4.1 mm, decreased from 4.2 to 3.9 mm, and remained
from unchanged at 3.9 mm. The pupil diameter difference was a 0.3 mm increase and a 0.3 mm decrease. The
increase, decrease, and no change of pupil diameters
were 5, 2 and 3, respectively. The near reflex value was
1.1 mm; from 3.8 mm to 2.7 mm. Five subjects showed
an increase, decrease and no change of pupil diameter.
In subject G, the min-to-max or max-to-min pupil
diameters increased from 4.3 to 4.4 mm and decreased
from 4.6 to 4.3 mm. The differences of pupil diameter
were a 0.1 mm increase and a 0.3 mm decrease. The

pupil diameter changing counts showed increase of two
and decrease of eight. The near reflex value was 1.2mm; from 4.5 mm to 3.2 mm. Two subjects showed anincrease and decrease of pupil diameter.
In subject H, the min-to-max pupil diameters
increased from 4.2 to 4.6 mm. The difference of pupil
diameter was 0.4 mm. The pupil diameter increased in
all trials. The near reflex value was 1.8 mm; from 5.1
mm to 3.3 mm. Two subjects showed an increase inpupil diameter.
In subject J, the max-to-min pupil diameters decreased (from 5.2 to 4.3 mm). The difference of pupil
diameter showed a 0.9 mm decrease. The pupil diameterdecreased in all trials. The near reflex value was 1.9mm; from 4.5 mm to 2.6 mm. Three subjects showed adecrease in pupil diameter.
Table 4 shows the pupil diameters from min-tomax or max-to-min, difference and changing counts inrobot-assisted eating of all subjects in P3.
In subject A, the max-to-min pupil diameters
decreased from 4.4 to 2.9 mm. The difference of pupil
diameter was 1.5 mm. A decrease in pupil diameters
appeared in all trials of all subjects.

Discussion
Characteristics between visual axis and pupil diameter
during unassisted eating
Fig. 2 shows that the visual axis was placed only on
the spoon and the food from task start to CVP. The pupil
diameter increased slowly from task start to the endof P2. In addition, the pupil diameter at P3 increasedslightly with CVP. The subject in Fig. 2 showed three
types of pupil diameter transitions; increase, decrease,and no change (Table 3). However, the difference of
pupil diameter in each type was less than the near reflex.

Suzuki A et al.

Asian J Occup Ther 11: 43−52, 201649

Table 3. Pupil diameter of unassisted eating in phase 3
Subject

Pupil diameter (mm)Max (Min) to Min (Max)Near reflex (mm)

Type

Dif.

Counts

Max

Min

Dif.

A

3.8
4.2
3.9

4.1
3.9
3.9

Inc
Dec
No

0.3
0.3
0.0

5
2
3

3.8

2.7

1.1

B

5.8
6.2
5.7

5.9
5.8
5.7

Inc
Dec
No

0.1
0.4
0.0

2
4
4

4.9

3.4

1.5

C

4.5
4.7
4.5

4.6
4.5
4.5

Inc
Dec
No

0.1
0.2
0.0

6
2
2

4.8

2.7

2.1

D

5.2
5.2
5.5

5.4
5.1
5.5

Inc
Dec
No

0.2
0.1
0.0

5
3
2

4.4

3.2

1.2

E

3.6
3.7
3.5

3.7
3.5
3.5

Inc
Dec
No

0.1
0.2
0.0

2
7
1

3.4

2.3

1.1

F

3.6
3.9
−

3.7
3.6
−

Inc
Dec
No

0.1
0.3
−

2
8
0

3.2

2.7

0.5

G

4.3
4.6
−

4.4
4.3
−

Inc
Dec
No

0.1
0.3
−

2
8
0

4.5

3.2

1.3

H

4.2
−
−

4.6
−
−

Inc
Dec
No

0.4
−
−

10
0
0

5.1

3.3

1.8

I

4.8
−
−

5.1
−
−

Inc
Dec
No

0.3
−
−

10
0
0

4.3

3.4

0.9

J

−
5.2
−

−
4.3
−

Inc
Dec
No

−
0.9
−

0
10
0

4.5

2.6

1.9

K

−
5.4
−

−
5.0
−

Inc
Dec
No

−
0.4
−

0
10
0

5.0

3.3

1.7

L

−
4.0
−

−
3.6
−

Inc
Dec
No

−
0.4
−

0
10
0

3.5

2.4

1.1

A near reflex test is an examination to look at about 100
mm front of a subject immediately from a far-off place.
The pupil diameter decreases in healthy subjects. The
phenomenon results from an accommodation reflex anda convergence reflex (Bando, 1996; Leigh & Zee, 1991).
The near reflex differs from light reflex in terms of pathways (Tazaki & Saito, 2013). The CVP of the subject
was more distant than the near reflex. Reportedly, therecorded distances of CVP in the 19 subjects were large
among the subjects, ranging from 157−471 mm in theperformance of 0.1 spoon. The CVP distance of eachsubject was reduced slightly when the amount of juicein the spoon was increased (Sasaki et al., 2013).
Two subjects showed both an increase and decrease.
Three subjects showed only a decrease. In addition,
the difference of pupil diameters was smaller than thenear reflex in each subject. A recent report describedthat CVP occurs in eating motions using a spoon andchopsticks (Nito, 2011). The report suggests that the roleof the visual axis to the CVP reflected monitoring of
the food during eating motions. However, other reports
described that the motion carrying the spoon with thejuice did not need to constantly maintain the visual axison the cup of the spoon (Suzuki, Fujii & Nikara, 2009;

50

Visual Axis Analysis during Unassisted Eating and Robot-assisted Eating

Table 4. Pupil diameter of robot-assisted eating in phase 3
Subject

Pupil diameter (mm)Max (Min) to Min (Max)Near reflex (mm)

Type

Dif.

Counts

Max

Min

Dif.

A

−
4.4
−

−
2.9
−

Inc
Dec
No

−
1.5
−

0
10
0

3.8

2.7

1.1

B

−
6.1
−

−
4.6
−

Inc
Dec
No

−
1.5
−

0
10
0

4.9

3.4

1.5

C

−
4.2
−

−
3.0
−

Inc
Dec
No

−
1.2
−

0
10
0

4.8

2.7

2.1

D

−
5.6
−

−
3.9
−

Inc
Dec
No

−
1.7
−

0
10
0

4.4

3.2

1.2

E

−
3.6
−

−
2.8
−

Inc
Dec
No

−
0.8
−

0
10
0

3.4

2.3

1.1

F

−
3.9
−

−
3.1
−

Inc
Dec
No

−
0.8
−

0
10
0

3.2

2.7

0.5

G

−
4.9
−

−
3.2
−

Inc
Dec
No

−
1.7
−

0
10
0

4.5

3.2

1.3

H

−
5.4
−

−
3.7
−

Inc
Dec
No

−
1.7
−

0
10
0

5.1

3.3

1.8

I

−
5.2
−

−
3.4
−

Inc
Dec
No

−
1.8
−

0
10
0

4.3

3.4

0.9

J

−
4.9
−

−
2.9
−

Inc
Dec
No

−
2.0
−

0
10
0

4.5

2.6

1.9

K

−
6.0
−

−
3.8
−

Inc
Dec
No

−
2.2
−

0
10
0

5.0

3.3

1.7

L

−
4.3
−

−
3.0
−

Inc
Dec
No

−
1.3
−

0
10
0

3.5

2.4

1.1

Suzuki et al., 2011). Therefore, the motion carrying thespoon is mainly performed using a motor program that isreadily acquired in the brain. In addition, a recent study
using dominant and non-dominant hands has shown that
CVP had the same role as the eating motion (Takahashi,2013). The report implied that CVP affects monitoringwith a conscious guide of food. However, the relation of
the visual axis and pupil diameter during eating motions
has not previously been reported. These findings suggestthat the pupil diameter transition during fixation on thevisual axis of a spoon is not only done in the monitoringof the food.

Characteristics between visual axis and pupil diameter
during robot-assisted eating
Fig. 3 shows that the visual axis is placed among
the plate, the spoon, and the food from task start to theend of P2. First, the visual axis moved to the food earlyin P1. Next, the visual axis on the plate was equivalent
to the position at which the spoon of My Spoon arrived.
Finally, the visual axis shuttled back and forth among
the plate, the spoon, and the food in P1. Although thevisual axis moved to the plate from a distant place fromthe spoon of My Spoon, the pupil diameter increased
slowly. In early P2, the order of the visual axis position

Suzuki A et al.

Asian J Occup Ther 11: 43−52, 201651

on the spoon, the food and the plate was transitory.
Results suggest that the visual axis of the subjects serve
the role of monitoring during eating motions in robotassisted eating. These findings suggest that the visual
axis is used for adjustment between the spoon and thefood position.
Finally, the visual axis moved to the food, and thesubject gave an order to lift the food using the joystick.
During P2, the distance from the left eye to the plate did
not change, but the pupil diameter increased graduallyfrom P1 to P2 for reasons that remain unclear. In P3,
the visual axis is placed only on the spoon. The pupil
diameter decreased 1.7 mm, from 4.5 mm to 2.8 mm
using My Spoon. The visual axis position between the
spoon tip of My Spoon and the subject was nearer thanthe CVP of unassisted eating. Furthermore, the difference of the pupil diameter in robot-assisted eating was
greater than that for unassisted eating. Therefore, thepupil diameter in robot-assisted eating was less than thatduring unassisted eating. The minimum pupil diameterin robot-assisted eating resembles that of the near reflex.
These data show that the subject looked carefully at the
food and/or the spoon using accommodation convergence reflexes. The transitions of the visual axis and thepupil diameter were clear in all subjects. Results showthat the visual axis approached the spoon from the plate
to near the mouth. Using My Spoon, all subjects showeda similar transition of the visual axis and the pupil diameter. When the subjects have no somatosensory information, they depend only on visual information. Therefore,
robot-assisted eating must identify the distance to thespoon from the mouth using visual information.

careful monitoring of the food. During robot-assisted
eating the distance between the spoon and the subject
mouth must be measured visually. In robot-assisted
eating, somatosensory information is not obtained.
Therefore, anxiety occurs among all subjects when the
spoon tip nears the subject.
These findings show that unassisted eating androbot-assisted eating elicit different physiological responses in healthy subjects.

Differences between unassisted eating and robot-assisted
eatingAs described above, the visual axis showed adifference between unassisted eating and robot-assisted
eating. The maximum difference was the presence of
CVP. In unassisted eating, CVP is present, and the visual
axis is located on the food or the spoon from P3 start to
CVP. However, robot-assisted eating has no CVP. The
visual axis is located on the food or the spoon from start
until the end of the eating motion in P3. A recent report
described similar results of the visual axis in caregiver-assisted eating (Saitou, 2006). In addition, unassisted
eating showed numerous types of pupil diameter changes in 7 out of 12 subjects. Conversely, robot-assisted
eating showed a pupil diameter decrease in all subjects.
Even if the visual axis is applied to the food, the pupil
diameter changes differ. Unassisted eating has a visual
axis that did not monitor the food. However, it has beensuggested that the pupil diameter decreases to the same
degree as the near reflex when the visual axis shows

Acknowledgments: The authors thank Prof. Takuro
Hatakeyama, Dr. Sumio Ishii, Prof. Kunihiko Maeda
and Prof. Toshiaki Sato for their valuable suggestions
related to this study.
We also thank Ms Chihiro Sato OTR, Ayumi
Minegishi OTR and students of Yamagata Prefectural
University of Health Sciences for their excellent assistance. This work was partly supported by grants fromthe Yamagata Health Support Foundation.

Practical application of occupational therapy
In this study, unassisted eating and robot-assisted
eating showed clear differences in physiological responses. Because of influences such as head injury andspinal cord injury, a challenged person might use a meal
support robot. In robot-assisted eating, characteristics ofphysiological responses are important. However, voluntary eating with voluntary timing of the subject is necessary to improve QOL. OTRs must teach subjects to use
meal support robots for QOL improvement. Therefore,
it is necessary for OTRs to understand motion guidance
methods and characteristics of physiological responseusing assistive technology.
Study limitations
Findings of this study demonstrated that unassisted
eating and robot-assisted eating elicit different physiological responses in healthy subjects. Nevertheless, nocomparison was made with challenged persons during
unassisted eating or robot-assisted eating. In the future,
the authors would like to investigate unassisted eating
and robot-assisted eating with challenged persons.

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Fukushima, J., & Fukushima, K. (2004). Saccade and Smooth
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Goto, Y., Hatakeyama, T., & Katayama, T. (2008). A comparison of meal operation by a meal support robot andhelpers: How students feel about support equipment.
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extremity motion during eating in healthy subjects:
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curve. Master thesis of Yamagata Prefectural University
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Practice Skills for Physical Dysfunction Fifth ed. London:
Elsevier-Health Sciences Division; 263–274.
Saitou, H. (2006). The characteristics of perspective during
eating action – Comparison between self-and assisted
eating in healthy human subjects –, Master thesis of
Yamagata Prefectural University of Health Sciences, (inJapanese with English abstract).
Sasaki, S., Suzuki, Y., Nito, M., Kawakatsu, Y., & Fujii, H.
(2013). Contribution to visual axis by upper extremity

motion during eating in the healthy humans: Survey ofvarious amounts of juice of the spoon during eating.
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Soyama, R., Ishii, S., & Fukase, A. (2003), The Developmentof Meal-Assistance Robot ‘My Spoon’, Proceedings of
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myspoon/pdf/myspoon-icorr.pdf.
Suzuki, Y., Fujii, F., & Nikara, T. (2009). Many other attentions besides the visual attention are evoked within
the duration of the visual axis kept on the object. 36th
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Suzuki, Y., Fujii, H., Sato, T., Sasaki, S., & Fukuda, E. (2011).
Eye—hand coordination during eating among healthypeople. Japanese Occupational Therapy Research. 30,
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Asian Journal of Occupational Therapy
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